RAC Appeals Process 'Broken,' AHA Says
"What these auditors seem to be doing is focusing on cases with claims for care provided during short lengths of stay, with the presumption being that if the length of stay was short, these patients probably didn't need to be inpatients in the first place. So therefore, they gamble that's the case and recommend denial."
He adds, "It's almost un-American the way this is being rolled out."
"Essentially, the RACs are saying, 'you know, for all these short stay ones, we're going to assume that Medicare overpaid, and recommend denial, which moves a complex medical decision into a time-based criteria.'"
But in most of these cases, Hanks says, "when the patient presents, it's not clear what the clinical course is going to be, and where there's a substantial risk to the patient if (he or she is not admitted)."
Many of the denials his hospital is appealing have to do with patients whose care was billed as an inpatient but who in retrospect the auditors believe should have been on observation, a shorter, and less expensive category of outpatient as opposed to inpatient hospital care.
That means that patients and their families now have co-pays and deductibles, and don't qualify for Medicare coverage of many important types of post acute care services, such as a stay in a skilled nursing home. And that hurts beneficiaries, Hanks says.
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