Hi Chuck.  It is great to see that some people in Congress are aware of the problems with RAC audits.  Some parts of this bill are certainly exciting.  For example, it would be wonderful if RACs were required to compensate health care organizations when the health care organization prevails in an appeal.  The bill would require CMS to establish a rate schedule to compensate organizations that prevail on appeal.  Another provision in the bill is a requirement that when an inpatient admission is denied, the hospital be permitted to rebill the claim as an outpatient claim as long as outpatient care was medically necessary.  (The law indicates that the new bill would be treated as an “original” bill for purposes of the timely filing requirements.  It appears that the purpose of the provision is to permit rebilling after the one year claims filing deadline has passed.  I am not entirely certain that the proposed language will accomplish that, but that is clearly its goal.)  The Administrative Law Judges (ALJs) who hear appeals are typically allowing outpatient payment following a denial of an inpatient stay, but currently, it is necessary to take a case to the ALJ to achieve that result, and even then there is no guarantee that the hospital will receive compensation for the services it provided.  While one would hope CMS would correct this issue on its own, it hasn’t and I am happy to see an attempt to correct the problem legislatively.
However, no one should get too excited just yet.  Most bills introduced fail to become law.  In fact, the website govtrack.us gives the bill a 3% chance of becoming a law based on the site’s algorithm that examines a bills sponsors.  The site notes only 4% of all bills introduced become law. The bottom line is that while the bill is a good thing, everyone who is troubled by how RACs have conducted audits needs to reach out to their federal representatives and emphasize the issues.  I am happy to see some members of Congress willing to recognize the flaws in the current system.  However, unless a majority of Congress agrees, this bill won’t change anything.

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