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Compliance with CMS 4201-F pie chart

Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings

AppriseMD hospital utilization review data for the first two months of 2024 shows that Medicare Advantage Organizations (MAOs) are denying claims that would have been approved under Traditional Medicare. BACKGROUND MAOs must adhere to the same guidelines as Traditional Medicare as per the Center for Medicare and Medicaid Services’ (CMS) 2024 rule 4201-F. MAOs can […]
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Payer Claim Denials & Medicare Advantage Organizations Market Share

Medicare Advantage (MA) plans traditionally implement more restrictive medical necessity requirements than Traditional Medicare. They also produce a higher denial rate than all other payer categories combined, according to Crowe.  This leaves hospitals investing more time and resources into ensuring appropriate reimbursement. MA plans already account for a generous portion of Medicare plans in the US, and […]
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Centers for Medicare and Medicaid Services Final Rule 4201-F timeline

The Impetus Behind the 2024 CMS Final Rule

Arising from concerns that the Medicare Advantage Organizations (MAOs) were delaying and denying services and reimbursement, the Centers for Medicare and Medicaid Services (CMS) implemented 4201-F at the beginning of 2024. This rule was initiated after the publication of a report in April 2022 by the Office of the Inspector General (OIG), a division of […]
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Medical chart review

HHS OIG Report Shows Code Adjustments May Indicate Denials

In a report released March 2 by OIG, investigators found “that most 2019 MA (Medicare Advantage) encounter records contained at least one adjustment code and 55 million of these records contained codes that may indicate the denial of payments by MAOs Medicare Advantage Organizations).” The report’s key take away was that while most of the […]
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CMS proposed rule change laptop with text

CMS Proposed Rule Changes for MA Patients

CMS proposed rule impacts how hospitals determine LOS for MA patients   The Centers for Medicare and Medicaid Services (CMS) recently proposed rule changes (CMS-4201) that could have a significant impact on how hospital utilization management determines level of care for Medicare Advantage patients. The proposed rule1 reflects the agency’s focus on increasing transparency, improving health […]
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Payer Prior Authorization Continues to Create Roadblocks

Doctors surveyed by the American Medical Association said the payer prior authorization (PA) process creates delays in care, abandoned treatments, and impacts outcomes. The complexity and inconsistencies of payer PA processes continue to create roadblocks to care for both patient and providers, including hospitals. Although the American Medical Association, along with the American Hospital Association, […]
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checking armband

New UHC Hospital Services Observation and Inpatient Policy Takes Effect Dec. 1, 2022

UnitedHealthcare’s Observation Utilization Review Guide is sunsetting and will be replaced by the new Hospital Services: Observation and Inpatient Policy1. The change takes effect Dec. 1, 2022, for commercial, community and exchange plans. The new policy explicitly mentions InterQual, stating “InterQual criteria are intended to be used in connection with the independent professional medical judgment […]
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without proper documentation inpatient denials are often upheld

Without Proper Documentation, Inpatient Denials are Often Upheld

Peer-to-peer discussions between hospital physicians – or their physician advisors – and the insurance company’s medical director can often overturn inpatient denials. But without proper documentation they do not work to rescind denials. Proper documentation must include an assessment coinciding with a detailed treatment plan updated throughout hospitalization. AppriseMD recently recommended to appeal a case […]
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Medicare Appeals Process Needs Changes

Medicare Appeals Process Needs to be Amended

In her recent article, “Ghosting the Medicare Provider Appeals Process,” Knicole C. Emanuel Esq. argues that the process by which denied Medicare claims are reviewed and appealed is counter to rest of the U.S. legal system. The lengthy process for addressing denied Medicare claims is multi-tiered and, until recently, hampered by a years-long backlog due […]
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Determining observation stay guidelines

Which Guidelines Should Hospitals Follow for an Observation Stay?

Both national evidence-based guidelines and insurance company guidelines factor into level of care determination.   When it comes to determining a patient’s level of care for a short hospital stay, observation services are generally used for short-term monitoring, testing and evaluation to establish a treatment plan, and to give the treatment team time to see […]
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Justice Department files lawsuit against UHC to stop Change Healthcare acquisition

Justice Department Files Lawsuit Against UnitedHealth to Stop Change Healthcare Acquisition

The United States Department of Justice filed an antitrust lawsuit earlier this year aiming to stop UnitedHealth Group from acquiring Change Healthcare.1 Hospital CFOs and utilization review managers have much to watch in this case related to how it could not only impact competition in the markets but how it could impact the guidelines used […]
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AHA advocacy of rural hospitals agenda

AHA’s Advocacy of Rural Hospital Issues is Needed

The American Hospital Association (AHA) updated rural hospital leaders regarding its 2022 Rural Advocacy Agenda during the recent AHA Rural Health Care Leadership Conference in Phoenix, AZ, attended by AppriseMD CEO Franklin E Baumann, MD. “The 2022 Rural Advocacy Agenda focuses on broader, forward-looking legislative and regulatory priorities that are not necessarily connected to the […]
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AppriseMD physician advisors provide essential utilization review and denial management services to hospitals

How Does the Two-midnight Rule Apply When a Traditional Medicare Patient Has No Safe Discharge Plan?

