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PRRB 2012-D12 -3/09/12 (FY 2001)

This case involved the FI’s denial of Nursing & Allied Health (N&AH) education costs associated with Medicare plus Choice (M+C) days. In FY 1998, the Provider submitted UB-92 “no-pay” claim forms to the FI for services supplied to M+C enrollees during FY 1998. The purpose of submitting the no-pay bills was to obtain payments from Medicare for DGME & IME reimbursements for these patients as authorized by the BBA and CMS transmittal A-98-21.

The Provider encountered problems with the FI processing these “no-pay” bills during FY 1998. Due to the difficulty of processing the “no-pay” bills and the low DGME & IME payments, the Provider discontinued submitting these FY 1998 claims.

This case ultimately revolves around the Provider’s request to include M+C choice days that were not processed by the FI for recovery of N&AH education costs. As this was a new process, the instructions of submission were not fully worked through by CMS.

The Board determined that the FI improperly disallowed the N&AH payments in the Provider’s FY 2001 with respect to the discharges of M+C beneficiaries for FY 1998 and remanded the case back to the FI for processing.

Read more: Medicare Nursing & Allied Health – Research Medical Center

This case involved one hospital located in the Fort Wayne MSA that requested correction to total paid hours to exclude services paid but not-worked from its wage data for purposes of calculating the wage index. The Provider supplied documentation of the paid, un-worked hours to the FI. The FI rejected the Provider’s request stating that the Provider’s information was not supported with detailed documentation. The Provider according to the FI included only summary documentation in support of their request and rejected the request. The Provider’s subsequent request to CMS was also denied.

The Board ruled in favor of the FI. They concluded that the Provider did not provide adequate documentation in their request.

Read more: Medicare Wage Index – Fort Wayne MSA (Indiana)

Medicare GME/IME – Rush University Medical Center

PRRB 2012-D8 – 2/8/12 (FY 1993-1994)

PRRB 2012-D9 – 2/8/12 (FY 1996)

The following GME/IME issues were decided on:

1. Elimination of 14 Pathology FTE residents for GME purposes — The provider contends that these residents were improperly excluded by the FI. They provided as evidence a letter from the
   Provider’s Pathology Department Chairman. The FI contends the documentation provided was “simply not good enough” as the letter was constructed 10 years after the FY. The Board ruled in favor of the FI on this issue.
2. Overstated available beds for IME bed count – The Provider contended that the available beds were overstated to the extent of beds taken out of service during the FY for a major construction project. The argued that the evidence showed that these beds would take a minimum of 72 hours to be placed back in service. The FI contends that the Provider did not show that the beds in controversy were taken out of service and made unavailable. The Board concluded that a majority of the beds taken out of service were unavailable to inpatients and ruled for the Provider.
3. Overstated available beds for IME bed count; observation bed days – The Provider contends that the IME bed count is overstated because it does not properly reflect the days that beds were not available for inpatients as a result of their use for a non-PPS services: outpatient observation bed services. There was a self-disclosure by the Provider for erroneous billings for Medicare outpatient observation services rendered after 7/1/93. The FI contends that the billing issue raised questions about the core reliability of the observation information. The Board found that the observation services in question should be excluded from the available bed count, ruling in favor of the Provider.
4. Exclusion of time spent by I&R in research for count of IME FTEs – The provider contends that the resident FTEs spending time in research should be included in the IME FTE count and that this is consistent with 42 CFR 412.105. The FI contends that per 42 CFR 413.5 & 413.9, the research services specifically preclude the payment of Medicare funds for research not directly related to treating particular patients. Therefore the state any time spent by residents performing research activities not directly related to patient care is excluded from the resident count. The Board decided in favor of the FI that the research FTE time should be excluded from the IME FTE count.

Medicare GME/IME – Doctors Medical Center of Modesto

PRRB 2012-D11 – 2/24/12 (FY 2001 – 2007)

This is a very involved case dealing with the transfer of the residency program from Stanislaus Medical Center (SMC), Modesto to the Provider in 1997 upon the closure of the hospital. The Provider is appealing the elimination of the claimed GME/IME reimbursements for the 2001 through 2007 periods claiming that the transaction constituted a merger of SMC into the Provider. An argument was also presented by the Provider that this could be considered a new program.

