Case Management

Tip: Reviewing medical necessity of inpatient denials

Case Management Weekly, December 8, 2010

A two-step approach may be helpful when reviewing the medical necessity of an inpatient denial. Begin the review by determining whether the case meets inpatient screening criteria used by the facility. Case management, utilization review, or other clinical staff may complete this first step; it needn’t include a physician reviewer.  If a case meets screening criteria applicable at the time of the admission, consider an appeal.

If a case fails to meet screening criteria, move on to step two, a physician advisor review of the case. Some cases won’t meet screening criteria, but based on Medicare’s inpatient guidelines, nevertheless qualify for inpatient admission. If a physician advisor determines that a case meets Medicare requirements for inpatient admission and your facility decides to appeal the case, the physician advisor’s review may serve as the basis of your appeal statement.

This week’s tip is adapted from The RAC Survival Guide: Successful Management of Recovery Audit Contractors published by HCPro, Inc. For more information on this book or to order your copy, visit the HCMarketplace.

Do you have a question about a case management topic? Send it to Associate Editor Ben Amirault at An answer to your question might appear in a future issue of Case Management Weekly.

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