While Provider Reimbursement Review Board (PRRB) and/or Medicare Administrative Contractor (MAC) jurisdiction challenges used to be relatively infrequent occurrences, they have become more frequent and should be prepared for. At some point in the provider’s appeal process, it is highly likely that the MAC, PRRB or both will challenge jurisdiction, and the PRRB will review the appeal documentation and record and determine whether the appeal stands up to the current threshold. Unfortunately, through the end of 2014, the trend of PRRB jurisdictional decisions against providers continues to be the norm.
The PRRB published 25 jurisdictional decisions in the 4th quarter of 2014. Of these 25 decisions, three were in favor of the provider and twenty-two were not, with many cases containing multiple shortfalls. These decisions can be found using the following link:
In order to evaluate the trends and learn from the misfortunes of others, let’s review the decisions issued adverse to providers and see what we can learn. Here are the general categories of the negative decisions, with some cases having multiple shortfalls:
9 Decisions - These appeals were filed based on a revised NPR, where the revised NPR did not adjust the issue appealed. This highlights the importance of appealing all issues in which you are dissatisfied from the original NPR.
4 Decisions - The Request for Hearing and/or position papers were not filed timely. The PRRB has shown virtually no lenience for appeals filed after the 180-day appeal window.
3 Decisions - Providers appealed a recalculation of the SSI Fraction from the Federal fiscal year to the hospital fiscal year prior to deciding whether to actually pursue the recalculation. These appeals were deemed premature by the PRRB.
3 Decisions - The representative in these appeals could not produce all documentation to support the appeal as required by the PRRB.
2 Decisions - The individual appeals were withdrawn prior to the submission of the provider’s request to transfer issues to a group appeal. Therefore, the PRRB considered these requested transfers to be associated with issues no longer under appeal.
The following shortfalls were each mentioned at least once in relation to one of the various cases decided during this time period:
The representative transferred an issue from an individual appeal to a group appeal that was never contained in the individual appeal.
The provider requested Expedited Judicial Review (EJR) on an SSI Fraction case based on 1498-R grounds, which was denied as the PRRB has no jurisdiction under 1498-R.
The issue was not briefed in the provider’s position paper, so the issue was considered abandoned.
The issue was previously remanded by the PRRB to the MAC, so was no longer pending at the PRRB.
A good cause extension for time was requested (beyond the 180-days), but the PRRB ruled this issue was a known issue and additional time was not necessary.
The provider requested reconsideration of a prior jurisdictional decision, which was denied.
The issue was not properly transferred to a group appeal.
One appeal related to an issue where the full costs of the issue was not claimed in the cost report, and the ruling followed similar PRRB decisions for unclaimed cost.
A provider representative, that was not formally authorized, attempted to represent the provider on an issue.
An appeal was filed for an issue not protested on the cost report, which was a requirement for the fiscal year under appeal in the case.
The provider appealed an issue that the PRRB has no control, or jurisdiction, over.
A new PRRB Alert 10 decision, which is further detailed below.
In a November 3rd, 2014 jurisdictional ruling, the PRRB again weighed in on the Danbury case by issuing another PRRB Alert 10 decision. PRRB Alert 10 required hospitals with certain Medicaid eligible days cases pending at the PRRB to provide additional documentation. In review of this particular case, the PRRB reviewed the additional information provided by the hospital and determined the provider did not submit any additional arguments and/or documentation in response to the specific information / documentation requested in Alert 10. In particular, the PRRB detailed three flaws:
no detailed description of the process that the provider used to identify and accumulate the actual paid and unpaid eligible days was supplied,
no detailed explanation why the additional days at issue could not be verified by the State at the time the cost report was filed was provided, and
the provider did not present any evidence of the internal process it followed to gather State information for reporting DSH Medicaid eligible days on the cost report.
The PRRB found that although the provider explained general reasons why it was difficult to submit a complete and accurate listing of Medicaid eligible days at the time it filed its cost report, it did not explain which, if any, of those reasons were an impediment to the reporting of the days at issue in this appeal. While this issue is a slippery slope, there are steps that providers should be taking relating to Medicaid eligible days appeals. For more information on management of eligible days appeals, please contact us directly, as each case is different.
These decisions continue to highlight several tripping points that can easily be overcome when filing appeals:
In order to even qualify to file an appeal, a hospital must either claim or protest the cost of an item in the initial cost report filing. If protesting an item, the following steps are required:
a reasonable good faith estimate of cost must be entered on Worksheet E Part A Line 75,
an impact calculation must be provided to support the protested amount, and
a summary of the providers legal position supporting the protest must be provided. This requires the hospital reimbursement staff preparing the cost report to clearly understand the issues that should be protested, or to have adequate representation from someone that continually monitors these issues.
Upon the issuance of an NPR, an appeal must be filed within 180-days of the issuance date. If an issue is appealed in an individual appeal, a provider has an additional 60-days to add issues to the individual appeal. After this time has expired, the provider’s only avenue to pursue issues not appealed is through a reopening request, which the MAC may or may not allow.
Any individual appeal must have a reimbursement impact of at least $10,000, and a group appeal must have a reimbursement impact of at least $50,000 in order for an appeal to be filed.
The individual, or firm, providing representation must be very clear in representation letters filed with the PRRB, the specific issues and years in which the representative is authorized to act, must watch all due dates (i.e. position paper due dates, hearing dates, etc.) on the hospital’s behalf, and must diligently maintain all documentation relating to an appeal (some of which may have to be kept for 10+ years).
Hospitals, and hospital representation, must have a clear understanding of the documentation required to file an appeal, as well as to support post filing deadlines, position papers, and issue transfers.
If you have any questions or would like to discuss your particular situation, please contact Jeff Norman or Kyle Pennington at (972) 732-8100 or by email at jnorman@southwestconsulting.net or kpennington@southwestconsulting.net.
DON'T MISS OUT FUTURE PRRB DECISIONS!
