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George Washington University Hospital – FYE 12/31/99

CMS Admin Decision PRRB 2011-D31

Universal Health Svcs, Inc. – FY 2004 & 2005

CMS Admin Decision: PRRB 2011-D30

Both of the above PRRB decisions were overturned by the CMS Administrator. The common issue involved Medicare bad Debt claims that were denied by the FI because the accounts continued to reside at collection agencies. The issue involved the Bad Debt Moratorium that prevents CMS and te FIs from changing bad debt policy in effect prior to 1987.

The PRRB ruled in favor of the Providers stating:

“The Intermediary improperly disallowed the Provider’s claimed bad debts solely on the ground that accounts related to such bad debts still remained at an outside collection agency.”

Medicare DSH – Sampling; Medicare + Choice Days – Exempla Lutheran Med Ctr – FYE 12/31/04

CMS Admin Decision: PRRB 2011-D32

The CMS Administrator overturned the 6/3/2011 PRRB (2011-D32) decision allowing

Medicare + Choice days in the Medicaid fraction prior to October 1, 2004 discharges. The case also involved a dispute with the sampling methodology used by the Intermediary that was overturned by the PRRB. The CMS Administrator overturned both PRRB decisions.

As discussed above, we are very hopeful of a resolution for this issue based on the recent Appellate Court decision reported to you in the week of September 12th, 2011.

Medicare Dependent Hospital Status – Winn Parish Med Ctr 2001-05, 2007-08

CMS Admin Decision: PRRB 2011-D33

The CMS Administrator overturned the 6/13/2011 PRRB (2011-D33) decision allowing MDH status for a Provider covering 2002-2005 and 2007-2008 through a cost report reopening request to the FI. The CMS Administrator ruled that the PRRB lacked jurisdiction for this appeal.

Medicare IME/GME – Sutter 98-99 Managed Care Group

CMS Admin Decision: PRRB 2011-D34

The CMS Administrator overturned the 6/16/2011 PRRB (2011-D34) decision allowing the DGME/IME payments related to managed care days, discharges, and simulated payments solely on the grounds the provider failed to submit UB92 claim forms related to Medicare managed care beneficiaries.

Medicare + Choice Group – Partners 2002-2004 DSH

CMS Admin Decision: PRRB 2011-D37 – 8/23/11

The CMS Administrator overturned the 6/16/2011 PRRB (2011-D37) decision allowing the Medicare + Choice days to be included in the numerator of the Medicaid fraction used to calculate the DSH payment. The CMS Administrator has consistently overturned the PRRB decisions for Medicare + Choice DSH issue.

We are awaiting CMS response to the recent Appellate Court decision on this issue that appears to have placed a final nail in CMS’s longstanding position for this issue prior to October 1, 2004. This case was previously reported to you in our week of September 12th, 2011 report.

From CMS E-mail:

An error was discovered and fixed in the bill discharge date edit logic for the Fiscal Year (FY) 2011 INP PPS PC Pricer. The update is for claims dated from 10/01/2010 to 09/30/2011.  The update is dated 07/26/2011.

Inpatient Rural Hospital Demonstration – Cost Settlement Methodology

Pub 100-19 Demonstrations; Trans. 77 – July 22, 2011

Summary of Changes:

This demonstration reimburses specific hospitals for Medicare inpatient services through cost based reimbursement. Eight hospitals are continuing from the initial 5-year demonstration period, mandated by section 410A of the Medicare Modernization Act. Eighteen new hospitals will be starting the demo starting with cost report periods beginning May 1, 2011 through January 1, 2012. This CR identifies the hospitals, MACs and legacy contractors, and defines the payment methodology.

Decision: June 17, 2011

Consistent with what they do with the vast majority of the PRRB decisions, the CMS Administrator overturned both of the Board’s decisions concerning GME/IME issues.  The PRRB decision was originally reported in the week of June 6, 2011 NYNTK which is reposted below.

