By Jonna Mayfield, BSN, RN, CMGT-BC

Ask most hospital leaders where utilization management (UM) sits on the org chart, and you’ll usually find it buried under nursing or care management: staffed, budgeted, and evaluated like a clinical support service. That framing misses what utilization review does for the hospital’s bottom line, and it’s costing organizations far more than most finance teams realize. 

The Gap Between Observation and Inpatient Keeps Widening

The financial distance between an observation stay and an inpatient admission has been growing for years, and 2025 data shows it is accelerating. According to the American Hospital Association’s 2025 Cost of Caring report, Medicare Advantage plans reimbursed only 49% of the actual cost of care for patients held in observation status in 2024, and observation stays for MA patients now run 36.9% longer than for traditional Medicare beneficiaries — nearly double the gap seen just five years earlier. 

On the reimbursement side, Healthcare Financial Management Association’s (HFMA) modeling puts a standard inpatient case at roughly $6,500 in expected reimbursement compared with $2,000 for the same clinical presentation discharged as observation: a $4,500 gap for identical care. Depending on the DRG family and comorbidity capture involved, that swing can run as high as $8,000 per case. Multiply that by admission volume, and the revenue exposure from misclassified or simply unreviewed cases becomes a material line item, not a rounding error. 

The Math Hospital Leaders Should Be Running 

Consider a mid-size community hospital admitting roughly 15,000 inpatients a year. If just one case a day is missed, an observation stay that met inpatient criteria but was never escalated for review — the math looks like this: 

• At the conservative end of the range ($4,500/case): over $1.6 million in avoidable lost revenue annually. 

• At the higher end ($8,000/case): approaching $2.9 million a year. 

• The average annual salary for an UR/UM RN: roughly $85,000. 

A single, UR nurse pays their entire salary by correctly converting fewer than 20 cases a year, well under two a month. Everything beyond that is protected margin. Understaffing the department to save on one salary line, while missing reviews on admissions that should have converted, isn’t a cost-saving decision. It’s a revenue-losing one, and usually a much larger one than the staffing line it was meant to protect. 

Why Hospitals Can’t Fix This with Internal Staffing Alone 

Here’s the part most hospitals get wrong: they treat this as a headcount problem. It isn’t, and that’s exactly why adding another req rarely closes the gap. 

Coverage must be constant, and internal teams can’t be. CMS’s two-midnight rule means the window to get a status determination right is narrow: concurrent, at the front end, before discharge. That window doesn’t pause for PRN gaps, call-offs, vacation coverage, or a Saturday night with one nurse covering three units. An internal UR function is only as strong as its weakest shift, and every hospital has weak shifts. 

Dyad models don’t fail from lack of effort. They fail from structural conflict. When one case manager owns both discharge planning and utilization review, there’s no version of that job where UR wins consistently – there’s always an immediate patient in a room who needs to leave today. This isn’t speculation: Organizations where case managers prioritize discharge planning over UR saw a decline in revenue, an increase in denials, and an increase in readmissions, and had to separate the roles to fix it. As one case management consultant puts it, siloing UR away from bedside case management “sets the scene to diminish a sense of urgency,” even though effective utilization management is inherently an urgent, non-negotiable process.  Deferring a chart review to “later in the shift” feels reasonable in the moment. It just also happens to be the exact decision that quietly closes a revenue opportunity for good. This isn’t a training gap or a performance issue. It’s two full-time jobs competing for the same eight hours, and one of them has a patient standing in front of it. 

Consistency is the whole point, and consistency doesn’t scale with more individual hires. Medical necessity criteria applied by five different nurses across five different shifts, at five different experience levels, doesn’t produce five consistent outcomes. It produces variance, and variance is where both denials and missed conversions live. Hiring one more nurse into that same structure adds capacity. It doesn’t add consistency. 

That’s the real reason understaffed UM departments stay understaffed even after budget approval for a new position. The problem was never just headcount. It’s a structural mismatch between what the role requires (constant, criteria-driven, defensible review, every shift, every case) and what internal staffing models are built to deliver (flexible coverage that flexes toward whichever task has a patient attached to it). 

What Actually Closes the Gap 

Closing this gap requires taking concurrent review out of the internal staffing equation entirely, not adding to it. 

