By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On November 1, 2012, the American Hospital Association (AHA) filed a lawsuit against the U.S. Department of Health and Human Services (HHS) claiming that private auditors hired to crack down on improper Medicare payments are denying hospitals millions of dollars in medically necessary care, this is according to a number of sources. The AHA is seeking a court order declaring the practice invalid, saying it violates the Medicare Act.
Four hospital systems in Michigan, Missouri and Pennsylvania have joined the AHA as plaintiffs in the suit. The suit has been filed in federal court in Washington, D.C.
To read the AHA complaint against the HHS, click here.
AHA Calls Out Recovery Audit Contractors (RACs) in Lawsuit.
The lawsuit alleges Recovery Audit Contractors (RACs), private auditors used by the HHS, forced hospitals to repay Medicare for the costs of in-patient services by determining that Medicare beneficiaries should have been treated as out-patients instead of being admitted into hospitals as in-patients. The services provided to out-patients are much less, of course, and the bills for out-patient services are usually much lower.
In the official press release AHA argues when patients need treatment, the first step for a doctor is to decide whether to admit the patient to the hospital or to provide care in an out-patient facility. AHA believes doctors’ decisions are often more complicated for Medicare beneficiaries because the doctor is routinely second-guessed by RACs months or even years later. The president and CEO of AHA said this practice is “indefensible.”
Click here to read the entire press release from the AHA.
Neither the Centers for Medicare and Medicaid (CMS) nor the Department of HHS has commented on the pending litigation.
Before the Lawsuit AHA Praised the Office of Inspector General’s (OIG) Review of Medicare Contractors.
In October 2012, prior to the lawsuit, the executive vice president of the AHA wrote a letter to the Office of Inspector General (OIG) in response to the Work Plan for Fiscal Year 2013. In the work plan the OIG reviewed the effectiveness of various Medicare contractors, including RACs, Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs).
The letter states that these programs auditing payment accuracy are well intentioned, but hospitals are fed up with the RACs’ inaccuracy in determining whether the hospital received any overpayments. The letter also claims that hospitals are overwhelmed by the significant overlap and duplication of efforts between the RACs, MACs and ZPICs. These redundant audits drain time, funding and attention to patient care, according to the AHA.
According to the OIG review, hospitals reported appealing more than forty percent (40%) of all RAC denials, with a seventy-five percent (75%) success rate in the appeals process.
Click here to read the letter from the AHA to the OIG.
Steps to Take Once a Notice of a Medicare Audit Has Been Received.
When a physician, medical group or other healthcare provider receives a notice of an audit and site visit from a RAC, MAC or ZPIC, things happen fast with little opportunity to prepare. To help, read our checklist of what to do when notified of a Medicare or ZPIC audit. Click here for part one and click here for part two.
Don't Wait Until It's Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.
What you think about the lawsuit again the HHS? Do you support AHA’s decision to question the RACs’ auditing system? Please leave any thoughtful comments below.
Mitchell, Alicia. “Hospitals Sue Federal Government for Unfair Medicare Practices.” American Hospital Association. (November 1, 2012). Press Release from: https://www.thehealthlawfirm.com/uploads/AHA%20Sues%20Govnt%20PR.pdf
Pollack, Richard. “Letter: AHA Supports OIG Review of Effectiveness of Medicare Contractors, Including RACs, In 2013 Work Plan.” American Hospital Association. (October 24, 2012). Letter from: https://www.thehealthlawfirm.com/uploads/AHA%20letter%20to%20OIG%20on%20RACs.pdf
Morgan, David. “Hospitals Sue Government Over Private Medicare Audits.” Reuters. (November 1, 2012). From: http://uk.reuters.com/article/2012/11/01/us-usa-healthcare-medicare-idUKBRE8A01BZ20121101
Harris, Andrew. “American Hospital Association Sues U.S. Over Medicare.” Bloomberg. (November 1, 2012). From: http://www.bloomberg.com/news/print/2012-11-01/american-hospital-association-sues-u-s-over-unpaid-medicare.html
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
Tag Words: American Hospital Association (AHA), Recovery Audit Contractors (RACs), RAC audit, Medicare, Medicare audit, Medicare fraud, RAC audits Florida, Medicare audits Florida, defense attorney, defense lawyer, legal representation, fraud defense, fraud prevention, Medicare overbilling, Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), ZPIC audit, Centers for Medicare and Medicaid (CMS), U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG)
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