Hello, ProviderNation. The fine folks at CMS may have taken another step out of their Medicare appeals swamp. The agency has told its auditors that they’re to limit their post-payment reviews of appealed denials to “the reason(s) the claim or line item at issue was initially denied.”
It’s a fancy way of saying that the auditors will have to scale back their operations and focus solely on whether an alleged, discreet problem with a Medicare payment has been cured or not. Many providers would fix an alleged problem flagged by auditors, appeal the denial, and then find their appeal rejected because auditors went back and found some other reason to deny payment.
Enough, says CMS in its recent Medicare Learning Network newsletter.
Wide Range Of Audits Affected
“Post-payment review or audit refers to claims that were initially paid by Medicare and subsequently reopened and reviewed by, for example, a Zone Program Integrity Contractor (ZPIC), or Recovery Auditor, MAC, or Comprehensive Error Rate Testing (CERT) contractor, and revised to deny coverage, change coding, or reduce payment,” CMS says.
Neil Pruitt Jr., one of AHCA’s most outspoken Medicare reform leaders, says he’s glad to hear of the change.
“We’ve long encouraged common sense reforms at all levels to the claims appeal process,” he says. “With this improved policy, providers who follow the rules will be able to focus more on delivering quality patient care rather than wasting time on avoidable and unnecessary appeals.”
Some Denials Resolved Earlier
The new clarification “will hopefully allow providers to resolve some denials at the lower levels of appeal in situations where they are able to address the original basis for denial,” attorney Lanchi Nguyen Bombalier of Atlanta’s Arnall, Golden, Gregory LLP tells me.
That’s the good news. The bad news?
“With regard to the appeals quagmire, there is no indication that there is relief anytime soon,” Bombalier says. “As recently as April 2015, the Chief Administrative Law Judge (ALJ) reported that they received 474,000 appeals in FY 2014 for review. Considering there were 65 ALJ teams in 2014, with ALJ teams generally handling about 1,000 hearings per year, simple math suggests that it will be a while before the backlog improves, barring significant changes in the appeals system.”
So grab your shovels and sandbags, ProviderNation. There’s plenty more dredging to be done.
*(Special thanks to the fine folks at Wikimedia Commons for allowing us to use, “The swampy Glomsta area, outside of Stockholm,” by Sigurdas, for our cover photo.)