That means a dedicated team whose only job is utilization review: applying the same medical necessity criteria the same way, on every admission, every shift, with no PRN gaps and no competing discharge-planning priority pulling attention away. It means a Physician Advisor available for escalation on the cases that need real clinical judgment, not just a criteria check. And it means every review happening concurrently, at the moment the order is written, because that’s the only moment this revenue can still be protected. 

This is exactly the model Brundage Group Utilization Management runs. Our RNs handle remote, concurrent utilization review as their full-time function, so every admission gets reviewed against medical necessity criteria from the moment the order is written, patients land in the appropriate status, and hospitals are reimbursed accordingly. Your case managers get to do the discharge planning work that actually depends on their institutional knowledge, the post-acute network, the payer quirks, the family dynamics, instead of splitting attention with a job that needs full-time consistency to work. 

The hospitals still trying to solve this with one more internal hire aren’t wrong that they have a gap. They’re solving it at the wrong layer.

The post Utilization Review Isn’t a Nursing Function. It’s a Revenue Function. appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Dr. Rao serves as Associate Chief Medical Officer and Vice President of DRG Services at Brundage Group, all while continuing to practice as a board-certified internal medicine hospitalist.

At Brundage Group, Dr. Rao developed and launched a physician-led pre-bill DRG review service line that combines proprietary algorithms, Physician Advisor expertise, and coding collaboration. Clients using the service line have realized an average of more than $1 million in additional DRG reimbursement within 12 months.

Beyond his role at Brundage Group, Dr. Rao oversees onboarding, training, auditing, and mentoring for Physician Advisors and clinical coding teams nationwide and serves as an expert witness in legal disputes involving medical necessity, coding, and payment validation.

He is also active in shaping the field more broadly. Dr. Rao has presented at national conferences with the Association of Clinical Documentation Integrity Specialists (ACDIS) and the American Health Information Management Association (AHIMA), and in 2026 partnered with Pinson & Tang as the primary clinical contributor to its publications and webinars. Through the American College of Physician Advisors (ACPA), where he serves on the certification council and clinical documentation integrity committee, he is helping develop the field’s first clinical documentation integrity certification for Physician Advisors.

Becker’s “Rising Stars: 188 Healthcare Leaders Under 40” recognizes healthcare leaders under the age of 40 who are shaping the future of hospital and health system leadership.

About Brundage Group

Brundage Group is a leading provider of physician-led, tech-enabled clinical and revenue integrity solutions for U.S. hospitals and health systems. Its team of top-tier physician advisors, proprietary analytics and educational programs empower health care providers to ensure inpatient care is thoroughly documented, clinically justified and compliant with regulatory standards. Founded in 2007, Brundage Group is dedicated to enhancing clinical accuracy, regulatory compliance and financial health for hospitals and health systems nationwide, so they can focus on providing exceptional care to their patients and communities. For more information, visit brundagegroup.com.

Media Contact:
Lacey Thompson
Brundage Group
lthompson@brundagegroup.com

The post Dr. Hassan Rao-Becker’s Rising Stars Recognition appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Certus Radar

Why the Timing Matters

Since Medicare’s short-stay review shifted to MAC (Medicare Administrative Contractor) oversight, hospitals have faced tighter scrutiny of the two-midnight rule and self-denial/rebilling pathways. Manual, after-the-fact review makes it harder to catch short-stay cases before billing, increasing both denial risk and audit exposure.

Automating that review process, and the self-denial workflow that goes with it, helps a hospital identify, assess, and correct short-stay cases before they go out the door. In practice, that means:

• Staying aligned with CMS requirements, even under MAC review
• Catching short-stay risk proactively, instead of fighting denials after the fact
• Walking into MAC, RAC, and TPE reviews with stronger documentation and a consistent process behind you

What to Expect When You Make the Shift

One thing worth knowing before adopting this kind of automation: expect a new baseline, not an overnight fix. Case volume and correctly classified inpatient stays typically rise, and denials may tick up along with them. That’s usually a sign of stronger positioning with payers, not a step backward; net revenue improves as the new baseline sets in. The right way to measure performance is against that reset baseline, not against last year’s numbers.

It’s also worth being clear about what this kind of platform does and doesn’t do. It doesn’t direct patient care, and it isn’t a replacement for physician judgment. It ensures the care your physicians provide is documented, defensible, and reimbursable, with every recommendation backed by peer-to-peer review and appeals, so no one on your team defends a decision alone.

