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A federal agency is overtaxing hospitals in its efforts to determine if they are overpaid for treating Medicare patients, according to a new multistate study.
The watchdog arm of the government health insurance program for people 65 and older needs sweeping reforms, researchers from the University of Utah, Johns Hopkins University and the University of Wisconsin concluded. Chief among the recommended changes is more detailed data reporting, said co-author Jeannine Engel.
"We'd just like to know that Congress is seeing data that makes sense," added Engel, who is the billing compliance adviser for the University of Utah Health Care system.
The review of cases at three academic medical centers, including the U., appeared Monday in the Journal of Hospital Medicine.
Researchers reviewed audit and appeals data from 2010 to 2013 at the three university medical systems they work for. They found that government contractors reviewing Medicare hospital benefits have repeatedly probed why certain patients receive inpatient status, rather than outpatient status.
Inpatient classification affords more coverage. Outpatient treatment can include uncapped out-of-pocket fees and excludes patients from certain care after they leave the hospital.
The contractors audited hospitals at a rate about 25 times higher than the Centers for Medicare and Medicaid Services reported. The agency did not respond to Tribune requests for comment Wednesday.
Researchers also highlighted a lengthy review process. The average unheard appeal logged in a 555-day waiting period.
"This is a failure in due process," wrote co-author Ann Sheehy of the University of Wisconsin's medical school. "Hospitals cannot afford to have these claims tied up for so long."
Besides delays in appeals, hospitals spend too much money defending patient care decisions to the auditing contractors, the researchers said. On average, hospitals used resources equal to the cost of five employees.
Two-thirds of the appeals resulted in a decision that ultimately favored the hospitals, researchers added, but that's not spelled out in federal progress reports.
The researchers say they hope the findings will better inform policymakers and refocus federal attention on how best to care for patients.
Some reform efforts are underway, including a push to withhold contractors' pay for overturned appeals, but Engel said more changes are needed.
@anniebknox