As a follow up to our previous post IPPS Final Rule, Medicare DSH, Factor 3 & the Timing of Medicaid Days, we will again examine the current landscape of Medicare DSH reimbursement but this time with regards to Medicaid eligible days and how Barberton Citizens Hospital v CGS Administrators, LLC/Blue Cross and Blue Shield Association (Barberton) will affect a hospital's work identifying Medicaid eligible days for As-Filed cost reports and on a retroactive basis.
The Provider Reimbursement Review Board’s (PRRB) jurisdiction decision in the case of Barberton highlighted a number of issues that support the need for hospitals to perform retrospective reviews of their as-filed DSH calculations. Hospitals should be evaluating their overall DSH compilation program to ensure that it is timely, comprehensive and captures all the Medicaid eligible days the hospital is legally entitled to claim.
BARBERTON CITIZENS HOSPITAL CASE:
In Barberton, the MAC challenged the PRRB’s jurisdiction to hear a Medicaid eligible days appeal. The MAC asserted that the hospital cannot be dissatisfied with the MAC’s determination because the hospital did not claim the additional Medicaid days at issue in the as-filed cost report. The MAC relied upon the PRRB’s decisions in Norwalk Hospital v Blue Cross and Blue Shield Association and Danbury Hospital v Blue Cross and Blue Shield Association. In these decisions, the PRRB ruled that it is the hospital’s obligation to submit Medicaid eligible days data during the cost reporting process and that the hospital has the burden of proof to ensure that only days verified with the State as Medicaid eligible are claimed. To be heard by the PRRB, the hospital must establish a “practical impediment” as to why the hospital could not claim the days at issue when the cost report was filed.
We are not going to discuss the legal implications this decision has for pending or future PRRB cases regarding the Medicaid eligible days issue in this article. But we will use the provider’s assertions and the PRRB’s conclusions to highlight the importance of retrospective reviews of Medicare DSH calculations and the pursuit of appeals and/or reopenings of cost reports to include the identified additional days.
In Barberton, the PRRB ruled that:
- The provider established that there was an impediment associated with retroactive eligibility determinations – namely, that in-process eligibility determinations could take up to a year after the date of service; thus making it impossible for the provider to claim the days in the as-filed cost report.
-
There may be issues with the State’s database. In this case, there were gaps in the Medicaid eligibility database. As a result, at one point in time an eligibility match may result in a negative determination while at a future point in time, it may result in a positive determination. Unbeknownst to the hospital, changes to eligibility determinations and/or demographic data continue to be updated in the eligibility database. These changes yield different eligibility verification results based on the timing of the matching frequencies.
-
In this case, there were limitations regarding accessing the State’s database because necessary data elements are continually being updated. The State’s database is dynamic, not static and more times than not, matches performed significantly after the cost report is filed will yield more complete and comprehensive results.
The PRRB also noted with regard to the provider’s process of identifying Medicaid eligible days for the as-filed cost report that it had a comprehensive process that included, “All available and practical means to identify, accumulate, and verify with the State the actual Medicaid eligible days that were reported on its Medicare cost reports, and was diligent in following that process.” However, even with the robust process confirmed by the PRRB, the hospital’s consultants in this case, identified a substantial number of additional Medicaid eligible days that the hospital did not identify.
WHAT HOSPITALS ARE AND CAN BE DOING?
First, what are hospitals doing?
In far too many cases - Nothing. CMS’ data supports that there are many hospitals that never revisit their DSH calculation after the cost report is filed.
Not employing a second set of eyes. The hospital is handling this process internally without employing independent resources for a second look.
Second, what can hospitals do?
Complete retrospective Medicare DSH reviews. Medicaid eligibility determinations are a dynamic process and hospitals cannot be assured that they have captured all the days they are legally entitled to claim until long after the time the cost report is filed.
Solicit the help of an external, independent resource. As with many functions in many businesses – you cannot be an expert for all things. Determining a patient’s Medicaid eligibility is much more of a detailed and comprehensive process than is sometimes recognized by hospitals. All states have different processes and procedures for obtaining eligibility matches and most states have hundreds of eligibility codes to evaluate, many of which are not eligible for inclusion in the Medicare DSH calculation.
File PRRB appeals where appropriate
Pursue cost report reopenings where appropriate. On average, through cost reporting periods ending in 2014, a hospital has 5-7 fiscal years that are either still within the three year reopening window or remain unsettled. Provided the hospital meets the requirement for a cost report reopening (see instructions here), hospitals can pursue the inclusion of additional Medicaid eligible days for those fiscal years.
HOSPITAL BEST PRACTICES:
Evaluate your current process for compiling Medicaid days in the as-filed cost report. Are you putting your best foot forward? Can you meet the standard the PRRB set forth in Barberton? – “Barberton has provided substantial evidence that it used all available practical means to identify, accumulate and verify Medicaid eligible days when it filed its cost reports.”
Employ an independent third-party review of Medicaid eligibility subsequent to the filing of the cost report but before MAC audit. Yes, you can “refresh” the work that you performed internally at a subsequent date – but would that represent best practices or give the hospital the best opportunity to ensure that it is capturing all the Medicaid patient days that the hospital is legally entitled to claim?
If you enjoyed this post, perhaps you will find our most read article in August helpful by clicking HERE or you can get all future posts delivered directly to your inbox by clicking below!