Onboarding itself follows a structured path: contract review, an implementation and support-plan build, a defined kickoff, and readiness reviews ahead of go-live. Hospitals that start that process in the next few weeks are typically positioned for a go-live early next year, which is why acting now, rather than in Q1, can make the difference between starting the new year ahead and still catching up.

Making the Case Internally

If you’re evaluating whether this is the right time for your organization, a few questions are worth asking:

• How many observation cases are currently reviewed late, or not reviewed at all, because of census volume?
• What percentage of your team’s time goes to queue management versus actual clinical review?
• How prepared is your documentation for a MAC, RAC, or TPE audit today, versus what it could look like with a consistent, automated review process?

The hospitals that come out ahead under the current compliance environment aren’t the ones waiting for denials to force a change. They’re the ones building the process now, while they still have the choice of when and how to do it.

Why Before Year End, Specifically

Every quarter a hospital operates without this kind of process adds short-stay risk and missed observation reviews to that year’s numbers. Making the change before year-end gives the new baseline a chance to take hold before annual reporting, budget planning, and performance reviews lock in comparisons to the old numbers. Waiting until Q1 doesn’t just delay the fix; it means walking into next year’s audits and board conversations with another full year of the same exposure on the books.

The post Short Stay Compliance: Stay Off CMS’s Radar appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Physician Advisors frequently treat a peer-to-peer (P2P) call with a Medicare Advantage (MA) medical director as though it was an appeal. It is not. Nothing in 42 CFR Part 422 Subpart M (Grievances, Organization Determinations and Appeals) mentions P2P. Why not? Because P2Ps sit entirely outside the Medicare-regulated appeals process. MA plans are free to offer it, discontinue it, or use it however their contract allows, because the non-interference clause keeps CMS out of provider payment terms. Yes, P2Ps remain valuable as demonstrated by three scenarios. 

P2P and Prior Authorizations (Pre-Service Reviews) 

Beginning January 1, 2026, MAOs subject to 42 CFR 422.122 must decide prior authorization requests within seven calendar days, down from fourteen. That compression pushed some MA plans to stop offering P2Ps. Plans that keep option typically use it as an intent-to-deny mechanism. It starts with notification that the request does not meet inpatient criteria and will not be approved absent for more information. A P2P is usually offered within a 24 to 48-hour timeframe. 

The P2P is not an appeal. It is a tool that allows the MA plan to obtain additional information through reasonable outreach before finalizing its initial determination (formally known as an organization determination). This is why MA plans may refer to these as an “educational” P2P. Provide additional clinical details and the plan can still approve inpatient care within the seven-day timeframe. Miss it, and the hospital is looking at a formal adverse organization determination and a reconsideration request (the formal term for a first level MA appeal).

P2P and Concurrent Reviews 

Concurrent review runs on a longer clock, fourteen calendar days, because urgent and emergent inpatient services fall outside 422.122’s prior authorization rules. A patient already admitted and receiving inpatient-level care is a different situation than someone awaiting approval for an elective service.  

The intent-to-deny mechanics are identical to those used with a pre-service request, except the timeline is extended to fourteen days unless an expedited review is requested. The MA plan’s UR team flags that it does not see inpatient criteria, offers a P2P to gather clinical justification, and either authorizes the stay or issues the Integrated Denial Notice. The extra week allows both payers and hospitals a little more breathing room.  

P2P and Payment Reviews 

Then there is the P2P that has nothing to do with coverage at all. A true payment review is a contractual issue and is not regulated by CMS. Payers will often use the term “payment review” or “contractual review” when making an organization determination, so hospitals must be alert to this tactic and push back. An initial determination asking for approval of an inpatient admission, especially if the hospital has yet to submit a claim, is an organization determination. It is not a payment or contract dispute and would fall into one of the above categories.  

Aetna’s Level of Severity Inpatient Payment Policy authorizes inpatient urgent and emergent admissions of one midnight or more for contracted DRG providers but pays a lower severity rate on stays under five midnights unless MCG criteria are met. The admission itself is not denied; only the payment level is contested. A hospital that disagrees with the lower payment can request a severity review, A P2P-style discussion with an Aetna medical director. This P2P is a feature of the network contract, a negotiation tool, not a regulatory safeguard. 

