Medicare Advantage

Medicare Advantage

Formal written appeals of an upheld peer-to-peer

Case Study: Formal Appeal Overturns Upheld Peer-to-Peer

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

THE CHALLENGE Hospitals continue to face payer denials throughout the revenue cycle, including technical and administrative denials, as well as coding denials where Diagnostic Related Group (DRG) downgrades are a major pain point. Clinical denials are also rampant, whereby the payers are challenging the clinical judgement of providers despite clear evidence that, for example, inpatient […]

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AppriseMD Case Study Challenging MA denial overturned despite one-midnight stay

Case Study: Challenging MA Denial Overturned Despite One-Midnight Stay

Case Study, Two-Midnight Rule / By

CLINICAL SUMMARY: A 76-year-old female arrived at the emergency department critically ill, experiencing palpitations and shortness of breath. The patient had a complex medical history including ovarian and thyroid cancers, chronic heart failure (CHF) with reduced ejection fraction (EF 20%), stage 3b chronic kidney disease, gastroesophageal reflux disease, paroxysmal atrial fibrillation (A-fib) on anticoagulation, type 2

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MA patient in hospital

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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AppriseMD Case Study: Complex Medical History, ICD & Transfer Impact Inpatient Denial Reversal

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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