New Appeal Process Proposal Brings Comments

New Appeal Process Proposal Brings Comments

I have spoken in the past about the new proposed appeal process for Medicare patients whose status has changed from inpatient to outpatient. When new rules are proposed, I like to browse the submitted comments to get a feel for the sentiment in the community. And in every case, there are very good comments submitted that ask very astute questions – and other comments that actually show how people really feel. 

And this proposed rule is no different.

So far, the Centers for Medicare & Medicaid Services (CMS) has only posted 15 comments, and four of those are from some guy named Dr. Ronald Hirsch, who seems to have nothing else to do but flood CMS with questions. Now, of the others, several again discuss the problem with the three-day rule for Part A skilled nursing facility (SNF) access, and how patients whose status has changed currently lose that access (along with a request that CMS get rid of that). 

Another comment came from a hospital medical officer who was upset that outpatients get charged for their self-administered medications. And all of you have heard me say it time and time again: if a hospital is charging their patients, that’s on the hospital. In 2015, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) made it official that hospitals do not have to charge for those medications, so any hospital still doing so should simply stop the practice.

There is also a comment that the change from inpatient to outpatient should not happen because it results in higher costs for the patient. And of course, all of you know that I have talked about that in the past – and it’s simply not true. In most cases, inpatient care costs more. 

And as I have often seen, there was one comment that really stands out. Let me read part of it:

“I have been victimized by a situation wherein I was led to believe that my Medicare Part A would apply to my hospitalization. I first arrived when my bowel became obstructed and would not pass food. It became very serious over the night of the 23rd, and on the 24th, I was rushed to the hospital by ambulance with extreme pain. I was immediately admitted in emergency, vomited violently, and administered IV, given numerous scans, X-rays, etc. I was asked whether I had Medicare Part A and when I said yes, they said they were going to admit me into the hospital as an inpatient. I trusted them in this regard. I stayed overnight and spent a day in the hospital, leaving again at night around 11 p.m. on the 25th.. I had no notion that if I stayed there one more hour, perhaps my status would change! I was under the full impression that I would be covered by my Medicare Part A. It was only later that I got a letter dated the 27th, telling me that despite my inpatient status and all that I had been told, I was going to be denied Medicare Part A status.”

Continuing: “I was given no phone number or recourse to appeal what is clearly an unfair situation. I am entitled to Medicare as a senior citizen of the United States. This unilateral, unappealable decision will cost me at least $2,000 extra and needs to be corrected. I not only wish to comment herein but wish to see this situation corrected.”

Now, interestingly, this commenter attached the letter he received from the hospital, which actually was a very nice compliant self-denial notice, with the letter ending “please call the care management office listed below if you have any questions or concerns regarding this change.” That’s great, except there was no phone number anywhere to be found.

Now, will the new appeal process apply here? As proposed, because this patient was not transferred to an SNF, unless this patient has no Part B coverage, he will not be given appeal rights. But does he have a valid argument? Well, I would certainly love to see his medical records, because a bowel obstruction in most cases can have a two-midnight expectation, and his discharge at 11 p.m. could be viewed as an unexpected rapid recovery.   But of course, the biggest question is whether CMS will answer any of the questions from that Dr. Hirsch guy.

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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).

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