P2Ps Remain a Valuable Tool  

Hospitals should continue to request P2P within their contracts as a mechanism to discuss cases before an adverse organization determination is issued. Used correctly, before an intent-to-deny becomes an adverse determination, or before a severity dispute becomes a stalled claim, it resolves a disagreement with a phone call instead of a formal appeal that consumes UR time; neither side wants to spend.  

Knowing what type of P2P is being offered allows the Physician Advisor to employ the most strategic argument. Is it required outreach before the MA plan finalizes a coverage decision where CMS regulations set the tone? Or is the P2P a courtesy your contract happens to allow where the MA plan dictates rules of engagement. Brundage Group Physician Advisors are successful at preventing adverse determinations when given the opportunity through P2P; with a 61% success rate at receiving full inpatient payment when appealing Aetna low-severity inpatient payments.

Brundage Group can help. Not only do we have expert Physician Advisors, but we also offer operational assistance with scheduling P2Ps. Brundage Group has the experience and resources to support all P2P services. Outsource your Physician Advisor needs to Brundage Group, so P2P scheduling and clinical representation happen without disrupting bedside care. This allows your physicians to continue to treat patients without disruption for administrative reasons.

The post Peer-to-Peer Review: A Tool Not a Right for Hospitals  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Varady has led, advised and scaled numerous tech-enabled and physician-centric businesses over his 30-year career. As chief executive officer of Corridor, he transformed the business into a leader in revenue cycle and education solutions for post-acute care providers. He also served as CEO of Radsource, a leading provider of physician radiology services, and HWT, a health care data services firm.

“Des brings the industry knowledge and transformation experience to broaden our reach as we advance our next phase of growth. Together, we’re building on Brundage Group’s foundation to empower more hospitals and health systems in delivering exceptional care to their patients and communities,” said Tim Brundage, M.D., founder and CEO, Brundage Group.

In his role as president, Varady oversees Brundage Group’s operations across its growing suite of solutions — including clinical status integrity and denials management, real-time analytics and utilization management education — delivered by top-tier physician advisors through a tech-enabled platform.

“I’m energized by what we’re building at Brundage Group,” said Varady. “Hospitals and health systems are navigating unprecedented financial and operational pressures while pursuing new opportunities to improve performance through innovation, technology and physician engagement. We are uniquely positioned to help them as we expand our capabilities, deepen our partnerships and accelerate growth.”

About Brundage Group

Brundage Group is a leading provider of physician-led, tech-enabled clinical and revenue integrity solutions for U.S. hospitals and health systems. Its team of top-tier physician advisors, proprietary analytics and educational programs empower health care providers to ensure inpatient care is thoroughly documented, clinically justified and compliant with regulatory standards. Founded in 2007, Brundage Group is dedicated to enhancing clinical accuracy, regulatory compliance and financial health for hospitals and health systems nationwide, so they can focus on providing exceptional care to their patients and communities. For more information, visit brundagegroup.com.

Media Contact:
Lacey Thompson
Brundage Group
lthompson@brundagegroup.com

The post Brundage Group Expands Leadership Team to Accelerate Growth appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Certus Radar

Not a Generic Automation Tool

Certus Radar wasn’t built by a software team and handed to clinical staff. It was built by Physician Advisors and revenue cycle specialists who do this work every day, which is why it’s designed around a specific problem: knowing which accounts need physician-level escalation, and when, allowing Utilization Review (UR) staff to spend their time on the patients who need it most instead of working every case manually.

What Actually Matters to UR Teams

A few things come up again and again when hospitals describe what makes the platform useful in practice:

• It runs around the clock. Review coverage doesn’t pause for shift changes, holidays, or staffing gaps:  the queue keeps moving even when the team is stretched thin.
• It’s built for compliance, not just speed. Every workflow reflects current clinical and regulatory standards, continuously updated by the physician advisor team behind it.
• It gives leadership real visibility. Real-time KPI dashboards surface the metrics that affect financial performance, rather than retrospective reporting.

The Math Behind the Model

Here’s why the timing matters so much: a single well-timed status upgrade funds roughly 20 automated reviews, with an average upgrade rate above 50%. That’s a return most manual review processes can’t come close to matching, and it’s before factoring in the UR capacity freed up when automation, not staff, handles queue management.