Medicare GME/IME Issues  

Kaleida Health, Buffalo NY – FYE 12/31/98

PRRB 2011-D27

This Medicare appeal addressed the following two issues:

1. Whether the Intermediary’s adjustment of the Provider’s direct Graduate Medical Education per resident amount was proper.
2.  Whether the Intermediary properly excluded research time the Provider alleges was related to patient care from the Full Time Equivalent resident count for direct Graduate Medical Education and Indirect Medical Education.

The first issue involved the merging of three hospitals with Medicare certified teaching programs.  The FI in the issuance of the NPR used a weighted average of the base year (1984) for two of the hospitals.  The Provider appealed this weighted GME per resident determination.  The position of the Provider was that the FI had no right to redetermine the per resident amount after it was first established.  They argued that there are no statutes or regulations allowing this revised determination of the per resident amount.

The PRRB concluded that the FI’s adjustment to the Providers per resident was improper.

The second issue involved research rotations of residents that were not allowed by the FI.  The Provider argued that the documentation presented demonstrated that the time spent by residents performing research activities as part of the approved residency program should be included in the direct GME and IME FTE calculations.  The Provider pointed out that the residents rotations were in the hospital setting. 

The FI contended that the Provider failed to provide adequate documentation to substantiate the research time of the direct GME and IME FTE resident counts. 

The PRRB ruled in favor of the Provider and overturned the FI adjustment to GME and IME FTEs.

Decision: May 27, 2011

This is a very complicated case that has little relevance for future DSH appeals.  The issue involved a General Assistance program in Kansas called MediKan.  There was an original ruling by the CMS Administrator that remanded a component of the appeal back to the PRRB.  This subsequent PRRB decision involved this single issue.

The CMS Administrator modified the decision of the PRRB.  The PRRB decision was originally reported in the week of June 13, 2011 NYNTK that is reposted below. 

Medicare DSH – General Assistance Days

QRS 1996 DSH MediKan Days – FY 1996

PRRB No. 2011-D24

The original hearing for this case was decided in 2007 (See PRRB Case No. 2007-D24).  The case involves a General Assistance program in Kansas called MediKan.  In the original decision the PRRB found that the MediKan program was included in the State of Kansas’ approved state plan under Title XIX, and that the MediKan program compensates hospitals that serve a disproportionately high number of low-income patients.  As a result the PRRB found in favor of the Provider’s claim for these days to be included in the Medicaid patient day proxy. 

The CMS Administrator overturned this original decision and remanded the case back to the PRRB since there was no decision concerning the Hold Harmless provisions from CMS Program Memorandum A-99-62 (December 1999).

The PRRB ruled only on the Hold Harmless provision issue.  Based on the evidence provided, the PRRB found that the Fiscal Intermediary’s determination in the exclusion of the MediKan days was appropriate.

Decision: May 10, 2011

As expected the CMS Administrator overturned the PRRB’s decision on the Medicare M+C days issue.  Discussion of the original PRRB decision is presented below that was reported in the week of April 4^th, 2011 News You Need to Know(NYNTK):

QRS 1999-2003 DSH Medicare Part C Days Groups

2011-D19 – March 16, 2011

The issue for this case was whether the Intermediary should include dual-eligible, Medicare + Choice (M+C) patient days in the numerator of the Medicaid proxy in determining Medicare reimbursement for disproportionate share hospital (DSH) payments in accordance with the Medicare statute at 42 U.S.C Section 1395ww(d)(5)(F)(vi)(II).

In this case, the PRRB brought up the fact that this was essentially the same issue as decided in the Southwest Consulting DSH Medicare+Choice Days Group PRRB Decision No. 2010-D52 in September 2010.  There is a note in the decision about the impact of the CMS Ruling 1498-R.  The PRRB stated:

“…Although the category of days in issue here may arguably be included as “non-covered” days, the Ruling does not explicitly include M+C or other managed care days in its directive of those to be remanded, and remand under the Ruling was not raised by the Intermediary in any of the proceedings….”

Ruling 1498-R was therefore not applied as part of this decision. 

Consistent with the Southwest decision, the PRRB found in favor of the Provider.  This decision will most certainly be overturned by the CMS Administrator.  The case that will control the future outcome of this issue is the Northeast Hospital case that is currently in Federal Court.