Abstract
PURPOSE:
Medicare intermediary denial of primary joint replacements has become common over the past couple of years. Our community hospital had a marked increase in denials following the assignment of a new intermediary. Our purpose is to document the initial impact of these denials.
METHODS:
A retrospective review of the first 361 Medicare total joints (181 hips and 180 knees) after a new intermediary began processing claims was performed. Initial denial rate, positive response rate to first appeal, as well as delay in payments because of these denials were documented
RESULTS:
42 hips (23%) and 47 knees (26%) were initially denied. Following submission of more documentation by hospital and surgeons, 38% of hips and 34% of knees were subsequently approved. Secondary appeals are now being processed, and those will be included. Average time to hospital payment in cases that were not appealed was 18.3 days. Those paid after first appeal averaged a time to payment of 126.1 days.
CONCLUSION:
A new intermediary increased our denial rate from 0 to greater than 20 percent and significantly (p < 0.05) increased our time to payment. Importantly, the hospital has still not been paid for 60% of initial denials (just under 16% of all claims).
SIGNIFICANCE: Third party intermediaries can place financial strain on hospitals by aggressive interpretation of Medicare rules.
