Fear of denials could be pushing more joint procedures into outpatient setting

Hospital administrators are shifting patients who need knee replacement surgery into the outpatient setting rather than risk audits by Medicare contractors, surgeons warn, adding that the practice could be jeopardizing more frail patients.

The fear of audits comes despite the CMS banning Medicare contractors from reviewing inpatient total knee arthroplasty procedures after regulators last year began paying for procedures performed in the less expensive outpatient setting. But Dr. James Huddleston, chair of the American Association of Hip and Knee Surgeons, says the CMS previously has allowed Medicare auditors to ignore these bans, potentially setting hospitals up for denials.

“The CMS has explicitly stated it was suspending all audit activities in the past and didn’t stay true to their word,” Huddleston said. He cited an up tick in claims denials for coronary stents placed in inpatient settings once the CMS allowed the procedures to take place in outpatient settings. Like joint procedures, there was supposed to be a ban on audits for inpatient stent procedures.

A CMS spokesman said it will enforce a two-year ban on recovery audit contractors reviewing inpatient knee replacements. However, quality improvement organization (QIOs), another type of Medicare auditor, can review and deny such claims. However, RACs are the more frequently used auditor. Between 2011 and 2013, for example, RACS recovered $6.2 billion through hundreds of thousands of claims. QIOs review around 20,000 claims each year and have recouped $32 million since they started reviewing inpatient claims in 2016.

Hospitals prefer QIOs review claims instead of RACs because QIOs include clinicians who better understand medical decision-making.

The CMS’s original intent was to give doctors more autonomy over cost by determining which setting was best for patients based on their health. The only requirement was that documentation show the inpatient stay was warranted and met the two-midnight standard.

“We expect providers to carefully develop evidence-based patient selection criteria to identify these patients,” a CMS spokesman said. “Nothing in the final rule requires total knee replacements to be performed in the hospital outpatient setting.”

But Huddleston said he’s been told by doctors that hospital administrations are overruling those decisions and shunting patients into outpatient units.

By Virgil Dickson | Modern Healthcare

Image Credit: Getty Images


About Peter Coffaro 603 Articles
A growth-driven and strategic executive, Peter Coffaro commands more than 20 years of progressive management success within the medical device industry. As a District Sales Manager for Stryker Orthopaedics, Peter was responsible for managing and directing a regional sales force to achieve sales and profit goals within the Rocky Mountain region. Previously, he was the Director of Sales & Marketing for Amp Orthopedics. In this role, Peter was responsible for planning, developing, and leading all sales and marketing initiatives. Peter is a former orthopedic distributor in the Pacific Northwest. He has also worked with DePuy Orthopaedics as well as Zimmer, and held positions in sales, sales training, and sales management. Peter has an extensive background in organizational development, business development, sales management, negotiating and P&L management. Peter holds a B.S. degree in Biology from Northern Illinois University.

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