That math compounds every week the process isn’t in place. With a quarter left in the year, every cycle of missed or delayed reviews is a cycle of upgrades, and the revenue behind them that a hospital doesn’t get back. Standing up automation now is what turns the last few months of the year into a recovery window instead of a continuation of the same gap.

How It Works

Under the hood, the process runs in four steps:

1. Initial screening.
2. Automated scheduling.
3. Re-review and ownership transfer.
4. Tracking through resolution.

Getting there isn’t an overnight switch, but it isn’t a year-long project either. Most hospitals move from initial discussions to a signed agreement within a couple of months, followed by an onboarding period built around a defined kickoff, a readiness review, and a go-live date. The timeline is predictable, not open-ended.

The Result

Fewer cases fall through the cracks. Documentation becomes more consistent. And leadership gets a clearer line of sight into how utilization management is actually performing across the organization, not just a report of what happened last quarter, but a real-time view of what’s happening now.

What’s Next

In our final post, we’ll look at why the timing for adopting this kind of automation matters right now, including recent changes to how short-stay cases are reviewed, and what hospitals should expect as they establish a new performance baseline.

The post Turns Manual Reviews Into Real-Time Revenue Protection appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Observation status is the most obvious example. Patients who qualify for inpatient care are often reviewed too late or not at all, since manual triage can’t keep up with changing patient numbers. Every missed or delayed review means lost compliant revenue, not because the clinical decision was wrong, but because it wasn’t made in time.

With fewer staff, Utilization Review (UR) teams have to do more work with the same or even fewer people. Denials are increasing because payers are scrutinizing status decisions more closely, and inconsistent reviews give them more reasons to deny claims. Compliance checks are also stricter for short-stay and observation cases; hospitals need a process that is both fast and defensible. Each pressure makes the others worse: understaffed teams lead to inconsistent reviews, which drive more denials and bring even more scrutiny.

Why Q4 Is the Window to Fix This

With a little over a quarter left in the year, hospitals can either let these problems continue into 2027 or use the remaining months to make changes that will still count for this year. Missed reviews don’t disappear at year-end; they add up over time. Q4 often worsens staffing shortages, since holidays and PTO stretch UR teams even more when manual review can’t keep up.

Onboarding a new process also takes time: contract review, implementation, and go-live typically span a few months. Starting that clock now puts a hospital on track for a clean start next year, rather than beginning the process after the pressure has already peaked.

Where Hospitals Are Headed

The organizations that are succeeding see automation for utilization management and clinical documentation as a key strategy, not just a bonus. They combine automation with physician expertise, so UR staff can focus on cases that need their judgment, while routine queue management happens automatically.

Questions RCM Leaders Are Asking

What are the first steps to start automating UR?
Start by figuring out where reviews are breaking down: identify which cases are missed, delayed, or handled inconsistently, and why. Then, look for a platform that works with your current workflows instead of replacing them, so your screening process stays the same while automation handles scheduling and escalation.

How fast will we see results in denials and compliance?
Don’t expect an instant fix: look for a new baseline instead. As more cases are caught and corrected, you might see a short-term increase in both upgrades and denials. Over time, though, net revenue and audit readiness should improve as things stabilize.

How do we get staff buy-in for the transition?
Present this change as added capacity, not extra oversight. Staff aren’t being asked to do more; instead, they’re freed from manual queue management so they can focus where their judgment matters most. A short ‘what to expect’ session before launch and a follow-up a week or two later can help teams experience the change directly.

What should we look for when evaluating a platform?
Make sure the platform runs 24/7, including nights, weekends, and holidays. Check whether people with real UR and compliance experience manage its logic. See if it gives leaders real-time updates instead of just past reports, and whether it offers denial defense so your team has support.

What’s Next

Next, we’ll look at how one platform, Certus Radar, is designed to solve these problems. We’ll cover how it schedules reviews, why its timing benefits hospitals, and what changes when queue management is automated.

The post Q4: The Time to Fix Hospital RCM Pressure Points appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Jonna began her career as a hospital nurse, spending over a decade in the emergency room before moving into nursing leadership and eventually case management. It was through case management that she discovered utilization management (UM), a field that combined her clinical experience, critical thinking, and desire to help patients in a different way.

“I think you’re an investigator,” Jonna said of utilization management. “You’re looking through the record. You’re trying to see what qualifies.”

