The Provider Reimbursement Review Board (PRRB or Board) has published 177 jurisdictional decisions to date for 2015 and that is only through October of 2015. We will summarize November and December decisions once available. The published decisions can be found using the following link:
In a previous post, 124 negative jurisdictional decisions were summarized and some best practice tips were provided for hospitals and/or their counsel to be sure they are following. That post can be found HERE. Of the 177 total decisions posted, the remaining 53 were in favor of Providers; HOWEVER, in 21 of those, only some of the Providers within a group obtained a favorable jurisdictional decision or if multiple Notices of Program Reimbursement (NPRs) were appealed, jurisdiction was only taken over one of the NPRs but not the other.
Let’s get through the 21 decisions noted above first. Now, the Board sometimes finds jurisdiction for some Providers in a group, but not others, and often finds jurisdiction over one NPR, but not the other, when a Provider has appealed both an original and a revised NPR. Accordingly, here are the 21 “take the good with the bad” jurisdictional decisions.
8 Decisions - The Providers appealed original and revised NPRs, which were combined into one appeal. The PRRB determined that some of the Providers did not timely file the appeal based on the original NPRs, but did timely file the appeal based on the revised NPRs and vice versa. Further, where the Board found jurisdiction over the revised NPRs, but not the original NPRs, they often only found jurisdiction over one of the appealed issues and not the other appealed issues since they were not adjusted in the revised NPR.
2 Decisions - The PRRB determined that Providers in the groups were in two different group appeals for the same appealed issue, same fiscal year and dismissed the Providers from one group, but left them in the other.
1 Decision - The PRRB allowed a Provider to fight another day even though they were not properly included in the appeal, but it was because an NPR had not been issued yet, so the appeal was premature. In that same decision, the PRRB denied jurisdiction over another Provider who did not provide proper supporting documentation to meet the PRRB’s basic requirements for filing an appeal.
1 Decision - The Provider tried to transfer issues to various optional groups that were not properly formed and the PRRB denied the transfers. Luckily for the Provider, the PRRB did not dismiss the issues from the individual appeal.
1 Decision - The PRRB dismissed a Provider’s appeal from a revised NPR that did not adjust the issue, but not the Provider themselves as they also appealed the issue from the original NPR. However, that was not the case for 23 other Providers, since they only appealed from revised NPRs that did not adjust the issue. The PRRB denied jurisdiction over all 23. The PRRB also denied jurisdiction over three other Providers because they did not provide proper supporting documentation to meet the PRRB’s basic requirements for filing an appeal.
1 Decision - If a Provider is required to protest an issue and fails to do so, and the Medicare Administrative Contractor (MAC) does not adjust the issue, the PRRB is going to deny jurisdiction over that Provider or in this case, 5 Providers. For the remaining 4 Providers, who were not required to protest, the PRRB found jurisdiction and granted EJR.
1 Decision - The PRRB found no practical impediment and denied jurisdiction over the Medicaid eligible days issue and declined to exercise jurisdiction over the Observation bed days, Observation bed charges and Hospital discharge count issues because they were not claimed or adjusted on the cost report. However, the PRRB did find jurisdiction over the Labor and Delivery Room days issue pursuant to Bethesda Hospital Ass’n v. Bowen, 485 U.S. 399 (1988).
1 Decision - The PRRB said the appeal was moot. All the Providers in the group were challenging their DSH SSI ratios under the MMA § 951, but they had also previously appealed their SSI ratios and received remands. Accordingly, the Board decided that these Providers would receive revised SSI ratios without this appeal.
1 Decision - The PRRB dismissed one Provider from the group since they had not actually added the issue they tried to transfer, but remanded another since they did add and transfer the issue properly.
1 Decision - The PRRB dismissed a Provider’s appeal for premature filing, but it was only because the Provider appealed the MAC’s failure to timely issue their NPR before the year deadline was up. The Board said that once the year is up, refile! In addition, the Provider will still have the option to appeal the actual NPR once it is issued.
1 Decision - The PRRB determined that the publication of updated SSI ratios on the CMS website is not a final decision and dismissed the Providers who only appealed based on these ratios, but found jurisdiction for the other Providers. The Board also bifurcated the appeal into pre and post 1498-R groups, ruling that the legal issue being appealed by the Providers whose NPRs were issued prior to 1498-R was not the same as the legal issue being appealed by the Providers whose NPRs were issued after 1498-R.
1 Decision - The PRRB found no jurisdiction over Providers who appealed revised NPRs that did not adjust the issue being appealed, but granted jurisdiction over the Providers whose NPRs did adjust the issue and allowed the case to be bifurcated.
- 1 Decision – A Provider tried to break an appealed SSI issue into 5 different issues, but the PRRB reviewed the language and only allowed the originally appealed issue to be broken into 2 issues.
Practice Tip:
Since the Board will look at each Provider independently, you should not be harmed by being included in an appeal with other Providers who may have jurisdictional impediments.
It’s like I tell my kids, “follow the [Board] Rules and you cannot get in trouble!”
The remaining 32 decisions vary as to the reasons why the Board decided in favor of the Providers, but the overriding theme is to follow the “Practice Tips” and provide all the required and necessary information to support your position when asked or required by the PRRB. If you do, you will have a much better chance of getting a favorable decision or a chance to have the PRRB reverse a negative decision upon reconsideration, which happened in two of the decisions discussed below.
- 17 Decisions - The PRRB found jurisdiction over the Providers, issues and granted EJRs. Majority of these decisions were over appeals challenging the Two-Midnight Rule.
- 10 Decisions - The PRRB allowed groups/Providers to be bifurcated and found jurisdiction over the issues and Providers.
- 1 Decision - The PRRB found a practical impediment and jurisdiction over the Provider’s Medicaid eligible days issue.
- 1 Decision - The PRRB exercised its jurisdiction, asserting that the Provider preserved its right to claim dissatisfaction.
- 1 Decision - A Request for Reconsideration was granted and an appeal was reinstated by the Provider submitting all their “pleadings” proving that the Provider did timely add/appeal an issue. It was determined that the Provider mistitled the issue, which lead to the confusion!
- 1 Decision - A Request for Reconsideration was granted and a Provider was reinstated by proving that Labor and Delivery Room days were adjusted in the appealed revised NPR.
Bonus Tip:
The work papers for the last two cases listed had been timely provided to the PRRB prior to the initial decision denying jurisdiction. Do not miss your deadlines!
- 1 Decision - The PRRB found that the Provider’s appeal was timely filed even though it was past the 180th day.
Bonus Tip:
Thank goodness for weekends and Monday Holidays to give us those extra days! However, the moral to this story is to not forget all those negative decisions discussed above, not wait until the last minute to file an appeal and to always send your hearing requests with tracking through a reliable on-time delivery service.
So, while there is hope that Providers can receive a favorable jurisdictional decision at the PRRB, it should be noted that the deck does seem stacked against them (remember our negative decisions post?). We cannot stress enough that it is imperative to follow the Board rules and 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.
Again, HAPPY APPEALING AND GOOD LUCK!
