Southwest Consulting Associates Blog

The Hospital Outpatient Prospective Payment System (OPPS) FY 2020 proposed rule was put on display for public inspection on July 29, 2019 and published in the Federal Register on August 9, 2019. The 247-page FY 2020 OPPS proposed rule can be viewed in its entirety here. This proposed rule will affect discharges on or after January 1, 2020. 

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.  

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.

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.