As promised, we have an update to share from our “Front & Center with SCA President, Michael Newell: Alert 10 In Action.” post. Last week, a decision was issued by the Provider Reimbursement Review Board (PRRB) in Barberton Citizens Hospital v. CGS Administrators, LLC/Blue Cross Blue Shield Association (Barberton) in which the PRRB ruled in favor of Barberton. The PRRB concluded that it has jurisdiction to hear Barberton’s appeal to include additional Medicaid eligible days in the Medicare DSH calculation that were not included in the hospital’s as-filed cost report.
The MAC (CGS/BCBSA) had challenged the PRRB’s jurisdiction over the appeal issue due to the requirements set forth in Alert 10. If you’ll remember, PRRB Alert 10 which was issued in May 2014, required providers with pending Medicaid eligible days appeals supplement the record by providing:
A detailed description of the process that the provider used to identify and accumulate the actual Medicaid paid and unpaid eligible days that were reported on the Medicare cost report;
The number of additional Medicaid paid and unpaid eligible days that the provider is requesting to be included in the DSH calculation; and
A detailed explanation why the additional Medicaid paid and unpaid eligible days at issue could not have been verified by the state at the time the cost report was filed. If there is more than one explanation or reason, identify how many of these days are associated with each explanation/reason.
This is the only, to our knowledge, positive PRRB jurisdictional decision on the Alert 10 issue that resulted from the negative decision in Danbury. The PRRB ruled in this case that the hospital established that a practical impediment, through no fault of the provider, prevented the identification and verification of the eligible days at issue in the case. Therefore, this decision not only establishes that there are situations in which the PRRB will agree that appeal days at issue are valid and could not have been identified at the time the cost report was filed, but it also establishes the reasonable efforts on the part of the hospital at the time the cost report was prepared as detailed in SCA’s President, Michael Newell’s testimony.
As a result of Alert 10, providers would be wise to take a good look at their process for not only claiming Medicaid eligible days in as-filed cost reports but how they compile the data to be included in as-filed cost reports in general. Hospitals must have a consistent and detailed process for claiming “costs”, such as Medicare DSH, that fully addresses protest items, the filing of all allowable costs in the initial cost report, filing a timely cost report amendment(s) and appealing the issues protested or adjusted upon audit. The absence of a cohesive, consistent process is likely to result in hurdles and obstacles on the way to the successful settlement of appeals, or unfortunately, the dismissal of the appeal.
DON'T MISS TIMELY INDUSTRY UPDATES!
