Denials

Without proper documentation, inpatient denials are often upheld

Peer-to-peer discussions between hospital physicians – or their physician advisors – and the insurance company’s medical director can often overturn inpatient denials. But without proper documentation they do not work to rescind denials. Proper documentation must include an assessment coinciding with a detailed treatment plan updated throughout hospitalization. AppriseMD recently recommended to appeal a case …

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Determining observation stay guidelines

Which guidelines should hospitals follow for an observation stay?

Both national evidence-based guidelines and insurance company guidelines factor into level of care determination.   When it comes to determining a patient’s level of care for a short hospital stay, observation services are generally used for short-term monitoring, testing and evaluation to establish a treatment plan, and to give the treatment team time to see …

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P2P Review for Denied Inpatient Stay

Case Study: Alcohol withdrawal inpatient stay denial overturned based on care required

Alcohol withdrawal and a positive COVID infection resulted in an inpatient hospital stay for one patient; however, the insurance company denied the short stay. A detailed peer-to-peer discussion of this case with the insurance company overturned the denial based on the acute symptoms and the medical and supportive care required. CLINICAL SUMMARY: Alcohol Withdrawal A …

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Peer To Peer Review for Hospital Cases

Case Study: Acute diverticulitis stay denied

Healthcare insurance companies often deny inpatient hospital stays if the information provided does not show intensity of services significant enough to need inpatient care. If the patient’s care is more intense than the medical record implies a Peer-to-Peer discussion can provide more critical information to the insurance company. CLINICAL SUMMARY: Acute Diverticulitis A 69-year-old female …

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Review for Denied Inpatient Hospital Stays

Case Study: Denied inpatient stay due to suicidal ideation and drug overdose overturned

A recent case reviewed by AppriseMD showed a good example of how a case that on the surface appears inpatient appropriate can still be denied by the insurance company and overturned on peer-to-peer (P2P). Oftentimes a level-headed conversation with the insurance company will lead to the correct outcome. The case involved a drug overdose and …

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How does the two-midnight rule apply when a traditional Medicare patient has no safe discharge plan?

For a traditional Medicare patient admitted for observation, it is not uncommon to remain in the hospital longer than two midnights due to non-medical reasons including waiting for a transfer to another facility or family situations. In these cases, the reason the patient remains hospitalized is the lack of a safe discharge plan. Should such …

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Appealing denials through the Medicare Claims Appeals Process works

Though it took time and effort, an administrative law judge ruled in favor of a client hospital and overturned a Medicare claim denial for a total knee replacement surgery. The hospital can now fully recover the cost of that surgery, with interest. The case dates back to 2015 when a traditional Medicare patient underwent a …

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Good documentation can reduce hospital admission denials

We all know in clinical medicine that documentation is everything. Hence the old saying “If it’s not documented, then it didn’t happen.” This is particularly true outside of the clinical realm in the insurance world. Level of care is based on the clinical condition of the patient, how they present and how that meshes with …

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