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July 16, 2014 - USA Medical Center working to recover disputed Medicare funds
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Joan Winkle, Recovery Audit Coordinator in the USA Medical Center's Care Management Department

“Readmission penalties, along with value-based purchasing, hospital-acquired conditions, and Meaningful Use penalties can endanger a hospital fiscally,” says Joan Winkle, Recovery Audit Coordinator in the USA Medical Center's Care Management Department. “We want to keep Medicare dollars in the hospital, but we want to do it right.”

For the past five years, the Medical Center — like all Medicare providers — has faced closer and closer scrutiny of its claims. Winkle’s job is to demonstrate that the Medical Center followed Medicare’s rules and deserves the payment it received.

This new facet of federal scrutiny began several years ago when Medicare took a closer look at billing practices first in three states and then in seven, Winkle explains. It found enough questions to expand the thorough inspection to the rest of the U.S.

“It may be a coding problem; it may be treatment they deem not medically necessary,” but if Medicare’s auditors feel the hospital was reimbursed more than the rules allow, it sends a request for repayment.

When that letter arrives, requesting that the hospital send funds back to Medicare, Winkle sets the hospital’s response procedures into motion.

She works with the medical coders to make sure the coding is accurate; she reviews medical records, and she asks physicians to provide any details that might have been overlooked in the record. For instance, if Medicare questions a particular drug, the doctor may remember what other circumstances made the unusual choice the best choice for the patient.

“Sometimes, maybe, the documentation could have been better,” she says, but sometimes she can demonstrate that the hospital did follow Medicare-approved procedures. Then, working with others involved in the case, she drafts a letter of appeal.

“We get everyone involved,” she says.

“Medicare accounts for 17 percent of what we get,” Winkle says, “and that’s important money for us.”

“It’s worth fighting if it’s reasonable.” Just last summer, she drafted 82 appeal letters. If the initial appeal is rejected, the hospital can further amplify its response and move on to a second-level appeal. The third step would be to an administrative law judge. There are two additional steps, including appeal to the federal courts.

Sometimes the hospital has won its appeal and received Medicare funds again; sometimes it has lost. But it’s worth the effort, she says. In fact, the hospital has developed a form to help doctors remember to record all the data necessary for Medicare approval.

“Patients expect to be treated and doctors want to treat them,” she says. “That is what health care should be about.”

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