PRRB November and October jurisdictional letters reveal the secrets to appeals


January 04, 2017

The Provider Reimbursement Review Board (Board) determined that it has jurisdiction to decide a number of provider appeals related to the validity of the 0.2 percent decrease in the inpatient prospective payment system (IPPS) rate for fiscal year (FY) 2014, the calculation of disproportionate share hospital (DSH) Medicaid eligible days, and a Medicaid ratio issue related to Medicare rehab low-income patient payments. The Board also found jurisdictional impediments in several similar appeals due to insufficient documentation, a lack of timeliness, and other procedural errors (PRRB October 2016 Jurisdictional DeterminationsPRRB November 2016 Jurisdictional Determinations).

Medicaid eligible days. The Board held that a hospital could challenge the calculation of DSH Medicaid eligible days on its cost report even though it was not an issue challenged at the time of the final determination. The Board explained that a provider had a right to challenge the DSH calculation if it could establish a "practical impediment" for why it did not claim the days at issue at the time it filed its cost report.The Board agreed with the provider that retroactive eligibility and matching concerns regarding Medicaid eligible days constituted practical impediments.

Low-income patient payment. The Board also held that it could decide a low-income patient payment issue for an inpatient rehabilitation facility (IRF) despite the fact that Medicare law precludes review of IRF prospective payment system (PPS) rates. The Board held that the low-income patient adjustment was not a component of the IRF-PPS because the provider was challenging the accuracy of a Medicare contractor’s calculation of provider-specific data elements being used in the low-income patient calculation.

EJR. The Board granted providers’ requests for expedited judicial review (EJR) in several cases appealing the question of whether the 0.2 percent reduction in the IPPS rate set by the FY 2014 IPPS Final rule (78 FR 50495) was an improper exercise of the HHS Secretary’s authority. The Board explained that EJR was appropriate because it lacked the necessary legal authority to decide the question of the propriety of the IPPS reduction. The Board also granted providers’ requests for EJR in disputes over whether the providers had been paid the full amount of supplemental Medicare outlier payments.

Procedure. Procedural errors led the Board to find an impediment to jurisdiction in multiple cases. The Board found jurisdictional impediments in cases where providers failed to submit, as part of their appeals, the final determination they were appealing. In other cases, appeals were dismissed because the appeal was filed more than 180 days after the appealing party received the final determination it was appealing. The Board also held that it lacked jurisdiction to decide the number of exclusion days associated with the Medicaid fraction of DSH calculations because several providers did not claim the waiver days at issue on their cost reports.

MainStory: TopStory PRRBDecisions IPPSNews CMSNews BillingNews ClaimsAppealsNews CostReportNews DSHNews MedicaidNews MedicareContractorNews PaymentNews ProgramIntegrityNews ProviderNews

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