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# AppriseMD

Hospital Utilization Review Services

## Sitemaps

- [XML Sitemap](https://apprisemd.com/sitemap.xml): Contains all public & indexable URLs for this website.

## Posts

- [Utilization Review Management Can Help Hospitals with COVID Revenue Loss](https://apprisemd.com/utilization-review-managment-can-help-hospitals-with-covid-revenue-loss/) - Utilization review management can help fight against severe hospital revenue loss and pick-up the revenue cycle’s vigor.
- [Case Study: Untapped Potential for Hospitals, Appealing MA Denials to Skilled Nursing Facilities](https://apprisemd.com/case-study-untapped-potential-ma-snf-denials/) - AppriseMD successfully petitioned for a reversal of a MAO SNF denial, resulting in the MAO authorizing SNF post-acute care following discharge.
- [Case Study:  High Severity Reimbursement Approved Following Severity Discussion](https://apprisemd.com/case-study-high-severity-reimbursement/) - The severity review concluded with the payer medical director agreeing that the high severity payment determination was warranted and approved.
- [Case Study: Unlinking a Readmission Hospitalization During a Peer-to-Peer Payer Review](https://apprisemd.com/case-study-unlinking-readmission-p2p/) - AppriseMD was able to overturn a denial and get a patient’s readmission unlinked from the prior admission during a peer-to-peer payer review.
- [Case Study: New DRG Key to Overturning MCO Denial](https://apprisemd.com/case-study-drg-key-to-overturning-denial/) - An AppriseMD physician advisor found new DRG unrelated to the primary diagnosis was the key to overturning a partial denial from a MMC organization.
- [Case Study: Short Stay Common Diabetic Ketoacidosis Denial Overturned](https://apprisemd.com/case-study-short-stay-common-dka-denial-overturned/) - Can hospitals receive full inpatient admission reimbursement for a patient experiencing diabetic ketoacidosis who only spends one night in the hospital? Yes.
- [Case Study: Profound Obesity Risk Factor Overturns Denied Inpatient Stay](https://apprisemd.com/case-study-profound-obesity-risk-factor-overturns-denial/) - Medical necessity determinations are not always clear-cut as is shown in this case study involving a patient with profound obesity risk factor.
- [Case Study: Short Stay Involving a Patient with Lennox-Gastaut Syndrome Highlights the Need for P2P](https://apprisemd.com/case-study-lennox-gastaut-short-stay/) - Short stay case study from AppriseMD involving a patient with Lennox-Gastaut syndrome highlights the need for a peer-to-peer, resulting in denial overturned.
- [Case Study: Pediatric Short Stay Denial Reversed](https://apprisemd.com/case-study-pediatric-short-stay-denial-reversed/) - AppriseMD’s physician advisors successfully overturned a short stay 14-hour inpatient admission denial for a pediatric patient.
- [Case Study: Complex Medical History, ICD & Transfer Impacts Inpatient Denial](https://apprisemd.com/case-study-complex-medical-history-inpatient-denial-reversed/) - An inpatient level of care denied by a Medicare Advantage payer was overturned in case involving a stable patient with a complex medical history and a transfer.
- [Case Study: Challenging MA Denial Overturned Despite One-Midnight Stay](https://apprisemd.com/case-study-challenging-ma-denial-overturned-despite-one-midnight-stay/) - A challenging MA denial was overturned after an AppriseMD physician advisor facilitated a peer-to-peer review with the payer medical director.
- [Case Study: Infant Failure to Thrive Inpatient Denial Overturned](https://apprisemd.com/case-study-infant-failure-to-thrive-denial-overturned/) - Hospitals rely on AppriseMD physician advisors to overturn denials such as this case study involving an infant admission for failure to thrive denial.
- [Case Study: MA Denial Overturned](https://apprisemd.com/case-study-ma-denial-overturned/) - AppriseMD argued the presence of a rise in creatinine constituted hypertensive end-organ damage, the key factor for a MA denial being overturned.
- [Case Study: Inpatient Level of Care Payment Review Reversed After Peer-to-Peer](https://apprisemd.com/case-study-level-of-care-payment-review/) - Many hospitals and health systems have been forced to navigate a new payer tactic that reduces payment instead of a formal denial of inpatient level of care.
- [Case Study: Underpayment Determination Reversed Following Severity Discussion](https://apprisemd.com/case-study-severity-discussion/) - For hospitals, high-level severity denials are a major challenge resulting in increased administrative, clinical and financial burdens.
- [Phasing Out of the Inpatient Only List Begins](https://apprisemd.com/phasing-out-of-the-inpatient-only-list-begins/) - CMS began dismantling the Inpatient Only list (IPO) on January 1, 2026. This phasing out process will happen over the next three years.
- [Case Study: Formal Appeal Overturns Upheld Peer-to-Peer](https://apprisemd.com/case-study-formal-appeal-overturns-upheld-p2p/) - When P2P payer reviews are upheld, hospitals are left with two choices: forgoing reimbursement dollars to get paid promptly or initiate a formal appeal to overturn the denial.
- [Understanding Aetna’s New Level of Severity Inpatient Payment Policy](https://apprisemd.com/understanding-aetnas-new-level-of-severity-inpatient-payment-policy/) - Hospitals and health systems are facing a significant shift in how Aetna reimburses certain inpatient stays with its Level of Severity Inpatient Payment Policy.
- [Case Study: Secondary Review Recommendation Holds in Cellulitis Hospitalization](https://apprisemd.com/case-study-secondary-review-recommendation-holds/) - An AppriseMD physician advisor successfully defended a secondary review recommendation for an inpatient LOC admission, resulting in the denial being overturned.
