News Tagged as DSH

From: CMS Website

CMS allows the use of the DSH data for a limited period of time.  Over the past several years we have obtained hundreds of the SSI files for use in our Medicare appeals.  Past DUAs rarely had a return date included in the form.  CMS is now working to get a handle on this outstanding information. 

For DUAs without expiration dates, CMS is sending out e-mails with a 90 day notification for action.  We have received close to two hundred of these e-mails over the past week.  If you were the original requestor, you should also be receiving these e-mails.

According to CMS instructions, action is needed to either request an extension or to close the DUA and confirm that the data is destroyed.  The extension and or closure according to the instructions must be submitted by the requestor (Hospital).  Toyon is the custodian of the SSI data.  We are in the process of developing a process to handle the DUAs.  In our particular case, virtually all of the data files being used are still active as part of our Medicare SSI appeals.  CMS is requiring that the extensions be submitted to them between 60 – 90 days from the expiration date identified in the e-mail.

We are diligently working on sorting these out and will be communicating with the requestors in the near future.  The request for extension is very simple and we will be providing the framework of the e-mail to send to CMS.

Continued use of the DSH data will need to be updated annually.  Where the data is no longer needed, all of the original files and related linked files are required to be destroyed.  A signed confirmation of the destruction of the data is required as part of the final “closure request” submission. 

For questions, please contact Glenn Bunting or Ron Knapp at 925-685-9312.

Data Use Agreement (DUA) – Extensions & Closures

From: CMS Website

CMS SSI detail for data released on March 16, 2012 is now available to be requested by hospitals.  This information is free but requires a DSH Data Use Agreement be prepared and included in the request.  The requests are now all handled on-line.

We recommend all hospitals that receive Medicare DSH entitlements request this information for review and scrutiny of the match process.  Click here to view the DUA form required to request this data.  This form is to be completed, scanned and sent by e-mail to CMS at DataUseAgreement@cms.hhs.gov.  Notification of the DUA number creations will be sent to the Requestor within 3-5 business days of receipt of the request.  The data will be shipped to the Custodian in approximately 6-8 weeks.

The SSI issue continues to be litigated particularly for CMS’s inclusion of the Medicare Advantage days now contained in the SSI ratio development.  Verification of the changes made in the match process communicated in CMS-1498-R need to be carefully reviewed to verify that the changes were actually made.

If you have any questions concerning the process please contact either Glenn Bunting or Ron Knapp at 925-685-9312.

SSI Data Available from CMS – FY 2006 – 2009

CMS 2010 SSI Data File Posting/Removal – Sloppy Oversight

From: Toyon Associates – 5/4/12

As reported to you in a separate e-mail on Wednesday (5/2), CMS temporarily released the 2010 SSI file for use in the calculation of the Medicare DSH reimbursements.  After review of the data released, it was clear that something was seriously wrong with the file, as matched SSI days declined by 30% over FY 2009.

Prior to the March 2012 release of the SSI data for FYE 2006 – 2009, the Provider community had been waiting for over two years for SSI information.  This delay has backed up the finalization of tens of thousands of Hospital cost reports. 

What is disturbing about the temporary post on Wednesday is the utter lack of reasonableness testing of the 2010 file.  A quick summary of the past 4 years would clearly point out that something didn’t work in the 2010 match.  Check this summary that was put together as we were analyzing the released data in total:

 A simple check of the files prepared for the previous three years would have clearly demonstrated that something was wrong.  If CMS would be so careless in releasing this type of data, what else have they been allowing out that has not had appropriate review for reasonableness?

The impact of this CMS release was jaw dropping.  Those hospitals and hospital systems that pulled the data Wednesday morning were already reporting to their senior management the devastating financial impact of the new percentages.  Given the long delay in SSI issuance, the financial impact of the SSI is projected for multiple years.  Nationally, this erroneous SSI file impacted billions of dollars in Medicare DSH entitlements.

I believe the Provider community has every reason to expect better and more careful analysis by CMS of the data they release.  Hopefully, this is a bit of a wake-up call for CMS. 

CMS posted the 2010 SSI ratios earlier today on their website. In review of the ratios in this file, we found that over 90% of hospitals had a decrease in the SSI% compared to 2009. For our clients, the reductions averaged 27%.

After performing further analysis of the file and comparing the results to prior years, we found that total 2010 SSI-matched days were 30% lower than 2009.   The 2009 SSI days were reasonably close to the days for both 2007 and 2008. We concluded that there is clearly something wrong with the 2010 data.

We were able to reach CMS this afternoon and in a conversation with Tzvi Hefter, he acknowledged that there was something wrong with the data. Tzvi stated that the 2010 data file will be removed from the website.  The 2010 SSI file should therefore be disregarded, as CMS will be working on correcting this file. For those of you that pulled the file earlier today, you can now breathe a little easier given the drastic reductions that would have taken place to your allowable DSH entitlements.