For a traditional Medicare patient admitted for observation, it is not uncommon to remain in the hospital longer than two midnights due to non-medical reasons including waiting for a transfer to another facility or family situations. In these cases, the reason the patient remains hospitalized is the lack of a safe discharge plan. Should such […]
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Doctors in surgery, CMS to keep inpatient only list

CMS to Keep the Inpatient Only List

The Centers for Medicare and Medicaid Services’ decision to not eliminate the inpatient only list (IPO) was due to the numerous comments and feedback it received from the medical community, the COVID-19 public health emergency and the fact that the change “transpired quickly,” according to the final rule (CMS-1753FC) issued in December.1 Heading into 2022, […]
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Administrative law judge reviews appeals at the highest level

Appealing Denials through the Medicare Claims Appeals Process Works

Though it took time and effort, an administrative law judge ruled in favor of a client hospital and overturned a Medicare claim denial for a total knee replacement surgery. The hospital can now fully recover the cost of that surgery, with interest. The case dates back to 2015 when a traditional Medicare patient underwent a […]
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ehr, emr, electronic medical record graphic

Good Documentation can Reduce Hospital Admission Denials

We all know in clinical medicine that documentation is everything. Hence the old saying “If it’s not documented, then it didn’t happen.” This is particularly true outside of the clinical realm in the insurance world. Level of care is based on the clinical condition of the patient, how they present and how that meshes with […]
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Doctor with mask and stethoscope. Hospitals need every financial advantage they can to recoup revenue from the pandemic.

With COVID-19, Hospitals Need Every Financial Advantage

As hospitals in some areas face a new and devastating round of COVID-19 surges, the financial impact on those hospitals is not yet known. This new spike in cases comes on the heels of more than 16-months of instability caused by the pandemic and just when hospitals were starting to make gains financially. According to […]
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hospital bed depicting CMS reverses course on inpatient only list

CMS Reverses Course on Inpatient Only List

After what must have been significant feedback, the Centers for Medicare & Medicaid Services is now reversing its move to eliminate the inpatient only (IPO) list in 2022 and add back the 298 services removed from the IPO list in 2021. 1 If this goes through in 2022, it will require hospitals to be extra […]
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doctors in surgery

Eliminating the CMS IPO List will Continue to Complicate Hospital Stays

For an update on this issue, please read: CMS reverses course in inpatient only list   The Centers for Medicare & Medicaid Services (CMS) has begun to dismantle its inpatient only list, which has directed the level of care for more than 1700 procedures for physicians and hospitals since 2000. CMS said the move gives physicians […]
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Utilization Review: In-house or Outsource?

Utilization management programs are often in-house services provided by hospital staff. However, more and more hospitals are outsourcing utilization review management as the pressure mounts to contain costs, especially following the COVID-19 pandemic, and improve care. Hospitals benefit from outsourcing utilization review in several ways, as it can: Free up in-house physician advisors and chief […]
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AppriseMD physician advisors provide essential utilization review and denial management services to hospitals

Documentation – A Key for Reduced Denials

There is one relatively easy way hospitals can reduce claims denials: better clinical documentation. Insurance companies require documentation, and it is often the leading factor in level of care and admission denials. The importance of providing complete documentation never goes away. Treating physicians and utilization review managers must ensure that every admission includes: All the […]
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admissions and perioperative / ICU directions sign in a hospital

A Quiet Shift that Could Shake Up Hospital Utilization Review

There is a seismic shift happening in Utilization Review: As of Saturday, May 1, 2021, UnitedHealthcare, the country’s largest healthcare insurance provider, is changing guidelines to adjudicate the level of care cases for hospitals from Milliman Care Guidelines (MCG) to InterQual.1 AppriseMD will be working closely with our current hospital clients to ensure this is […]
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Recouping revenue lost to COVID

Utilization Review Management Can Help Hospitals with COVID Revenue Loss

COVID-19 continues to have detrimental effects not only on health of people, but also on the economy and businesses in general. Included in these businesses are hospitals which have been expected to be fully supplied, staffed and ready to provide cutting edge care throughout the pandemic.  According to a new report released in February from […]
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Providing the Best Outcome for Patients Through UR

“The Hippocratic Oath is one of the oldest binding documents in history. Written in antiquity, its principles are held sacred by doctors to this day: treat the sick to the best of one’s ability, preserve patient privacy, teach the secrets of medicine to the next generation…” 1 As a physician-owned company in which board-certified physicians carry out […]
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