- Product Headline: Observation or Inpatient: How to Avoid Medical Necessity Denials
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Educate physicians on information that is relevant to prove medical necessity.
One of the most common requests our physician advisors receive from hospitals is to review appropriate status assignment and determination of medical necessity. When the insurance company disagrees with a status, a denial is generated, often creating an opportunity for a peer-to-peer discussion to immediately resolve the situation. Based on experience, our physician advisors are more successful at overturning denials at the peer-to-peer stage.
When insurance companies mandate that the attending physician provide the peer-to-peer review, it creates a new challenge of how to coach the attending for success. Many physicians, particularly those early in their careers, have never performed a peer-to-peer or lack the experience to positively position themselves to support medical necessity. Others may see it as a waste of their valuable time. It is important to educate clinical physicians on what information is relevant to prove medical necessity while also streamlining an inefficient process.
Coaching attending physicians should ideally include succinct statements that are able to adequately convey medical necessity while avoiding information overload. Providing too much information in the prepared coaching materials could produce extra work. Creating a system of efficiency by striving to hit only the meaningful points empowers physicians, giving them the best opportunity for a favorable outcome.
A Case Example
Consider a scenario with a 50-year-old male patient with a history of chronic pancreatitis and ETOH abuse who presented with severe abdominal pain. His improvement was minimal and he remained NPO, requiring IV fluids, significant IV analgesia, IV antihypertensives, and IV antiemetics for two straight days. On review of the chart, it seemed obvious that given the patient’s severity of illness and intensity of service, with lack of improvement, he required inpatient status.
My recommendation was to upgrade from observation to inpatient. The insurer disagreed, denied the inpatient admission, and offered a peer-to-peer with the attending physician only. Aside from the frustration of a denial of services on what I believed was a straightforward inpatient case, I lost the option to perform the peer-to-peer and support my status assignment.
When coaching the attending physician, I immediately broke down each day of the patient’s stay and highlighted the medical necessity so the attending physician could easily present sequential facts during the peer-to-peer. In this particular case, the highlight of this patient’s care was the extensive use of multiple IV medications, including Dilaudid, Zofran, and IV fluids, compounded by his inability to tolerate any diet for two days with NPO status and limited intake thereafter. The breakdown to the attending was provided in bullet format, as follows:
- 4/30:n/v, abd pain, NPO IV Dilaudid: 4/30 1550, 1806, 2225; BPs:192/90, 172/75
- 5/1:remains NPO, IV Dilaudid x 6, IVF: Continuous, IV Zofran x 1, IV Hydralazine x 1, BPs: 182/97, 183/98, 186/100, 193/80
- 5/2:remains NPO as of 10:06 a.m., clears attempted, IV Zofran x 1, IV Hydralazine x 1, IV Dilaudid x 6, IVF, BPs: 176/78, 197/124, 180/102, 179/85, 182/94
- 5/3:still with severe pain, tolerating clears, IV Zofran x 1, IV Hydralazine x 1, IV Dilaudid x 5, IVF, BPs: 190/102, 186/66
- 5/4:discharged, IV dilaudid x 2, IVF
Additionally, I provided tips for the attending physician, sharing common tactics medical directors use to deny inpatient status. The feedback from the attending physician was overwhelmingly positive, as we saved him the time it would take to review the chart again and supplied him with relevant medical necessity. We also achieved a favorable outcome, as this denial was overturned and approved as inpatient.
The other goal on this case was to not only provide a clear picture of medical necessity and coach our physicians, but also to review the entire stay. We weren’t looking for a two- or three-day inpatient stay. The entire five days warranted inpatient care, and after the peer-to-peer, the insurer agreed.
Tips for Coaching a Peer-to-Peer
Always ask the insurer what information they have received and what the cause for denial was, as they may lack clinical information.
- Provide a concise, clear picture of the clinical scenario.
- Highlight the important points that best illustrate medical necessity for inpatient status.
- Avoid information overload.
- Coach how to rebut an insurer’s cause for denial (i.e. the patient was only admitted for so long; this is observation). Answer: Timing is not the basis of appropriate status assignment, medical necessity is. (The obvious exclusion is Medicare.)
As physician advisors at Brundage Group, our primary goal is to educate physicians to understand and optimize both medical necessity and documentation. Doing this appropriately on the front end will avoid unnecessary denials and subsequent peer-to-peers. In the event we have a denial and the insurer requires the attending physician to perform the peer-to-peer, coaching is a viable alternative prior to a written appeal, and has created a new educational opportunity for clinical providers. This education empowers physicians, creates positive experiences, and makes the chance of overturning the next such denial much greater.