In this episode, we are joined by Dana Aylward, Senior Consultant at BESLER, to discuss the rights a provider has after a cost report has been settled.
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Mike Passanante: Hi, this is Mike Passanante. And welcome back to the Hospital Finance Podcast.
Today, I’m joined by Dana Aylward who is a Senior Consultant in our Reimbursement Team here at BESLER. And Dana is going to talk to us about the rights a provider has after your cost report has been settled.
Dana, welcome to the program.
Dana Aylward: Welcome! Thank you.
Mike: So Dana, first, why don’t you talk to us about what the Notice of Program Reimbursement is because that’s a pretty key term for what we’re going to be talking about in the podcast here today.
Dana: Right! So, the Notice of Program Reimbursement or also known as the NPR is the final audited Medicare cost report. The NPR is supposed to be issued one year or longer after the Medicare cost report has been filed and accepted. The desk review (or also known as the audit) may take months to complete while others may move more quickly.
Mike: And what are some of the benefits of reviewing that NPR?
Dana: Well, the NPR will impact a provider’s settlement and payment rates. Since NPR’s may be issued in the most inopportune time such as the cost report preparation, year-end or other various pressing responsibilities, the provider may not have the ability to review the results. When hospitals go through the desk review, the audit process can be grueling. Often, negative issues may arise where the hospital does not fully agree with the outcome. If timing is an issue or if an item may be under dispute, the NPR can still be issued.
In other cases, there may not be an intensive audit and the cost report will be finalized with positive or neutral results. In either scenario, the hospital has rights to appeal or reopen their cost report.
Mike: So, can anything else be done once the NPR has been issued? What are the rights that a provider has?
Dana: Well, yes, the provider does have the right to appeal. Well, we must now include intended appealable items on the original submitted cost report or commonly referred to as the “as filed.” There may be other issues that arise.
We may find unintentional mistakes made by a Medicare auditor which may have substantial financial impact on the hospital. There can be input errors in DSH, IME, and GME or other reimbursable areas where the settlement was improper. These errors may be miniscule, while others may be over $100,000.
It is not common to find these types of errors. However, the provider must be cognizant of any open cost reports as it may affect future reimbursements. If a prior year is still opened, the provider should evaluate any financial implications.
Personally, I have seen medical education FTE issues that affect future years in IME and GME payments, or in cost reporting terms, this would be prior and penultimate year FTEs.
Mike: Okay. And is it worth pursuing issues with the PRRB?
Dana: Absolutely! While many of our clients appeal popular topics such as Bay State or Allina, we have also represented providers for smaller or less common issues.
There is a risk with an appeal in settlement which may take years or decades to occur such as the SSI Remand Bay State cases. Some of the settlements go as far back as the 1990s which is a whole podcast on its own.
While these issues today have had positive outcomes and continue to circulate the district court, there are some decisions however that can negatively affect our appeals and end up being dismissed or withdrawn. Without pursuing these issues, there never have been highly successful cases such as budget neutrality or Allina.
Mike: And what if a provider has an appealable item?
Dana: Well, if a provider does have an issue to appeal, that provider or provider representative must submit the required documents to the Provider Reimbursement Review Board within 180 days of the NPR (which is essentially six months).
Depending on the nature of the appeal, the issue may either be filed into an individual appeal or a group appeal.
For the appeal or appeals, they must be filed on forms issued by the PRRB. For individual appeals, you have Model Form A which is an individual appeal which may include multiple issues under one provider number. If the provider forgot to include an issue, they may file Model Form C after Model Form A to add any additional issues they may have forgotten beforehand.
For group appeals, you would use Model Form D where you would take the individual appeal issue and transfer it to a group. The group may be either a mandatory or CIRP group which are related parties, or you may file it under an optional group which is for hospitals that are unrelated to one another.
Lastly, you also have Model Form E where the provider may add an issue directly into a group appeal from the NPR. This must be within 180 days of the NPR, and it does not satisfy the 180-day window for additional issues.
I would recommend using this form if the provider is certain on their issues.
Mike: And Dana, should a provider file an appeal or a reopening?
Dana: After the NPR has been issued, the provider may have the opportunity to appeal a decision or determination made during audit. There may be other issues that are beyond the scope of a cost report such as challenges to regulations, CMS methodology where a provider may wish to pursue an appeal. Providers have the ability to file appeals if the items were included on the protested line at the time of initial submission. If the hospital did not meet the requirements, then the issues will eventually be dismissed.
While some findings may warrant a reopening, filing an appeal is used to protect their rights. If an opening request is denied, an appeal can accomplish the same result. An appeal, however, can be costly and time-consuming.
Mike: So, I’m a provider, and I filed an appeal. Now what?
Dana: Once an appeal is acknowledged by the Provider Reimbursement Review Board, the PRRB will assign a case number and due date. It is critical to maintain all due dates and details of the appeal. If any dates or documents are missed, the PRB will dismiss the case.
Typically, the PRRB will assign the first round of due dates about six months in advance. This allows the provider to determine a strategy or next step.
Mike: Dana, these appeals are such an important issue to the provider community today. And we thank you for stopping by and talking about the rights that providers have after they file their cost report.
Dana: You’re welcome. Thank you very much for having me.
