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Mentor moment: CMS update indicates high provider success rate for appealing denials

Case Management Weekly, July 7, 2010

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Editor’s note: This post originally appeared on HCPro’s Revenue Cycle Institute website. 

A recent CMS report indicates that providers have been winning more appeals since the last update.

The June 14 report “The Medicare RAC Program: Update to the evaluation of the three-year demonstration,” updated information from CMS’ previous report, issued during January 2009 and including data inclusive through March 27, 2008. The new report, which includes statistics through March 9, 2010, reveals that the number of appeals claims dropped significantly from 118,051 reported in 2009 to 76,073 in the new data. This is because CMS no longer counts claims individually at each level of appeal. It now counts each claim once if appealed to any level.

CMS also removed claims from the appealed category if a claims contractor reversed a denial after a provider submitted additional documentation. However, because the claims contractor decides the first level of RAC appeals, it is unclear why these aren’t considered appeals, says Kimberly Anderwood Hoy JD, CPC, director of Medicare and compliance at HCPro, Inc., in Marblehead, MA. If CMS counted each of these claims as an overturned determination it would have shown that providers were even more successful in appealing denials, says Hoy.

“It would be interesting to see how much higher the overturned percentage would be if these cases were included,” she says. “Already, the stats show RACs were overturned in about two-thirds of appealed cases.”

CMS also increased the number of overall RAC determinations by 73,000 claims. The effect of including more claims in the determinations number caused the overall percentage of overturned cases to appear lower than it otherwise would have been, says Hoy.

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