Providers won appeal decisions for more than 43 percent of claims in fiscal year 2011, according to newly released CMS data. That represents almost $38 million.


Of the 903,372 claims that recovery auditors (RACs) determined were overpayments, 56,620 were appealed by providers. Decisions were rendered in favor of the provider in 24,548 of those claims, the data showed.


A closer look at the numbers shows that providers won the most money back when they appealed complex reviews. Claims involving almost $30 million were overturned after complex reviews.


However the rate of overturned claims was not the highest for complex reviews. Almost 22,200 claims were appealed after complex reviews and just 20 percent were overturned. Appeals of automated reviews were overturned in 57 percent of cases, the data showed.


Part A claims were appealed most often, 13.7 percent of the time. Of the claims that were appealed, providers had decisions in their favor 23.1 percent of the time, the data showed.


Part B claims were appealed just 4.9 percent of the time, though CMS notes that Part B and DME claims often “are corrected through the appeals process, which means the reason for the denial is upheld but the provider is allowed to correct the claim and rebill using the appropriate code(s),” CMS noted. However, of the 20,406 claims that were appealed, 14,352 or 70 percent were decided in the providers’ favor.


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About the Author


Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation’s leading independent authority on home healthcare business, regulation and reimbursement.


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