Coping with the Incompetence of Others

Tales abound regarding contractors’ errors negatively impacting providers. 

If you read my previous article on the audit by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) on billing of services by acute-care hospitals that were provided to patients who were inpatients at another facility, you will recall that because the Centers for Medicare & Medicaid Services (CMS) did not have properly functioning edits, the acute-care hospitals now will have to pay back millions of dollars for services they provided.

But situations like this are not rare. My reporting in this article includes two more examples of some of the ridiculous things that providers have to go through because of the incompetence of others.

I recently was contacted by a revenue integrity director at a hospital about an audit performed by their Medicare Administrative Contractor (MAC). They sent in the records as requested and then received denials. The denial code specified that the services did not meet the medically necessity guidelines outlined in the MAC’s local coverage determination (LCD). The hospital reviewed the charts and felt that the guidelines were in fact met, so they appealed.

After the appeals were submitted, they were informed that there was “a claims processing issue” and the denials had been issued in error. When they queried via the claims processing system, they could see that the claims were now paid in full. So at that point, they were not happy at having to take the time to write the appeals, but grateful that the claims were paid in full. Now, you would think that was the end of story.

Well, not so fast. A month later, they received a letter from the appeals department at that same MAC telling them that their appeal was reviewed and the decision was unfavorable, because the claim was already paid. Wait – what just happened?

Here’s what: Several claims were denied, so the hospital appealed. While their appeal was in the mail, the denials were overturned since they were denied in error. But since the appeal was already in process, it could not be cancelled, so the MAC reviewed the appeal and denied it.

Yep, the MAC issued an unfavorable decision on an appeal arguing that a claim was correct while at the same time agreeing that the claim was correct. Not only that, the decision letter provided instructions on how the hospital could appeal the unfavorable decision to the next level.

“But the hospital got all their money, so shouldn’t they just move on?” you might ask. Well, the hospital’s concern is that these unfavorable appeals now will be recorded at the MAC and will harm the hospital’s overall overturn rate, potentially leading to more audits. I am also concerned that the MAC will use the unfavorable decision with lack of further appeal as proof that they are doing a good job in their audits. So, what is the hospital’s next step? The hospital is going to try to work with the MAC and get those appeals off their record.

And in another example of providers suffering the consequences of a Medicare contractor’s poor work performance, NGS sent out a notice this past Thursday indicating that many Part B claims submitted in September did not properly cross over to the supplemental insurer because the Benefits Coordination and Recovery Center improperly applied edits that were not to go into effect until Oct. 1. A reasonable person might expect the MAC to go back and fix the claims by bypassing the edits and submitting the claims to the secondary payer.

But that is not what is happening. Providers who received a letter informing them of the error were also informed that they must submit the claim directly to the secondary insurer. And since these claims normally cross over automatically, these providers are unlikely to have these payers set up in their systems, requiring a lot of extra work. And when the secondary payers get claims directly from the provider and not from CMS, I suspect that the secondary payer is going to reject them because they did not come directly from CMS.

I understand that Medicare is a huge conglomerate with millions of moving parts, but why does it seem that providers always face the consequences when others are at fault?

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Inpatient Admission Order: Master the Who, When, and How

The Inpatient Admission Order: Master the Who, When, and How

During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.

June 20, 2024
Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

May 21, 2024
Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

June 26, 2024
Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.

July 11, 2024
Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.

June 26, 2024
Mastering E/M Coding: Navigating the Evolving Landscape

Mastering E/M Coding: Navigating the Evolving Landscape

Join industry expert, Kathy Pride, RHIT, CPC, CPMA, CCS-P, for an in-depth exploration of Evaluation and Management (E/M) coding, tailored for healthcare professionals navigating recent guideline changes. Dive into advanced topics beyond mere code selection, including shared visits, criteria for selecting E/M levels, and documentation best practices. Gain clarity on complex guideline terminology and ensure compliance with regulatory standards. This comprehensive session is essential for coders, auditors, educators, and practitioners seeking to enhance their proficiency in E/M coding and maximize revenue capture.

June 19, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Honor Memorial Day with Savings! Get 20% off all items using code MEMORIAL24 at checkout. Shop today and save! Offer valid until May 31. Exclusions apply.

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.