The FI in their original audit of the Provider determined that the program did not constitute a merger but was considered a new program. Subsequent to this both the CMS and the FI determined that this determination of a new program was incorrect and recouped all Medicare GME/IME entitlements.

The Board rejected
the Providers arguments citing that the facts of the case did not support a
determination that the Provider’s Program is either a new residency program or
that there was a merger between SMC and the Provider.

Medicare DSH – Norwalk Hospital

PRRB 2012-D14 – 3/19/12 (FY 2005)

In this appeal the FI challenged the PRRB’s jurisdiction over Medcaid eligible days where there was no adjustment made by the FI in the finalization of the Medicare cost report.  The Board concluded in this case that they do have jurisdiction over the DSH – Medicaid Eligible Days issue.

This decision provides an excellent presentation of the history of the DSH issue.  Glenn Bunting, our Appeals Vice President highly recommends review of this case if you are interested in understanding the chronology of this issue since it’s implementation in May 1986.

Read more:

Medicare GME/IME – Alegant Health Immanuel Med Ctr

PRRB 2012-D7 – January 20, 2012 (FYE 6/30/00 – 6/30/03)

There are two DGME/IME issues in this case:

1. Whether the Hospital had properly established an affiliation agreement with another Hospital for 10 resident FTEs that were disallowed by the Intermediary.
2. Whether there the claimed New Psychiatric Residency program met the new program requirements.

The PRRB ruled in favor of the Hospital in issue one and against the Hospital in issue two. 

Medicare DSH – Lifespan SWC 2003 DSH Mcare + Choice Days Group

PRRB 2012-D6 – January 18, 2012 (FYE 9/30/03)

The Hospitals are appealing the exclusion of the Medicaid eligible patient days also enrolled in an M+C managed care plan from the Medicaid fraction for Medicare DSH allowable reimbursement purposes.  The year of this appeal is prior to CMS 10/1/04 implementation of the specific inclusion of these types of days in the Medicare fraction of the DSH proxy.  

Based on similar federal court decisions for Northeast Hospital and Metropolitan Hospital, the PRRB agreed with the Hospitals request for inclusion of these days in the Medicaid fraction.

Wage Index Issues – Youngstown – Warren 02 MSA WI Group

PRRB 2012-D5 – January 6, 2012 (FFY 2002)

The Providers are challenging the Youngstown-Warren Metropolitan Statistical Area (MSA) Wage Index applicable to the Federal Fiscal Year 2002 as improperly established under the Medicare PPS. The final determination being appealed is the notice of the FFY 2002 hospital wage index published by CMS in the Federal Register (Final Rule FR 8/1/02).

This is a significant decision as it reflects another of  a series of decisions that were initiated from the Medicare PPS wage index audit.  The appeal included the following specific issues that were estimated to have a $267K impact to Medicare PPS reimbursements:

1. Disputing the inclusion of “Bonus” hours
2. Disputing the inclusion of “Call Back” Hours
3. Exclusion of contracted Pathology service costs
4. Exclusion of contracted Per fusionist service costs
5. Exclusion of self-insurance workers compensation costs
6. Exclusion of on-site day care costs

The Group prevailed in issues 1 – 5 of the appeal.  Issue 6 was denied.  The PRRB stated that day care service costs were already included in the initial wage data and the claim reflected a duplication of costs.

Medicare GME/IME – Oakwood Annapolis Hospital

PRRB 2012-D4 – December 30, 2011 (FYE 12/31/04 – 12/31/06)

The dispute in this appeal is whether the Hospital met the definition of a “new” residency program in 2004.  The facts in this case were fairly complicated and should be read in the case if you have a similar type of case.  The PRRB ruled in favor of the Hospital and that it was under the current rules and regulations considered a “new” residency program.

Medicare Bad Debts – Lakeland Regional Medical Center

PRRB 2012-D3 – December 14, 2011 (FYE 9/30/05)

This appeal involved the Hospital claiming Medicare bad debts that were continuing to be pursued by an outside collection agency.  The PRRB ruled in favor of the hospital primarily based on the Medicare Bad Debt Moratorium policy that in place since 1987.