Medicare Advantage (MA) plans and commercial payers may deny claims for what seem like preventable readmissions, but hospitals may be able to overturn them when patient noncompliance is the driver, an appeals expert said. It’s one of the variations on the theme of readmission denials that could be ripe for appeals and possibly won’t be the uphill battle they sometimes are.

One hospital recently changed a payer’s mind about a readmission after proving it had done everything it could to help a noncompliant patient, said Denise Wilson, senior vice president of Denial Research Group/AppealMasters in Towson, Maryland. She cautioned, however, that these appeals are iffy. “It’s a tough nut to crack,” Wilson said. “You can say, ‘We did everything possible to make sure the patient had all the support and resources when they went home and gave them a good discharge plan,’ but it’s not always in your control and sometimes not easy to prove they were not compliant.”

In this case, a 34-year-old patient was discharged March 8, 2022, from an inpatient hospital stay with a diagnosis of osteomyelitis and dry gangrene of the left foot that had caused the amputation of his fourth toe. Before his admission, the patient had been treated for the osteomyelitis with IV antibiotics at home, but the home health agency said he wasn’t compliant with the treatment plan and had “a long history of medical noncompliance and poorly controlled diabetes,” Wilson said at a webinar sponsored by the Association for Healthcare Denial and Appeal Management.^[1] The MS-DRG for this admission was 617 (amputation of lower limb for endocrine, nutritional and metabolic disorders with complications and comorbidities).

To help the patient after discharge with home IV antibiotics and wound care, home health was arranged and follow-up visits were set for primary care, endocrinology, surgery and infectious disease, Wilson said. The care team decided to switch the patient’s home IV antibiotic from vancomycin to Daptomycin, which could be administered less frequently because of his “noncompliance with frequency of home IV dosing.”