CLINICAL SUMMARY: A 50-year-old patient was hospitalized overnight after arriving in the emergency room with constant left flank pain. The patient was seen in the emergency room (ER) the previous week with similar symptoms, which doctors diagnosed as a 5 mm, left proximal ureteral stone with mild hydroureteronephrosis. The patient was treated and sent home […]
Case Study: Overnight Short-Stay Denial Reversed Read More »
Medicare Advantage (MA) plans traditionally implement more restrictive medical necessity requirements than Traditional Medicare. They also produce a higher denial rate than all other payer categories combined, according to Crowe. This leaves hospitals investing more time and resources into ensuring appropriate reimbursement. MA plans already account for a generous portion of Medicare plans in the US, and
Payer Claim Denials & Medicare Advantage Organizations Market Share Read More »
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
Case Study: Readmission Linking for Hospital Stays Reversed Read More »
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
Case Study: Peer-to-Peer Review of Overlooked Medical Details Can Overturn Denials Read More »
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
Case Study: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial Read More »
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
Without Proper Documentation, Inpatient Denials are Often Upheld Read More »
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
Which Guidelines Should Hospitals Follow for an Observation Stay? Read More »
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
Case Study: Alcohol Withdrawal Inpatient Denial Overturned Based on Care Required Read More »
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
Case Study: Acute Diverticulitis Stay Denied Read More »
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
Case Study: Denied Inpatient Stay Due to Suicidal Ideation and Drug Overdose Overturned Read More »