From the article:
When providers try to appeal adverse benefit determinations to the administrators of health and benefit plans governed by the Employee Retirement Income Security Act (ERISA), all too often the response to the appeal is simply non-informative. It is not unusual for a provider’s appeal to be met with a form letter containing no more than a sentence or two that the original benefit determination is being upheld because “benefits were paid in accordance with plan terms,” or some similarly vague statement. This rarely assists providers in understanding the bOn February 17, 2009, the Centers for Medicare & Medicaid Services (CMS) implemented the Long Term Care Hospitals (LTCHs) Special Project (the Special Project). The Special Project calls for an expanded medical necessity review of admissions and continued stays at LTCHs for claims going as far back as October 1, 2007. As the Special Project unfolds, it is becoming clear that, like the Recovery Audit Contractor (RAC) demonstration program, auditors are taking an aggressive approach in their review of claims, and are using the results of their reviews to disallow claims. For LTCHs, there is a lot at stake with the Special Project, because it appears fueled by a perception at CMS that LTCHs are too costly to the Medicare program. sis for the benefit determination because provider often do not know the plan terms.