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“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…” 1 As a physician-owned company in which board-certified physicians carry out […]
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The hard truth is that denials are a major pain point for all hospitals. Hospitals and health systems know this. The difficulty lies in the execution. Healthcare organizations can no longer afford to take a hit on reimbursement, therefore medical necessity determinations and denial management must become a priority.
In this review, AppriseMD looks at how hospitals can tackle barriers to reimbursement, increase the focus on medical necessity and uncover hidden factors that contribute to revenue loss.
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.