Member May: Not Admitting Defeat: Overturning Rehab Admission Denials (1.25 CME)-Not Admitting Defeat: Overturning Rehab Admission Denials

Video Transcription

Video Summary

In the video, the panel discusses the challenges of obtaining prior authorization for inpatient rehab services and provides strategies for appealing denials. They emphasize the importance of understanding the criteria for medical necessity and functional improvement, as well as maintaining strong documentation to support the need for rehab services. The panel also discusses the use of templates for authorization and appeal letters, and the importance of being proactive in advocating for patients' needs. They share experiences with expedited appeals and the success rates they have achieved. The panel highlights the need to educate patients and families about their rights and the appeals process, and to involve them in decision-making and appeal efforts. They also mention that some hospitals have admitted patients to inpatient rehab before obtaining formal authorization, leading to successful approval after admission. The panel acknowledges the challenges of dealing with Medicare Advantage plans and emphasizes the need for strategic planning and a strong understanding of the rules and regulations. Overall, the video provides valuable insights and practical strategies for navigating the prior authorization and appeal process for inpatient rehab services.

Keywords

prior authorization

inpatient rehab services

challenges

strategies

medical necessity

documentation

appeals process

experiences

success rates

Medicare Advantage plans

strategic planning