“Physicians should assess whether they have meritorious grounds for an appeal before doing so because if the Qualified Independent Contractor renders an adverse decision then they will be required to pay interest on the overpayments in addition to the amount of the overpayment,” said Mr. Clark, who is chair of the American Bar Association’s Health Law Section. “Some basic issues are whether the underlying documentation is complete and supports the claims for reimbursement that have been made and whether the coding used is appropriate.”
Physicians should also consider the number of claims at issue and the amount of payment before deciding whether to pursue the appeal, Ms. Gustafson adds.
“In many physician cases, the amount at issue may not be worth the time associated with pursuing the appeal,” she said.
On the other hand, appealing is the only way to stop a recoupment demand, said Dr. Brent Moody, a member of the American Academy of Dermatology’s Workgroup on Innovation Payment Delivery and an American Academy of Dermatology Association adviser to the American Medical Association’s Relative Value Scale Update Committee (RUC).
“If a provider thinks they’re in the right, they should appeal,” Dr. Moody said in an interview. “It’s their right to appeal. They should exercise that right if they believe the RAC audit is incorrect.”
The government meanwhile, is taking steps to reduce the appeals backlog. Earlier this year, CMS offered to pay hospitals 68% of inpatient-status claims in exchange for withdrawing their pending appeals. If hospitals accept the offer, the move would free up the system for other pending claims, Ms. Gustafson said.
Mr. Clark does not foresee the appeals bottleneck truly loosening until Congress funds additional administrative law judge positions, he said.
“There’s a well known saying that well describes this problem: ‘Justice delayed is justice denied,’ ” Mr. Clark said. “The specter of having to wait months or years before an appeal can be heard is simply inexcusable given the intrusive nature of the RAC audits, the uncertainties involved, and the impact on the ability of physicians to practice medicine without fear of financial ruin.”
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