That investigative side of the work quickly became a passion. For the past 15 years, Jonna has specialized in utilization management, including consulting with hospitals across the country on best practices, staffing challenges, and process improvement. Today, she brings that experience with her as Director of Utilization Management at Brundage Group.

Clinical Experience Meets Critical Thinking

For Jonna, her years in the emergency room continue to shape how she approaches utilization management.

The fast-paced environment taught her how to adapt quickly, while years of clinical experience strengthened the critical thinking skills she now uses to evaluate patient records and apply clinical criteria.

“You’re using your critical thinking skills as a nurse to see what qualifies in this patient’s condition.”

Jonna Mayfield, RN, BSN, CMGT-BC

That clinical perspective is what allows utilization management to go beyond checking a diagnosis against a set of criteria. It requires understanding the patient’s condition, treatment pathway, documentation, and clinical story as a whole.

It also creates opportunities for education. When documentation does not fully support a physician’s decision, Jonna’s team can engage directly with physicians to better understand the case and help strengthen the documentation.

“Over time, we’ll see an improvement just from having those brief conversations with the doctor,” Jonna said.

For her, those conversations are an important part of the work, not just correcting an individual case, but helping improve processes over time.

The Power of Education

Education is a recurring theme throughout Jonna’s approach to utilization management. She believes the strongest results come from helping healthcare teams understand the reasoning behind the work, rather than simply telling them what to do.

“I love that Brundage Group focuses on education,” she said. “We’re trying to educate as we go so that we’re actually improving processes along the way.”

That philosophy is particularly important in a field that Jonna believes is often underrepresented in traditional nursing and medical education. Understanding utilization management, documentation, and the importance of appropriate level-of-care decisions can benefit clinicians throughout their careers.

Technology as a Tool for Expertise

Jonna has watched utilization management evolve throughout her career. Early in her career, nurses relied heavily on physical books and learned many processes through trial and error. Today, technology provides faster access to information, more educational resources, and opportunities to streamline the review process.

She sees AI as another tool that can help clinicians spend less time searching through records and more time applying their expertise.

A tech-enabled review could pull together the most relevant information from a patient’s chart, potentially reducing the time a nurse spends gathering data. But Jonna is clear about where the expertise still belongs.

For Jonna, the future of utilization management isn’t replacing clinical expertise. It’s about giving experienced clinicians better tools to use that expertise more efficiently.

Making a Difference Behind the Scenes

After decades in nursing, Jonna’s motivation ultimately comes back to the same reason she entered the profession in the first place: making a difference.

And that impact doesn’t have to be visible to the patient.

“You don’t have to be at the bedside with that patient to make a difference,” she said.

A well-supported utilization management decision can help ensure a patient is placed at the appropriate level of care, while accurate documentation and review can help prevent unnecessary denials and support appropriate reimbursement for hospitals.

For Jonna, the connection between those two outcomes is what makes the work so rewarding.

“I love to see that we can decrease hospitals’ denials and we can improve their revenue,” she said. “And it’s all because of this expert team that we have that can come in and make a difference.”

After 35 years in healthcare, Jonna’s role may look very different from where she started, but her purpose hasn’t changed.

“I just have a passion for what we do and love to be able to make an impact for hospitals.” At Brundage Group, Jonna continues to bring that passion to her work every day, combining decades of clinical experience with a commitment to helping hospitals and the patients they serve.

The post Spotlight: Jonna Mayfield | Making an Impact Beyond the Bedside appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

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.

The post Aetna Low Severity Payments: Why They Happen and How to Fight Them appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS

Every so often a query crosses our desk that isn’t leading, isn’t vague, and isn’t technically non-compliant; it’s just too much. Too many findings crammed into one question, redundant phrasing irrelevant to the query purpose, and answer options that muddy rather than clarify the actual question.

We call this query bloat, and it’s just as damaging to a compliant, clinically meaningful query as leading language is.

The Scenario: Everything and  the Kitchen Sink 

A recent query asked the provider to clarify “any clinical significance” for a bundled list of risk factors, clinical indicators, and treatments with options ranging from “clinically insignificant” to “represents metabolic encephalopathy” to “represents baseline dementia only.” 

The patient: an elderly woman with dementia, admitted for weakness and a UTI, with mental status that fluctuated throughout the stay against a baseline already documented as “typically disoriented.” 