- [Are Rising Healthcare Costs And Increasing Denial Rates Impacting Your Hospital’s Revenue?](https://apprisemd.com/rising-healthcare-costs-denial-rates-impact-hospital-revenue/) - Exploring effective denial management strategies makes a significant difference for a hospital’s revenue. Specialized physician advisors can help.
- [Case Study: Readmission Linking Denial Overturned After P2P](https://apprisemd.com/case-study-readmission-linking-denial-overturned/) - Crucial factors can get overlooked and contribute to a denial showing the need for physician advisors to conduct P2P to clarify medical records.
- [Physician Advisors: Specialists For Your Utilization Management Team](https://apprisemd.com/physician-advisors-specialists-um-team/) - Physicians specialize in medicine for various reasons, though primarily to improve patient outcomes by providing more focused care and reducing medical errors. This also allows physicians to see more patients in a period, making them more efficient at delivering quality care. The concept of specialization in healthcare is not new, however it is not always
- [Payer Claim Denials & Medicare Advantage Organizations Market Share](https://apprisemd.com/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
- [Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings](https://apprisemd.com/medicare-advantage-noncompliance-two-midnight-rule-findings/) - AppriseMD hospital utilization review data for the first two months of 2024 shows that Medicare Advantage Organizations are denying claims that would have been approved under Traditional Medicare.
- [Hospitals Should File A Complaint When Medicare Advantage Plans Do Not Follow Two-Midnight Rule](https://apprisemd.com/hospitals-should-file-a-complaint-when-the-medicare-advantage-ma-plans-do-not-follow-the-two-midnight-rule/) - An American College of Physician Advisors’ (ACPA) recent report concurs with earlier data from AppriseMD that many Medicare Advantage Organizations (MAOs) are not complying with the guidelines that the Centers for Medicare and Medicaid Services established under rule 4201-F. In its News to Note from July 20241, the ACPA looked at whether all of the
- [Case Study: Sepsis Presents Challenging Denial](https://apprisemd.com/case-study-sepsis-presents-challenging-denial/) - AppriseMD does a peer to peer review and gets a challenging overturn for the denial of a 3-day inpatient stay due to sepsis.
- [Case Study: Post C-Section Wound Infection and Asthma Exacerbation Denial Overturned](https://apprisemd.com/case-study-post-c-section-wound-infection-and-asthma-exacerbation-denial-overturned/) - AppriseMD did a peer to peer review and successfully overturned the inpatient denial for a post C-section wound infection and asthma exacerbation hospital case.
- [Case Study: Post-Operative Pulmonary Embolism Inpatient Denial Overturned](https://apprisemd.com/case-study-pulmonary-embolism-inpatient-denial-overturned/) - Medical necessity often requires nuanced interpretations based on an individual’s medical history. This case study examines a post-perative pulmonary embolism.
- [Case Study: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial](https://apprisemd.com/case-study-two-midnight-rule-ma/) - This case shows a second-level review followed up by a peer-to-peer to overturn a denied stay based on a the Two-Midnight rule and the severity of the illness.
- [Case Study: TKA Inpatient Status Denied Despite Being on CMS Inpatient Only List](https://apprisemd.com/case-study-tka-inpatient-status-denied-despite-being-on-cms-inpatient-only-list/) - Insurance companies are more likely to approve inpatient status for surgeries included on the CMS Inpatient Only List (IPO). Reviewing such cases is important.
- [Case Study: Poorly Controlled Diabetes Inpatient Denial Overturned](https://apprisemd.com/case-study-poorly-controlled-diabetes-denial-overturned/) - Read more about how AppriseMD’s processes supported inpatient status for a patient with uncontrolled diabetes and hyperglycemia. Result: denial overturned.
- [Case Study: Physician Advisor Secondary Review Insight on MA Case](https://apprisemd.com/case-study-physician-advisor-secondary-review/) - This AppriseMD case study highlights how experienced UM physician advisors can assessing medical necessity during secondary review and peer-to-peers.
- [Case Study: Peer-to-Peer Review of Overlooked Medical Details Can Overturn Denials](https://apprisemd.com/case-study-medical-details-peer-2-peer-overturn-denial/) - This case shows a second-level review followed up by a peer-to-peer review that overturns a denied stay based on a the Two-Midnight rule and medical necessity.
- [Case Study: IPO List Proves Critical in Overturning Denied Inpatient Stay](https://apprisemd.com/case-study-ipo-list-denial-overturned/) - AppriseMD physician advisors overturned a denied inpatient stay for a myomectomy by discussing this procedure’s placement on the IPO list due to high risk
- [Case Study: Denial Reversed in Short Stay Alcohol-Induced Pancreatitis Admission](https://apprisemd.com/case-study-denial-reversed-short-stay-alcohol-induced-pancreatitis/) - AppriseMD saw a denial reversed for a patient who met inpatient criteria for acute pancreatitis on admission, despite leaving against medical after short stay.
- [Case Study: Chest Pain, Non-cardiac Can be Difficult to Get Admission Status Correct](https://apprisemd.com/case-study-chest-pain-non-cardiac-can-be-difficult-to-get-admission-status-correct/) - Chest pain is one of the most common ER diagnoses. Getting the admission status correct and paid by the insurance company can be tricky but achievable.
- [Case Study: Alcohol Withdrawal and AMA Departure Can Still Qualify as Inpatient Stay](https://apprisemd.com/alcohol-withdrawal-and-ama-departure/) - Does leaving the hospital against medical advice (AMA) equal an outpatient short stay? Not necessarily. AppriseMD reviewed one such inpatient denial case.
