Why Are Patient Appeals More Common Than Expected?

As required by their Statement of Work, Livanta, the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for regions 2, 3, 5, 7, and 9, published their annual report for the 2022 calendar year (CY). As a reminder, the BFCC-QIO is charged by the Centers for Medicare & Medicaid Services (CMS) with “improving healthcare services and protecting beneficiaries through efficient statutory review functions, including quality-of-care reviews for Medicare beneficiaries.”

As recently discussed in other RACmonitor articles, Livanta also performs other duties for CMS, including short-stay inpatient admission reviews and high-weighted DRG reviews, but those tasks are not included in this report.

The first message from Livanta’s report is that patient appeals are much more common than one might expect. They note that they handled over 200,000 hospital discharge and post-acute service termination appeals in 2022 as one of two BFCC-QIOs. If Kepro receives a similar number, that means over 1,000 Medicare beneficiaries file an appeal every single day, encompassing hospitals, skilled nursing facilities (SNFs), home health agencies, hospices, and comprehensive outpatient rehabilitation facilities.

Looking closer at the data, a few findings stand out.

First, it appears that the pre-admission Hospital Issued Notice of Non-Coverage, the HINN 1, is used very infrequently. Patients are encouraged to appeal when given the HINN 1, yet Livanta received only 208 appeals in 2022, with nearly 80 percent coming from Region 2, consisting of New York, New Jersey, Puerto Rico, and the U.S. Virgin Islands. Of those 208 HINN 1 appeals, Livanta agreed with the provider almost 84 percent of the time.

The HINN 10, the notice used when the hospital utilization staff determines that ongoing inpatient care is not necessary, but the physician will not discharge the patient (so they asked Livanta to make the decision) was also uncommon, occurring 111 times, with Livanta siding with the hospital over 78 percent of the time.

On the other end of the appeal spectrum lies the bulk of the work done by Livanta.

Although the percentage varies by region, about 62 percent of the appeals were filed by Medicare Advantage (MA) beneficiaries over the discontinuation of their care at a SNF, the coverage of home care services, or coverage of care at a comprehensive rehabilitation facility (CORF). These are also known as Grijalva appeals, named after the lawsuit that led to the requirement that a process be developed to give these patients appeal rights. Unfortunately, Livanta does not break down the statistics, but one can speculate that the majority of the appeals would be of SNF and home care services.

Looking at Region 5, which encompasses Illinois, Minnesota, Indiana, Michigan, and Ohio, as an example, there were 52,834 appeals of termination of home care, SNF, or CORF care by Medicare Advantage patients, but only 9,457 appeals of termination of the same services by patients with traditional Medicare. This likely reflects the tight oversight that MA plans have when their enrollees are admitted to a SNF to determine coverage on a nearly daily basis, compared to traditional Medicare, wherein the facility makes its own determination of when the Part A stay is no longer necessary.

Back to hospital appeals – the number of patients who appealed their discharge, as described in the Important Message from Medicare (IMM) presented to every inpatient, was similar across Medicare and Medicare Advantage patients, with a total of 40,146 appeals filed. For these appeals, Livanta agreed with the facility on the discharge 86.8 percent of the time. Interestingly, patients in Region 7, encompassing Iowa, Kansas, Missouri, and Nebraska, seemed drastically less likely to appeal their discharge, although this may be simply due to their drastically smaller population, compared to other regions.

Livanta also addresses quality-of-care concerns submitted by Medicare beneficiaries. While they provide ample data, little of it is directly actionable, as it is too non-specific. What is clear is that in every region, the most common concern was “apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis (that) prompted this episode of care (excludes laboratory and/or imaging, procedures and consultations).” Of the many quality-of-care concerns, overall, in less than 13 percent of the appeals was the concern confirmed by the Livanta reviewer. 

How does Livanta establish what the appropriate quality of care is? In every diagnostic category for which they provide data, they use UpToDate as their reference. Livanta justifies the use of UpToDate by noting that it “is a comprehensive resource consisting of peer-reviewed, physician-authored articles on thousands of clinical topics. Its review articles are continuously updated by incorporating new evidence from hundreds of medical journals, and cited evidence is graded on its strength and quality. Unlike similar repositories that are designed to be used quickly at the point of care, UpToDate articles generally include more thorough explanations of both the foundations and nuances of their topics.”

As with most statistical reports, the interpretation of data is often influenced by the perspective of the person reviewing it. In this case, it appears first that Livanta does not simply sit around and collect money from a lucrative CMS contract. They clearly work hard for their money. It also seems that for the most part, providers are doing right by patients, winning most appeals.

But perhaps the message should be that while providers are generally making the right decisions about care, perhaps a better job needs to be done communicating with patients about their medical benefits and their medical care.

I am sure every provider would love to provide, and every patient would love to receive, unlimited care to every patient at no cost to anyone, but that is not the reality of our healthcare system. We must work with within the system we have.

If you are interested to see the statistics for your region and state, you can find the reports at https://livantaqio.com/en/About/Annual_Report.