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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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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.
Case Studies
An AppriseMD physician advisor spoke with the insurance company medical director regarding a denial. The patient’s medical history was discussed during the call, including the patient’s coronary artery bypass graft surgery in 2021, hypertension, Hodgkin’s lymphoma and obstructive sleep apnea. The patient did not have any significant postoperative complications and was discharged after two midnights. After a lengthy conversation, AppriseMD was able to overturn the denial due to the significant medical history which made this patient a higher risk for the procedure.
The Peer-to-Peer discussion resulted in the approval of an inpatient level of care, overturning the denial. However, the insurance company did raise quality concerns with this case. The patient required a higher level of care and multiple days were spent waiting on transfer to a higher level of care at the university hospital. The insurance company medical director felt it was important to seek alternate centers if no beds were available initially and saw the need for a quality review.