It is inevitable that once in all of our lives, each one of us shall receive bad news. As a result, people are suckers for apparent happy endings. As a relevant current example, television talent competitions are stocked to the rafters with contestants that have heart-touching back stories and only fair-to-middling talent, which goes a long way to supplying a false sense of security in a populace that has been conditioned to accept bad news as normal. In reality, happy endings are few and far between, there are no magical winged ponies or unicorns and people are not suckers solely in the realm of desiring such a happy ending.
For all of these reasons, I exist in life as something of a cross between a spirit guide and interpreter, leading all of those within my sphere of influence toward a higher truth by finding the illusions implanted in other things. It is in this capacity that I come to you today, and since it is Wednesday, the subject today is the CMS version of the effectiveness of the Recovery Audit program.
On June 1, without fanfare (as has been their habit lately), CMS released a one-page appeals update for the RAC program. If you concentrate on just the numbers in the report, you would come to the sugar-coated conclusion that the percentage of claims overturned on appeal for all denials stands at 2.7% for Fiscal Year 2011, which concluded on September 30, 2011. The total number of dollars overturned, to hear CMS tell it, was $37.9 million. If the update stopped there, the prince and the princess would live happily ever after. Unfortunately, the update contains small print that in this case deflates the entire argument.
On the update, below numbers showing the number of claims with overpayment determinations and the numbers appealed, CMS includes this phrase:
“The number of claims that have been appealed is limited to claims originating in FY 2011, with appeals initiated through 9/30/2011. Each level of the appeal process has statutory time frames that provide due process to providers. Since these time frames extend beyond the end of the fiscal year, each update will represent a snapshot in time to ensure accurate data.”
The translation to this is that the numbers in the CMS update address only completed appeals that began during the last fiscal year. In CMS’ zeal to deliver good news, they have left out an enormous universe of appeals still in process. According to the latest AHA RACTrac survey report that was released on May 10th, seventy-five percent of RAC appeals are still in process, many at the 2nd or 3rd level. Suddenly, when we get a full view of the appeal picture, CMS’ representation of the success of the RAC program comes off as less than truthful.
The timing of the release of this report requires some critical thinking as well. I wrote a few weeks ago about the U. S. Senate Finance Committee requesting “white papers” from all interested stakeholders with recommendations on how to reduce fraud, waste and abuse in the Medicare program. The Committee’s deadline for submissions is the end of June.
CMS has been teetering along a carefully-drawn line of their own design that at all times brings forth a public stance that is best distilled by the phrase, “Remain calm. All is well”. With outside entities such as the General Accounting Office, the OIG and the AHA generating report after report stating that the current multi-tiered approach to improper payments is failing at all levels, CMS is becoming desperate to present evidence that shows that the opposite of the reports is true. From the Centers’ vantage point, even a small, carefully-crafted version of good news is worth reporting. Unfortunately, what CMS has produced is the stuff of legend; not quite true, not quite false and leaning heavily towards exaggeration.
The problem with this approach is that CMS is not Babe Ruth. There will be no miracle two-home-run games for the sick child, no called shot and no bigger-than-life persona that can magically turn the disease-infested plague drama that is current anti-waste efforts into a happy story for the ages. I exist today to tell you that CMS’ RAC appeal numbers do not add up. If this post has helped just one person avoid being a sucker for a day, I consider my journey a success.