After a year of cutting jobs, freezing pay, and delaying new construction, hospitals in the Minneapolis-St. Paul area turned their businesses around in 2009 and appear to be back in the black. Collectively, net income for hospitals swung to $327 million for the first three quarters of 2009, compared with a loss of $42 million during the same period in 2008, according to the Minnesota Hospital Association, which surveyed 22 hospitals.
Three of the top five insurers in Connecticut have received regulatory approval to raise their rates by double-digit percentages for 2010. A state legislator says regulators aren't doing their job, but both the Connecticut Insurance Department and health insurance companies say that premiums are only keeping pace with medical costs, the Hartford Courant reports. Rate increases recently were released in a report by the Office of Legislative Research, as requested by state Rep. James Shapiro.
Appealing RAC denials is certainly a complex process, but providers can take certain steps to increase their success rate.
When chart requests come in, the appeals process begins, and it can last through up to seven different levels, with each level becoming more expensive to pursue. So determining the proper preemptive actions to take is vital.
"Success with RAC appeals is not about winning a single appeal, or even 10 appeals, or even 100 appeals," said Michael Taylor, MD, senior medical director of government and regulatory affairs at Executive Health Resources in Newtown Square, PA. "You can be extremely successful in your appeals, but if you can only appeal half your cases because of limitations in your human resources, you won't be successful overall in reclaiming the appropriate funds."
For an appeal to have a high likelihood of success, your argument must address three components, according to Taylor:
Clinical: You must have a strong medical necessity argument using evidence-based literature.
Compliance: You need to demonstrate a compliant process for certifying medical necessity.
Legal: You want to demonstrate, when applicable, that the RAC has not opined consistent with the Social Security Act.
And build your appeals with the Administrative Law Judge (ALJ) level in mind. "Start with your head there, and work toward it, it will save you a lot of work in the long run," said Tanja Twist MBA, HCM, director of patient financial services at Methodist Hospital of Southern California in Arcadia (CA).
To effectively and efficiently handle the appeals process, Twist recommended the following technique tips:
Use medical necessity to support your dispute. "Physicians' intent is critical at this stage," said Twist. "Back that up with the clinical evidence."
Bring to light any discrepancy with Medicare policy and procedure, and cite regulations when applicable. "You're going to have to prove that it was necessary and that the intent was there, and that you followed the guidelines," said Twist. "We had good results with this at the ALJ level."
Keep all your deadlines and submit complete evidence. If you don't submit evidence by the second level, they do not have to introduce it into the ALJ process, so make sure you fix problems you uncover as you go, she said.
Do not use template letters. Twist's hospital attempted to use them in the beginning and quickly realized this was not the way to go. Letters should be developed on a case-by-case basis.
Assign one person in the department to take ownership of the process. It's not something that you can multiple people do.
James Carroll is associate editor for the HCPro Revenue Cycle Institute.
An international human rights organization is reviewing whether Atlanta-based Grady Memorial Hospital violated the rights of patients of its now-closed outpatients dialysis clinic. The Inter-American Commission on Human Rights has asked the U.S. government to respond to accusations by the patients' attorneys, who assert that the hospital violated the patients rights to life and well-being. The approximately 50 patients are virtually all poor illegal immigrants who paid nothing for their treatments, the Atlanta Journal-Constitution reports.
Both the House and Senate bills would provide $5 billion to create a temporary insurance pool until an insurance exchange is developed. Under the House bill, this program would be available to people who have a preexisting condition or have been uninsured for at least six months. Under the Senate bill, individuals would have to meet both requirements to be eligible. Here, the Los Angeles Times tries to further explain how the insurance pool would work.
The Washington, DC, Department of Health Care Finance started work a little more than a year ago with a mandate to end years of dysfunction in the city's Medicaid program, after sloppy accounting had cost the city tens of millions of dollars from the federal government, the Washington Post reports. But a year after halting Medicaid claims so it could straighten out its billing, the DC Child and Family Services Agency told city officials that it faces a shortfall of about $10 million because it hasn't fixed all of the problems and isn't ready to resume claiming money from Medicaid, the Post reports.