AHLA. LL. PRRB Appeals The View from the Board

Transcription

1 AHLA LL. PRRB Appeals The View from the Board Michael W. Harty Chairman PRRB Board Member, Office of Hearings/PRRB Centers for Medicare and Medicaid Services Windsor Mill, MD Institute on Medicare and Medicaid Payment Issues March 25-27, 2015

2 PRRB APPEALS THE VIEW FROM THE BOARD American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues Baltimore, MD Thursday, March 26, Board Members Michael W. Harty, Chairman 1/29/17 Clayton J. Nix, Esq. 9/24/17 L. Sue Andersen, Esq. 5/6/18 Charlotte F. Benson, CPA 9/7/2017 Jack Ahern 3/18 1 1

3 Office of Hearings, CMS Benjamin Cohen, Director, Office of Hearings, CMS Brenda Thew, Deputy Director, Office of Hearings PRRB MGRB Hearing Officers Medicaid State Plan Amendments Medicare Advantage/Prescription Drug Contract Determinations 2 PRRB Appeals Division of Jurisdiction and Case Management Lisa Ogilvie, Director Christine Blowers, Deputy Director Division of Hearings and Decisions Paul Crofton, Director 3 2

4 Division of Jurisdiction & Case Management Establish initial case setup, Responds to and initiates all correspondence, Case management issues, Jurisdictional reviews, EJRs, Freedom of Information Requests, and Keep the case tracking database updated 7 Attorneys 9 Paralegal Specialists 4 Division of Hearings and Decisions Handles cases from scheduling of hearing through decision issuance Mediation 3 Board Advisors 1 Paralegal Specialist 5 3

5 Appeals Inventory FFY * Inventory as of 10/01 6,683 5,041 7,124 9,311 New Appeals 652 3,907 4,400** 1,521 Appeals Closed 2,294 1,824 2,225*** 1,118 Inventory as of 9/30 5,041 7,124 9,311 9,714 * Oct Feb. 6, 2015 ** Highest Number of New Appeals 4,086 in FY 1999 *** 73 Cases Closed by 30 Board Decisions **** Highest Ending Inventory 10,366 in FY Appeals Inventory FFY FFY 2012 FFY 2013 FFY 2014 FFY 2015* Group Appeals 2,802 56% 3,664 51% 5,326 57% 5,662 58% Individual Appeals 2,239 44% 3,460 49% 3,985 43% 4,052 42% Total 5, % 7, % 9, % 9, % * Feb

6 New Appeals FFY 2012 FFY 2013 FFY 2014 FFY 2015** Groups % 1,750 45% 2,412 55% % Individual Appeals Hospitals % 2,001 51% 1,950 44% % Other Facilities* % 156 4% 68 1 % 33 2% Total % 3, % 4, % % * CAHs, RHCs, Hospice & HHAs ** Oct Feb PRRB Inventory February 2015 # Open Appeals FYE # Open Appeals Pre 2000 Pre , , , Total 9,

7 Group Cases By Issue * DSH SSI 1,036 DSH - Dual Eligible 1,387 DSH Section 115 Waiver Days 81 DSH - Charity/General Assistance 88 DSH - Labor/Delivery Room 78 DSH - Medicare+Choice/Advantage 1,558 DSH Other 119 Uncompensated Care FFY 92 Subtotal DSH-related 4,439 *Inventory as of Feb Group Cases by Issue (continued) Budget Neutrality 157 Wage Index 65 Bad Debt 222 IME/GME 104 Rehab LIP 62 Two Midnight 0.2% Reduction 182 Outlier Payments 219 Standardized Amount 67 Other 145* Subtotal Non-DSH Issues 1,223 Total Groups 5,662 *Includes SNF RCL, SCH, Hospice, etc. 11 6

8 CMS 1498 Remands through February 2015 Standard Alternative Total SSI Ind SSI - Groups L&D- Ind L&D - Group Dual Elig Ind Dual Elig - Groups Total Board Activity FY * Live/Telephonic Hearings 30 Published Decisions (73 Cases) 232 EJRs Grant 168 Denied Jurisdictional Decisions Unclaimed Costs No Adjustment/Not Protested Refusal by Medicare Contractor to Correct/Include an Item after Cost Report has been filed but before NPR DSH Eligible Days *Approximately Hearings Scheduled per Month 13 7

9 How the Board Decided Provider 9 MAC 21 Modified MAC 4 Total Issues Administrator s Determination Reversed 9 Affirmed 2 Declined to Review 19 Modified 3 Total Issues

10 Published Decisions ISSUE Number of PRRB Administrator Issues Bad Debts - Moratorium 1 Provider Rev. Rural Hospital Reclassification 1 Provider Rev. Rural Health Clinic Visits 1 Provider Rev. GME - ACA 5504(a) & (b) 1 Provider Rev. Nursing Allied Health 1 Provider Rev. Community Mental Health Clinic 1 Provider Rev. All-Inclusive Rate Provider 1 Provider Rev. CAH - CRNA 1 Provider Rev. GME - New Program 1 Provider Dec. Jurisdiction/Interst Expense 2 MC/MC Rev./Affirmed SCH -Market Share 1 MC Affirmed DSH Charity Care Days 3 MC Dec. Hospice Cap Caluaction 1 MC Dec. Hospice 2% Reduction 1 MC Dec. Jurisdiction 1 MC Dec. Bad Debts - Must Bill 1 MC Dec. Bad Debts - Collection Effect 2 MC Dec. Bad Debts - Written Off Before 120 Days 1 MC Dec. Bad Debt - Pending at Collection Agency 2 MC Dec. State Provider Tax 1 MC Dec. GME - Temporary Cap 1 MC Dec. Investmant Income Offset 2 MC Dec. Occupational- Mix Survey 1 MC Dec. Hospice Cap New Provider 1 Modified Dec. Bad Debts - Must Bill 1 Modified Modified SCH - Low volume Adjustment 2 Modified Modified 16 Board s Decision Inventory 3/2013 3/2014 3/2015* FY FY FY FY FY FY FY 2015* 4 Total * Oct March

11 Board s Initiatives Faster Issuing Decisions New Format Reduce Old Appeals Inventory 18 Reduce Board Inventory Board s goal for 2015 is to reduce the number of appeals older than five years old by half. As of January 1, 2015 Current Filed 2014/2015 4,411 2-Years Old Filed , Years Old Filed Years Old Filed * Years Old - Filed * Years Old + Filed * 335 (*1912) 9,594 * 1912/2 =

12 Board s Initiatives Convert to a Paperless System Missed Position Paper Due dates Mediation Appeal/Reopening Alert