Complex Medical History

Physician advisor managing the formal written appeal process

Case Study: Managing the Formal Written Appeal Process

Appeal Management, Case Study, Formal Appeal, Medicare Advantage, Two-Midnight Rule / By

THE CHALLENGE In 2025, inpatient (IP) and outpatient healthcare claim denials increased by 12% and 14% respectively and the average amount per claim increased by 18%1, forcing hospitals to address payer denials head-on. Most health systems deploy a multi-prong approach to ensure appropriate reimbursement, including outsourcing at least a portion of their revenue cycle operations.

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Physician advisor reviews a lower level of severity determination after engaging in a severity discussion.

Case Study: High Severity Reimbursement Approved Following Severity Discussion

Case Study, Level of Care / By

THE CHALLENGE Last year, several payers implemented or announced some tactical changes in their provider reimbursement policies. The providers took a hit with these evaluation and management (E/M) downcoding programs, resulting in lower-tier payments to providers if the payers disagreed with the severity of the patients’ illnesses. Regulatory review has sidelined the rollout of some

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Doctors work on a patient in the Emergency Department

Case Study: New DRG Key to Overturning MCO Denial

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A 34-year-old patient arrived in the emergency department (ED) experiencing complications from alcohol withdrawal, which began while staying at a sober living home. He began experiencing lightheadedness, nausea, vomiting and epigastric pain in addition to developing a bilateral rash to his upper extremities and was transported to the ED. The patient reported drinking

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Doctor performs labs in emergency department.

Case Study: Readmission Linking Denial Overturned After P2P

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A 79-year-old male patient arrived in the emergency department (ED) complaining of weakness, extreme lethargy and the inability to eat for the past three days. The patient’s past medical history included prostate cancer s/p resection with metastases to the bladder and lumbar spine on antiandrogen, hypothyroidism, hypertension, hyperlipidemia, CAD s/p stent placement x2,

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emergency-hospital-sign

Case Study: Profound Obesity Risk Factor Overturns Denied Inpatient Stay

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A 29-year-old male patient with no significant past medical history arrived at the Emergency Department with ongoing abdominal pain, cramping and tenderness in the left upper quadrant and epigastric region. This patient presented with a weight of 523 pounds, a BMI of 87 and labs as follows: WBC 12.07, ANC 9.34, Hgb 13.4,

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patient with Lennox-Gastaut syndrome, a complex, rare and severe childhood-onset epilepsy

Case Study: Short Stay Involving a Patient with Lennox-Gastaut Syndrome Highlights the Need for P2P

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A six-year-old male patient with Lennox-Gastaut syndrome, a complex, rare and severe childhood-onset epilepsy, arrived in the emergency department (ED) after experiencing breakthrough cluster seizures at home and en route to the hospital after starting a new treatment medication the day prior. Once in the ED, the patient experienced three more seizures, one

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Patient blood pressure taken in ER

Case Study: MA Denial Overturned

Case Study, Medicare Advantage, Peer-to-Peer, Two-Midnight Rule / By

AppriseMD recently argued that the presence of a rise in creatinine constituted hypertensive end-organ damage, which was the key factor for a Medicare Advantage denial being overturned. CLINICAL SUMMARY: An elderly patient with a history of hypertension and thyroid disease sought treatment in the emergency department after a fall. The patient suffered a closed head

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EKG and stethoscope for case study complex medical history

Case Study: Complex Medical History, ICD & Transfer Impacts Inpatient Denial

Case Study, Denial Management, Peer-to-Peer / By

An inpatient level of care (LOC), initially denied by a Medicare Advantage payer, was approved after a peer-to-peer discussion involving a stable patient with a complex medical history and condition that required a transfer to a higher LOC. The short stay exemplifies the importance of having physicians with both payer and clinical experience facilitate the

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Medical chart documentation

Case Study: Hospital Stay Due to Injury and Complex Medical History

Case Study / By

According to the CDC’s National Center for Health Statistics*, there are 130 million visits a year to Emergency Departments, 35 million of which are injury related. Many injury-related ER visits do not result in admission to the hospital, but for those that do, hospital utilization review managers need to provide insurance companies sufficient documentation showing

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