If your utilization review (UR) team has worked with Aetna Medicare Advantage plans, you’ve probably seen the term “Low Severity” more than once. It appears on inpatient claims when Aetna’s clinical review decides the documented severity of illness doesn’t support full inpatient reimbursement. This has become one of the most debated payer tactics hospitals deal with today.
What’s most frustrating isn’t that these denials happen, but how often they turn out to be incorrect.
What “Low Severity” Actually Means
When Aetna approves inpatient but will only reimburse for “Low Severity” care, they are creating a new category of inpatients. By approving these claims as inpatient, Aetna avoids issuing a denial and reframes the argument as a payment issue instead of a coverage issue. Often, this decision comes from an automated screening tool or a reviewer using general severity criteria without exercising physician judgment as required by Federal regulations.
The issue is that illness severity isn’t always clear from just vitals and lab results. A patient who seems stable on paper might be getting worse, may have already failed outpatient care, or could have other health problems that make a “low severity” case truly risky. Coded data and screening tools are designed to match patterns, not to use clinical judgment, and Low Severity denials often highlight this gap.
Why These Denials Are Winnable
Because Low Severity determinations often rely on incomplete clinical reasoning rather than a full case review, they can often be overturned in peer-to-peer (P2P) reviews. This works best when the Physician Advisor makes a clear, clinically sound argument.
That’s what makes the difference. A generic P2P call rarely convinces an Aetna medical director to pay the full inpatient rate. It takes a Physician Advisor who knows how to build the right clinical argument, one built for how Aetna’s reviewers actually think.
The numbers show a clear trend. Across many clients, Brundage Group’s Physician Advisors have achieved a 61% overall overturn rate on Aetna Low Severity cases.
Why Many Hospitals Leave This Revenue on the Table
Hospitals that struggle with Aetna Low Severity payments often run into the same three issues:
What a Stronger Approach Looks Like
Hospitals that get the best results see Aetna Low Severity payments as a problem they can solve, not just the cost of doing business. This means:
- Pursuing the P2P discussion by default, not by exception
- Matching the case to a Physician Advisor who can speak to the specific clinical scenario and refute severity screening criteria
- Preparing an argument built around the moments of clinical decision-making the payer’s criteria didn’t capture
- Tracking overturn rate by payer so the pattern is visible, not anecdotal
You don’t need a new department for this. What’s needed is the discipline to go after every winnable case and the right physician expertise to make a strong argument.
The Real Question to Ask
Aetna Low Severity payments clearly show a bigger truth in revenue integrity management: the key factor isn’t usually whether a case can be defended. It’s whether someone calls to defend it, and whether that person knows how to make the right argument.
A 61% overturn rate shows that these cases are often winnable. For most UR and revenue integrity teams, the real question isn’t if Aetna Low Severity determinations can be overturned, but how many are being left unchallenged.
Every unchallenged Low Severity payment is revenue your hospital already earned and simply isn’t collecting. Brundage Group’s Physician Advisors can help you close that gap.
Interested In Finding Out How Much a Dedicated Physician Advisor Program Could Recover Your Aetna Low Severity Determinations?
Our team can show you what is possible for your hospital.
