Understanding the Medicare Appeals Process

The US Medicare system provides health insurance for seniors and certain disabled individuals. When Medicare denies or ends coverage for a patient's care (for example, a hospital stay or treatment), the patient or their caregiver can file an appeal to challenge that decision.

Here's how the process works:

• The Denial:
  Medicare denies or ends coverage for a specific medical service.
• The Appeal:
  The patient (beneficiary) or their representative files an appeal, asking for the decision to be reviewed.
• The Review:
  A Medicare physician (a doctor familiar with Medicare's rules and patient needs) reviews the case—usually within 24 hours.
• The Decision:
  The physician either approves the appeal (care continues) or denies it (the original decision stands).
• The Communication:
  Specially trained nurses at Acentra Health take the physician's complex, clinical notes and translate them into clear, empathetic letters. These letters are sent to:
  • The Beneficiary: Explaining the outcome and the reasons in plain language.
  • The Hospital or Care Provider: So they know whether to continue or end care.
• What Happens Next?
  • If the appeal is approved: The provider must continue or resume care, and Medicare may continue covering the services.
  • If the appeal is denied: The provider can proceed with discharge or ending services, but the patient is informed in advance and told about their right to appeal again at a higher level.
• Multiple Levels of Appeal:
  The Medicare system allows for several rounds of appeal. Each letter from Acentra Health includes instructions on next steps, deadlines, and contact information for further help.

Acentra Health supports 45 Medicaid agencies and 25 federal agencies, managing thousands of Medicare appeals every month. Nurses were manually translating dense, clinical physician notes into plain, empathetic language for both patients and providers—under strict 24-hour deadlines. This process was:

• Manual and labor-intensive
• Required fast, accurate translation of complex medical jargon
• Led to high operational costs and nurse burnout

Acentra Health partnered with Microsoft to develop MedScribe—a generative AI web app powered by Azure OpenAI Service. MedScribe automates the drafting of personalized, plain-language appeal response letters from physicians' notes, ensuring clarity, empathy, and compliance.

• Azure OpenAI Service: Generates human-friendly, empathetic letters from clinical notes
• Microsoft Azure: Secure, HIPAA-compliant cloud infrastructure
• Power BI: Tracks performance metrics (approval ratings, letter volume, time per letter)
• Continuous Feedback Loop: Nurses provide real-time feedback to refine AI outputs

• Accuracy: Ensuring medical information is translated correctly
• Empathy: Maintaining a compassionate tone in sensitive communications
• Compliance: Meeting HIPAA and regulatory requirements
• Solution: Close clinical-technical partnership, iterative prompt refinement, and secure cloud deployment

• 11,000 nursing hours saved
• Nearly $800,000 in cost savings
• Productivity increase:20–30 letters/day per nurse (up from 12–14)
• 50% reduction in time per letter (from 6 to 3 minutes)
• 99% approval rate for MedScribe-generated letters from nursing staff
• 65,000 letters completed in the first six months

• Clinical-technical partnerships are essential for successful AI adoption
• Continuous feedback loops drive ongoing improvement and trust
• Security and compliance must be built in from day one
• Start with high-volume, repetitive tasks for maximum impact
• Measure what matters: hours saved, cost reduction, and user satisfaction

🐯 Tiger Takeaway:

If your healthcare organization is still manually processing high-volume administrative tasks, you're burning money and burning out staff. Acentra Health's MedScribe shows that AI can deliver real savings, boost productivity, and improve both patient and staff experience—without sacrificing compliance or compassion.

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