Southwest Consulting Associates Blog

As we conclude the end of the first quarter subject to the 2016 OPPS Final Rule, hospitals MUST evaluate the new substantive reimbursement requirement (beginning on page 255 of the Federal Register 2016 OPPS Final Rule) recently imposed by CMS.  Introduced in the 2015 IPPS Proposed Rule, and later adopted in the 2016 OPPS Final Rule, CMS incorporated into the regulations a concept initially introduced by the PRRB Board Rules in 2008.  

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.    

It is not uncommon for patients to retroactively become Medicaid eligible or ineligible a few months (or longer) after a hospital’s cost report filing.  It is also not uncommon to get false positive or negative results due to the tools and methodology used to perform a Medicaid eligibility match.  As most healthcare reimbursement professionals would surely agree, retroactive Medicaid eligibility verification is especially important for its impact on a qualifying hospital’s Medicare Disproportionate Share (DSH) calculation.  When done so properly, retroactive verification of Medicaid eligible patients can confirm compliant results and yield significant increases to the Medicaid fraction of the Medicare DSH calculation.  

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:

In anticipation of the upcoming 2017 IPPS proposed rule (usually put on display in mid-April), SCA has been focusing our attention on the possible changes to the Uncompensated Care (UC) reimbursement program.  Use as your backdrop the following facts:

• The 2016 uncompensated care pool (UCP) is $6.4 billion and all “eligible” hospitals are fighting for a piece of that pie.

• If the most recent filed S-10’s are used, it appears that there will be a dramatic shift in UCP dollars among States.

• If the most recent filed S-10’s are used, it appears that there will be a significant redistribution of UCP dollars among hospital types, with the general theme being a shift from proprietary and non-profit hospitals to government-owned hospitals (in the hundreds of millions of dollars).

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.

In this post, we will examine the current landscape of Medicare DSH reimbursement with regards to Factor 3 and how the FY 2016 IPPS final rule will affect a hospital's work identifying Medicaid eligible days for As-Filed cost reports and on a retroactive basis.

CMS is implementing an important change to the data used to develop Factor 3 of the DSH computation for federal fiscal year 2016, effective October 1, 2015. The reaction to this change should include an examination of how providers prepare their as-filed DSH calculation and what retrospective work should be done to affect their federal fiscal year 2017 factor – as the opportunity to make changes is fast closing.

OVERVIEW:

This is the first in a series of updates related to the new Medicare DSH payment under the Affordable Care Act (ACA), specifically as it relates to the identification of Uncompensated Care (UC) Cost as computed by the Medicare Cost Report Worksheet S-10. CMS, in its FY 2016 proposed rule issued in April 2015, simply stated that:

• “Because of concerns regarding variations in the data reported on Worksheet S-10 and the completeness of the data, we did not propose to use data from the Worksheet S-10 to determine the amount of uncompensated care for FY 2014.”

• For the same reasons stated above, CMS elected not to use S-10 data for FY 2015.

• CMS stated that, “For FY 2016, we believe it remains premature to propose the use of Worksheet S-10.”

So at first blush, it appeared that CMS just “kicked the can” down the road again and while the agency reaffirmed its objective of moving to S-10 as the Factor 3 methodology, it didn’t necessarily sound as if that change was just around the corner. At least not until CMS responded to the many public comments (published in the 2016 IPPS final rule) that it received in this latest round of rulemaking.

The 2016 IPPS Final Rule was published in the Federal Register on August 17, 2015 and will be effective October 1, 2015.  Below is SCA’s “as brief as we can make it” summary on the rule as it affects disproportionate share hospitals (DSH).  We will be rolling out more detailed analysis in the coming weeks with our take on the impact to Uncompensated Care Reimbursement (UC).

The 2016 IPPS Proposed Rule for Acute Care Hospitals was put on display on April 17, 2015. All comments to the rule were to be submitted by June 16, 2015. As in past years, Southwest Consulting Associates (SCA) performed extensive analysis of the Proposed Rule and submitted detailed comments in response to CMS’ 2016 IPPS Notice of Proposed Rulemaking (NPRM). SCA’s comments primarily related to the proposed changes to the Payment Adjustment for Medicare Disproportionate Share Hospitals (DSH) including the Uncompensated Care (UC) payment component.