- [Case Study: Total Knee Replacement Inpatient Denial Overturned](https://apprisemd.com/case-study-total-knee-replacement-inpatient-denial-overturned/) - Inpatient stays for procedures commonly done on an outpatient basis can lead to denials, this case study looks at an overturned total knee replacement denial.
- [Case Study: Asthma and High BMI](https://apprisemd.com/case-study-asthma-high-bmi/) - An AppriseMD case review physician successfully overturned a denied inpatient stay for asthma after completing a Peer-to-Peer with an insurance company medical director.
- [Case Study: Type 2 Diabetes and Chronic Kidney Disease](https://apprisemd.com/case-study-type2-diabetes-chronic-kidney-disease/) - Even with concerns about waiting on a transfer for a patient with Type 2 diabetes and chronic kidney disease, the payer reversed this denial for inpatient LOC.
- [Case Study: AMA Inpatient Denial Overturned](https://apprisemd.com/case-study-ama-inpatient-denial-overturned/) - AppriseMD’s new case study shows the likelihood of ongoing treatment needed for sepsis due to a urinary tract infection and a mild heart attack was reason enough to approve an inpatient level of care despite a one-night stay.
- [Eliminating the CMS IPO List will Continue to Complicate Hospital Stays](https://apprisemd.com/eliminating-the-cms-inpatient-only-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
- [How Does the Two-Midnight Rule Apply When a Traditional Medicare Patient Has No Safe Discharge Plan?](https://apprisemd.com/does-the-two-midnight-rule-apply-to-traditional-medicare-patient-with-no-safe-discharge-plan/) - For a traditional Medicare patient admitted for observation with no safe discharge plan, should such a patient’s status be changed from observation to inpatient when crossing the second midnight? The short answer is no.
- [Case Study: Chest Pain, Unstable Angina P2P Reveals Intricate Case](https://apprisemd.com/case-study-chest-pain-unstable-angina-p2p-reveals-intricate-case/) - After a patient with chest pain and unstable angina was denied for inpatient stay by insurance companies, AppriseMD did a peer to peer review which resulted in an overturn of the denial.
- [Case Study: Multiple Sclerosis Inpatient Stay Denial Upheld](https://apprisemd.com/case-study-multiple-sclerosis-inpatient-stay-denial-upheld/) - AppriseMD provided level of care determination and peer to peer review for thus Multiple Sclerosis hospital case where the patient was denied inpatient stay.
- [Case Study: Complications Following Mastectomy](https://apprisemd.com/case-study-complications-following-mastectomy/) - AppriseMD shares a case study where a hospital stay from a mastectomy case was denied, and then overturned after a peer to peer review by physician advisors.
- [Case Study: Medical Necessity and Reasonable Expectations](https://apprisemd.com/case-study-medical-necessity-reasonable-expectations/) - AppriseMD’s latest case study centers on a patient that was hospitalized for chest pain, and the claim was denied based on unproven medical necessity and a lack of reasonable expectation of hospitalization that crossed two midnights.
- [Case Study: COPD Needing Inpatient Level of Care](https://apprisemd.com/case-study-copd-needing-inpatient-level-of-care/) - AppriseMD does a peer to peer review with the insurance medical director for denial inpatient stay for a patient with a lengthy past medical history & COPD.
- [Case Study: Diabetes Patient Short Stay](https://apprisemd.com/case-study-diabetes-patient-short-stay/) - After an inpatient admission was denied for a diabetes patient, AppriseMD did a P2P review and overturned the inpatient denial when the insurance company doctor reviewed the case.
- [Case Study: Bilateral Pneumonia](https://apprisemd.com/case-study-bilateral-pneumonia/) - This case study from AppriseMD talks about a patient with bilateral pneumonia who had denied inpatient stay, and the P2P that was completed between our physician and the insurance company medical director.
- [The Financial Impact of Weekend Utilization Review](https://apprisemd.com/the-financial-impact-of-weekend-utilization-review/) - Missing adequate weekend assessments exposes up to 29% of hospital days to potential payment issues. Physicians consider many factors during the complex clinical judgement used in determining a hospital admission. Many hospitals operate with reduced staffing on the weekends, and this can have a significant impact on reimbursement when factoring that weekends encompass approximately 105
- [Utilization Review: In-House or Outsource?](https://apprisemd.com/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
- [Good Documentation can Reduce Hospital Admission Denials](https://apprisemd.com/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
- [CMS to Keep the Inpatient Only List](https://apprisemd.com/cms-to-keep-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.
- [Case Study: Alcohol Withdrawal Inpatient Denial Overturned Based on Care Required](https://apprisemd.com/case-study-alcohol-withdrawal-inpatient-stay-denial-overturned-based-on-care-required/) - A denied inpatient hospital stay is overturned after peer-to-peer review for an alcohol withdrawal and a positive COVID infection case by help of the utilization management experts at AppriseMD.
- [Case Study: Hospital Stay Due to Injury and Complex Medical History](https://apprisemd.com/case-study-hospital-stay-due-to-injury-and-complex-medical-history/) - The hospital utilization review managers at AppriseMD provide insurance companies sufficient documentation showing the cause for admission in order to avoid an inpatient denial for an ER stay.
- [Which Guidelines Should Hospitals Follow for an Observation Stay?](https://apprisemd.com/which-guidelines-should-hospitals-follow-for-an-observation-stay/) - Health Insurers have their own set of observation guidelines created in-house which should be reviewed with external guidelines when deciding level-of-care for a short observation stay.
