Special report on reimbursement. Medicare program abandons 1986 malpractice rule

Area of Science:

• Healthcare Reimbursement Policy
• Healthcare Law and Regulation

Background:

• Hospitals face challenges with incorrect malpractice insurance cost apportionment due to invalid regulations applied since May 1, 1986.
• The Centers for Medicare & Medicaid Services (CMS) has indicated it will not reopen closed cost reports for corrections, despite acknowledging the invalid regulation (HCFA Ruling 91-1).

Purpose of the Study:

• To outline strategies for hospitals to obtain corrected Medicare reimbursements.
• To advise on navigating the appeals process for fiscal years with pending claims or cost report issues.

Main Methods:

• Analysis of existing regulations and legal precedents regarding hospital reimbursement appeals.
• Review of the Provider Reimbursement Manual (HIM-15) concerning cost report reopening procedures.
• Guidance on actions for claims pending before fiscal intermediaries, courts, or the PRRB.

Main Results:

• Hospitals with claims already pending do not require further action for corrected reimbursements.
• Expedited processing for PRRB appeals can be achieved by requesting the Board to determine jurisdiction and remand for payment.
• Hospitals without pending claims can utilize the three-year reopening period for cost reports via fiscal intermediaries, with appeal rights to the PRRB if denied.

Conclusions:

• Hospitals can pursue corrected reimbursements through specific procedural steps, even when CMS denies reopening of closed reports.
• The PRRB's authority to review denials of reopening requests is supported by federal court rulings, providing a viable appeal path.
• Strategic engagement with fiscal intermediaries and the PRRB is crucial for hospitals seeking to rectify reimbursement errors.