This is Our Concern, Dude….

U.S. Rep. Jim McDermott, D-Wash., is pressuring HHS officials to solve their administrative appeals crisis.

U.S. Rep. Jim McDermott, D-Wash., is pressuring HHS officials to solve their administrative appeals crisis.

Good afternoon, ProviderNation.

U.S. Rep. Jim McDermott has some, um, questions about the monstrous backlog of health care appeals that has so, um, disconcerted folks lately.

In a “This is our concern, Dude,” letter to Health and Human Services Secretary Kathleen Sebelius, McDermott says he’s “troubled” that patients may be getting buried in paperwork and that the recovery auditors (RAs) themselves are “the proximate cause” of all this trouble.

The distinguished gentleman from the fine state of Washington (who also happens to be the ranking member on the Health subcommittee for House Ways & Means) says he hears that even though Medicare beneficiaries are supposed to be moved to the front of the line in all appeals, “because of the sheer number of appeals, some beneficiaries are even having troubling having their appeals heard.”

This, as everyone’s favorite medievalist might say, is intolerable.

But the real target of McDermott’s letter appears to be the RAs themselves. He says that the government can save itself a lot of trouble “without any intervention by Congress” by, among other things:

1.)    Changing the “two midnights” policy. McDermott has been on this before, and he says the policy is “flawed and unworkable.” He adds that “the underlying issue that is driving the need for more concrete admission standards” is the RA program, which McDermott says “should be re-examined and modified.”

“I know that CMS has limited the ability of RAs to review claims under this policy while the policy is adjusted but I note that Medicare Administrative Contractors (MACs) are able to deny improper claims that they identify as part of the probe and educate reviews,” McDermott says. “I continue to have serious reservations about this policy and believe that it will only exacerbate the appeals backlog. Because important issues such as these are not well understood, I ask that you reconsider whether this policy is ready for enforcement—even limited enforcement through probe and educate reviews.”

2.)    Adding “enhanced accountability” for the auditors. McDermott says he’s worried that the auditors seem to be playing with house money—even if they lose on appeal. “I suggest that there needs to be some financial penalty associated with RA collections that are overturned on appeal,” he says. “If providers are winning these appeals by large margins, which seems to be the case, this seems only fair.” And finally, the government should make sure that …(see #3).

3.)    The new “pause” in audits actually “addresses the problem,” McDermott says. “I suggest that the pause be continued until relevant parties are certain they have a plan in place to (a) make appropriate modifications to the RA program and (b) address the existing backlog of appeals,” he says. “In addition, you might consider limiting the lookback period associated with claims submitted during the pause.”

Bill Myers is Provider’s senior editor. E-mail him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

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Filed under Long term care, Post-acute care

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