- [Without Proper Documentation, Inpatient Denials are Often Upheld](https://apprisemd.com/without-proper-documentation-inpatient-denials-are-often-upheld/) - AppriseMD shares why and what kind of documentation is needed for successful peer to peer discussions for overturning denied hospital inpatient stays.
- [Case Study: One-day Inpatient Denial Overturned](https://apprisemd.com/case-study-one-day-inpatient-denial-overturned/) - A case study from AppriseMD where physician advisors did a peer to peer review and successfully overturned a denied hospital inpatient stay
- [Case Study: Hyperemesis Gravidarum 4-day Inpatient Stay](https://apprisemd.com/case-study-hyperemesis-gravidarum-denied-stay/) - After overturning a 4-day inpatient denial for a pregnant patient with hyperemesis gravidarum, the insurance company medical director said it was very difficult to overturn these cases.
- [New UHC Hospital Services Observation and Inpatient Policy Takes Effect Dec. 1, 2022](https://apprisemd.com/new-uhc-hospital-services-observation-and-inpatient-policy-takes-effect-dec-1-2022/) - AppriseMD shares information about the new UHC Hospital Services Observation and Inpatient Policy that takes effect Dec 1, 2022.
- [Payer Prior Authorization Continues to Create Roadblocks](https://apprisemd.com/payer-prior-authorization-continues-to-create-roadblocks/) - AppriseMD shares important industry news: doctors surveyed by the American Medical Association said the payer prior authorization (PA) process creates delays in care, abandoned treatments, and impacts outcomes.
- [CMS Proposed Rule Changes for MA Patients](https://apprisemd.com/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
- [Case Study: Medical Necessity Behind Short Stay is Key](https://apprisemd.com/medical-necessity-key-in-short-stay/) - CLINICAL SUMMARY: Medical Necessity Behind Short Stay is Key This case involves a one-day inpatient denial for a 30-year-old patient treated for acute pancreatitis. With abdominal pain and nausea, the patient went to the Emergency Department where he was found to have upper abdominal pain and tenderness, a lipase of 1,447 U/L (reference range 16-77 This case highlights the benefits that physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.
- [Case Study: Denied One-Day Stay Overturned](https://apprisemd.com/denied-one-day-stay-overturned/) - CLINICAL SUMMARY: Denied One-Day Stay Overturned This case involved a patient who presented to the ER with nausea, vomiting, dry mouth, dehydration, blood sugars greater than 400 and upper abdominal pain. He was diagnosed to have DKA (diabetic ketoacidosis). This 54-year-old patient was not able to take insulin for several days leading up to this This case highlights the benefits that physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.
- [Case Study: Post-Surgery Inpatient Admission Denial Overturned](https://apprisemd.com/case-study-post-surgery-inpatient-admission-denial-overturned/) - CLINICAL SUMMARY: Post-Surgery Inpatient Admission Deemed Medically Unnecessary Overturned A 52-year-old patient underwent a planned ventral incisional hernia operation, performed laparoscopically using an intraperitoneal onlay mesh placement. The patient was classified as ASA Class III, defined by the American Society for Anesthesiologists (ASA) for patients with “severe systemic disease that is not incapacitating” with a This case highlights the benefits that physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.
- [Case Study: Readmission Linking for Hospital Stays Reversed](https://apprisemd.com/case-study-readmission-linking-reversed/) - CLINICAL SUMMARY: Recently, physicians admitted a 73-year-old patient with an extensive medical history twice within an 8-day period. The patient required inpatient level of care (LOC) for both hospitalizations. The patient was hospitalized with pneumonia during the first inpatient stay, and the second inpatient hospitalization addressed exacerbated congestive heart failure (CHF). The patient arrived for This Medicare Advantage case shows a second-level review followed up by a peer-to-peer with the payer to overturn a denied stay based on a the Two-Midnight rule and the severity of the illness.
- [The Impetus Behind the 2024 CMS Final Rule](https://apprisemd.com/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.
- [Case Study: Overnight Short-Stay Denial Reversed](https://apprisemd.com/case-study-overnight-short-stay-denial-reversed/) - CLINICAL SUMMARY: A 50-year-old patient was hospitalized overnight after arriving in the emergency room with constant left flank pain. The patient was seen in the emergency room (ER) the previous week with similar symptoms, which doctors diagnosed as a 5 mm, left proximal ureteral stone with mild hydroureteronephrosis. The patient was treated and sent home This Medicare Advantage case shows a second-level review followed up by a peer-to-peer with the payer to overturn a denied stay based on a the Two-Midnight rule and the severity of the illness.
- [Payers, Artificial Intelligence and Revenue Cycle](https://apprisemd.com/payers-artificial-intelligence-and-revenue-cycle/) - As the use of artificial intelligence (AI) in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials should be scrutinized by providers to ensure the denial is appropriate. A recent Healthleaders report asked a key question all revenue cycle managers must consider: What is the balance
- [Case Study: Denied Inpatient Stay Due to Suicidal Ideation and Drug Overdose Overturned](https://apprisemd.com/case-study-denied-inpatient-stay-due-to-suicidal-ideation-and-drug-overdose-overturned/) - AppriseMD did a peer to peer review and successfully overturned the inpatient denial for a suicide ideation and drug overdose hospital case.
