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Payers, Artificial Intelligence and Revenue Cycle

July 18, 2024

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 […]

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White Papers

Turning UM data into revenue opportunities white paper

Utilization management 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.

Read our latest white paper, "Turning UM data into revenue opportunities: Exploring the balance between care and cost."

Case Studies

Case study alcohol withdrawal and AMA departure can still qualify as inpatient stay

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.

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