Without proper documentation, inpatient denials are often upheld

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 after a Peer-to-Peer resulted in a denial being upheld due to lack of proper documentation. The case involved a 63-year-old patient admitted for syncope and a COVID-19 infection. The denial was upheld because of the minimal amount of clinical information that was available in the patient’s documentation. This left the physician advisor little room to argue for overturning the denied payment.

The original denial was based on MCG criteria which includes no evidence of hemodynamic instability. In this case, the patient’s orthostatic hypotension was a type of hemodynamic instability. Had this been more regularly updated and recorded and clearly written in assessment and plan – for example, “Orthostatic hypotension – continue IVF” – the inpatient stay could have met the MCG criteria and the insurance company’s criteria as well as medical director’s criteria in the P2P.

The AppriseMD physician advisor explained the case to the insurance company, noting that orthostatic hypotension was a concern throughout the stay. He provided the insurance company with the initial orthostatic vital sign readings, but the denial was upheld because the information at hand was not updated throughout the hospitalization, documenting ongoing orthostatic readings and their need for IV fluids. Following the P2P, the physician advisor recommended that the hospital appeal the upheld denial because he felt that properly documenting on-going orthostatic vitals, which required on-going IV fluid therapy, could have made the case stronger.

The physician advisor saw an opportunity for improved documentation, explaining that there was ongoing IV fluid therapy but the assessment and plan lacked reasons for this in the documentation. Had the attending physician stated in the patient’s documentation that orthostatic hypotension was being addressed with ongoing IVF, it could have made the difference and given the insurance company reason to overturn the denial.

Insurance companies require detailed documentation, and it is often the leading factor in level of care and admission denials. The importance of providing complete documentation never goes away. Treating physicians and utilization review managers must ensure that every admission includes:

  • A detailed record of the patient’s past medical history as well as detailed subjective account of the patient’s current clinical presentation.
  • An objective record, detailed and updated throughout the hospitalization (avoid copy/paste). Remember the saying, “if you didn’t document it, then you didn’t do it.”
  • Assessment including a detailed list of all problems and a discussion of differential diagnoses. The complete thought process that went into admitting the patient should also be documented.
  • Treatment plan – a plan of action including diagnostic recommendations, treatment options and follow-up plans.

Without this documentation, cases are much more likely to be denied or pushed to a lower level of care by the insurance provider, as it was in this case.

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