Providers aren’t ‘gam­ing the sys­tem’ by pur­su­ing RAC ap­peals

Modern Healthcare - - COMMENT -

Re­gard­ing the re­cent ar­ti­cle “Hos­pi­tals rake in $1.3 bil­lion from Medi­care ap­peals set­tle­ments” (, June 12), I take is­sue with the state­ment from one of the sources say­ing that providers “game the sys­tem by ap­peal­ing ev­ery claim de­nial, bring the ap­peals sys­tem to a stand­still and then be paid re­gard­less of the out­come of their case. This es­sen­tially in­cen­tivizes hos­pi­tals to con­tinue to over­whelm the sys­tem with friv­o­lous ap­peals.”

Any­one who has spent time on the re­ceiv­ing end of the re­cov­ery au­dit con­trac­tors would never make such an un­founded and un­in­formed state­ment. It is not the providers gam­ing the sys­tem—we are tak­ing care of ben­e­fi­cia­ries and only try­ing to get re­im­burse­ment for care pro­vided. It is not part of our busi­ness plan to place hun­dreds of thou­sands of dol­lars in limbo (re­mem­ber, the money is taken back) while the back­logged ap­peals process churns ever slower. Hos­pi­tals have spent valu­able re­sources (money and per­son­nel) fight­ing these take-backs. No­body would make such an ap­proach the ba­sis for a hos­pi­tal’s in­come strat­egy.

Also, the head­line that hos­pi­tals are “rak­ing in $1.3 bil­lion” is de­cep­tive. What about the bil­lions providers haven’t re­couped and the mil­lions they spend de­fend­ing them­selves?

Michelle McA­doo, RN RAC co­or­di­na­tor/de­nials man­age­ment Pardee UNC Health Care Hen­der­son­ville, N.C.

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