Denials

Case Study: Readmission Linking for Hospital Stays Reversed

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

CLINICAL SUMMARY: Recently, physicians admitted a 73-year-old patient with an extensive medical history twice within an 8-day period. The patient required inpatient level of care (LOC) for both hospitalizations. The patient was hospitalized with pneumonia during the first inpatient stay, and the second inpatient hospitalization addressed exacerbated congestive heart failure (CHF). The patient arrived for […]

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AppriseMD physician advisors provide essential utilization review and denial management education for treating physicians

Case Study: Peer-to-Peer Review of Overlooked Medical Details Can Overturn Denials

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

CLINICAL SUMMARY: A 22-year-old patient, four weeks postpartum, arrived in the emergency department suffering from abdominal pain and nausea. An ultrasound revealed the common bile duct was dilated to 8 mm, and a CT scan showed gallstones. In addition to steatosis, the patient also had a positive Murphy’s sign. Lab tests performed during the patient’s

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Case Study: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial

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CLINICAL SUMMARY: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial   A 68-year-old patient with an extensive medical history arrived at the emergency room after three days of acute gastrointestinal (GI) bleeding. The patient experienced nausea and observed bright red stool blood that persisted. The patient’s medical history included atrial fibrillation treated with an

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without proper documentation inpatient denials are often upheld

Without Proper Documentation, Inpatient Denials are Often Upheld

Denial Management, Utilization Review / By

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?

Blog, Length of Stay, Utilization Review / By

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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Case Study: Alcohol Withdrawal Inpatient Denial Overturned Based on Care Required

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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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Case Study: Acute Diverticulitis Stay Denied

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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

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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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AppriseMD physician advisors provide essential utilization review and denial management services to hospitals

How Does the Two-midnight Rule Apply When a Traditional Medicare Patient Has No Safe Discharge Plan?

Blog, Length of Stay, Medicare / By

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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Administrative law judge reviews appeals at the highest level

Appealing Denials through the Medicare Claims Appeals Process Works

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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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