Apprise MD

Missing adequate weekend assessments exposes up to 29% of hospital days to potential payment issues because for approximately 105 weekend days of every year, many hospitals operate with lower hospital utilization management and physician advisor staffing.

The Financial Impact of Weekend Utilization Review | AppriseMD The Financial Impact of Weekend Utilization Review / Blog, Utilization Review / By AppriseMD Missing adequate weekend assessments exposes up to 29% of hospital days to potential payment issues. Physicians consider many factors during the complex clinical judgement used in determining a hospital admi...

A recent article outlined how hospitals are likely to see a rise in "fights" for Medicare Advantage reimbursment due to reduced "benchmark payments and increasing regulatory oversight from CMS," which is causing MA to rethink its expansion, thus "setting the stage for increasing reimbursement fights with hospitals." All signs point to hospitals increasingly needing more denial management physician advisory services with payer expertise.

Read full article here https://www.beckershospitalreview.com/finance/medicare-advantage-increasingly-the-lynchpin-in-hospital-payer-fights.html

More about denial management physician advisory at apprisemd.com

Apprise MD physician advisors overturned a denied inpatient stay for a myomectomy by discussing this procedure’s placement on the inpatient-only (IPO) list, which is for surgeries that are considered high risk. Even though the patient was discharged on the day of surgery, this reversal shows the importance of peer-to-peer discussions conducted by physician advisors with regulatory and payer knowledge, combined with at least five years of clinical experience.

https://apprisemd.com/case-study-ipo-list-denial-overturned/

Apprise MD recently announced two new leadership team members: Dr. Sana Omer Mian and Dr. Anthony Ciesielsk. Dr. Mian will join the team as Manager of Provider Services after previously serving as AppriseMD's Lead Case Preparation Physician. Dr. Ciesielski will work alongside Dr. Mian also as a Manger of Provider Services after stepping into the interim role for several months. Both physicians have demonstrated exceptional leadership and dedication to their work with partner hospitals and health systems.

As the use of artificial intelligence in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials should be scrutinized by providers to ensure the denial is appropriate.


Read blog at https://apprisemd.com/payers-artificial-intelligence-and-revenue-cycle/

In our latest case study, see how a one-night inpatient hospital stay was initially denied by the insurance company, but overturned after an AppriseMD physician advisor explained the details that resulted in appropriate reimbursement for services provided.



Read the full case study at https://apprisemd.com/case-study-denial-reversed-short-stay-alcohol-induced-pancreatitis/

Dr. Kate Rout is Apprise MD 's Featured Case Preparation Physician of the month. Dr. Rout has proven to be an outstanding CPP. Her enthusiasm and commitment are shining examples within our organization. She has demonstrated exceptional efficiency and has significantly contributed to fostering a positive team environment. She is always ready to assist and consistently meets her goals.

State insurance commissioners are taking action against healthcare insurance companies in four states. "Payers have faced state penalties in 2024 for slower reimbursements, improper claim denials, or the sale of unapproved products" as reported by Beckers this week.

Read more at https://www.beckerspayer.com/payer/5-payers-recently-fined-by-states.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=1704C4337067B1U

Hospital utilization review data that AppriseMD collected in the first two months of 2024 shows that MAOs are denying claims that would have been approved under Traditional Medicare.
Continue reading at https://apprisemd.com/turning-um-data-into-revenue-opportunities/

Hospitals don't have to lose reimbursement dollars when patients leave the hospital against medical advice. This AppriseMD Case Study illustrates how physician advisors work with insurance company medical directors during peer-to-peer discussions to unravel details of a case that may be more complicated than the initial review shows.

Case Study: Denial Reversed in Short Stay Alcohol-Induced Pancreatitis Admission | AppriseMD Case Study: Denial Reversed in Short Stay Alcohol-Induced Pancreatitis Admission / Case Study, Denial Management / By AppriseMD CLINICAL SUMMARY: A 30-year-old patient arrived at the emergency room suffering from abdominal pain, nausea and vomiting. The patient’s symptoms had been occurring for th...

The American Medical Association wants to ensure medical staff have a say in what AI is adopted for patient care. At Apprise MD , we know this is also important in ensuring that automated denials don't impede care.




https://healthexec.com/topics/artificial-intelligence/medical-staff-must-have-say-what-ai-adopted-patient-care-says-ama?utm_source=newsletter&utm_medium=he_news

Revenue recovery data can give hospitals the chance to focus on, and aggressively approach, problematic issues impacting the revenue cycle. One common and costly issue plaguing many hospitals is long observation stays.

Read more at https://apprisemd.com/turning-um-data-into-revenue-opportunities/

The frequency with which some MAOs continue to deny services and reimbursement more than toes the line; it crosses the line.

