Brundage Group’s Success in Overturning Patient Status Denials from Kodiak’s Medicare Advantage Study

By Tim Brundage, MD, CCDS

A recent study by Kodiak analyzed claims data from 1,900 hospitals. Significant insights emerged regarding compliance with the Medicare Two-Midnight Rule among various payors, including commercial managed care plans, Medicare Advantage (MA) plans, and traditional Medicare. The findings underscore a critical issue that hospitals face today: payors often apply their criteria for inpatient admissions rather than adhering to the Two-Midnight Rule for all Medicare beneficiaries.

The Centers for Medicare and Medicaid (CMS) mandated use of the Two-Midnight Rule when determining the medical necessity of inpatient services by MA plans effective January 1, 2024.  Although Medicare Advantage beneficiaries are entitled to the same covered services as those with traditional Medicare, they have historically experienced lower inpatient rates due to stricter medical necessity criteria. Implementation of the Two-Midnight Rule was supposed to eliminate that discrepancy.

Despite the new Medicare Advantage coverage changes, the data suggest widespread non-compliance, which poses a financial risk to hospitals.

The study reveals that Medicare Advantage plans have yet to fully comply with the Two-Midnight Rule, leading not only to revenue loss but unnecessary expenses for hospitals when appealing these noncompliant denials. This trend highlights the urgent need for hospitals to be vigilant in monitoring MA plan medical necessity denials.

At Brundage Group, we understand the complexities of navigating this landscape. Our expertise in overturning medical necessity denials is more crucial than ever in this environment of payor non-compliance. Our team challenges inappropriate denials, making sure hospitals capture appropriate revenue for the care delivered to MA plan beneficiaries in good faith.

The findings from Kodiak’s study remind Brundage Group of our critical role in safeguarding our hospitals’ interests. Our compliant approach to medical necessity denials helps to ensure admissions are accurately classified according to established guidelines.

By partnering with Brundage Group, you gain access to a team knowledgeable about the Two-Midnight Rule and adept at leveraging data-driven insights to strengthen your case against payor denials. We actively monitor trends by payor, provide expert guidance, and share valuable information to enhance your organization’s ability to navigate these challenges.

The data from Kodiak’s study highlights the pressing need for healthcare systems to be proactive with their utilization review strategies. With Brundage Group, you will be prepared to challenge unjust denials and benefit from our extensive knowledge of payor behaviors and regulatory requirements.

In an increasingly complex compliance landscape, Brundage Group’s expertise in overturning medical necessity denials is a key resource for healthcare systems. Our expertise, combined with insights from proprietary analytics platform, equips hospitals to navigate the nuances of payor behaviors confidently.