As we all reflect on 2015, it is easy to remember all the obstacles we faced, many of which I have discussed in past articles and Monitor Mondays broadcasts. We had the fiasco of the home health face-to-face documentation requirements, in which two successive open door forums from the Centers for Medicare & Medicaid Services (CMS) presented completely contradictory guidance. We spent the year dealing with the return of the Recovery Auditors (RAs) looking at DRGs and medical necessity and expecting them to start looking at short stays, only to have CMS delay that until 2016. We saw the Office of the Inspector General (OIG) use extrapolation more often, with huge financial effects as covered by Frank Cohen, and saw them audit the billing of observation services for the first time.

And of course CMS went back to the future by proposing and then finalizing a new exception to the “two-midnight rule,” which brings a renewed spotlight to physician judgment of risk and severity. CMS also modified the payment structure for observation services, including a twist that pays hospitals substantially less if they do more for patients. CMS also introduced the Comprehensive Care for Joint Replacement program, first proposing it as CCJR and then finalizing it as CJR, making it the first mandatory “bundled” payment program. And of course, the Medicare Advantage plans continued to confound us with their arbitrary rules and increasing denials.

But amid all that uncertainty and change, there were positives. A law was passed requiring observation notices for all patients, which will help prevent ongoing confusion and finger-pointing. CMS also adopted a broad range of RA reforms. And among those positive occurrences were many people who made a positive difference for all of us in 2015. I’d like to recognize three of those people.

Guy Higgins, the coordinator of clinical denials and appeals at Infirmary Health in Alabama, noted that Cotiviti, the RA that used to be called Connolly, had, without notice, started sending out separate additional documentation requests (ADRs) for different types of audits – and the paper ADRs providers received didn’t match the ADR requests that were posted on the RA portal. While the RA stayed within its ADR limit, the use of two ADRs was contrary to the RAC statement of work. That, along with the differences in the paper and electronic ADRs, created havoc.

Not one to take things lying down, Guy started making waves at CMS, and it worked. CMS scolded Cotiviti, and it now is reverting to one ADR per 45-day cycle (and hopefully they will see the paper and electronic versions matching up this time).

Our next hero is Dr. Roy Baker, the physician advisor at Self Regional Healthcare in South Carolina. Roy was sick and tired of the Medicare Advantage denials issued by Humana. He had retrospective denials for which Humana had already issued concurrent admission approvals. He also saw DRG downgrades when there was clear clinical evidence that the hospital had coded it correctly. As with Guy, he did not roll over and surrender. He contacted CMS and complained. He also suggested that CMS check to ensure that when Humana downgrades the DRG paid to the hospital, that it also adjusts the claim information reported to CMS, since that same downgrade of the hospital payment also lowers the hierarchical condition category coding that serves as the basis for the monthly payment that Humana gets from CMS. And his efforts paid off: he is no longer seeing those egregious denials. Since Dr. Baker reported his method, we’ve seen others use the same method with great success. Thanks to some detective work by Janet Skurski, the coordinator of clinical appeals and denials at OSF Health in Illinois, we now know how CMS wants to receive those complaints, at least as of Dec. 7. To file your complaint, go online to, click on “submit request,” then “Medicare Advantage,” then “plan payment,” then “click next” and follow the instructions to report your issue. Provide CMS with specific case details and contact information. Just in case, do not include any protected health information.

My third hero is Dean Baker, an economist and co-director of the Center for Economic and Policy Research in Washington, D.C. who wrote an article on Huffington Post about UnitedHealthcare’s (UHC’s) threat to leave the health insurance exchange. He suggested that UHC was lying about losing money and that they were threatening to leave as a way to get a pay raise or more favorable regulations. He pointed out that if all other insurers can make money in the exchange, UHC must have some pretty bad management to lose money. Furthermore, only about 1 percent of UHCs covered lives are in the exchange, so even if they were losing a bit of money, I think that they can afford to suck up a small loss for the good of the country.

I am sure that 2016 will bring us more angst and more heroes. I hope you’ll keep reading and listening to Monitor Mondays to keep up with the ever-changing world of healthcare regulations.

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians.

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