Case Study – Complex Coordination of Benefits Denial

By: Emily Blizzard, Esq., Associate Attorney, The Law Offices of Fotheringill & Wade, LLC  Issue: A Maryland hospital cancelled a request for authorization due to the belief that authorization was not required from the secondary payer. Subsequently, it was learned that the insurance company was actually the primary payer for most of the charges, causing denial of the submitted claim.

Aetna Discontinues Unpopular Observation Notification Policy- But There’s a Catch

By: Emily Blizzard, Esq., Associate Attorney, The Law Offices of Fotheringill & Wade, LLC In the March 2018 Edition of the Aetna OfficeLink Update, Aetna announced a major change to their observation notification policy. Effective July 1, 2018, Aetna will “no longer require notification for observation greater than 24 hours.” This change will come as a relief to many hospitals. The soon-to-be phased out Aetna policy, in practice, caused Aetna to refuse observation notification until 24 hours had elapsed, but then after the 24 hour mark would require notification within the inpatient notification timeframes. This differs from most insurers, who would require observation notification for observation care of any length, […]

An Aetna Medical Director Admitted He “Never Once” Reviewed Medical Records- What Now?

Emily Gillingham, Associate Attorney at Fotheringill & Wade, LLC Almost every day, one of our hospital clients refers a case to our firm that has us questioning how an insurer could have reached the decision they did. We got a unique look into the inner workings of Aetna’s utilization management department this week with the bombshell revelation, reported by CNN, that a former Aetna Medical Director, Dr. Jay Ken Iinuma admitted in a deposition that he never looked at a patient’s medical records during his time at Aetna. What’s worse? Dr. Iinuma further testified that this was what he was instructed to do in Aetna’s training for the position. The […]

CMS Announces New and Expanded Appeal Settlement Initiatives

On Friday, November 3, 2017 CMS announced that it will make available a new settlement option for eligible providers and suppliers with a low volume of Medicare Part A and B claim appeals pending at OMHA and/or the Medicare Appeals Council. CMS also announced that OMHA will be expanding the Settlement Conference Facilitation Process for certain appellants that are not eligible for the LVA option. Low Volume Appeals The low volume appeals settlement option (LVA) will be limited to appellants with a low volume of appeals pending at OMHA and the Council. Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and […]

American Hospital Association Calls on CMS to Address ‘flaws and inaccuracies’ in OIG Audits

In a letter dated October 2nd, the American Hospital Association has called on CMS to take a more active role regarding hospital compliance reviews conducted by the Office of Inspector General (OIG). Citing fundamental flaws and inaccuracies, both in the OIG’s understanding and application of Medicare payment rules and in the procedures used to conduct the audits, the AHA asserts that the flaws “result in vastly overstated repayment demands, unwarranted reputational harm, and diversion of hospital and physician leaders’ time from their core mission of caring for patients.” The AHA further asserts that the OIG’s mistaken legal interpretations result in uneven application of Medicare payment rules and that there is […]