Medicare Appeals

Talk about beating a dead horse. I am once again blogging about my what has become my new favorite topic, Medicare appeals or the Recovery Audit Contracting process.  Today, I read a great article by our RAC consultant, Tom Herrmann in the January - February edition of the Journal of Health Care Compliance.  The article is on the latest announcement from the Office of Medicare Appeal Hearings on delays in adjudicating cases due to the massive backlog of appeals.  Tom also provides a great overview of the RAC process.  

The item where I take issue is where he describes what we as providers need to do to facilitate the ALJ adjudication process.  It's always about what we as providers can do.  What is rarely mentioned is the albatross created by Health and Human Services to root out improper Medicare payments, i.e, catch fraudulent providers to facilitate the process.  

Very little of the Government's role related to the RAC process is automated.  They open mail and process appeals manually; can you believe it in this day and age?  They are well over a year away from any automation and we know how well the Feds are at bringing systems up these days.  

They created a RAC process that is wrought with problems.  As I have blogged previously, they expected hospitals to roll over and simply budget for the RAC process in our operating budgets as most hospitals did initially.  We never did at WMHS; we challenge every case where we believe the correct care was provided.  Isn't it interesting that we have never won an appeal by the RAC auditor who is incentivized by the number of cases that they target?  We have never won an appeal at the Qualified Independent Contractor level either.  We have won almost every case at the Administrative Law Judge level as have most hospitals because the ALJs are not incentivized.  They adjudicate the cases appropriately and as a result, the appeals at this level have proliferated. So, why not restructure the process up front.  

Marilyn Tavenner, the CMS administrator, is now trying to convince us that CMS is exploring ways to improve  the RAC process.  I am sure they are but it's time to ask the people who they are burdening financially and administratively with this boondoggle for our advice and guidance.