- [HHS OIG Report Shows Code Adjustments May Indicate Denials](https://apprisemd.com/hhs-oig-report-shows-how-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
- [Case Study: Awaiting Discharge to Skilled Nursing Facility](https://apprisemd.com/case-study-awaiting-discharge/) - Extended hospital stays where a patient is medically ready to discharge but awaiting admission into a Skilled Nursing Facility or Acute Inpatient Rehabilitation continues to be an issue and can lead to revenue loss. AppriseMD recently overturned an inpatient denial for an 11-day hospital stay that was extended awaiting discharge. CLINICAL SUMMARY: Awaiting discharge to
- [Case Study: Inpatient Denial Overturned for Elderly Patient with Significant Risk Factors](https://apprisemd.com/case-study-elderly-patient-inpatient-denial-overturned/) - Inpatient denials for elderly patients on Medicare Advantage plans can appear hard to refute due to the criteria laid out by CMS and health plans. However, significant risk factors such as prior recent strokes and urinary tract infections, especially in older patients, are reason enough to attempt to reverse the initial denial. See one case
- [Documentation – A Key for Reduced Denials](https://apprisemd.com/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
- [Providing the Best Outcome for Patients Through UR](https://apprisemd.com/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…
- [A Quiet Shift that Could Shake Up Hospital Utilization Review](https://apprisemd.com/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
- [CMS Reverses Course on Inpatient Only List](https://apprisemd.com/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
- [With COVID-19, Hospitals Need Every Financial Advantage](https://apprisemd.com/with-covid-19-continuing-and-staff-shortages-hospitals-need-every-financial-advantage-they-can-find/) - 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
- [Appealing Denials through the Medicare Claims Appeals Process Works](https://apprisemd.com/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
- [Case Study: Acute Diverticulitis Stay Denied](https://apprisemd.com/case-study-acute-diverticulitis-stay-denied/) - AppriseMD performs a Peer-to-Peer review for a diverticulitis case that was denied inpatient hospital stay. Learn more about how utilization review can help overturn cases like this.
- [AHA’s Advocacy of Rural Hospital Issues is Needed](https://apprisemd.com/ahas-advocacy-of-rural-hospitals-is-needed/) - AppriseMD provides utilization management physician advisor services for rural hospitals, and strongly supports the AHA's Rural Advocacy Agenda initiatives to keep rural hospitals open and solvent for the communities they serve.
- [Justice Department Files Lawsuit Against UnitedHealth to Stop Change Healthcare Acquisition](https://apprisemd.com/antitrust-lawsuit-against-unitedhealth/) - AppriseMD shares important information about the U.S. Department of Justice's antitrust lawsuit to stop UnitedHealth Group from acquiring Change Healthcare is one to watch.
- [Medicare Appeals Process Needs to be Amended](https://apprisemd.com/medicare-appeals-process-needs-to-be-amended/) - Expert UR Management and physician advisor company AppriseMD share why the medicare appeals process needs to be amended. Contact us to learn more about secondary reviews, short stay reviews & payer peer-to-peer reviews customized to your hospital size and need.

## Pages

- [Home](https://apprisemd.com/) - AppriseMD helps hospitals optimize reimbursement, reduce denials and shorten revenue cycle with experienced denial management physician advisors.
- [Stay Apprised](https://apprisemd.com/stay-apprised/) - Stay apprised of our healthcare utilization review, physician advisory and denial management insights by joining our mailing list.
- [Case Studies](https://apprisemd.com/case-studies/) - Case studies show how AppriseMD helps hospitals overturn denials through effective peer to peer reviews and utilization management services.
- [Turning UM Data into Revenue](https://apprisemd.com/turning-um-data-into-revenue-full-text/) - Turning UM Data in Revenue Opportunities Exploring the balance between care and cost 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
- [Leadership Team](https://apprisemd.com/leadership-team/) - The physician-owned and operated AppriseMD provides MD-level physician advisor and denial management services with an expertly led leadership team.
- [Inpatient Only List Compliance](https://apprisemd.com/inpatient-only-list-compliance/) - The often-murky waters of inpatient admission denials grow clearer under the Inpatient Only list, which directs the care levels for procedures covered by CMS.
- [Healthcare Insights](https://apprisemd.com/healthcare-insights/) - AppriseMD offers healthcare insights on utilization review, denial management and revenue integrity to help hospitals achieve excellence in UM.
- [Featured Case Preparation Physician](https://apprisemd.com/featured-case-preparation-physician/) - AppriseMD's Featured Case Preparation Physicians review medical records to summarize complex care and assist physician advisors with determinations.
- [Industry News](https://apprisemd.com/healthcare-insights/apprisemd-blog/) - Industry News from AppriseMD AppriseMD Insights Phasing Out of the Inpatient Only List Begins The Centers for Medicare & Medicaid Services (CMS) began dismantling the Inpatient Only (IPO) list on January 1, 2026, by removing 285 musculoskeletal, orthopedic and spine procedures. This phasing out process will happen over the next three years1, allowing more procedures
- [RAC Monitor Medicare Advantage & Two-Midnight Rule Data Review Follow-Up](https://apprisemd.com/rac-paper/) - This paper examines P2P data for compliance and a key utilization review change taking effect on New Year’s Day in 2026 impacting the Medicare Advantage market.
- [Medicare Advantage & Two-Midnight Rule Data Review Follow-Up](https://apprisemd.com/medicare-advantage-two-midnight-rule-data-followup/) - Our MA & the Two-Midnight Rule Data Review paper examines a year of AppriseMD P2P data and reviews the Medicare population landscape and key UR review changes.
- [News](https://apprisemd.com/news/) - News impacting hospital denial management, physician advisors and utilization management teams.
- [RAC Monitor Mondays](https://apprisemd.com/rac/) - AppriseMD provides denial management and physician advisory solutions that optimize revenue cycle and reimbursement and is a sponsor of RAC Monitor Mondays.
- [About Us](https://apprisemd.com/about/) - AppriseMD's team of board-certified physicians with payer and clinical experience provide physician advisory, denial and utilization management services .
