Protecting Provider Revenue
Listen to the full interview with McGraw and Maynard:
by Dawn Crump, Senior Director, Revenue Cycle and Denial Management Solutions, Intersect Healthcare
Reproduced with permission of RCM Answers
Dawn Crump
Senior Director, Revenue Cycle and Denial Management Solutions, Intersect Healthcare
Twitter: @IntersectAppeal
Its been 10 years since the Recovery Audit Contractors rocked hospital providers world with a record number of audits and overpayment determinations. Commercial health plans took notice and refined the art of audits and denials, creating even more administrative burdens and financial liabilities for hospitals and patients to shoulder. 2019 will be no different, commercial health plans will continue to deny short stays, experimental procedures, high cost drugs and common costly procedures for lack of medical necessity. There will be even more growth in clinical diagnosis validation denials which are not only costly but time consuming to appeal. More and more hospitals will escalate their payment disputes and look for settlements to alleviate some of the burden brought on by heavy denials. Hospitals need to work together within their internal departments to fix true denials and externally with their peers to identify egregious behavior and look for wins to stop the abuse from payers.
By R. Kendall Smith, Jr., MD, SFHM
A report released by the HHS Office of Inspector General (OIG) in September 2018 found that Medicare Advantage Organizations (MAOs) overturned a jaw-dropping 75 percent of their own denials from 2014 to 2016. Even more startling was that independent reviewers at higher levels within the appeals system reversed originally denied claims, finding in favor of beneficiaries and providers.
Furthermore, 45 percent of contracts were cited by CMS for sending denial letters with incomplete or misleading information, which may have hindered providers’ or beneficiaries’ chances of prevailing with an appeal. What appears of immense concern in this report was the comment that CMS continues “to see the same types of actions in its audits of different MAOs every year.” More telling was that 76 MAO contracts overturned more than 90 percent of their own denials upon appeal, including seven contracts that overturned more than 98 percent.”
Given these astounding overturn numbers, one has to wonder why beneficiaries and providers appealed only 1 percent of denials to the first level of appeal—reconsideration by a Quality Improvement Organization or their MAO. The remaining 99 percent of denials go unchallenged despite an almost four out of five chance of prevailing on appeal.
In the words of Bob Marley: “Get Up, Stand Up, don’t give up the fight.” Stop letting money flow down the drain.
Tracey Tomak, PMP, RHIA, the director of project management and client engagement at Intersect Healthcare, was quoted in this article. For the full journal and original article, see the source information below.
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Intersect Healthcare invites all healthcare leaders and revenue cycle professionals to join them September 22-26, 2018, at AHIMA booth 219. Learn how the VERACITY software suite offers the most comprehensive and user-friendly solution for managing audits, revenue risks, denials, and appeals.
September 20, 2018, Towson, MD—Intersect Healthcare, the leader in Payment Compliance, Audit & Denial Management software for hospitals and health systems, announced it will be presenting its full suite of VERACITY™ revenue recovery software at the 90th AHIMA Convention and Exhibit.