Secondary Review

Case Study Readmission Unlinked after P2P

Case Study: Unlinking a Readmission Hospitalization During a Peer-to-Peer Payer Review

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

CLINICAL SUMMARY: A 70-year-old patient arrived in the Emergency Department (ED) from an assisted living facility (ALF) as his renal function deteriorated, and he slipped into a severely depressive state. The patient appeared pale and withdrawn, and the ALF staff reported that the patient did not eat or drink for approximately three weeks. Additionally, the […]

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Patient in ER for cellulitis

Case Study: Secondary Review Recommendation Holds in Cellulitis Hospitalization

Case Study, Denial Management, Second-Level Review / By

CLINICAL SUMMARY: A 35-year-old patient arrived in the Emergency Department suffering from a painful abscess and swelling on the left buttock. The patient, whose medical history includes hidradenitis suppurativa, bipolar 1 disorder and asthma, described the pain as an excruciating stabbing sensation rated at a level 10. Furthermore, the patient reported shortness out of breath

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PA secondary reviews raise reimbursement

Case Study: Physician Advisor Secondary Review Insight on MA Case

Case Study, Denial Management, Medicare, Two-Midnight Rule / By

CLINICAL SUMMARY: An 88-year-old patient with a complex cardiac history of chronic congestive heart failure and dilated cardiomyopathy arrived at the emergency department (ED) with worsening shortness of breath and intermittent dizziness. The patient’s medical history included COPD, dilated cardiomyopathy, ventricular tachycardia with implantable cardioverter-defibrillator (ICD) shocks, atrial fibrillation (for which the patient uses Eliquis®),

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