- [After-Hours Coverage](https://apprisemd.com/after-hours-coverage/) - Hospitalizations don’t stop after-hours, neither should utilization review. Optimize revenue no matter what time it is using after-hours coverage.
- [Medicare Advantage & the Two-Midnight Rule: 2024 Findings](https://apprisemd.com/medicare-advantage-two-midnight-rule-2024-findings/) - Early 2024 data suggests MAOs are not complying with the CMS 2024 final rule 2401-F which reenforces the two-midnight rule.
- [Industry News OV](https://apprisemd.com/healthcare-insights/apprisemd-blog-oldversion/) - AppriseMD's industry news blog provides information regarding utilization review, denial management, revenue cycle, CMS standards and much more about UM.
- [Contact Us](https://apprisemd.com/contact-us/) - Contact AppriseMD to learn more about our physician advisory and denial management services to optimize reimbursement at your hospital.
- [Optimize Reimbursement - Landing Page](https://apprisemd.com/optimize-reimbursement/) - Optimize reimbursement! It all begins with superior denial management and physician advisory services focused solely focus is medical case review for hospitals.
- [Addressing Healthcare Reimbursement](https://apprisemd.com/addressing-healthcare-reimbursement/) - AppriseMD looks at how hospitals can tackle barriers to reimbursement, increase focus on medical necessity & find hidden factors contributing to revenue loss.
- [Appeal Reviews](https://apprisemd.com/appeal-reviews/) - Hospitals request appeal reviews to determine whether or not cases for a denial past the payer peer-to-peer time period has merit.
- [Utilization Review Education](https://apprisemd.com/utilization-review-education/) - AppriseMD provides utilization review education to treating physician and UM teams through internal peer-to-peer reviews.
- [Discharge Reviews](https://apprisemd.com/discharge-reviews/) - AppriseMD understands how discharge issues can impact your hospital finances. Our physician advisors provide discharge reviews, offering insight and guidance.
- [Medicare Short Stay Chart Audit Reviews](https://apprisemd.com/medicare-short-stay-chart-audit/) - Medicare short stay chart audit reviews cover high risk chart audit reconsiderations to ensure compliance and promote quality improvement for hospitals.
- [Payer Peer-to-Peer Reconsideration Reviews](https://apprisemd.com/payer-peer-to-peer-reconsideration-reviews/) - A payer peer-to-peer reconsideration review resolves medical necessity before a claim is submitted reducing denial rates and improving reimbursement.
- [Second-Level Utilization Reviews](https://apprisemd.com/second-level-case-reviews/) - AppriseMD's second level case reviews are complex case reviews that require additional insight from our experienced denial management physician advisors.
- [Utilization Case Review](https://apprisemd.com/utilization-case-review/) - AppriseMD overturns denials to increase revenue with accurate medical necessity determinations achieving excellence in utilization review.
- [Overflow Coverage](https://apprisemd.com/overflow-coverage/) - Augment your team with overflow coverage on weekends, nights & holidays, or outsource all physician advisory services. No automation or software installation.
- [Physician Advisory](https://apprisemd.com/physician-advisory/) - AppriseMD partners with utilization management teams to provide physician advisory service to reduce denials, increase compliance and optimize reimbursement.
- [Denial Management](https://apprisemd.com/denial-management/) - AppriseMD’s denial management physician advisors overturn denials before the claim is submitted so hospitals can reclaim revenue earlier.
- [Implementing the 2024 CMS Final Rule: Five Points of Focus for Utilization Review Teams](https://apprisemd.com/cms-2024-final-rule-five-points-of-focus-for-utilization-review/) - We’ve outlined five important points utilization review teams and physician advisors should focus on moving into 2024 as the 2024 CMS Final Rule is implemented.
- [White Papers](https://apprisemd.com/white-papers/) - AppriseMD white papers on denial management and utilization case review issues and research.
- [Thank You](https://apprisemd.com/thank-you/) - Thank you for contacting us, we will get back to you shortly.
- [Should hospitals pursue appeals of Medicare denials?](https://apprisemd.com/should-hospitals-pursue-appeals-of-medicare-denials/) - The appeals process for denied Medicare claims has sped up. That means hospitals now have one less reason not to pursue appeals of Medicare denials.
- [Rightsizing Length of Stay](https://apprisemd.com/right-sizing-length-of-stay/) - Hospitals working to improve efficiency by rightsizing length of stay and reducing avoidable hospital inpatient days must implement a comprehensive process.
- [Privacy Policy](https://apprisemd.com/privacy-policy/) - Read the AppriseMD Privacy Policy here.
- [Outpatient Arthoplasty Surgery Position Paper](https://apprisemd.com/outpatient-arthroplasty-surgery-a-position-paper-from-apprisemd/) - Hip and knee replacements performed as an outpatient procedure should not be a viewed as an appropriate or mandatory setting for arthroplasty procedures.
- [Careers](https://apprisemd.com/careers/) - AppriseMD employs physician advisors and case preparation physicians for utilization management, denial management and physician advisor services.
- [Beyond the Pandemic Part 2](https://apprisemd.com/beyond-the-pandemic-part-2/) - This paper, Beyond the Pandemic, Part 2, is a compendium of research that explores how hospitals can adapt to the new reality following the COVID-10 pandemic.
- [Beyond the Pandemic Part 1](https://apprisemd.com/beyond-the-pandemic-part-1/) - This paper explores the changes caused by the pandemic, root causes and the impact on hospitals. Part 1 addresses sicker patients and longer stays.
