Preventive Measures Are The Only Good Answer, Right?

I keep seeing articles and speakers give the advice to “Appeal, Appeal, Appeal“, even to Medicare beneficiaries, who are getting hit with co-pay bills for outpatient services, when they feel that an admission should have been considered an inpatient admission.

Consider this article, which advises exactly that:

What hospital patients need to know about Medicare: Linda Rhodes – Wed, 23 Oct 2013 23:53:16 GMT

What hospital patients need to know about Medicare: Linda RhodesPennLive.comIn fact, a RAC audit has up to three years to deny payment upon their review. And just like the response to the three day rule, hospitals, doctors, and consumer advocates a …


I expected times like this – but I never thought they’d be so bad, so long, and so frequent.

Not Bad, But Really? Is ThatThe Real Answer?


That article, however well intended, made me cringe, even though I’ve made the same argument myself, to hospitals, advising them to appeal everything they feel was rightly an inpatient admission that was subsequently denied by any one of the sundry reviewers that CMS now employs.

And truth be told, many audits need to be challenged on their face, simply because the reviewers make mistakes, also.

The rise of Recovery Audit contractors for Medicaid has exacerbated the issue, as well, thanks to the Affordable Care Act:

Verifying an audit’s accuracy – Thu, 24 Oct 2013 15:47:20 GMT

Verifying an audit’s accuracywww.behavioral.netAllegations of fraud can flow into Medicaid authorities via customer complaints, internal whistleblowers, managed care organizations, and relatively new Medicaid recovery audit contractor (RAC) programs. …

Granted, my own company is called “Appeal Academy” and we tend to have work due to appeals. We do educate about winning appeals for claims denials. However, we also intend the knowledge used to win appeals to be stuck back into the funnel, so to speak, further UP stream, so that the denials can be avoided in the first place, thereby ulitimately relieving the need for and cost of appeals.

We’re Treating The Symptoms, Not the Causes

Even so, there are other icebergs out there.

Even so, there are other icebergs out there.


Shouldn’t we know better? A year ago, the common wisdom was to appeal everything, and concentrate your efforts on either the Discussion Period, or the ALJ level of appeal, Level 3. Then the damn broke. The ALJ started getting 5,000 appeals request per week – confirmed at The Seventh National RAC Summit by the Honorable Judge Moore, Deputy Chief Administrative Law Judge (see slide 9). And now, if you’ve been submitting any appeals to that level, you know that you may be waiting up to almost 2 years to get to that hearing.

So appeals, now, may indeed be “winnable,” albeit the money will be in limbo for all that time — until your appeal is adjudicated, one way or the other.

Now comes the 2014 IPPS Final Rule, which I predict will provide both more Observation stays, and more denials for Inpatient Short Stays, if not more technical denials across the board for all types of Inpatient stays, regardless of LOS.

But How Do You Identify The Causes?



Yes, but even Superman couldn’t deter a determined criminal mastermind.

Given all that, I think it’s time to step back and take a different look at the problem. To that end, we asked someone who knows how to look at it from a “higher altitude,” if you will. We contacted a former hospital system CEO who was known for being both successful and creative. We asked her to come on the show and share with us her view and some of her suggestions for how our listeners and members could begin to formulate a plan to not only change their lot, their own performance, but perhaps their department and more – how to get others involved. She accepted our invitation, and this week’s Finally Friday! show will let you all hear straight from her and her team, how they recommend you at least START to do this, and get results that matter.

Any manager’s job involves knowing what needs to happen or change, then what to change it into, and then how to make that change happen. This week’s show will give you a start on doing all that.

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