A Medicare Advantage (MA) plan’s refusal to authorize inpatient rehabilitation for a patient with a bilateral amputation and active anemia is the kind of case that drives the use of expedited appeals. The MA plan told the hospital the medical complexity wasn’t there for acute rehabilitation, but its decision was reversed with an expedited appeal to the independent review entity for Medicare Part C.
“The process worked,” said Brian Moore, M.D., medical director of utilization management and physician advisor services at Atrium Health in North and South Carolina, at a Sept. 21 town hall sponsored by the American College of Physician Advisors. “We should understand how and when to push back.”
Expedited appeals are a secret weapon for overturning pre-service benefit denials, Moore said. CMS allows physicians and other hospital clinicians to fast-track certain MA appeals on behalf of enrollees, while shifting the burden to MA plans to justify denials. Some hospitals use expedited appeals only for post-acute care denials—admissions to skilled nursing facilities, long-term acute care hospitals, inpatient rehabilitation facilities and possibly home health. They don’t go down this road for other types of denials, such as inpatient admission vs. observation, because some MA plans dismiss these appeals based on language in the Medicare Managed Care Manual. “We are not using any of the CMS regulatory appeal pathways for level of care if we are contracted” with the MA plan, said Edward Hu, M.D., system executive director of physician advisor services at UNC Health in Chapel Hill, North Carolina.
But hospitals may start to think differently now that the proposed 2022 Outpatient Prospective Payment System (OPPS) regulation, which would reverse the elimination of the inpatient-only list, has made patient status a matter of beneficiary safety, Hu said. Because expedited denials are filed on behalf of patients using an appointment of representative (AOR) form, CMS’s reframing of patient status for procedures could have a ripple effect on expedited appeals. “If CMS is now saying status is a safety issue, that impacts the beneficiary,” Hu said. And if expedited appeals are about beneficiary protection, perhaps there’s a case to be made now that inpatient vs. outpatient disputes are a good fit.
