Whats the Insurance Taking About a Peer to Peer to Reverse Denial
Inpatient admissions less than two days in length which have been denied past a commercial carrier are appropriate for Peer-to-Peer Review, but not all hospitals and doctors take the time or the volition to practise these reviews. Once nosotros have moved past the extreme situation of the COVID-nineteen pandemic, hospitals are going to expect hard at finding whatever way they can recoup dollars. We take done a limited study and seen the benefit of P2P reviews at AppriseMD and how information technology tin can reverse denials and recoup dollars for hospitals.
Instance Study: Can Peer-to-Peer Reviews Overturn Short Hospital Stay Inpatient Denials?
Peer to Peer Reviews for Short Inpatient Infirmary Stays Meeting InterQual® but Denied past Commercial Insurance Tests Observation Stay Status in Airplane pilot Study
Challenge: Overturning Inpatient Denials
Insurance carriers reimburse inpatient hospital and ascertainment hospital stays at significantly unlike rates. Insurance companies often deny an inpatient overnight stay and instead pay for an observation stay at a significantly lower rate – even though the care provided to the patient was not reduced and the patient met guidelines (e.yard. InterQual™, MCG) for inpatient level of care. The Healthcare Council of Western Pennsylvania plant in a 2019 study of data "hospitals receive $225 million less in payments" due to a higher rate of observation cases.1
Despite the difference in payment charge per unit, inpatient level of care denials for commercial short stay cases are oftentimes left undisputed and the peer to peer (P2P) procedure is not utilized. Attention physicians may view the P2P procedure as not beneficial or not likely to outcome in an overturned denial or increased payment charge per unit. The attention doc'south patient load and full general reluctance to speak with insurance company physicians tin as well play a factor in the number of P2P reviews conducted by hospitals. Withal it is in the best interest of the hospital to effort P2Ps for these cases as it can recoup significant dollars appropriate for the care given.
Approach: Increase P2P Reviews to Overturn Denials
The approach for this pilot was to accept advantage of the MD P2P reviews offered by insurance carriers to review short patient stays denied for inpatient level of care and instead allowed as observation stays. The reviews involved an enhanced level of preparation which included a doc representing the hospital speaking to a medico from the insurance carrier to review the example details including clinical history prior to admission, admitting diagnoses and comorbidities, testing results and procedures performed also as the general progress of the patient. National evidence-based guidelines are likewise discussed when appropriate also every bit carrier specific level of intendance guidelines.
AppriseMD conducted a airplane pilot P2P study with i hospital to review inpatient admissions with a two-twenty-four hour period or less length of stay. The cases met InterQual™ (IQ) guidelines for inpatient level of intendance and were denied by the commercial carrier. The small airplane pilot study consisted of twenty cases determined to be "hopeless" in terms of getting an overturn decision from the insurance carrier based on instance management and the attending doc's stance.
A doctor from AppriseMD performed a comprehensive chart review for the admission in question equally well as any prior admissions and created a detailed case summary of the admission. AppriseMD acted as a full advocate of the hospital and as such reached out to the insurance company for each example offer flexibility in setting coming together times and dates to eliminate scheduling issues that can happen with attending physicians. A second lath certified, licensed dr. from AppriseMD with at least v years of inpatient clinical experience also every bit commercial insurance feel and so reviewed the case summary and made additions or corrections. This second medico too reviewed a real-fourth dimension updated commercial insurance database maintained by AppriseMD that includes specifics of each commercial carrier including guidelines used, specific rules and individual medical managing director approaches. The AppriseMD doc was optimally positioned to comport the P2P review with the insurance representative physicians in place of the attention medico with knowledge of the case'south clinical facts as well as the position the payer could take.
Results:
Eight denials were overturned. In improver to advocating for the overturned denials, AppriseMD physicians built a data base of diagnosis and carriers to track trends. Despite the minor numbers in the cases reviewed, the data showed cardiac issues including chest pain, angina and NSTEMI seem to exist about amenable to a successful overturn during this limited pilot. Other overturned diagnoses were diabetic ketoacidosis and a smoke inhalation. Nausea and airsickness, abdominal pain and TIA were less likely to be overturned.
Overturned denials were relatively even between the six carriers represented in the cases reviewed showing no clear payer trends.
| P2P Completion Charge per unit Details (20 cases provided) | P2P Successful Denial Overturn Charge per unit Details |
| 95% = xix/20 Completed five% = ane Not Completed | 42% = 8/14 Successful Denials Overturned 58% = eleven/19 Attempted, Not Overturned |
Insights
Almost whatsoever diagnosis coupled with an intensive, preplanned, and structured P2P performed by a md with extensive P2P experience offers the opportunity for successful deprival overturn. In particular, cardiac diagnoses will have good success with this approach. The airplane pilot P2P instance written report included a small, limited number of cases over a 57-day time period, all the same the overturn rate shows that significant dollars can exist recouped by hospitals with continued practice of P2P reviews done with thorough planning and preparation.
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Source: https://apprisemd.com/case-study-can-peer-to-peer-reviews-overturn-short-hospital-stay-inpatient-denials/
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