A study led by Ann Sheehy, MD, MS, associate professor and head, Hospital Medicine, found that hospitals in three healthcare systems (Johns Hopkins, University of Wisconsin, and University of Utah) waited an average of over 4.5 years to conclude the Medicare reimbursement audit and appeals process because of an extensive Medicare appeals backlog. 

The study, which was published in Journal of Hospital Medicine in April, 2017, analyzed all complex Part A appeals between October 1, 2013 and May 1, 2016 at the hospitals that reached Level 3 of the Medicare appeals process. 

Researchers found that government contractors were responsible for 70.7 percent of the Medicare appeals backlog and delay, and hospitals were accountable for 29.3 percent. 

Of 135 Level 3 cases studied, administrative law judges ruled in favor of hospitals 71.1 percent of the time. 

The study authors wrote, "As CMS [Centers for Medicaid and Medicare Services] explores bundled payments and other reimbursement reforms, perhaps the need to distinguish observation hospital care will be eliminated. Short of that, additional actions must be taken so a just and efficient Medicare appeals system can be realized for observation hospitalizations."

Resources:

• Sheehy AM, Engel JZ, MD, Locke CFS, Weissburg DJ, Eldridge K, Caponi B, Deutschendorf A. 2017. Hospitalizations with observation services and the Medicare Part A complex appeals process at three academic medical centers. J. Hosp. Med. 12(4):251-255
• "Medicare Appeals Backlog Delays Decision Process By 4.5 Years," RevCycle Intelligence, May 11, 2017
• "Study: Medicare audit, appeals process exceeded 4.5 years due to backlog," Becker's Hospital CFO Report, May 12, 2017