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Recovery Audits Targeted by House Bill, AHA Suit

James Carroll, for HealthLeaders Media, November 9, 2012

"What the federal government is doing is wrong, unfair, and a clear violation of federal law," Rich Umbdenstock, president and CEO of the AHA, stated in the AHA letter. "Doctors and nurses provide the best care possible using their medical judgment and training. Allowing government auditors to second-guess these difficult medical decisions about where to best treat a patient years later based on a cold record and then refuse to pay for that care is indefensible."

While this is arguably the biggest RA-related news to surface in the past few weeks, it's not the news worth only noting.  The AHA is also urging the Office of the Inspector General to examine the inaccuracies of the Recovery Auditors.

In a letter issued October 24 to HHS Inspector General Daniel Levinson, AHA Executive Vice President Rick Pollack recommends halting inappropriate payment denials by RAs, streamlining CMS' integrity programs to eliminate duplicative audits, and investing in provider education and payment system fixes to prevent payment mistakes.

Pollack cites AHA RACTrac data, which verifies that hospitals reported appealing more than 40% of all Recovery Auditor denials with a 75% success rate in the appeals process. He urged the OIG to review of the effectiveness of the auditors and CMS-related oversight efforts and to pay particular attention to how often RA determinations result in inappropriate denials of payment for medically necessary and reasonable services, not only on whether RAs identify improper payments and refer potential fraud cases to law enforcement.

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