Crisis in Health Care: Medicare Denials in Florida : a Briefing |
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admission admitted Andy Ireland appeal appropriate assure attestation BEN BLAZ beneficiaries bill Board BOONE BUDDY MACKAY BUTLER DERRICK cian Citrus County CLAUDE PEPPER CLINEFELTER clinical committee Congress contract cost criteria decisions denial denying payment doctor Financing Administration FISHER Foundation for Health Gary Wright going HCFA Health Care Financing hearing Hernando County herniorrhaphies hospitals and physicians implementation inpatient intensified review Leesburg Regional Medical length of stay letter MACKAY MARY ROSE OAKAR Medi medical necessity medical record Medicare coverage ment MERWIN Okay outpatient basis panel Peer Review Organization physi physician advisors physician review pital Prednisone prior PRO's problems procedure Professional Foundation PROS Prospective Payment System providers quality issues questions reconsideration referred regulations response review process Ryan SANSING specialty staff standards STATEMENT submit sure surgery Susanne Snyder talking Tampa there's thing tient tion trying understand utilization review
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Page 4 - Utilization and quality control peer review organizations (PROi) review the services provided to Medicare patients to assure that services are medically necessary, provided in the appropriate setting, and meet professionally-recognized standards of quality health care.
Page 64 - FRO requirements seem to be predicated on the expectation that hospitals and physicians will circumvent the Medicare prospective pricing system to thwart its cost containment goals. Certain categories of claims are reviewed without regard to actual hospital performance, so all hospitals are subject to the same basic review. Hospitals with many admissions in the required review categories will be subjected to more intensive review, even if their overall performance is outstanding. Although the second...
Page 63 - ... expected of them only from patterns of retroactive denials. Medicare's review system is designed on the premise that there are generally understood medical criteria and standards that hospitals and physicians can be expected to know and abide by. If that is the case, it should be possible for the PROs, on behalf of Medicare, to say what the standards are. It should be possible for hospitals to use these standards to avoid future penalties. But these standards do not exist as clear-cut rules or...
Page 63 - ... .regarding the nature of the transgression that has led to the denial, and if the providers cannot understand coverage standards, they will seem positively mysterious to beneficiaries. Unless beneficiaries are better informed about the limits and extent of Medicare coverage, they cannot be prudent users of their Medicare benefit nor informed purchasers of supplemental coverage. Medical criteria and standards must be subject to open discussion. HCFA should be required to assess the reliability...
Page 64 - FRO is required to use a specialist (for example, a cardiologist to review heart surgery) only at the reconsideration stage. An obstetrician may review rehabilitation services, or an internist may review orthopedic surgery. This may contribute to the high rate at which decisions are overturned by PROs on further review, and it has affected the credibility of PROs within the physician community. The...
Page 62 - PROs are not publicly held accountable for their actions. Their objectives are negotiated behind closed doors with HCFA, without public input. Neither the hospital not the physician is able to challenge the PRO's decisions to an entity outside of the PRO, so there is no objective oversight to assure the appropriateness of the PRO 'a denials.
Page 49 - Act of 1984, the Consolidated Omnibus Budget Reconciliation Act of 1985, and the Omnibus Budget Reconciliation Act of 1986.
Page 49 - It is our intention to insure rational action based on facts. We will attempt to identify problems, change practice patterns, and educate. By the same token, we will move aggressively to correct problems as quickly as possible. And if circumstances merit, we will not hesitate to invoke the most severe penalties available.
Page 63 - Medicare coverage, they cannot be wise users of their Medicare benefit nor informed purchasers of supplemental coverage. Medical criteria and standards must be subject to open discussion. HCFA should be required to assess the reliability and validity of the utilization criteria and quality review screens that are used by PROs. At the...
Page 49 - They were also given the mandate to review elective surgical procedure before surgery occurs and provide for a second surgical opinion in certain cases. These are sensitive and complex issues. We have already obtained a wide range of expert input and we will be asking for public comment on proposed regulations which we plan to publish in the near future.