If you have any questions, please contact me at 925-685-9312.

Ron Knapp

Executive Vice
President

HHS Files Petition to Supreme court on Equitable Tolling Issue
From: King & Spalding 4/23/12

Note: Toyon Associates is pursuing this equitable tolling issue for several of our clients.

Article Excerpt:
On April 13, 2012, Health and Human Services Secretary Kathleen Sebelius filed a petition for writ of certiorari with the U.S. Supreme Court requesting that the Court overturn the D.C. Circuit’s ruling that equitable tolling applies to the 180-day time limit for providers to file administrative appeals of final Medicare cost report payment determinations. Sebelius v. Auburn Regional Medical Center, U.S., No. 11-1231, petition for cert. filed Apr. 13, 2012.

At issue is the June 2011 decision, whereby the D.C. Circuit’s three-judge panel ruled that equitable tolling is available for Medicare cost report appeals because a claim for Medicare payment is analogous to a contract claim. Auburn Regional Medical Center, et al. v. Sebelius, 642 F.3d 1145 (D.C. Cir. 2011). By way of background, the equitable tolling issue arose in the context of provider appeals of the SSI Ratio component of the disproportionate share hospital (DSH) adjustment for fiscal years 1987-1994. The providers did not appeal the SSI Ratio issue to the Provider Reimbursement Review Board (PRRB) until they learned of the issue in 2006 (as a result of the Baystate litigation), more than a decade after the 180-day window for appealing their Medicare cost reports had passed.
Read more…

Click here to view the Supreme Court petition submitted by HHS.

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:

CMS Releases Long Awaited Revised SSI Percentages

From: CMS Website – 3/16/12

At the end of business last Friday, CMS released updated SSI information that reflected revised releases of the FFY 2006-2007 information and the first time release of FFY 2008 & 2009 percentages.  This is the first release of any SSI percentage information in almost two years.  The delay has virtually stopped all finalization of Medicare cost reports that are impacted by Medicare DSH entitlements.

This release should usher in a flood of finalized cost reports over the next several months.  In the issuance of this SSI data, CMS has claimed to have corrected and updated the data for the following: 

• Inclusion of Medicare Advantage days in the SSI percentage calculation
• Updated the match process to follow the guidelines of CMS-1498-R 

We have constructed a table of the SSI% information for 2005-2009.  The file contains the original and revised SSI% for 2006 and 2007.  If you would like a copy of this SSI summary file, click here.

From: US District Court of Columbia – 1/30/12

Great news from the US District Court of Columbia – Regarding the issue of Part A exhausted dual-eligible days and the inclusion of these patients in the Medicaid fraction for Medicare DSH purposes.  The DC court concluded that these types of days must be included in the Medicaid fraction for the period at issue.

This court followed the Northeast decision from the DC Circuit and concluded that CMS’s current policy on these days cannot be applied retroactively to periods before the 10/1/04 rule change.

Toyon has in place literally hundreds of years of appeals outstanding that this decision will apply to assuming CMS does not appeal the decision. We are hopeful that this will help move these appeal years to settlement resolutions over the next year.

SSI Data to be Released in 60 to 90 Days

From: HFMA Region 11 Conference – 1/30/12

Paul Crofton from the PRRB shared in a session earlier this week at the HFMA Region 11 conference, that CMS would be releasing the long awaited SSI information within the next 60 to 90 days.  The final PPS rules for FFY 2011 modified the match process and the paid claims information included in the SSI match from 6 months after the fiscal year to 15 months of paid claims information after the fiscal year (See 8/16/10 FR Excerpt). Based on the new criteria SSI criteria effective for issuances on or after October 1, 2010, we should be anticipating the following SSI issuances: 

•          FFY 2006 – Reprocessed Listing
•          FFY 2007 – Reprocessed Listing
•          FFY 2008 – New Release (After 3/31/10)
•          FFY 2009 – New Release (After 3/31/11)
•          FFY 2010 – New Release (After 3/31/12)

The delay in the SSI issuance has created a tremendous back log in the finalization of Medicare Hospital cost reports (Providers Qualifying for DSH).  We will be anticipating a deluge of finalized cost reports for the Spring and Summer of 2012.

From: Federal Register – 1/18/2012

Federal Register Summary:

This proposed rule addresses the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments under the Social Security Act. Under this limitation, DSH payments to a hospital cannot exceed the uncompensated costs of furnishing hospital services by the hospital to individuals who are Medicaid-eligible or “have no health insurance (or other source of third party coverage) for the services furnished during the year.” This rule would provide that the quoted phrase would refer in context to a lack of coverage on a service-specific basis, so that the calculation of uncompensated care for purposes of the hospital specific DSH limit would include the cost of each service furnished to an individual who had no health insurance or other source of third party coverage for that service.