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Insights and Trends

Our Response: CMS Review Choice Demo and It’s Impact

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) raised the possibility of moving forward with a proposed pre- or post-claim review demonstration program in up to four states in 2021 despite industry pushback. Since the initial announcement, CMS continues to push for advancement of the program. Stakeholders noted the implementation would increase the administrative burden already placed on providers dealing with staffing shortages and capacity issues due to the COVID-19 pandemic.

We have been following the proposal closely on behalf of our partners and clients. This month, we provided additional feedback that further supports comments supplied in February 2021. We recommended retracting the notice at least until after the declared public health emergency (PHE) has ended – allowing for sufficient time to address concerns. While we remain supportive of CMS in its efforts to identify and address improper behavior, we explained our belief that the demonstration will not achieve these goals and that it may jeopardize patient access to medically appropriate care.

If CMS decides to move forward with the proposal, our partners will be well-prepared, thanks to the integration of extensive protocols put in place to actively identify and address issues around patient admissions that could lead to improper payments.

  1. Significant investments in the latest technology that help consistently distinguish appropriate from inappropriate patients, coupled with a skilled and dedicated staff that focuses on documentation review and admission criteria.
  2. Ensuring the appropriate patients are admitted has always been and will continue to be a top priority. Strong communication across the care continuum has helped ensure that care teams are regularly briefed on patient profiles and given the tools to make the right decisions for both patients and the facility.
  3. Our ongoing coordination between referral sources to develop consistent transition processes. This communication continues to facilitate strong partnerships that focus on patient placement in the right setting, at the right time.

This proposal further emphasizes the importance of having a dedicated team of appeals and denials experts to focus on the latest CMS regulations and to ensure your hospital is readily prepared and can adjust accordingly.

On behalf of our hospitals and our contract management partners, our dedicated denials and appeals team continues to efficiently and successfully navigate the ever-changing healthcare landscape, in turn reducing denial rates and helping to ensure medically appropriate patients receive the vital care they need to recover.

Click here to read our full response to CMS.

Read the whitepaper, “Ask the Expert: 10 Things to Know About Denials” to learn key strategies to help overcome challenges.

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