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Recovery Audits Targeted by House Bill, AHA Suit

James Carroll, for HealthLeaders Media, November 9, 2012

"It is a danger to our patients in that we are spending resources on bureaucratic and administrative costs versus clinical costs," Wiik says. "However, we will deliver the care necessary to our patient in the highest quality form regardless of the funding mechanism; you can't let the governmental administrative costs reduce the quality of care given."

"That said, we need to receive every dollar in which we are legally entitled to ensure that we keep our doors open operationally by balancing these two things the best we can."

In a press release issued November 1, the AHA states specifically that it is contesting HHS's denial of reimbursement for reasonable and medically necessary cases that the government believes should have been provided in an outpatient facility or department instead of the inpatient section of the hospital.

"When a patient needs treatment, the first step is for a doctor to decide whether to admit the person to the hospital or to provide care in an outpatient facility. The decision is often complicated for Medicare patients because of advanced age and the presence of other ailments, such as diabetes or high blood pressure, which makes the physician's decision as to where best to treat them more difficult," the AHA states in the letter.

As a result, RAs are reviewing and denying cases from hospitals and physicians years after the care was provided without ever seeing or talking to the patient. Not surprisingly, the press release states that hospitals appeal these "questionable decisions," they prevail at least 75% of the time.

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