Utilization Review FAQs

Solution: AppriseMD physicians are well-versed in the CMS guidelines and are up to date with any changes to the standard protocol. We will review all short stay inpatient cases on an individual basis to confirm compliance. A customized report is generated for each short stay review by our physician review team.

Solution: AppriseMD is acutely aware of CMS guidelines when reviewing for traditional Medicare patients for level of care or length of stay. We follow all CMS regulations including the two-midnight rule. For managed Medicare patients, each case is reviewed on an individual basis by our physicians with expertise in managed care as well as clinical experience; the level of care and length of stay decision is unique to each patient and each managed Medicare vendor.

For both traditional and managed Medicare patients, two, if not three, AppriseMD physicians review a case before it is sent back to the client hospital.

Solution: AppriseMD strives to be current with CMS regulations, such as current IPO procedures and recent changes to the IPO exclusivity. AppriseMD physicians will review the entirety of a medical record for potential risks and review accordingly for best patient and hospital outcome. In addition, AppriseMD stays current with the commercial carriers‘ approaches.

A recent AppriseMD Orthopaedic Societies position paper regarding outpatient arthroplasty shows our thinking regarding TKA and THA.

Solution: AppriseMD combines the clinical experience and utilization expertise of its review physicians with your hospital’s discharge patterns and will collaborate with your treatment team to review for the best outcome for your patients and revenue stream. We strive for a safe and efficient discharge plan for all patients. Two, if not three, AppriseMD physicians review a case before it is sent back to the client hospital. If warranted, an AppriseMD physician will attempt a peer-to-peer discussion with the treating attending to discuss any discrepancies.

Solution: Each hospital client has different needs and expectations regarding how clinical review is performed. Some require strict adherence to guidelines; others require clinical judgement above and beyond the guidelines. We will work with you to determine the best approach for your hospital. A clinical conference about each individual case allows custom advocacy for level of care and length of stay. AppriseMD reviewers are experts in national evidence-based guidelines and will incorporate clinical judgement as well as custom consideration for hospital guidelines. We do not check boxes and our clinical judgement breaks the cookie-cutter constraints. This sets AppriseMD apart from competitors to ensure a custom, individualized, clear and strong review for each patient case.

Solution: Yes! As a physician-run company, we pay due diligence to the best interest of the patient and the hospital. We will conduct peer-to-peer discussions with the treating physician to decide the most appropriate and safe level of care, regardless of equal payer reimbursement for a level of care. Being a physician-owned organization and having a team of physicians means we care about treatment of patients and share in your commitment to patients AND that we share your oath to care for them to the best of our ability. Further, AppriseMD will work with your utilization team to organize a hierarchical escalation of peer-to-peer review with your hospital physicians in the event a level of care agreement is not met post peer-to-peer with AppriseMD physician and hospital treating physician.

Once again, AppriseMD reviews each patient case on an individual basis and, with respect of the treating physician’s time, will reach out for a peer-to-peer when clinically warranted or impactful.

Solution: AppriseMD will pursue peer-to-peer discussions with commercial payers that are of economic interest to the client and requested by the client. Every day AppriseMD advocates for our clients by doing well-researched and executed payer peer-to-peers. AppriseMD reviewers are experts in and leverage national evidence-based guidelines with clinical judgement. Our ultimate goal is appropriate reimbursement.

When appropriate, AppriseMD will advise if an appeal is worth proceeding with by providing an extended review for the client, or AppriseMD can proceed with an appeal on behalf of the client. Once again, the level of AppriseMD involvement is custom to the client hospital’s operations.

AppriseMD offers Payer Peer-to-Peer services to attempt commercial denied level of care cases. We recently completed two case studies showing the efficacy of attempting such denials that resulted in as much as 4x ROI.  Our preliminary results for the second study demonstrated a nearly 55% overturn rate to date.