The Original Query 

Clarification of Clinical or Diagnostic Findings

Dear Dr.,

Based on your medical judgment, can you further clarify any clinical significance for the risk factors, clinical indicators, and treatments below:

☐ Risk factors, clinical indicators, and treatments below are clinically insignificant

☐ Risk factors, clinical indicators, and treatments below represent metabolic encephalopathy

☐ Risk factors, clinical indicators, and treatments below represent patient baseline confusion and is dementia only

☐ Other (please specify): ___________

☒ Clinically unable to determine / Unknown

Female patient, 90+, with pertinent history of dementia, atrial fibrillation, stated chronic renal failure, HTN, IDDM, depression, HLD, and GERD, brought in from home. Patient is admitted for generalized weakness and UTI.

Clinical Indicators: 

ED Note: Independently ambulatory at baseline and is typically disoriented at baseline according to her three family members present.

— Arrival to the ED she was unable to rise and walk or transfer on her own.

— PSYCHIATRIC: Normal mood and affect. Calm, cooperative. She is not oriented to the year or month which is baseline per the family.

Hosp Day 1: Remains mildly confused but is able to state she is at the hospital and believes it is a different month. She was awake when checked overnight and reported sleepiness but has not slept yet.

Hosp Day 2: She does have a history of dementia; however, they feel it was worsening.

— NEUROLOGIC: Alert and oriented x 3, GCS 15, normal mentation and speech. Moves all extremities x 4 without motor or sensory deficit.

Hosp Day 3: She was found to have a urinary tract infection and was started on Rocephin and admitted here. Her mental status has cleared, but she still continues to be quite weak. She could not participate in therapy yesterday but did participate somewhat this morning.

Treatment: 

Rocephin 1 g, 100 mL/hr, IV Piggyback, Daily 

What Went Wrong 

Asking whether a list of risk factors and treatments “represents” a diagnosis is like asking whether a grocery list “represents” dinner. The question remains: what is being cooked?

The Kitchen Sink: Per the Query Practice Brief, risk factors and treatments aren’t separate from clinical indicators. They are clinical indicators. Throwing them together amid the clinical question blurred and bloated the intent of the query. In fact, there is no reason to include risk factors as these are general findings that can point to a variety of conditions and doesn’t necessarily mean the condition is present. The query should include only relevant clinical indicators that support a vague, incomplete, or missing diagnosis.

The False Choice: “Clinically insignificant,” asks whether something matters at all. If the provider selected that option, then how would they reconcile it with an actual diagnosis? How does that selection bring clarity to the health record and support accurate coding?

The Missed Boat: The golden opportunity to ask one definable question: What is the significance (if any) of acute confusion in a patient with an infection and underlying dementia?

A Tighter Version of the Same Query 

Dear Dr,

Please clarify the etiology of the patient’s mental status changes during this admission:

☐ Metabolic encephalopathy (e.g., related to infection)

☐ Baseline dementia, no acute change

☐ Other (please specify): ___________

☐ Clinically unable to determine

Clinical Indicators:

ED Note: … typically disoriented at baseline according to her three family members present…. PSYCHIATRIC: … She is not oriented to the year or month which is baseline per the family.

Hosp Day 1: Remains mildly confused but can state she is at the hospital and believes it is a different month…

Hosp Day 2: She does have a history of dementia; however, they feel it was worsened… NEUROLOGIC: Alert and oriented x 3, GCS 15, normal mentation and speech.

Hosp Day 3: She was found to have a urinary tract infection and was started on Rocephin and admitted here. Her mental status has cleared…

Same clinical scenario, same underlying uncertainty but now the provider is being asked one identifiable question supported by the indicators that actually bear on it, with options that are genuine, mutually exclusive alternatives.

Query IQ Tip 

Before a query goes out, ask: could I state, in one sentence, the single clinical question this is asking?  If the answer requires an “and,” or the options require the provider to compare apples to oranges, it’s not a sharp query — it’s a bloated one. 

The Takeaway 

This is the discipline Brundage Group builds into every revenue integrity review. Feedback helps your CDI and Coding teams grow their skills and better engage providers through concise, focused queries that matter. If your queries are getting flagged, going unanswered, or just not landing with providers, that’s revenue sitting exposed. Let’s talk about what a sharper approach looks like for your team.

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