Overview of Recent CMS Reviews of PRRB Decisions

The CMS administrator has recently issued six decisions reviewing Provider Reimbursement Review Board (PRRB) decisions released earlier this year. Below is a summary of these decisions.

Research Medical Center v. Wisconsin Physician Service (Review of PRRB Dec. No. 2012-D12) May 14, 2012 — An intermediary properly disallowed additional 1998 data to be considered for a provider’s fiscal year 2001 nursing and allied health (N&AH) education payments for Medicare+Choice (M+C) enrollees. Under CMS payment methodology, the provider was only permitted to submit additional N&AH days’ data for the period ending December 31, 1998, it the data was submitted by December 31, 2000.

Norwalk Hospital v. BCBS/National Government Services Inc. (Review of PRRB Dec. No. 2012-D14) May 21, 2012 — The PRRB did not have jurisdiction to adjust the number of Medicaid days in the provider’s disproportionate share hospital (DSH) calculation. The provider failed to demonstrate that it was dissatisfied with the intermediary’s determination of the number of Medicaid days, and as such the PRRB did not have jurisdiction. There was no practical impediment to the provider to make it impossible for the provider to obtain the necessary data in time to file a claim for these days on its cost report, and, as such, the possible jurisdiction provided by the U.S. Supreme Court in Bethesda Hospital v. Bowen (485 U.S. 399 (1988), did not exist. The decision of the PRRB was reversed.

Rush University Hospital Medical Center v. BCBS/National Government Services, Inc. (Review of PRRB Dec. No. 2012-D9) April 4, 2012 — The PRRB incorrectly reversed the intermediary’s finding that certain beds were available for inpatient care. The provider did not present adequate documentation of its claims regarding either of the two contested groups of beds. The PRRB’s determination that research time could not be counted in determining indirect medical education costs, however, was correct.

Rush University Hospital Medical Center v. BCBS/National Government Services, Inc. (Review of PRRB Dec. No. 2012-D8) April 4, 2012 –The PRRB erred when it accepted the contentions of the provider that certain beds be excluded from the resident-to-bed ratio because they had been removed from service or were used for observation services. The Administrator found that the provider had not submitted adequate documentation to support the unavailability of the beds. The Administrator upheld, however, the PRRB’s determination disallowing claimed costs for resident time spent in elective rotations or in research activity.

Alameda Hospital v. BCBS/First Coast Service Options, Inc. (Review of PRRB Dec. No. 2012-D10) April 10, 2012 — The decision of the PRRB to remand the case so that the intermediary could examine the hospital-based skilled nursing facility’s alternative proposal for application of the low occupancy adjustment to its routine cost limits was appropriate.  The decision in Mercy Medical Skilled Nursing Facility v. Thompson, C.A. 99-2765 (D.D.C. May 14, 2004) that CMS changed its policy for determining the 112 percent reimbursement gap that affects atypical service exception requests without proper notice and comment period does not apply to the provider’s low occupancy issue.

Canon Healthcare Hospice v. CMS (Review of PRRB Dec. No. 2012-D15) June 6, 2012 — There was no legal basis on which the PRRB could permit or approve a waiver of recoupment from a hospice of payments exceeding the hospice cap during the cap period ending October 31, 2006. The PRRB erred, therefore, when it waived the recoupment of the portion of the overpayment attributable to Hurricane Katrina. The waiver granted by the HHS Secretary did not affect conditions for payment or any requirements related to reimbursement.