Southwest Consulting Associates Blog

As a primary component of Medicare Disproportionate Share reimbursement, a hospital’s Supplemental Security Income (SSI) percentage plays a significant role in determining the reimbursement impact.  Also referred to as the “Medicare” fraction of the Medicare DSH calculation, the SSI ratio represents the percent of patient days for beneficiaries who are eligible for both Medicare Part A and SSI.  By default, SSI ratios are based on the Federal Fiscal year end (10/01 – 09/30) and are generally published annually by the Centers for Medicare and Medicaid Services (CMS).  This concept makes sense for providers whose cost reporting period mirrors the federal fiscal year, but what about providers with cost reporting periods that differ from the Federal fiscal year?

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.