All told, the auditors in those years requested records on 2.6 million Medicare patient encounters, discovering errors in half of them, usually for care delivered in settings that were too expensive or billed using the incorrect code. The average individual payment denial was for $507.
Seven years ago, Congress ordered Medicare to hire four private companies, known today as recovery audit contractors, to police Medicare payments and detect cases where hospitals, doctors and suppliers were being overpaid. In 2011, the program recovered $488 million for Medicare after accounting for contractor fees and successful appeals of payment denials.
The hospital industry points to the high rate of cases that hospitals win on appeal as a sign that the program is flawed. The American Hospital Association supports bills in the House and Senate to scale back auditing, bolstered by hospital-reported survey findings that 40% of all denials are appealed and 70% are successful.
AHA officials said the discrepancy between the hospital-reported appeal rates and OIG-reported rates was due to the AHA data being two years fresher than the government-analyzed data. AHA officials also said their data was drawn only from hospitals, while the OIG figures pertained to all Medicare Part A and B providers.