Apprise MD

09/11/2025

Crucial factors can get overlooked and contribute to payer denials, emphasizing the need for physician advisors to engage in peer-to-peer (P2P) discussions with the payers to clarify medical records. Our new case study shows how a 30-day readmission was used to deny a claim that was reversed during a P2P between a payer medical director and an AppriseMD physician advisor.

Read the full case study at:

Short stay case study from AppriseMD involving a patient with Lennox-Gastaut syndrome highlights the need for a peer-to-peer, resulting in denial overturned.

09/09/2025

Apprise MD is a proud supporter and corporate member of the American Board of Quality Assurance & Utilization Review Physicians, Inc. The organization is hosting its 48th Annual Conference beginning September 11 in Clearwater Beach, Florida. Learn more here:

Annual Health Care Quality & Patient Safety Conference - A Multifaceted approach to health care quality and patient safety

09/05/2025

An Apprise MD physician advisor uncovered that a payer’s denial of services stemmed from a 30-day readmission/DRG linking denial and subsequently clarified the two distinct and unrelated admissions during a peer-to-peer (P2P) review with the payer medical director. Following the P2P, the denial was rescinded, resulting in increased reimbursement.

Read the full case study at: https://apprisemd.com/case-study-readmission-linking-denial-overturned/

08/26/2025

Microsoft’s newly developed AI-enabled diagnostic system achieved high diagnostic accuracy when paired with OpenAI during a recent experiment in diagnosing complex medical cases. Several limitations with the experiment were noted, including a lack of real-world constraints and absence of specialists in its comparisons.
Read more about the experiment at

MAI-DxO AI reportedly diagnosed complex medical cases with over four times higher accuracy than generalist physicians and saved costs.

08/21/2025

Another health insurance company is sued over the alleged use of AI in claim denials, according to an article published by HealthExec which states that “unlawful and unethical actions undermine the fundamental principle that healthcare decisions in America should be made by doctors.”

Read more about this at https://healthexec.com/topics/healthcare-management/legal-news/hospital-sues-insurer-over-use-ai-deny-2m-claims.

AdventHealth Shawnee Mission is suing Blue Cross and Blue Shield of Kansas City over its AI claims audits, which have rejected some 350 incidents of patient care. The hospital claims the insurer is violating state and federal laws.

08/19/2025

Medicare Advantage plans received more than $1 billion from the federal government for veterans enrolled in their plan, even though no Medicare health services were utilized under the MA plan.

Read more about the duplicate payments at https://www.beckerspayer.com/policy-updates/lawmakers-target-medicare-advantage-va-loophole-wsj/

08/14/2025

Medical necessity determinations are not always clear-cut, accentuating the need for seasoned physician advisors to engage in clinical discussions with payers to overturn denials. The latest Apprise MD case study highlights the importance of challenging payer denials to recover appropriate reimbursement. Read the entire case study at

Short stay case study from AppriseMD involving a patient with Lennox-Gastaut syndrome highlights the need for a peer-to-peer, resulting in denial overturned.

08/12/2025

61% of physicians fear the unregulated use of AI by insurance companies in prior authorization denials, according to a survey by the American Medical Association.
More about the survey can be found at

Over 60% of doctors say unregulated AI tools systematically deny patients coverage for necessary care. The AMA is fighting to fix prior authorization.

08/07/2025

A commercial payer overturned their denial following a peer-to-peer discussion by an physician advisor who focused on the medical management of a comorbid patient with a high-risk surgical status, even though the patient did not require surgery.
Read the full case study at https://apprisemd.com/case-study-profound-obesity-risk-factor-overturns-denial/

08/05/2025

The urged Congress to enforce penalties against MA plans that do not comply with federal rules, including plans that do not adhere to medical necessity criteria.

You can read the AHA’s statement on ways to strengthen the MA program to ensure that seniors have timely and appropriate access to care at https://www.aha.org/system/files/media/file/2025/07/AHA-Statement-on-House-Ways-and-Means-Committee-Hearing-on-Medicare-Advantage.pdf

07/29/2025

With American Board of Quality Assurance & Utilization Review Physicians, Inc. – I just got recognized as one of their top fans! 🎉

07/24/2025

AppriseMD applauds the collaboration between Joint Commission and Coalition for Health AI (CHAI) in efforts to scale the responsible use of AI in delivering better healthcare.

https://www.jointcommission.org/en-us/knowledge-library/news/2025-06-the-joint-commission-and-coalition-for-health-ai-join-forces