Report on Medicare Compliance Volume 31, Number 13. April 11, 2022 Physicians Don’t Have to Specify Scientific Evidence in Chart, Expert Says

Report on Medicare Compliance Volume 31, Number 13. April 11, 2022 Physicians Don’t Have to Specify Scientific Evidence in Chart, Expert Says

By Nina Youngstrom

Hospitals should be on the lookout for possible claim denials that refer to physicians failing to specify in the patient’s chart the journal articles or other scientific evidence that informed their clinical decision-making. That goes against CMS policy and is grounds for appeal, an expert said.

At least one payer has instructed hospitals to only include in their appeals of claim denials the literature citations that had been considered by the treating physician, according to an excerpt of a letter from a Medicaid third-party auditor to a hospital that was posted to a group email list.

But physicians don’t document that way, said Denise Wilson, senior vice president of Intersect Healthcare + AppealMasters in Towson, Maryland. For example, they wouldn’t write notes that attribute their admission of a cardiac patient to a publication of the American College of Cardiology. Physician decisions are based on training and experience, and as long as appeal writers can support the physician’s decision based on standards of care that are consistent with the American College of Cardiology, “the hospital should get paid,” said Wilson, president of the Association for Healthcare Denial and Appeal Management.

That’s been CMS’s position since it was called the Health Care Financing Administration (HCFA). In HCFA 95-1, CMS explained that “Medicare payment to providers, practitioners, or other suppliers is premised on the presumption that they have such knowledge, as evidenced by their licensure. No other evidence of knowledge of local medical standards of practice is necessary.”[1]

Connect the Clinical Dots in Appeals

The payer also told the hospital that appeals shouldn’t be just a recitation of clinical facts without an explanation of how they address medical necessity. That’s a truism for all appeal letters, Wilson said. “You can’t just say, ‘Look how sick the patient was.’ You have to say, ‘Because they had condition A and B, that increases the risk of the patient going into heart failure or renal failure,’” she explained.[2] “That supports why they have to be treated in an inpatient setting.” Here’s where evidence-based guidelines come in. For example, appeal writers would cite a peer-reviewed journal article from the American College of Cardiology to support their argument for the physician’s admission of a patient who presented with acute decompensated heart failure and pneumonia, for example. “But you can’t just cite a long list of case facts and not put it into context.”

Wilson also cautioned that sometimes private payers refuse to put through appeals to the second level unless they have new information. But providers are entitled to make the same points in the second appeal if they believe they weren’t heard in the first appeal. Anyway, the reality in the commercial world is that appeals internally often are pro forma—a mechanism to get to external review or alternative dispute resolution, she said. “They are essentially cutting off our right to appeal.”

1 HHS, Health Care Financing Administration, “Requirements for Determining Limitation on Liability of a Medicare Beneficiary, Provider, Practitioner, or Other Supplier for Certain Services and Items for Which Medicare Payment Is Denied,” Ruling No. 95-1, December 1995, https://go.cms.gov/3uYYZg8.

2 Nina Youngstrom, “Example of an Appeal Letter and Checklist,” Report on Medicare Compliance 31, no. 13 (April 11, 2022).}