Quoted from McKnights News February 19, 2016 … “A bill that aims to ease the overwhelming backlog of Medicare appeals would cost the federal government more than a billion dollars, according to a cost estimate released Tuesday.

The Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act (AFIRM Act) of 2015 would cost $1.7 billion over the next ten years if it is passed in 2016, the Congressional Budget Office estimated in its report. The bill was formally introduced in December by Finance Committee Chairman Orrin Hatch (R-UT) and ranking member Ron Wyden (D-OR).

In addition to the $1.7 billion, tangential costs of $35 million would hit taxpayers over the same decade, CBO said.”

Blogger comment:

It will cost $1.7 billion to save what?  Our negative over reaching government of lawmakers and regulators infer that the providers are cheaters and they have to catch them and hurt them … it really hurts everyone but more so the patients.  For thirty years the use of claims denials has created more costs than savings.  What a denial does is to hurt everyone.  The provider who has incurred costs to care for the patient is hurt for nonpayment of the claim cost including medications, supplies, equipment, labor and overhead. The claims reviewer is hurt when the claim is reviewed on a billing form then denied due to lack of, according to their interpretation, acceptable documentation and wastes more than they recover.  The nurse, therapist, physician, biller and business office are hurt when sending in reams of paper spend 35% of their time trying to meet the subjective, arbitrary and capricious interpretation by a nonclinical reviewer denies a valid claim.   The patient is hurt who believes they are covered by Medicare or Medicaid and find out months later that the claim has been denied and they will be responsible for additional costs to appeal.  The family who believes their loved ones are covered by Medicare and Medicaid so they don’t have to file bankruptcy trying to get their parent or themselves well will have to help paying for the costs to appeal.

And it hurts the taxpayer who foots all the bills while the lawmakers and regulators make it impossible to be efficient and cost effective because of this negative approach to accountability.  This has cost the taxpayer trillions of dollars in wasted time away from patient care and deprived the elderly $3 trillion in reimbursable Medicare coverage based on reviewers who thought they were saving the government money.

The $1.7 billion estimated cost will be three times that and the recoveries, if the appeals are ever adjudicated, will be less than the cost to prosecute.  As usual the lawmakers make laws that cost the taxpayer money and don’t produce positive outcomes.

Over the last thirty years my business was to assist the providers, clinical staff, patients and their families to appeal claims that were inappropriately denied and we won them all.  Why we devised a software system that would document the patient’s reimbursable problems, interventions and outcomes.

The government has been found guilty of denying claims inappropriately … see Fox v Bowen (1986) and Jimmo v  Sibelius (2011).  When government gets to be the problem and infers we are all cheaters and takes punitive action over justice we all become cheaters and liars.  Jerry Rhoads