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Hospitalists Back Bill to Reform Medicare Audit Process


A bill proposed in Congress to streamline the audit process of the Centers for Medicare & Medicaid Service (CMS) is being hailed by hospitalists as a needed step forward.

The Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015 would speed up the Recovery Audit Contractor (RAC) appeal process, shorten look-back periods, increase transparency, and allow licensed attorneys to serve as Medicare magistrates to adjudicate certain appeals. The proposed legislation, which was passed by the Senate Committee on Finance in June, is sponsored by Sen. Orrin Hatch (R-Utah) and Sen. Ron Wyden (D-Ore.).

"Although RAC audits, appeals, and hospital payment issues may seem convoluted and not a direct hospitalist issue, the flawed audit and appeals system has negative downstream effects on hospitalist practice, autonomy, and ultimately negatively impacts the patients we care for," SHM Public Policy Committee member Ann Sheehy, MD, MS, FHM, writes in an email to The Hospitalist. "We need audits in the Medicare system, but RAC reform is needed and long overdue."

Dr. Sheehy, a hospitalist at the University of Wisconsin School of Medicine and Public Health in Madison, testified in May 2014 before the House Committee on Ways and Means' Subcommittee on Health about the impact Medicare's two-midnight rule and RAC audit process have on hospitals.

Dr. Sheehy says hospitalists dealing with RAC audits of patients under observation status can wait years for appeals to be heard.

"At the heart of the observation problem is the reality that a provider's clinical judgment can be questioned by an auditor up to three years after care was delivered and payment denied," Dr. Sheehy adds.

The pending bill's bipartisan support is a hopeful sign, says hospitalist Jairy Hunter III, MD, MBA, SFHM, associate executive medical director for case management and care transitions at the Medical University of South Carolina in Charleston. Dr. Hunter, who attended SHM's Hospitalists on the Hill advocacy day last March, says efforts to streamline bureaucratic issues are an indication that politicians are starting to understand the impact of CMS' myriad rules and regulations.

"We advocated for much more sweeping improvements, but in my view, this is somewhat of a start," he says. "It means that Congress and the lawmakers are hearing what we're saying." TH

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