As providers start to receive their Notice of Program Reimbursement (NPR) it is imperative that attention be paid to any adjustments affecting your Medicare Inpatient Bed Days (“MIBD”) attributable to Part A and Part C patients. While the reasons for the same vary, MIBD are one of the main components for the Electronic Health Record (“EHR”) calculation and is subject to adjustment during the cost report settlement process. Should a provider be faced with a potential recoupment, the appeal options are limited at best. According to guidance from the Centers for Medicare and Medicaid Services (“CMS”), there are three types of appeals: (1) eligibility, (2) meaningful use, and (3) incentive payment calculation. For the purposes of this discussion we will focus solely on number three, the incentive payment calculation.

As outlined in 42 U.S.C. § 1395ww (n) (4) (A) (i):  `

(A) Limitations on review

There shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise, of—

(i) the methodology and standards for determining payment amounts under this subsection and payment adjustments under subsection (b)(3)(B)(ix), including selection of periods under paragraph (2) for determining, and making estimates or using proxies of, discharges under paragraph (2)(C) and inpatient-bed-days, hospital charges, charity charges, and Medicare share under paragraph (2)(D);

While the statute prohibits a provider from challenging the methodology, it does not preclude a challenge based on the underlying data used in the computation. Should a challenge be warranted, CMS mandates that the proper forum is the Provider Reimbursement Review Board (“PRRB”). Further, any challenges to the PRRB are due within 180 days of the NPR.

Should you need additional information, please contact Todd Prine at (214) 373-7077 or via e-mail at todd.prine@campbellwilson.com.