Southwest Consulting Associates Blog

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:

https://www.cms.gov/Regulations-and-Guidance/Review-Boards/PRRBReview/List-of-PRRB-Jurisdictional-Decisions.html

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.    

AND...the negative jurisdictional decision trend continued for 2015...  

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.  Of those 177, only 53 were in favor of Providers; and, 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.  The decisions can be found using the following link:

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.

CMS issued CMS Ruling 1498-R2 on April 22, 2015 concerning SSI ratios for periods before October 1, 2004. In addition, CMS also posted revised SSI ratios in accordance with the terms of the ruling.

CMS Ruling 1498-R was originally issued in 2010 as a result of the court’s decision in the Baystate case. Generally, the ruling called for the recalculation of SSI ratios for open cost reports and for properly pending Disproportionate Share Hospital (DSH) appeals on the Baystate issue, in accordance with the court’s ruling in that case. However, also included was a provision to incorporate into the revised ratios non-covered Part A days, which was contrary to CMS’ policy and practice during those years.

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.

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.  

Thursday November 20, 2014, I testified before the Provider Reimbursement Review Board (PRRB) in a jurisdictional hearing concerning the May 2014 issuance of PRRB Alert 10 that resulted from an adverse decision in the Danbury case. Much has been written about PRRB jurisdiction, and specifically, the Danbury decision and subsequent PRRB Alert 10 – including pieces authored by Southwest Consulting Associates. However, this was the first hearing that I am aware of since the issuance of Alert 10 to delve deeply into specifics of what that alert requires. If there was any question in your mind regarding the shift in the “jurisdictional” ground beneath providers’ feet, I am here to confirm for you that the ground is in fact shifting and the dominos are now falling.

On May 23, 2014, the Provider Reimbursement Review Board (PRRB) issued Alert 10 following its decision in Danbury Hospital v. Blue Cross Blue Shield Association (Danbury). This decision, and subsequent Alert, further signals a continuing trend relating to the documentation of Medicaid paid/eligible days and the importance of claiming all such “allowable costs” (or eligible patient days in the Medicare DSH context) in the initial cost report filing.

Alert 10, in conjunction with changes made to 405.1811(a)(1) and 405.1885(a)(1) in 2008 and the Agency’s interpretation of the United States Supreme Court decision in Bethesda Hospital Association v. Bowen, highlights the PRRB’s view regarding the requirement that hospitals must claim all allowable costs in its initial cost report filing and must show that any costs claimed through an appeal for Medicaid paid/eligible days could not have been claimed in the initial cost report filing. Let’s dig into this in more detail and review the actual Alert 10 requirements and why this is an issue that REQUIRES YOUR ATTENTION.

Filing an appeal with the Provider Reimbursement Review Board (PRRB) has transformed through metamorphosis several times over many years, resulting in a process littered with tripping points for providers seeking a hearing for an issue with which it is dissatisfied.  At some point in the provider’s appeal process, it is likely that the MAC, PRRB or both will challenge jurisdiction.  The PRRB will review the appeal documentation to determine whether the provider’s filing passes muster and can proceed past go (there’s that monopoly reference again).  

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!