Wiki Hospital admissions being denied

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Tringenary

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I have been seeing more and more admissions being denied by insurance companies. My question is we are specialist being consulted and even some times performing procedures. Colonoscopy and EGD. Is it illegal to change an In pt vist to and out pt visit if the insurance company is denying the admission?
 
The only one that can change the admit to outpatient is the admitting provider and only based on a request of hospital UR. As the consulting provider you cannot change the patient status nor the POS. The question is what is the reason for the denial, what is the diagnosis code(s) you are using for the services, what was the reason for the procedures or test and why was the payient admitted.
 
yes it is. Guidelines state you must use the POS code as to where the patient was when care was rendered. Inpatient admissions get denied quite a bit actually. The hospital will appeal the insurance company's decision because the hospital wants to get reimbursed as well. If it denies, then you have to bill the patient.
 
This is a Medicaid HMO Pt. Can not bill caid pts. The entire admission was denied not medicall necessary to admit tyhe pt and the hospital appeal was also denied.
 
Hmmm I worked at Medicaid and my job was to be the one that determined whether to deny the admit or not. Now just because the admit is denied does not mean the provider cannot bill their part. However the POS must still be inpatient. CMS does allow the facility UR to re evaluate the stay and request from the attending an order to convert to outpatient status. If he does then you will re bill with output POS. I agree that you cannot bill the patient just because the stay was denied. Even if they are not Medicaid. This is not the fault of the patient. But many times we paid the physician even though we denied the stay for the facility for failure to meet inpatient medical necessity.
 
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