Continue reading our white paper, "Medicare Advantage and the Two-Midnight Rule: 2024 Findings," to explore the impact of CMS-4201-F on hospital reimbursement at apprisemd.com

AppriseMD hospital utilization review data for the first two months of 2024 shows that Medicare Advantage Organizations (MAOs) are denying claims that would have been approved under Traditional Medicare.

Read more at https://apprisemd.com/medicare-advantage-noncompliance-two-midnight-rule-findings/

Understaffed teams represented the top workforce challenge currently facing revenue cycle departments, according to Sage Growth Partners as reported by Becker's Healthcare.

www.beckershospitalreview.com

The Two- Midnight rule maintains that inpatient LOC service is considered appropriate if the physician expects the patient to require medically necessary, hospital-level care across two midnights. This expectation needs to be supported in the patient's medical record, a key factor for reimbursement. Read more at apprisemd.com/medicare-advantage-two-midnight-rule-2024-findings/

Medicare Advantage plans account for a generous portion of Medicare plans in the US, and projections show that by the end of 2024 they will hold a majority.

Read how this rise can impact reimbursement atapprisemd.com/medicare-advantage-two-midnight-rule-2024-findings

Getting appropriately reimbursed for healthcare services is paramount, and many hospitals are finding it especially challenging to receive appropriate payment from the Medicare Advantage programs. Read more about this in recent article, "Health system-payer negotiations 'coming to a head'."

Inappropriate, long observation stays can negatively impact a hospital in several ways, including patient satisfaction, length of stay and reimbursement.
Read more at https://apprisemd.com/turning-um-data-into-revenue-opportunities/

Short, one-night hospital stays can be challenging to overturn when denied by the insurance company. Apprise MD was able to overturn this denial by educating the payer about the patient’s prior hospitalization and the subsequent failed maximal outpatient care. This underscores the value of using experienced physician advisors when it comes to advocating for the most appropriate level of care.

Read the full case study at apprisemd.com/case-study-overnight-short-stay-denial-reversed/

Arising from concerns that the MAOs were delaying and denying services and reimbursement, CMS implemented 4201-F at the beginning of 2024.

Read more at apprisemd.com/medicare-advantage-two-midnight-rule-2024-findings/

According to , "North Platte, Neb.-based Great Plains Health plans to stop contracting with Medicare Advantage plans in 2025."

https://www.beckerspayer.com/contracting/nebraska-health-system-to-drop-all-medicare-advantage-plans.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=1704C4337067B1U

Managed care organizations pose a significant challenge to a hospital's ability to collect reimbursement for medical services rendered, which is why ensuring compliance requires provider vigilance.




https://apprisemd.com/medicare-advantage-two-midnight-rule-2024-findings/

Apprise MD looked at data from our partner hospitals and health systems in the first two months of 2024 to examine how the final rule 4201-F is being implemented. Read our latest paper to see what we found.

Medicare Advantage & the Two-Midnight Rule: 2024 Findings | AppriseMD Medicare Advantage & the Two-Midnight Rule 2024 Data Findings & Historical Review Early 2024 data suggests Medicare Advantage Organizations (MAOs) are not complying with the Centers for Medicare and Medicaid Services’ (CMS) 2024 final rule 2401-F. The MAOs pose a significant challenge to a hospita...

AppriseMD utilizes a dedicated team to handle the payer peer-to-peer for denied claims. The team's reporting data includes an analysis of why the denied admissions expired during the payer reconsideration window. Understanding why these cases were not completed helps address and eliminate barriers.

Read more at https://apprisemd.com/turning-um-data-into-revenue-opportunities/

Physician advisors are a critical part of the utilization management process. They assist in level of care determinations and in overturning admission denials early to avoid payment denials. Given that physician advisor services are a vital component of utilization management and the revenue cycle, determining a return on investment for these services is crucial.

More at https://apprisemd.com/turning-um-data-into-revenue-opportunities/

By analyzing utilization management data, insights into a hospital's reimbursement practices are illustrated, which can aid in the root cause identification of denials. This highlights areas that require more attention and education. Read more at https://apprisemd.com/turning-um-data-into-revenue-opportunities/

It is critical that hospital revenue cycle managers actively and consistently review and analyze data to uncover strategies to achieve the best financial results.
Read more at

Turning UM Data into Revenue Opportunities | AppriseMD Turning UM Data into Revenue Opportunities Exploring the balance between care and cost Utilization management (UM) data analysis transforms revenue cycle and care management practices, yielding greater earnings to support hospital and health system operations and sustainability while improving the t...

Apprise MD named Dr. Vanessa Lara its Featured Case Preparation Physician of the month. Dr. Lara's dedication, professionalism and exemplary work ethic have earned her this distinction. She has been a valuable employee, not only meeting but exceeding expectations and showing remarkable ability to work collaboratively with others. Dr. Lara matching this year is a testament to her hard work and we have no doubt she will continue to excel in her medical career journey.

https://apprisemd.com/featured-case-preparation-physician/