Denial Management
Revenue Integrity Insights
A Collection of White Papers from AppriseMD
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.
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.
In 2021 and 2022, as COVID-related illnesses waned, the average length of stay (ALOS) and patient acuity continued to increase across the U.S. as hospitals began to see sicker patients due to an extended period of delayed care. This new trend emerged as pent-up demand for elective procedures increased and spikes in hospitalizations continued to cycle in the fall of 2022 due to things like new COVID variants and a respiratory syncytial virus (RSV) outbreak. Understanding the changes caused by the pandemic, their root causes and their impact on hospitals is critical in building strategies that will help hospitals address the trends.
Dealing with Denials
An in-depth look at the causes of inpatient denials and what healthcare organizations can do to keep them from happening.
Read more
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.
Position Paper
Outpatient Arthroplasty Surgery: A position paper from AppriseMD
Read More
The American Association of Hip and Knee Surgeons have stated that hip and knee replacements can be safely performed in the outpatient setting in some specific circumstances. However, the wording implies the procedure is most appropriate in an ideal patient when performed in a facility and by a surgical team specifically equipped for this type of procedure. The clear implication is that an outpatient procedure should not be a viewed as an appropriate or mandatory setting for arthroplasty procedures.
bEYOND THE PANDEMIC
Part 2: How Hospitals Can Adapt to the New Reality, a compendium of research by AppriseMD.
Part 2
As the pandemic recedes, the average length of stay continues to increase nationwide despite a drop in COVID-related illnesses. The American Hospital Association* reported that the average patient length of stay increased by 19.2% in 2022 compared to pre-pandemic levels. A combination of factors was responsible for this change. It is clear hospitals will continue to face challenges in 2023. Understanding the residual effects caused by the pandemic, their root causes, and their impact on the continuum of care, is critical to building strategies to effectively manage hospital capacity and resources.
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.
Rightsizing LOS
A look at how to improve efficiency by rightsizing length of stay and reducing avoidable hospital inpatient days.
Read more
Hospitals working to improve efficiency by rightsizing length of stay and reducing avoidable hospital inpatient days must implement a process that begins prior to admission and extends beyond discharge. Extended hospital stays beyond what is needed for high quality care and avoidable readmissions, can be associated with an increased potential for complications such as hospital acquired infections and patient safety events. Reducing extended stays relies on a coordinated, multi-facetted process to reach the desired outcomes.
Medicare Appeals
A look at the process involved in appealing Medicare cases through to an administrative law judge.
read more
Hospital executives and case review managers should soon see the back-logged appeals process speed up for denied Medicare claims. That means hospitals now have one less reason not to pursue appeals of Medicare denials.
According to attorney Knicole C. Emanual, writing for RACmonitor, The Centers for Medicare and Medicaid Services (CMS) has given The Office of Medicare Hearings and Appeals (OMHA) enough new funding to hire 70 additional administrative law judges. These new judges will be charged with hearing the backlog of appeals cases that up until now had a 4-6-year waiting period. Emanual writes, “OMHA now has the capacity to hear and render decisions for approximately 300,000 appeals per year,” which she said was higher than the number of appeals being filed.1