RAC Monitor’s Monitor Monday Webcast February 10, 2014

Play webcast
Chuck’s intro of Drew – 11:50
Drew starts – 11:57
Drew ends – 15:41
Chuck thank you ends -15:59

Good morning, Chuck. Good morning, everyone.

Look, the problem is evident. The solutions are more challenging. So, again, we urge all listeners if they have any questions or comments or potential solutions, please email them to cbuck@racmonitor.com and you can cc: me at awachler@wachler.com.

I don’t read the suspension of assignment of cases, and remember they’re not suspending appeals, suspension of assignment of cases for two years as anything that the ALJ is doing that is flaunting the 90 day statutory deadline for a hearing decision, but rather a recognition of the sheer volume of appeals is making it impossible to provide a timely hearing. Our listeners should remember that the ALJs have really been our protection against aggressive RAC denials that have been incentivized by contingency fees and that approximately 70% of these are overturned. Even before we’ve had these new rules on part b billing, it is the ALJs that almost universally granted part b payment in spite of CMS pressures not to do so. So, we have some significant problems. I think with our listeners, mostly hospitals, one of the biggest problems is the inappropriateness really of withholding under the statute when you can’t get a timely hearing and being out of those dollars for that period of time.

But, there are other issues also. We’re seeing probe reviews by MAC on its Two Midnight Rule. We like to use our access to the ALJs to review the current denials to see if they’re appropriate. If we have to wait three years to get to an ALJ and we have to rely only on the denial rate that’s been generally overturned at 70%, and so it’s hard to make judgments. Prompt hearings are also important for big box cases. I have a client that came in with a $3.2 million dollar audit. They’re not in a position to survive 3-4 years while this money is withheld. They’ll be put out of business even if they’ll ultimately prevail. We also see it with ZPICs that may put a provider on prepayment review which we get overturned sometimes 100%, but if they have to wait 3 years it can’t solve that problem.

So the knee-jerk reaction can be “Wait, CMS is picking up billions of dollars, can’t we use that to hire more resources?” Well, we have a sequester and the last thing we want is ALJs incentivized to deny claims so there’s money to pay salaries. So it can’t really come exactly from the CMS side.

Practical solutions:

  • I think the most important thing is that we create an infrastructure that I think Judge Griswold, at least through this forum, is beginning to have stakeholders have a consistent opportunity to meet and develop rules that are consistent across the board. It increases on the record decisions.
  • An aggregation of cases in a more efficient manner.
  • An alternative dispute resolution during this time that we’re waiting.
  • Maybe the ability to settle cases.
  • Electronic filing.
  • Uniformity of processes among ALJs.
  • The ability to really bill part b which many hospitals can’t do.

And so with that, I want to applaud Chief Judge Griswold for confronting these daunting problems. Let’s support her efforts to try to find solutions while keeping up legal and political pressure to protect the due process rights of beneficiaries and providers.

With that, I turn it back to you, Chuck.

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