Hospitalizations With Observation Services and the Medicare Part A Complex Appeals Process at Three Academic Medical Centers.

Hospitalists and other providers must classify hospitalized patients as inpatient or outpatient, the latter of which includes all observation stays. These orders direct hospital billing and payment, as well as patient out-of-pocket expenses. The Centers for Medicare & Medicaid Services (CMS) audits hospital billing for Medicare beneficiaries, historically through the Recovery Audit program. A recent U.S. Government Accountability Office (GAO) report identified problems in the hospital appeals process of Recovery Audit program audits to which CMS proposed reforms. In the context of the GAO report and CMS's proposed improvements, we conducted a study to describe the time course and process of complex Medicare Part A audits and appeals reaching Level 3 of the 5-level appeals process as of May 1, 2016 at 3 academic medical centers. Of 219 appeals reaching Level 3, 135 had a decision--96 (71.1%) successful for the hospitals. Mean total time since date of service was 1663.3 days, which includes mean days between date of service and audit (560.4) and total days in appeals (891.3). Government contractors were responsible for 70.7% of total appeals time. Overall, government contractors and judges met legislative timeliness deadlines less than half the time (47.7%), with declining compliance at successive levels (discussion, 92.5%; Level 1, 85.4%; Level 2, 38.8%; Level 3, 0%). Most Level 1 and Level 2 decision letters (95.2%) cited time-based (24-hour) criteria for determining inpatient status, despite 70.3% of denied appeals meeting the 24-hour benchmark. These findings suggest that the Medicare appeals system merits process improvement beyond current proposed reforms. Journal of Hospital Medicine 2017;12:251-255.

Phonetic difficulty and stuttering in English.

Previous work has shown that phonetic difficulty affects older, but not younger, speakers who stutter and that older speakers experience more difficulty on content words than function words. The relationship between stuttering rate and a recently-developed index of phonetic complexity (IPC, Jakielski) was examined in this study separately for function and content words for speakers in 6-11, 11 plus-18 and 18 plus age groups. The hypothesis that stuttering rate on the content words of older speakers, but not younger speakers, would be related to the IPC score was supported. It is argued that the similarity between results using the IPC scores with a previous analysis that looked at late emerging consonants, consonant strings and multiple syllables (also conducted on function and content words separately), validates the former instrument. In further analyses, the factors that are most likely to lead to stuttering in English and their order of importance were established. The order found was consonant by manner, consonant by place, word length and contiguous consonant clusters. As the effects of phonetic difficulty are evident in teenage and adulthood, at least some of the factors may have an acquired influence on stuttering (rather than an innate universal basis, as the theory behind Jakielski's work suggests). This may be established in future work by doing cross-linguistic comparisons to see which factors operate universally. Disfluency on function words in early childhood appears to be responsive to factors other than phonetic complexity.