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Category: SCH

New Medicare PRRB Appeal Opportunity

Toyon is in the process of setting up appeals for its clients related to the recent ruling that opens the door for an appeal of “predicate facts,” or factual determinations that are relevant to the fiscal year at issue but which were actually decided in a year outside of the current year in dispute. Examples of now appealable predicate facts include IPPS standardized payment rates, SCH and MDH base rates, IME/GME base year resident counts, and GME base year per-resident amounts.

Click here to review the full press release from Toyon.

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Lawmakers take a stand for Rural Hospitals

From: AHA News – 2/6/15

Article Excerpt:

A bipartisan group of lawmakers have recently introduced a spate of AHA-backed legislation that supports small and rural prospective payment system (PPS) hospitals and critical access hospitals (CAH).  Securing passage of the legislation is part of the AHA’s advocacy agenda. The rural hospital relief bills include the following.

 Making MDH program, low-volume adjustment permanent.Sens. Charles Grassley, R-Iowa, and Chuck Schumer, D-N.Y., joined Reps. Tom Reed, R-N.Y., and Peter Welch, D-Vt., on Feb. 3 to introduce the Rural Hospital Access Act, S. 332/H.R. 663, legislation that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for small rural PPS hospitals.

Without congressional action, the current short-term extension of the programs will expire on March 31. In letters of support for the legislation, AHA Executive Vice President Rick Pollack called these “vital programs for America’s rural hospitals and the patients and communities they serve.”

Under the MDH program, about 200 hospitals that are more dependent on Medicare revenue because of the high percentage of Medicare beneficiaries in rural areas receive the sum of their PPS payment rate, plus three-quarters of the amount by which their cost per discharge exceeds the PPS rate. The enhanced low-volume adjustment helps level the playing field for hospitals in small and isolated communities, which frequently cannot achieve the economies of scale possible for their larger counterparts.

Extending the Rural Community Hospital Demonstration. Rep. Don Young, R-Alaska, introduced on Feb. 3 the Rural Community Hospital Demonstration (RCH) Extension Act, H.R. 672, which would extend the demonstration for five years.

The program enables rural hospitals with fewer than 51 acute-care beds to test the feasibility of cost-based reimbursement. Currently, 23 small rural hospitals participate.

“By extending the demonstration for five more years, your legislation will ensure that RCH continues to help America’s communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need,” the AHA’s Pollack wrote the bill’s sponsor in a letter of support. The program was created by the 2003 Medicare Modernization Act of 2003 and extended by the Affordable Care Act.

Removing 96-hour certification requirement for CAHs. Sens. Pat Roberts, R-Kan., and Jon Tester, D-Mont., Jan. 27 introduced a Senate companion to the Critical Access Hospital Relief Act, S. 258/H.R. 169. The legislation would remove the 96-hour physician certification requirement as a condition of payment for CAHs.

Medicare currently requires physicians to certify that patients admitted to a CAH will be discharged or transferred to another hospital within 96 hours in order for the CAH to receive payment under Medicare Part A.

The Centers for Medicare & Medicaid Services (CMS) has not historically enforced the requirement, but in recent guidance related to its two-midnight admissions policy implied that it will, a situation that would threaten patients’ access to longer care when needed. The legislation would not remove the requirement that CAHs maintain an average annual length of stay of 96 hours, nor affect other certification requirements for hospitals.

“This absurd rule puts arbitrary limits on how many hours patients can stay in critical access hospitals, and asks doctors to be clairvoyant and predict the unknown when admitting a patient,” said Roberts, who is co-chairman of the Senate Rural Health Caucus.

Original co-sponsors include Sens. John Thune, R-S.D., Jerry Moran, R-Kan., John Barrasso, R-Wyo., Daniel Coats, R-Ind., Grassley, Thad Cochran, R-Miss., Deb Fischer R-Neb., Steve Daines, R-Mont., James Inhofe, R-Okla., Roger Wicker, R-Miss., John Hoeven, R-N.D., Heidi Heitkamp, D-N.D., and Tammy Baldwin, D-Wis.

The AHA’s Pollack wrote the bill’s sponsors that the measure would “provide important relief for (critical access hospitals) and help ensure all Americans – no matter where they live – have access to essential health care services.”

Read more…

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Extension of Payment for Low Volume Hospitals and MDH Program for FY2014

From: Federal Register – CMS-1599-IFC2; Filed 3/14/14; Publication 3/18/14

CMS issued an interim final rule to implement an extension to the adjustment for Low Volume hospitals and the Medicare Dependent Hospital program by six months to March 31, 2014.  This extension was implemented by the “Pathway for SGR Reform Act of 2013.”

In the case of the Low Volume Hospital program, this legislation extended the provisions originally implemented by ACA that expanded the definition of a Low Volume Hospital to include hospitals that have less than 1,600 Medicare discharges and are located more than 15 road miles from another “subsection (d)” hospital through March 31, 2014.  This provision originally ended on October 1, 2013.

CMS posted new Low Income percentages in Table 14 today on their website.  For hospitals that have qualified for this additional reimbursement in the past, this table will inform you whether you still qualify for the add-on and what the percentage is effective October 1, 2013.  It is possible for hospitals to qualify for this add-on that previously did not.

In order for the applicable Low Volume percentage increase to be applied to payments for discharges on or after October 1, 2013, a hospital must do the following:

  • For newly eligible providers, the hospital must make its request for Low Volume status in writing.  This request must be received by its MAC no later than March 31, 2014.
  • For hospitals receiving this add-on during FY2013, the hospital must send written verification that it continues to be more than 15 miles from any other “subsection (d)” hospital that is received by the MAC no later than March 31, 2014.

This Low Volume add-on has not been paid by CMS due to the retroactive passage of the law.  CMS will be providing guidance on the systems implementation for these provisions, including changes to PRICER software used to make the payments in an upcoming transmittal.  By the time of implementation of this add-on, March 31, 2014 will already have passed.  It would therefore appear that retroactive reprocessing of the claims will need to take place.

Given that it is March 14, 2014, it is very important to review Table 14 and submit the appropriate requests to the MAC ASAP as March 31st is only two weeks from today.

Extension of Payment for Low Volume Hospitals and MDH Program for FY2014

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