Viewpoint: AHA takes wrong approach in guidelines for addressing Medicare appeals

The Council for Medicare Integrity has come out against the American Hospital Association's recommendations for Medicare appeals.

In a July 10 announcement, the nonprofit advocacy organization said the AHA's recommendations are "unconscionable" given current integrity program reforms.

The announcement was in response to a brief filed by the AHA June 22 after Judge James Boasberg with the U.S. District Court for the District of Columbia asked the association to provide input on how to reduce the Medicare appeals backlog at the administrative law judge level.

The council said the AHA's recommendations are redundant based on current CMS rules, and that they also indicate a desire to sideline Medicare's Recovery Audit Contractor program, designed to identify and correct improper payments.

"The AHA's suggestions are unconscionable given the recent Medicare Trustees' Report predicting Medicare Part A insolvency is just eight years away," said Kristin Walter, spokesperson for the council. "For this reason alone, there is a shared responsibility among all stakeholders to ensure that overpayments are returned to the Medicare Trust Funds.We must have balance between program integrity efforts and due process. Real appeals reforms are necessary to improve the Medicare appeals process, just as CMS reformed the RAC program. Program integrity, quality of care and financial solvency should not suffer while appeals reform continues to evolve."

The council specifically pointed to the AHA's recommendation that HHS penalize RACs with an overturn rate at the administrative law judge level greater than 40 percent in a given quarter.

The council contended this recommendation "is clearly redundant and not nearly as strict as the 10 percent threshold currently in place per CMS."

The AHA also recommended that hospital-related claims that would be performed by RACs be performed instead by quality improvement organizations, described as groups "of health quality experts, clinicians and consumers organized to improve the quality of care delivered to people with Medicare."

Ms. Walter responded to that recommendation by saying she believes quality improvement organizations are not as equipped for the job as Medicare's audit program.

"CMS and RACs have proven that RACs are the best equipped to identify and pursue overpayments. Plus, the current QIO fixed-fee payment structure will lead to higher costs to perform overpayment reviews and are contrary to national calls to move healthcare towards pay-for-performance models," she said.

Read the council's full response to the AHA's recommendations here.

 

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