Unfortunately, most jurisdictional decisions being issued are resulting in providers not proceeding past go and appeals are being dismissed prior to providers’ cases being heard. It is important that providers and/or their counsel continually review what is happening at the PRRB and evaluate their practices against the decisions rendered so that the rug is not pulled out from under their issues like in more than 80% of the cases we are about to review!
The PRRB published 123 jurisdictional decisions issued between January and July of 2014. These decisions can be found using the following link: http://www.cms.gov/Regulations-and-Guidance/Review-Boards/PRRBReview/List-of-PRRB-Jurisdictional-Decisions.html. In order to evaluate the trends and tripping points, SCA has reviewed each of the decisions and grouped them into the following 10 (yes, 10) categories with only the first being in the hospital’s favor (less than 20%):
PRRB jurisdictional decisions issued in provider’s favor – 24 decisions
Revised NPR appeals with no adjustment on the issue appealed in the revised settlement – 44 decisions
Appeals not filed timely – 15 decisions
Representation / Documentation issues – 11 decisions
Non-appealable issue – No PRRB jurisdiction – 8 decisions
Attempts to change the nature of an appeal – 8 decisions
Fiscal year ending after 12/31/2008 – Issues not properly protested – 4 decisions
Unclaimed cost – 4 decisions
Immaterial financial impact – 2 decisions
Issues not within the scope of the audit – 2 decisions
Provider had multiple appeals on an issue – 1 decision
For more in-depth details regarding the PRRB decisions in each category, please download our ‘PRRB Decision Summary 1/1/14-7/31/14’ HERE.
Bottom Line
These decisions highlight several tripping points that must 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
A summary of the providers legal position supporting the protest must be provided
ir="ltr"> 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, any appeal must be filed within 180-days of the issuance of the NPR. 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.
With all of the recent regulatory changes and the hurdles above, it would appear that the deck is stacked against the provider. If the provider is going to prevail at the PRRB level they must, above all else, make sure they are meeting jurisdictional requirements.
If you would like more information on this topic, feel free to give us a call.