- [Apply](https://apprisemd.com/careers/apply/) - Careers: Application Submission AppriseMD hires highly skilled medical professionals not currently in practice, retired physicians, and doctors currently in practice to prepare inpatient cases for utilization review.
- [UM Data Analytics](https://apprisemd.com/utilization-management-data-analytics/) - A collection of Healthcare Information Research, including Case Studies, Position Papers and White Papers from AppriseMD
- [FAQs](https://apprisemd.com/utilization-review-faqs/) - What is utilization review and how does it work? Learn about utilization management, denial management and revenue integrity physician advisor services at AppriseMD.
- [Our Mission & Vision](https://apprisemd.com/mission-and-vision/) - AppriseMD's mission is to change the way hospitals handle utilization review and physician advisory to reflect a focus on care and costs with equal measure.
- [The Impact of Weekend Utilization Review on Reimbursement](https://apprisemd.com/impact-of-weekend-utilization-review/) - Lower weekend hospital staff levels can lead to delays in patient determinations/level of care, which impacts care, patient satisfaction & reimbursement.
- [The Use of AI in Claims Denials](https://apprisemd.com/use-of-ai-in-claims-denials/) - 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. 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.
- [Turning UM Data into Revenue Opportunities](https://apprisemd.com/turning-um-data-into-revenue-opportunities/) - Turning UM Data into Revenue Opportunities Exploring the balance between care and cost 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 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.
- [Dealing with Denials](https://apprisemd.com/dealing-with-denials/) - Ninety percent of inpatient denials are preventable. So why do they keep happening?

## Categories

- [Utilization Review](https://apprisemd.com/category/utilization-review/)
- [Peer-to-Peer](https://apprisemd.com/category/peer-to-peer/)
- [Position Paper](https://apprisemd.com/category/position-paper/)
- [Case Study](https://apprisemd.com/category/case-study/)
- [COVID-19](https://apprisemd.com/category/covid-19/)
- [Medicare](https://apprisemd.com/category/medicare/)
- [Inpatient Only List](https://apprisemd.com/category/inpatient-only-list/)
- [Length of Stay](https://apprisemd.com/category/length-of-stay/)
- [Rural Health](https://apprisemd.com/category/rural-health/)
- [Blog](https://apprisemd.com/category/blog/)
- [Observation and Inpatient Policy](https://apprisemd.com/category/observation-and-inpatient-policy/)
- [Denial Management](https://apprisemd.com/category/denial-management/)
- [Appeal Management](https://apprisemd.com/category/appeal-management/)
- [CMS](https://apprisemd.com/category/cms/)
- [Payers](https://apprisemd.com/category/payers/)
- [Discharge](https://apprisemd.com/category/discharge/)
- [Medical Necessity](https://apprisemd.com/category/medical-necessity/)
- [Readmission](https://apprisemd.com/category/readmission/)
- [Two-Midnight Rule](https://apprisemd.com/category/two-midnight-rule/)
- [Medicare Advantage](https://apprisemd.com/category/medicare-advantage/)
- [Second-Level Review](https://apprisemd.com/category/second-level-review/)
- [Medicaid](https://apprisemd.com/category/medicaid/)
- [Formal Appeal](https://apprisemd.com/category/formal-appeal/)
- [Level of Care](https://apprisemd.com/category/level-of-care/)

## Tags

- [Utilization Review](https://apprisemd.com/tag/utilization-review/)
- [Case Review](https://apprisemd.com/tag/case-review/)
- [Utilization Management](https://apprisemd.com/tag/utilization-management/)
- [Hippocratic Oath](https://apprisemd.com/tag/hippocratic-oath/)
- [Inpatient Denials](https://apprisemd.com/tag/inpatient-denials/)
- [Short Hospital Stay](https://apprisemd.com/tag/short-hospital-stay/)
- [COVID-19](https://apprisemd.com/tag/covid-19/)
- [Hospital Revenue](https://apprisemd.com/tag/hospital-revenue/)
- [Hospital Admissions](https://apprisemd.com/tag/hospital-admissions/)
- [Inpatient Stay](https://apprisemd.com/tag/inpatient-stay/)
- [InterQual](https://apprisemd.com/tag/interqual/)
- [Reduce Denials](https://apprisemd.com/tag/reduce-denials/)
- [Chart Documentation](https://apprisemd.com/tag/chart-documentation/)
- [CMS Inpatient Only List](https://apprisemd.com/tag/cms-inpatient-only-list/)
- [Administrative Law Judge](https://apprisemd.com/tag/administrative-law-judge/)
- [Denials](https://apprisemd.com/tag/denials/)
- [Appeals](https://apprisemd.com/tag/appeals/)
- [Chest Pain](https://apprisemd.com/tag/chest-pain/)
- [Two Midnight Rule](https://apprisemd.com/tag/two-midnight-rule/)
- [Inpatient](https://apprisemd.com/tag/inpatient/)
- [Bilateral Pneumonia](https://apprisemd.com/tag/bilateral-pneumonia/)
- [Diabetes](https://apprisemd.com/tag/diabetes/)
- [COPD](https://apprisemd.com/tag/copd/)
