Recent PRRB and CMS Administrator Decisions: A Summary for Providers

by Baker Donelson
Contact

In recently released decisions, the PRRB and the CMS Administrator addressed a number of issues of interest to many providers. Short summaries of those decisions are provided below. The PRRB and CMS Administrator post their decisions on their websites: PRRB decisions and CMS Administrator decisions.

GME and IME FTE Count – New Program, Affiliated Group

The Board affirmed the Intermediary’s adjustment, finding that the Provider did not establish a new medical residency training program, but rather was a new site for an existing program. The Board further found the Provider was not part of an affiliated group because there was no agreement in place. The Administrator declined to review.

Alegent Health – Immanuel Med. Ctr. v. Wisconsin Phys. Serv., PRRB Hearing Dec. No. 2012 D16 (June 15, 2012), declined to review, CMS Adm’r Dec. (Aug. 1, 2012).

DSH – Medicaid Fraction, Charity Days

The Board found that the Intermediary properly excluded New Jersey Charity Care Program (NJCCP) days from the Medicaid fraction of the Medicare Disproportionate Share Hospital (DSH) calculation for FYs 2000-2004. The CMS Administrator affirmed the Board’s ruling.

Ober Kaler DSH Charity Care Groups v. BlueCross BlueShield Ass’n/Highmark Medicare Servs. and Cahaba Gov’t Benefit Admins., PRRB Hearing Dec. No. 2012-D17 (June 20, 2012), aff’d, CMS Adm’r Dec. (Aug. 15, 2012).

Bad Debt – Indigency Documentation

The Board reversed the Intermediary’s adjustment and found the Provider’s bad debt supportable by adequate documentation. The Administrator reversed, finding the Provider’s patient account histories did not constitute adequate documentation capable of verification of the Provider’s indigency determinations and that accounts deemed charity accounts are not allowable as bad debts.

Doctors Hosp. v. BlueCross BlueShield Ass’n/CGS Admins., LLC, PRRB Hearing Dec. No. 2012-D18 (July 18, 2012), rev’d, CMS Adm’r Dec. (Sept. 11, 2012).

Allocation Statistics – Laundry/Linen, Central Supply

The Board upheld the Intermediary’s adjustments to the Providers’ statistical bases for allocating Laundry/Linen and Central Supply. The Board held that, although prior approval by the Intermediary is not necessary to support an alternative statistical basis for allocation, the Provider failed to support that its allocation basis was more accurate. The Administrator declined to review.

HCR Manor Care 1999 Laundry and Central Supply Statistics Group v. BlueCross BlueShield Ass’n/Highmark Medicare Servs., PRRB Hearing Dec. No. 2012-D19 (July 19, 2012), declined to review, CMS Adm’r Dec. (Aug. 22, 2012).

Board Jurisdiction – Cost Not Claimed on Cost Report

The Board held it did not have jurisdiction to entertain this appeal. It found the Provider failed to claim the physician malpractice costs on its cost report and that the Intermediary’s inclusion of the costs for wage index purposes did not allow the costs to be considered claimed as allowable costs generally. The Board found that since this was the only issue appealed and it did not have jurisdiction under 42 U.S.C. § 1395oo(a), it did not have any discretionary authority under 42 U.S.C. § 1395oo(d) to exercise jurisdiction. The Administrator declined to review.

John H. Stroger, Jr. Hosp. of Cook Co. v. BlueCross BlueShield Ass’n/Nat’l Gov’t Servs., Inc., PRRB Hearing Dec. No. 2012-D20 (Aug. 1, 2012), declined to review, CMS Adm’r Dec. (Sept. 25, 2012).

Skilled Nursing Facility (SNF) Exception Request – Peer Group Data

The District Court remanded this case for a determination of the effect of CMS’s failure to remove misclassified costs from the data used to create the peer group used to process the Provider’s exception request. The Board found insufficient evidence presented by the Provider to support that the peer group was improperly constructed. The Administrator declined to review.

San Joaquin Comm. Hosp.-SNF v. BlueCross BlueShield Ass’n/ First Coast Servs. Options, Inc., PRRB Hearing Dec. No. 2012-D21 (Aug. 8, 2012), declined to review, CMS Adm’r Dec. (Oct. 2, 2012).

Allocation of Physician Costs Between Part A and Part B

The Board found the Intermediary’s allocation of the physician costs between Part A and Part B was improper. The Provider elected as a teaching hospital to be paid on a reasonable cost basis for its physician services in lieu of being paid under the physician fee schedule. Such basis requires that the physician compensation be allocated and that the allocation must be capable of substantiation. The Board held that in the absence of an allocation agreement, an allocation based on other hospitals’ allocations may be applied, and that the Intermediary is to apply the average allowable Part B percentage of teaching hospitals in the state for that same cost reporting period. The Administrator declined to review.
Lemuel Shattuck Hosp. v. BlueCross BlueShield Ass’n/Nat’l Gov’t Servs., Inc., PRRB Hearing Dec. No. 2012-D22 (Aug. 10, 2012), declined to review, CMS Adm’r Dec. (Sept. 25, 2012).

DSH – Medicaid Fraction, Charity Days

The Board found that the Intermediary properly excluded Colorado Indigent Care Program days from the Medicaid fraction of the Medicare Disproportionate Share Hospital (DSH) calculation for FYs 1991-2006. The CMS Administrator affirmed the Board’s ruling.

QRS 1991-2006 Colorado DSH/Gen. Assist. Days Group v. BlueCross BlueShield Ass’n/Trailblazer Health, PRRB Hearing Dec. No. 2012-D23 (Sept. 6, 2012), aff’d, CMS Adm’r Dec. (Nov. 6, 2012).

IME and GME FTEs – Base Year Count

The Board affirmed the Intermediary’s adjustments. It found the Provider was not entitled to include the full-time equivalent (FTE) residents of another hospital in its base year count for the following reasons: (1) the Provider was not affiliated with the other hospital via an affiliation agreement; (2) the Provider failed to timely apply for additional FTEs as part of the redistribution process; (3) the Provider was neither a new facility nor located in a rural area, which are requirements for relief as a rural facility servicing a medically underserved population; and (4) the Provider was not entitled to relief under the temporary cap increase exception. The Administrator declined review.

Swedish American Hosp. v. Wis. Phys. Serv., PRRB Hearing Dec. No. 2012-D24 (Sept. 6, 2012), declined to review, CMS Adm’r Dec. (Oct. 18, 2012).

Board Jurisdiction – Redistribution of Residency Slots

The Board ruled that it did not have jurisdiction to review the issue appealed and dismissed the appeal. The issue in dispute was the accuracy of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provisions under section 422 related to the redistribution of the 1996 resident cap amount. The statute specifically prohibits appeal of this issue. The Administrator declined review.

Bergen Reg. Med. Ctr. v. BlueCross BlueShield Ass’n/Novitas Solutions, Inc., PRRB Hearing Dec. No. 2012-D25 (Sept. 25, 2012), declined to review, CMS Adm’r Dec. (Nov. 20, 2012).

 

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Baker Donelson | Attorney Advertising

Written by:

Baker Donelson
Contact
more
less

Baker Donelson on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Privacy Policy (Updated: October 8, 2015):
hide

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.

Security

JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at info@jdsupra.com. In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at: info@jdsupra.com.

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.