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Denial Management
Revenue Integrity Insights

A Collection of White Papers from AppriseMD

New from AppriseMD

Addressing Healthcare Reimbursement

A Focus on Denial Management and Medical Necessity

The hard truth is that denials are a major pain point for all hospitals. Hospitals and health systems know this. The difficulty lies in the execution. Healthcare organizations can no longer afford to take a hit on reimbursement, therefore medical necessity determinations and denial management must become a priority.

In this review, AppriseMD looks at how hospitals can tackle barriers to reimbursement, increase the focus on medical necessity and uncover hidden factors that contribute to revenue loss.

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Medicare Advantage & the Two-Midnight Rule: 2024 Findings

A Data and Historical Review

Early 2024 data suggests Medicare Advantage Organizations (MAOs) are not complying with the Centers for Medicare and Medicaid Services’ (CMS) 2024 final rule 2401-F. The MAOs pose a significant challenge to a hospital’s ability to collect reimbursement for medical services rendered, which is why ensuring compliance requires provider vigilance. Download this paper to uncover insights on the following:
  • The impetus behind the 2024 CMS final rule
  • MAO market share
  • The Two-Midnight rule
  • CMS-4201-F key factors
  • AppriseMD data examining how the new rule is being implemented
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The Use of AI in Claims Denials

A Compendium of Artificial Intelligence Use in Utilization Review

Payers deny claims at a rate that climbs higher each year. However, the increasing use of artificial intelligence (AI) to automatically deny claims without review creates a new issue for hospitals and revenue cycle managers struggling to reduce denials. While healthcare insurance companies promote the use of AI as a denial mitigation tool to process claims more efficiently, three class action lawsuits filed late last year are raising concerns that insurance companies use AI to deny claims without ever examining patient records. As the use of AI in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials needs to be scrutinized by providers to ensure the denial is appropriate, which also satisfies numerous state insurance laws requiring proper evaluation of healthcare claim denials. This publication is a review of publicly available news articles discussing the use of AI in claim denials.
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Is your hospital losing money over the weekend?

The impact of weekend utilization review on reimbursement

It’s common to find hospital utilization management teams and physician advisory staffing lower during weekends. Lower staff levels can lead to delays in patient determinations that ensure treatment is at the appropriate level of care (LOC). Staffing issues can also stall discharges, keeping patients in the hospital even though they are ready to leave. Both scenarios can negatively impact quality of care, the patient experience, and hospital resources. Prolonged hospital stays have been linked to an increased risk of hospital-acquired infections and other complications, while poor triage and discharge processes impact patient satisfaction scores (HCAHPS). All of these have financial ramifications that should be mitigated.
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Turning UM Data into Revenue Opportunities

Exploring the balance between cost and care

Utilization management (UM) data analysis transforms revenue cycle and care management practices, yielding greater earnings to support hospital and health system operations and sustainability while improving the timely delivery of quality care.

UM balances the delivery of the right care at the right time in the right setting. Providing the right, or medically necessary care, depends upon providing patients with treatment needed to achieve the best possible medical outcome without over- or under-utilizing services. The complexity of the cost structure in the U.S. healthcare system adds another hurdle. Even though medical necessity is the foundation upon which UM rests, it does not exist in a vacuum. It is intricately linked to cost. Achieving a utilization management balance can improve a hospital’s quality of care while at the same time reducing costs.

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Implementing the 2024 CMS New Rule: Five Points of Focus for Utilization Review Teams

Implementing the 2024 CMS Final Rule

Five Points of Focus for Utilization Review Teams

2024 CMS Final Rule

Although this is new territory for MAOs, at AppriseMD we believe under the Center for Medicare and Medicaid Services’ (CMS) new Rule 4201-F, MA patients will eventually be treated the same as Traditional Medicare patients given CMS’s standard and the considerable support by hospitals, physician advisors, and the America Hospital Association. It may take time for the complete change to happen. Some MAOs will not comply. Some will try and get it wrong. Some will comply and get it right. We’ve outlined five important points utilization review teams and physician advisors should focus on moving into 2024 as the rule implementation takes shape.
 
Beyond the pandemic, Part 1 sicker patients and longer stays, a compendium of research from AppriseMD

Beyond the Pandemic

Part 1: Sicker Patients and Longer Stays, a compendium of research by AppriseMD

Part 1

In 2020, hospitals encountered a crisis unlike any they had faced before. More than two years later, hospitals are still coping with the repercussions of the COVID-19 pandemic both in terms of patient volumes and financial challenges.

DownloadPart 1

Dealing with denials, a compendium of research by AppriseMD

Dealing with Denials

An in-depth look at the causes of inpatient denials and what healthcare organizations can do to keep them from happening.

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Ultimately hospitals and other healthcare providers can no longer ignore the impact inpatient denials can have on their cash flow. Ninety percent of all denials are preventable, so why aren’t more denials being prevented? If an organization takes a focused and unremitting approach to tackling this problem, it can see improvements in lowering denials and increasing overturned denials. This approach requires persistence and commitment to proper documentation, plus a clear utilization review strategy together with a team approach. The result will help support the financial health and future sustainability of the organization.

 

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Beyond the Pandemic, Part 2 How Hospitals Can Adapt to the New Reality

Beyond the Pandemic

Part 2: How Hospitals Can Adapt to the New Reality, a compendium of research by AppriseMD.

Part 2

In Part 2 of our compendium of research, we look at strategies to bend hospital utilization curves by right sizing length of stay as well as keys to addressing post-disc.

Download Part 2

DENIAL MANAGEMENT
PHYSICIAN ADVISORY
UTILIZATION CASE REVIEW

Optimize patient care, reduce denials and maximize reimbursement through our unique approach to achieving excellence in utilization management.

Discuss your hospital’s utilization and denial management needs with our team.

 

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