- [Sepsis](https://apprisemd.com/tag/sepsis/)
- [C-section](https://apprisemd.com/tag/c-section/)
- [Wound Infection](https://apprisemd.com/tag/wound-infection/)
- [Asthma](https://apprisemd.com/tag/asthma/)
- [Diverticulitis](https://apprisemd.com/tag/diverticulitis/)
- [Denial Upheld](https://apprisemd.com/tag/denial-upheld/)
- [Multiple Sclerosis](https://apprisemd.com/tag/multiple-sclerosis/)
- [American Hospital Association](https://apprisemd.com/tag/american-hospital-association/)
- [Guidelines](https://apprisemd.com/tag/guidelines/)
- [Justice Department](https://apprisemd.com/tag/justice-department/)
- [Alcohol Withdrawal](https://apprisemd.com/tag/alcohol-withdrawal/)
- [AMA](https://apprisemd.com/tag/ama/)
- [Injury](https://apprisemd.com/tag/injury/)
- [Complex Medical History](https://apprisemd.com/tag/complex-medical-history/)
- [Observation Guidelines](https://apprisemd.com/tag/observation-guidelines/)
- [Short Stay](https://apprisemd.com/tag/short-stay/)
- [ALJ](https://apprisemd.com/tag/alj/)
- [One-Day Stay](https://apprisemd.com/tag/one-day-stay/)
- [NSTEMI](https://apprisemd.com/tag/nstemi/)
- [Breast Cancer](https://apprisemd.com/tag/breast-cancer/)
- [Hyperemesis Gravidarum](https://apprisemd.com/tag/hyperemesis-gravidarum/)
- [BMI](https://apprisemd.com/tag/bmi/)
- [Observation and Inpatient Stay Policy](https://apprisemd.com/tag/observation-and-inpatient-stay-policy/)
- [Hospital Services](https://apprisemd.com/tag/hospital-services/)
- [Prior Authorization](https://apprisemd.com/tag/prior-authorization/)
- [Type 2 Diabetes](https://apprisemd.com/tag/type-2-diabetes/)
- [Chronic Kidney Disease](https://apprisemd.com/tag/chronic-kidney-disease/)
- [CMS Proposed Rule](https://apprisemd.com/tag/cms-proposed-rule/)
- [Total Knee Replacement](https://apprisemd.com/tag/total-knee-replacement/)
- [Inpatient Stay Denial](https://apprisemd.com/tag/inpatient-stay-denial/)
- [Inpatient Denial](https://apprisemd.com/tag/inpatient-denial/)
- [Skilled Nursing Facility](https://apprisemd.com/tag/skilled-nursing-facility/)
- [Elderly Patient](https://apprisemd.com/tag/elderly-patient/)
- [Medicare Advantage](https://apprisemd.com/tag/medicare-advantage/) - Medicare Advantage
- [Mastectomy](https://apprisemd.com/tag/mastectomy/) - mastectomy
- [Angina](https://apprisemd.com/tag/angina/) - angina
- [Overdose](https://apprisemd.com/tag/overdose/) - overdose
- [TKA](https://apprisemd.com/tag/tka/)
- [Medical Necessity](https://apprisemd.com/tag/medical-necessity/)
- [Pancreatitis](https://apprisemd.com/tag/pancreatitis/)
- [Diabetic Ketoacidosis](https://apprisemd.com/tag/diabetic-ketoacidosis/)
- [Post-Surgery Admission](https://apprisemd.com/tag/post-surgery-admission/)
- [cholecystitis](https://apprisemd.com/tag/cholecystitis/)
- [Readmission](https://apprisemd.com/tag/readmission/)
- [CMS](https://apprisemd.com/tag/cms/)
- [CMS Final Rule 2024](https://apprisemd.com/tag/cms-final-rule-2024/)
- [Artificial Intelligence](https://apprisemd.com/tag/artificial-intelligence/)
- [Non-compliance](https://apprisemd.com/tag/non-compliance/)
- [reimbursement](https://apprisemd.com/tag/reimbursement/)
- [weekend utilization review](https://apprisemd.com/tag/weekend-utilization-review/)
- [Revenue Cycle](https://apprisemd.com/tag/revenue-cycle/)
- [level of care](https://apprisemd.com/tag/level-of-care/)
- [American College of Physician Advisors](https://apprisemd.com/tag/american-college-of-physician-advisors/)
- [Second Level Review](https://apprisemd.com/tag/second-level-review/)
- [Secondary Review](https://apprisemd.com/tag/secondary-review/)
- [physician advisor](https://apprisemd.com/tag/physician-advisor/)
- [pediatric](https://apprisemd.com/tag/pediatric/)
- [pulmonary embolism](https://apprisemd.com/tag/pulmonary-embolism/)
- [DKA](https://apprisemd.com/tag/dka/)
- [ICD](https://apprisemd.com/tag/icd/)
- [end-organ damage](https://apprisemd.com/tag/end-organ-damage/)
- [Lennox-Gastaut syndrome](https://apprisemd.com/tag/lennox-gastaut-syndrome/)
- [Seizure](https://apprisemd.com/tag/seizure/)
- [Epilepsy](https://apprisemd.com/tag/epilepsy/)
- [Obesity](https://apprisemd.com/tag/obesity/)
- [RSV](https://apprisemd.com/tag/rsv/)
- [DRG](https://apprisemd.com/tag/drg/)
- [physician advisors](https://apprisemd.com/tag/physician-advisors/)
- [healthcare costs](https://apprisemd.com/tag/healthcare-costs/)
- [Cellulitis](https://apprisemd.com/tag/cellulitis/)
- [Level of Severity](https://apprisemd.com/tag/level-of-severity/)
- [Payment Policy](https://apprisemd.com/tag/payment-policy/)
- [Aetna](https://apprisemd.com/tag/aetna/)
- [failure to thrive](https://apprisemd.com/tag/failure-to-thrive/)
- [written appeal](https://apprisemd.com/tag/written-appeal/)
- [lumpectomy](https://apprisemd.com/tag/lumpectomy/)
- [Hypertension](https://apprisemd.com/tag/hypertension/)
- [Stroke](https://apprisemd.com/tag/stroke/)