Medicare guidelines for managed care

Started by Momentum70
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Momentum70

Momentum70

Full Member
15+ Year Member
Has anyone worked for a managed medicare company like Humana or United doing to review for approval to IPR. I do peer to peers all the time and i swear its luck of the draw on getting patients approved for transfer from acute to ipr. The constant thing i hear is “they dont fit medicare criteria for ipr”. I know the basics and when i ask which criteria they never will say specifics. Just usually the same line about not fitting over and over. If they elaborate at all they just say the person doesnt need a pmr doctor and they recommend snf. Id love to know the specifics of the criteria or list they have to go off for their decisions.
 
Medical necessity and complexity…

“Sorry patient doesn’t have active medical needs”. Acute renal failure, anemia with recent GIB, resp failure, CIM. Ended up getting approved.

“Sorry patients vital sign is unstable to do rehab”. HR 101. Could not get approved.
 
I don’t have their guidelines but I’m sure they have them. Do they necessarily follow them? In my experience likely not.

Most denials are easily overturned and some insurances deny about everything on first pass. Just do the peer to peer and present information of why they are a good candidate. Most peer reviewers don’t have all the info and if you sort it out for them I have found good success. Doesn’t mean you win all peer to peers. I feel like the written appeals process is when insurance is forced to follow their guidelines, but don’t necessarily follow before that. Unfortunately people don’t appeal often and just want to get out of the hospital.
 
DMBandFan86 said:
Medical necessity and complexity…

“Sorry patient doesn’t have active medical needs”. Acute renal failure, anemia with recent GIB, resp failure, CIM. Ended up getting approved.

“Sorry patients vital sign is unstable to do rehab”. HR 101. Could not get approved.
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So many times it starts, sorry i dont see they have medical need, then go over the needs and changes to sorry i dont think they are safe to discharge.....WTF
 
Momentum70 said:
Has anyone worked for a managed medicare company like Humana or United doing to review for approval to IPR. I do peer to peers all the time and i swear its luck of the draw on getting patients approved for transfer from acute to ipr. The constant thing i hear is “they dont fit medicare criteria for ipr”. I know the basics and when i ask which criteria they never will say specifics. Just usually the same line about not fitting over and over. If they elaborate at all they just say the person doesnt need a pmr doctor and they recommend snf. Id love to know the specifics of the criteria or list they have to go off for their decisions.
Click to expand...
As the other poster mentioned luck of draw. uHC is particularly bad and wants to deny everything - they recently denied a BL amputee patient admission to our unit - I told my staff before denial oh there’s no way they can deny that. Sure did. Sometimes shaming them into the nonsense of what they are saying works sometimes it’s multiple appeals sometimes family appeals are very successful sometimes dramatics etc
 
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