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Summary on CMS Ruling No. 1498-R

 

CMS Ruling No. 1498-R
Effective April 28, 2010
 

The PRRB and the other Medicare administrative appeals tribunal lack jurisdiction over provider appeals of any of three issues (described below) regarding the calculation of the Medicare disproportionate share hospital (DSH) payment adjustment. 

 

1  Appeals of the Data Matching Process Used in Calculating the SSI Fraction
 

  • In the forthcoming FY 2011 IPPS final rule, CMS expects to respond to public comments on the proposed new data matching process, make any changes to such matching process that seem appropriate, and adopt finally a new data matching process. If the FY 2011 IPPS final rule results in a new data matching process, then CMS will use that new data matching process in calculating SSI fractions and DSH payments for specific claims that are found to qualify for relief under this Ruling. However, if a new data matching process is not adopted in the FY 2011 IPPS final rule, then CMS will implement this Ruling by using the same revised data matching process as the agency used to implement the Baystate decision.
     

  • CMS' action eliminates any actual case or controversy regarding the hospitals previously calculated SSI computation.

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    2  Appeals of the Exclusion from the DPP of Non-Covered Inpatient Hospital Days for Patients Entitled to
    Medicare Part A, and Days for Which the Patient's Part A Inpatient Hospital Benefits were Exhausted
     

  • CMS and the Medicare contractors will resolve each properly pending DSH appeal, for cost reports with patient discharges before October 1, 2004, in which the hospital seeks inclusion in the DPP of inpatient days where the patient was entitled to Part A benefits but the inpatient hospital stay was not covered under Part A or the patient's Part A hospital benefits were exhausted.
     

  • CMS and the MAC will include non-covered inpatient hospital days (MSP) and exhausted benefit days of patients entitled to Part A (provided that the patient was also entitled to SSI) in the SSI fraction numerator and denominator.
     

  • Non-covered or exhausted benefit days do not belong in the Medicaid fraction numerator which consists of the number of Medicaid-eligible inpatient days of persons "who were not entitled to benefits under Part A."
     

  • If the hospital were dissatisfied with such recalculated (or calculated) DSH payment, Section 5 of this Ruling provides that the resultant NPR (whether revised or initial) would be subject to administrative and judicial review in accordance with the applicable jurisdictional and procedural requirements of section 1878 of the Act, the Medicare regulations, and other agency rules and guidelines.

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    3  Appeals of the Exclusion from the DPP of Labor/Delivery Room Inpatient Days
     

  • For the cost reporting period beginning before October 1, 2009, CMS and the Medicare contractors will resolve each pending claim in a DSH appeal in which a hospital seeks inclusion in the DPP of LDR inpatient days. The DSH payment adjustment will be recalculated by including LDR days in the Medicaid fraction or the SSI fraction (whichever is applicable) regardless of the LDR patient occupied a routine bed before occupying an ancillary bed.
     

  • This Ruling is not an appropriate basis for the reopening of any final determination of the Secretary or a fiscal intermediary or of any decision by a reviewing entity.
     

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    4  Implementation
     

    In order to resolve in an orderly manner pending administrative appeals of any of the three DSH issues for qualifying patient discharge dates and cost reporting periods (as described above in Sections 1, 2, and 3 of this Ruling) that have been rendered moot by the Ruling, the administrative appeals tribunals will use one of two procedures to begin the overall process of implementing the Ruling.
      

  • Standard Implementation Procedure - the administrative tribunal (i.e., the PRRB, etc.) will determine whether each claim at issue is for one of the three DSH issues and other agency rules and guidelines.
     

  • Alternative Implementation Procedure - the hospital in a single provider appeal may submit a written request to the administrative tribunal requesting a remand of each and every specific claim on any of the three DSH issues for qualifying patient discharge dates and cost reporting periods.
     

  • CMS and the MAC will recalculate the provider's DSH adjustment and make any payment deemed owing. Also, they will apply this Ruling, on all three DSH issues, to "open" hospital cost reporting periods in which the contractor has not yet final settled the Medicare cost report.
     

  • For such properly pending appeals, CMS and the contractors will recalculate the hospital's SSI fraction and DSH payment adjustment for the period at issue by including the inpatient days of a person entitled to Medicare Part A in the numerator of the hospital's SSI fraction (provided that the patient was also entitled to SSI) and in that fraction's denominator, even if the inpatient stay was not covered under Part A or the patient's Part A hospital benefits were exhausted.
     

  • The administrative appeals tribunals, the fiscal intermediaries, and other Medicare contractors may not reopen any determination or decision with respect to any of the three DSH issues for the above-described patient discharge dates and cost reporting periods (as set forth in Sections 1, 2, and 3 of this Ruling).
     


  • Link References

    Ruling Index
    Original Policy on DSH Issues (Per CMS)
    Revised Policy on DSH Issues (Per CMS)
    Appeals of the Exclusion from the DPP of Labor/Delivery Room Inpatient Days
    Notes from CMS Ruling 1498-R
    Amendments
    CMS Ruling No:1498-R (Dated: April 28,2010)