discussion week 13
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School for Professional Studies, CUNY *
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380
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Medicine
Date
Feb 20, 2024
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docx
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Uploaded by aminashaik76
The CMS and the AHA do not agree in terms of reimbursement because the CMS is trying to save money on unnecessary medical expenses. The AHA on the other hand feels that the RACs do not have enough medical knowledge to decide whether patient care should be denied reimbursement. The AHA feels that
CMS rules are at times not appropriate leading to delayed or low reimbursements. I feel that the CMS should work with the AHA and a common ground should be achieve whereby overpayment does not occur and the hospitals do not suffer from low payments. The AHA feels that the two-midnight rule causes improper payments because to decide the patient status the provider must consider several factors. Some of them are the availability of services needed for the patient in a particular setting, types of facilities that will accept the patient depending on their insurance, the patient medical history that includes secondary conditions, the severity of illness the patient presents with and the prediction that the patient could suffer from a sudden emergency condition and the availability of diagnostic services at the facility. So, we see that when a patient is first admitted the physician does not have enough information to keep them as patients needing inpatient services or as outpatients. Also, the time it takes for the test results to come in or consulting physicians to discuss the situation. In the meantime, the patient may need general life sustaining intervention. Only after that the care could be tailored with less expensive techniques which could be after 2 midnight. The decision to select the type of care for a patient is complex and cannot fairly be based on a certain amount of time. Finally, if the outcome is different CMS does not feel that the reimbursement is appropriate just because the physician did not document on admission that the patient should be admitted as an inpatient. This is not fair on the part of CMS. Also, if CMS does not want to reimburse it as an inpatient stay, then they should reimburse it as a short inpatient stay. In addition, they don’t provide any guidance to the physician as to what qualifies as an inpatient stay, and they don’t want to agree with the physician’s judgment. “The rule also allows physicians to utilize judgment to admit patients for shorter durations but does not provide explicit guidance on when they may do so.” (Caspi, 2015, Dive brief Section) The 0.2% payment cut made by CMS was in their justification that many patients could have been treated with less costs as per the two midnight. However, there was no proof provided as to where exactly the payment cuts were made and how this general number of is justified as a cut. IPPS rates are updated annually, and rates of services and goods do change according to changing market conditions. Besides this RACs are using automated screening without doing any manual review leading to improper reimbursements. RACs scrutinize inpatient claims more because they find it more lucrative in terms of their own payment (contingency fees). In the process even if the hospital is right, it is hospital that loses more in terms of time and finance to continue operating. Denied claims are not flexible toward rebilling and this is frustrating for physicians because even when physicians receive a notice of an audit, they do not have sufficient time to prepare. Not only this, but the RAC can also conduct audits up to 3 years old. This makes it difficult for doctors to decide because they are always under pressure that they will scrutinize by the RAC after more than a year. A doctor may not be able to remember everything that happened despite all documentation and therefore become defenseless even if they had made the best decision for the patient at that time. The AHA argues that RACs take more than a year from the date of service to deny or accept claims. So, it is only fair that the provider be given more time to go over the case and remember incidences to gather more evidence. Also, after 1 year if the RAC thinks that the service could have been provided in an outpatient setting
then physicians should be allowed to defend their arguments by providing supplemental evidence or amending Part A claim rather than being told to resubmit as a part B claim.
The HHS has set a deadline for RAC to review appeals and send an answer within 90 days. The AHA knows that when those appeals are re-evaluated, they do get overturned most of the time. The problem
is that many hospitals are facing the same problem, and that money is required for running the hospital or increasing necessary facilities is stuck with the CMS due to improper RAC judgment. The HHS can definitely do more by dealing with outstanding payments and returning a bulk of the money to the hospitals. The process is not made easy for hospitals because there is no incentive for this as CMS has claimed to be, and they want to add more layers of review from the lower levels. According to Larry “Early on, if you got a denial, you could read the thought process of the reviewer. Increasingly today, we get these blurbs of meaningless information at levels 1 and 2.” (Eramo, 2013, Why else could the numbers be low? Section) It is also possible that the denial is not read carefully and the reason for denial
is just copied and pasted from one to another. To deal with the appeals process providers must spend a lot of money and time despite the limits set by the CMS. References:
Eramo Lisa A. (2013) RACs Appeal – It is not easy work but Hospitals and providers are succeeding. Radiology today. 14(10). 20. Retrieved from: https://www.radiologytoday.net/archive/rt1013p20.shtml
Caspi, Heather (2015) 2016 OPPS rule finalizes two midnight policy, doesn’t take criticism. Healthcare dive. Retrieved from: https://www.healthcaredive.com/news/2016-opps-rule-finalizes-two-midnight-
policy-doesnt-take-criticism/408466/
According to the two-midnight rule for PART A reimbursement, the patient must be admitted by a qualified physician and must require necessary medical services for at least 2 midnights. The CMS is strictly saying the patient must stay for the full two days, till 12 am of the second night. Patients that are admitted at about 1 am are more likely not to cross the second 12 am midnight hour than those that come at 11pm. CMS has made contradictory statements in the past that it would rely on physician judgment to qualify the patient as an inpatient who needs to stay at least 2 midnights at the hospital. The HHS has not required an RAC to have a physician’s qualification to make this judgment or to judge the treating physician’s judgement. Yet RAC can decide if the patient should be denied inpatient status. Even if the patient stays only for one night it is quite possible that they were being provided with intensive inpatient only for one day or a litter more but less than two days. These inpatient intensive care
services mostly could not be provided at an outpatient setting. Besides this the medical necessity for the services provided for each patient is different and if AHA provides proof of this CMS should not delay reimbursement. Also because of not expecting the RACs to respond in accordance with the deadline of
the 90 days rule some providers only appeal those claims with very high monetary values and accept the
unfair denials on low cost claims. Worst of all, if a patient deserves to get more reimbursement by being admitted as an inpatient and the RAC denies the claim and places it in the outpatient category then the patient must bear the cost sharing burden which is unfair to the patient. The problem is that there is a lack of agreement between the provider and the auditors to set and abide by guidelines for appropriate payment.
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