The intermediary
applied a policy that had no foundation in law when it adjusted the
reimbursements due the providers, Medicare-certified long-term acute
care hospitals that did not participate in Medicaid; the adjustments
were reversed. The providers claimed Medicare bad debts on their cost
reports for beneficiaries that were also eligible for Medicaid benefits
under the state program. Applying the must-bill policy, the intermediary
disallowed the bad debts because the providers did not first bill
the state Medicaid program and receive remittance advice. The providers
argued that there was no requirement that hospitals must enroll in
Medicaid to receive reimbursement for Medicare bad debts and that
the policy was not applied previously. The intermediary stated that
notice of this policy was provided to the providers, and that the
application of the must-bill policy was mandated by 42 C.F.R. §413.89(e), because
writing off the bad debt before billing the state does not constitute
a reasonable collection effort, as well as Provider Reimbursement
Manual provisions.
Although providers are required to attempt to collect debt,
there is no requirement in the regulations or the manual that they
must enroll in Medicaid or submit bills to the state. Further, the
state Medicaid program would not process bills that were submitted
by a non-Medicaid participating provider. Since the intermediary inappropriately
changed the policy, the adjustments were reversed.
Dec.
No. 2010-D25, Select Specialty ‘05 Medicare Dual Eligible Bad
Debts Group, April 13, 2010, ¶82,642.
Exclusion of days in DSH calculation
The intermediary was correct not to include certain patient
days in the Medicaid fraction of the disproportionate share hospital
(DSH) calculations for four hospitals because the individuals were
eligible for coverage under Medicare Part A. The hospitals provided
inpatient services to what they thought were Medicaid-eligible patients,
but who were later, after the services were provided and billed, determined
by the state to be entitled to Medicare Part A benefits. Since the
hospitals never billed the Medicare program for the days as they counted
these days as Medicaid days. The intermediary, knowing that these
services were covered under Medicare Part A, did not include the days
in the Medicaid fraction of the of the hospitals’ disproportionate
patient percentages calculation.
The hospitals contended that the days had to be included in
the Medicare fraction if they were excluded from the Medicaid fraction
because the patients could not be considered both entitled to and
not entitled to Part A benefits. The hospitals were responsible for
timely billing the Medicare program, and since none of the unbilled
days were charged to beneficiaries as utilized Medicare days, they
could not be counted as Medicare “covered patient days” which
would have allowed them to be included in the calculation. Regulation 42 C.F.R. §412.106(b),
which governs the Medicare fraction calculation, provides that only “covered
patient days” under Medicare can be included in the computation
of the Medicare fraction. The requirement that a provider timely bills
for payment of services corresponds with the incorporation of the
days in the DSH calculation, and the Provider Reimbursement Review
Board is not required to direct the intermediary to correct the hospital’s
mistake.
PRRB Hearing Dec. No. 2010-D26, April 14,
2010, ¶82,643.
Expedited judicial review
Several
providers’ request for expedited judicial review (EJR) before
a federal district court of a CMS ruling regarding disproportionate
share hospital (DSH) payment days was granted because, among other
things, the Provider Reimbursement Review Board (PRRB) had no authority
to invalidate any provision of the CMS’s ruling and, as a result,
EJR was appropriate for the federal court to resolve the issue and
determine the PRRB jurisdiction. CMS’s ruling on the providers’
DSH calculation counted in the supplemental security income fraction
dual eligible days, which were noncovered inpatient hospital days
for patients entitled to Medicare Part A and days for which patient’s
Part A inpatient hospital benefits were exhausted. The providers asserted,
among other things, that this ruling was forbidden by statute and
regulation, and would result in injuries exceeding well above $50,000.
The PRRB lacked authority to make a determination on the merits and
concluded that EJR was appropriate.
PRRB Hearing,
Dec. No. 2010-D36, Southwest Consulting 2004 DSH Dual Eligible Days
Group, CHI 2004 Dual Eligible Days Group, and Caritas Christi Health
Care 2004 DSH Dual Eligible Days Group, June 1, 2010, ¶82,644.
