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Second Level Utilization Review

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    Improve Patient Care

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    Increase Patient Satisfaction

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    Optimize Reimbursement

Utilization Review Physician Experts

Second Level Case Reviews are complex case reviews that require additional insight. Escalating these cases to AppriseMD ensures two physicians review the case during a clinical conference providing a timely turnaround to determine the most appropriate utilization. Our reviews include process improvements aimed at mitigating risk and reducing the probability of reimbursement losses. When volumes are high, a third physician reviews these cases, ensuring nothing is missed in the documentation and reviews.

Benefit from internal peer-to-peer discussions initiated with the treating physician for case clarification, redirection to a lower level of care, discharge consideration or potential education.

CASE STUDY:

CLINICAL SUMMARY: Awaiting Discharge to Skilled Nursing Facility

A 54-year-old patient was admitted to the hospital for right hip pain and the inability to walk. The patient had a left total hip arthroplasty and was planning to have bariatric surgery to assist with weight loss and future right hip replacement. A CT showed no hip fracture but possible avascular necrosis of the femoral head. Orthopedics was consulted and recommended outpatient follow-up with a plan for pain control and therapies. Placement in a skilled nursing facility was pending insurance authorization, which extended the hospital stay by two additional days.

The patient has a complex medical history of obesity, lymphedema, hypertension, obstructive sleep apnea for which a CPAP machine was being used, Rheumatoid arthritis, asthma/dyspnea on exertion, gastroesophageal reflux disease and mood disorder. The patient was given naproxen, cyclobenzaprine and oxycodone for pain control.

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

Discuss your hospital's denial prevention and appeal management needs with our team.

 

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