Medicare Cost Report Appeals and Reopenings

HRS has extensive experience with appeals processing and utilizes both in-house and top industry counsel to properly represent our clients at a peak level. Initial Hearing Requests before the Provider Reimbursement Review Board require experience and precision to perfect an appeal regarding a provider’s dissatisfaction with a Medicare contractor’s final determination or the direction of the Centers for Medicare & Medicaid Services (CMS). With the appeal in place, HRS may file both Preliminary Providers Position and Final Providers Position briefings while also attempting to gain an Administrative Resolution through mediated proceedings with PRRB officials. Should these administrative filings and negotiations not bring the desired result, HRS resources include retaining specialized healthcare counsel to initiate legal proceedings in federal court.

The strength of the Medicare Appeal process begins with an understanding of the notice and comment opportunities presented through the rulemaking process to a comprehensive understanding of regulatory Final Rules. With this breadth of knowledge, authoritative appeals perfect our clients claim to reimbursements conforming to complicated statutory formulas.

HRS currently offers dispute resolution services on the following Cost Report Categories:

DSH Uncompensated Care Pool Allocation

• DSH Factor 3
• DSH Factors 1 & 2

DSH Supplemental Security Income (SSI) Ratio

• SSI Errors (Baystate)
• Medicare Part C (Medicare and Medicaid Fractions)
• Dual Eligible (Medicare and Medicaid Fractions)

Crossover Bad Debts

• Reimbursement did not include allowable bad debt contrary to statutory instructions

Two Midnight Rule

• Improper rulemaking regarding 0.2% decrease in in IPPS rates for all hospitals FY 2014-2017

Standardized Payment Amount

• Calculated improperly by including both discharges and transfers in baseline data resulting in reduced average cost per discharge.

ATRA (American Taxpayer Recovery Act)

• Pursue restoration of 0.7% payment cut made after 2017

HRS also files reopening requests when necessary, and provides guidance and audit support when interacting with the MAC.