News: CMS proposed rule on status appeals contains complex ambiguities, AHA says

CMS has released a proposed rule on Medicare appeals rights for patient status changes, according to the American Hospital Association (AHA).

The proposed rule contains several changes to the appeals process for Medicare beneficiaries wishing to challenge an inpatient or outpatient classification status. The most contentious among them, however, is with respect to the lookback period during the retrospective appeals process.

According to the new proposed rule, Medicare patients may appeal status changes that “occurred prior to the implementation of the proposed prospective appeals process dating back to Jan. 1, 2009.” However, as the AHA noted, there are a number of unresolved ambiguities in that timeline.

“For example,” the AHA argued, “Recovery Audit Contractor (RAC) audits can have a look-back period of only three years from the date a claim was submitted.” They continued, “most hospitals have a medical record retention policy that is far shorter than 15 years,” with “many organizations retaining records for seven years from the date of service in accordance with CMS’ own medical record and maintenance and access regulations.”

In other words, under the proposed rule, should a beneficiary make an appeal for a treatment taking place prior to a hospital’s record retention date, the hospital wouldn’t be able to provide any information regarding the hospitalization.

The issue is further compounded by the fact that, since 2009, most hospitals have transitioned to electronic health records: i.e., “providers may not have the ability to re-bill or send a corrected claim for beneficiary accounts that predate any of these changes.”

The proposed rule also contains modifications to the retrospective appeals process for skilled nursing facilities, prospective appeals, as well as modifications to the existing expedited appeals process and Medicare change of status notice.

Editor’s note: To read the AHA commentary, click here. To read the CMS proposed rule, click here.