In addition, some 60% of the 41,000 appeals made to ALJs in fiscal year 2012 were “partially or fully favorable to the defendant,” the senators said in an announcement. “Such a high rate of reversals raises questions about the quality of initial determinations and whether providers and beneficiaries are facing undue burdens on the front end,” they added.
Explore This IssueJanuary 2016
Hopeful for Help
Dr. Wanamaker, president of Health Alliance PO/IPA, a multi-specialty group of some 400 physicians, said that any improvements to the audit program would be beneficial for otolaryngologists. The “onerous” process can consume the time of clerical staff, office managers, accountants, and healthcare attorneys. And all that time means money. “Any time you’re going up against a government agency, they basically have unlimited resources in personnel and dollars and time,” Dr. Wanamaker added. “We certainly don’t, especially with all the other issues we’re coping with.”
He believes that despite the high rate of reversals, many otolaryngologists at small practices settle cases—even if they did nothing wrong—“just to make it go away.”
“The cost of being right and the penalties of being wrong could basically put a practice out of business,” Dr. Wanamaker said.
Some healthcare professionals have said that fears of being audited can cause physicians to practice defensive medicine, ordering tests and procedures that aren’t clinically necessary but that doctors believe might serve as protection from later lawsuits. Dr. Wanamaker framed the issue as otolaryngologists undercoding or undervaluing their work.
“They feel like that is going to insulate them,” he added. “If you’re a specialist that sees a lot of complex patients, your bell-shaped curve of the distribution of visits from Level 2, 3, 4, [and] 5 should be skewed more towards a higher level because you’re seeing more difficult patients with more complex histories and more challenging problems. And there’s a tendency to be afraid to do that for fear of attracting attention, because the peak of their curve has shifted toward a higher level.”
Dr. Wanamaker said one major fear of audit programs is that their existence, while well intentioned to root out fraud and abuse, makes otolaryngologists and others who endure a review feel targeted by the process. “If they latch on to you, you’d like to think they didn’t just have to justify their existence, but most people believe that they’re going to look until they find something,” he added. “And if they look hard enough, the rules are so complex, they will find something even if you’re doing it mostly right.”