Sheila Kennedy’s opinion piece as usual was slanted to her left-leaning view [Anthem’s algorithm, March 21]. While commercial insurance carriers are notorious for denying “medically unnecessary” services, Medicare is in fact very focused on efficiencies as well. The difference is that commercial payors will deny the claim up front, giving you an opportunity to appeal right away, allowing additional documentation to support the need for services.
It may well be that the doctor’s documentation supporting the service, rather than Anthem’s algorithm, is really to blame. Medicare, on the other hand, will allow the services to proceed, be billed, then pay the doctors, hospital and rehab center—but come back years later to review the claim and deny it on the grounds of “medical necessity.”
Congress created the Audit Recovery Program several years ago, employing auditors who are paid a percentage of claims they recover. During the demonstration program, about one-third of hospital inpatient claims were denied. Billions of dollars have been retroactively denied to hospitals and other providers across the country due to medical necessity. There is a lengthy, multi-stage appeals process during which a majority of the appeals are overturned, but the process costs hospitals and other providers billions of dollars.
After all the appeals have been processed, statistics show the auditors were wrong more than they were right in denying claims, resulting in far less “savings” to the Medicare Trust Fund than initially reported. The program, however, has added billions of dollars of cost to the health care system.
We need to improve our health care payment system—but more government intervention is not the answer.
John A. Torr