Reimbursement News

How to Rescue Revenue Cycle with Medicare Appeals Pending

By Jacqueline DiChiara

- The rehabilitation needs of Medicare beneficiaries within the state of California may be in jeopardy. Payment for hundreds of thousands of claims for services is being denied. Most of these denials are reportedly invalid, confirms past appeal reports.

Medicare beneficiaries claims denial

In an effort to rescue its revenue cycle, Casa Colina Hospital and Centers for Healthcare filed suit requesting the Department of Health and Human Services (HHS) to address pending appeals. Such appeals have remained in a state of limbo for two years. Casa Colina requests timely Medicare patient care appeals as mandated under federal law in an effort to recover necessary funding.

According to press release commentary from Felice Loverso, Ph.D, President and CEO of Casa Colina Hospital and Centers for Healthcare, Casa Colina merely aims to align Medicare with implemented rules via Congress.

Loverso (pictured left) and Ronald Connelly, Principal at Powers Sutter & Verville, PC, chatted last month with RevCycleIntelligence.com to explain how they are best salvaging their revenue cycle as the suit progresses. The following is the latter half of their two-part discussion.

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    Ronald Connelly: There are a couple of other pending cases. One is currently in the DC Circuit Court of Appeals, and that case was brought by the American Hospital Association, also seeking to force the government to comply with this 90-day deadline. Another case is in the Fourth Circuit Court of Appeals, and that's Cumberland County Hospital System versus Burwell, with the same issue, seeking to force the government to comply with the 90-day deadline.

    Felice Loverso: We support them, as well as other organizations like the California Hospital Association and the American Medical Rehabilitation Providers Association. However, we wanted to put a face to this issue. We want our Congressional leaders to know how this is affecting a small hospital in Pomona, California - just like David and Goliath.

    RevCycleIntelligence.com: I'm sure you've made some changes to the way your revenue cycle carries out. What adaptations have you made?  

    Loverso: We've removed many administrative posts to save money. However, we will not take money out of the clinical world. I'm a clinician myself, and clinicians are the last to go in hospitals, at least this hospital. We also take money from our foundation to subsidize our Wounded Warrior Program, which is one of the largest in the nation. We’ve taken over 90 catastrophic injuries out of Iraq and Afghanis tan and are one of the largest private rehabilitation hospitals in the United States working alongside the VA and the DOD, complementing their service delivery model. If things continue at this pace, I see real draconian consequences for a little hospital in southern California, for not doing anything wrong, which is quite extraordinary.

    RevCycleIntelligence.com: As an industry, where should new focus be placed? What’s next on the horizon?

    Connelly: [The Centers for Medicare & Medicaid Services] CMS has requested more funding from Congress, but it’s not enough to clear the backlog. And the Office of Medicare Hearings and Appeals – the [The Department of Health and Human Services] HHS office that decides [Administrative Law Judge] ALJ appeals – launched a number of initiatives to try to streamline things and move appeals through faster. I think that these measures will not be sufficient to clear the backlog in any reasonable time and certainly won't get them down to 90 days.

    Loverso: Medicare beneficiaries, people with strokes, amputations, spinal cord injuries, traumatic brain injuries, deconditioning, and burns need and are entitled to this level of rehabilitation care. We can't think it's just okay to put everyone in a nursing home. Our Congressional leaders would do well in understanding some of the things that they're asking the CMS to do.