Payer Peer-to-Peer
Reconsideration Review

Resolve Medical Necessity Before the Claim is Submitted
Enhance Revenue Cycle by Reclaiming Revenue Earlier
Increase Reimbursement
Improve Revenue Integrity

Overturning Denials Before Claim Submission

Our denial management physician advisors utilize our proprietary database to review payer determinations on previous cases before performing the Payer Peer-to-Peer Reconsideration Review. We advocate on our client’s behalf to resolve medical necessity before the claim is submitted, averaging an exceptional ROI for our partner hospitals. Hold payers accountable and gain actionable insights to improve utilization review.

CASE STUDY:

CLINICAL SUMMARY: Hyperemesis gravidarum 4-day inpatient stay

A 34-year-old patient who was 13 weeks pregnant was admitted to the hospital recently with hyperemesis gravidarum with electrolyte imbalances. The patient had experienced several days of nausea and emesis; she also had a low-grade fever of 100.5 degrees with a white blood cell count of 20k and bicarb of 17. An abdominal MRI showed no appendicitis; urinalysis noted epithelial cells, moderate bacteria, trace protein and ketones. Treating physicians began ceftriaxone for asymptomatic bacteriuria. The patient experienced sudden onset back and pelvis pain with unclear etiology. She was started on morphine. A retroperitoneal ultrasound showed mild right renal fullness. Physicians consulted urology concerned for obstructing nephrolithiasis in the setting of the pregnancy. Urology concluded the patient could have recently passed a stone, but no current stone required management.

The patient’s electrolytes stabilized during the four-day stay and outpatient IV fluids were arranged for given the ongoing hyperemesis gravidarum. There was no urine culture growth, therefore antibiotics were stopped at discharge. The patient had a close obstetrics follow-up post discharge.

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DENIED INPATIENT STAY

The insurance company denied the four-day hospital stay at the acute inpatient level of care without detailed reasoning in its denial letter. Therefore, a Peer-to-Peer discussion with the medical director was scheduled.

APPRISEMD PROCESS

An AppriseMD physician advisor conducted the P2P with the insurance medical director to discuss the patient and the denial reasoning for the hyperemesis gravidarum case. After a detailed discussion, the denial was overturned based on the amount of pain medication the patient required. The patient had severe flank pain and a stone evaluation. In addition, the patient underwent a retroperitoneal ultrasound. The urology consult felt this was not related to a kidney stone. Ultimately, the patient improved but it required significant pain medication and antiemetic medications which allowed for inpatient approval.