{"id":630,"date":"2019-03-08T17:28:01","date_gmt":"2019-03-08T17:28:01","guid":{"rendered":"https:\/\/advantagehcconsulting.com\/blog\/?p=630"},"modified":"2019-03-08T17:28:02","modified_gmt":"2019-03-08T17:28:02","slug":"fight-to-get-sequestered-funds-excluded-from-cap-overages-hits-roadblock","status":"publish","type":"post","link":"https:\/\/advantagehcconsulting.com\/blog\/2019\/03\/08\/fight-to-get-sequestered-funds-excluded-from-cap-overages-hits-roadblock\/","title":{"rendered":"Fight To Get Sequestered Funds Excluded From Cap Overages Hits Roadblock"},"content":{"rendered":"\n
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The math might be against you.<\/em><\/strong><\/p>\n\n\n\n

If you think it\u2019s unfair that Medicare calculates your hospice aggregate cap using funds you never receive, you\u2019re not alone. But the Provider Reimbursement Review Board <\/strong>doesn\u2019t agree with you.<\/p>\n\n\n\n

The PRRB released a long-awaited decision Feb. 28 addressing the issue of including sequestered funds in hospices\u2019 cap calculations, report attorneys Brian Daucher <\/strong>and Ashton Massey <\/strong>with Sheppard Mullin <\/strong>in Costa Mesa, California. In the case, five California hospices \u2014 three owned by Silverado Hospice <\/strong>and two owned by ProCare Hospice <\/strong>\u2014 appealed cap overage amounts ranging from about $10,000 to more than $80,000.<\/p>\n\n\n\n

Background:\u00a0<\/strong>The\u00a0Centers for Medicare & Medicaid Services\u00a0<\/strong>said it would start including the 2 percent in sequestered funds in hospices\u2019 cap calculations back in 2014, applying to 2013 cap years. In other words, Medicare uses the 2 percent of funds you are never paid to calculate how much over the cap \u2014 if at all \u2014 you are and the resulting repayment amount.<\/p>\n\n\n\n

Many hospices have appealed that cap calculation. The calculation can make a big difference in how much an over-cap hospice owes back, notes consultant Tom Boyd <\/strong>with Simione Healthcare Consultants <\/strong>in Rohnert Park, California. And now the PRRB finally has issued a decision on the topic \u2014 and it\u2019s not good.<\/p>\n\n\n\n

\u201cAfter considering the Medicare law and regulations, the parties\u2019 contentions, and the evidence submitted, the Provider Reimbursement Review Board \u2026 finds the Medicare Contractor properly applied sequestration to the Hospices\u2019 aggregate cap payments and calculated the Hospices\u2019 aggregate cap overpayments correctly,\u201d says PRRB Decision 2019-D18. The decision addresses the hospices\u2019 2013 caps adjudicated by MAC National Government Services<\/strong>.<\/p>\n\n\n\n

The hospices\u2019 argument: <\/strong>A March 2015 Technical Direction Letter from CMS, which instructs \u201cthe Medicare Contractor to use the full payment amount rather than the net reimbursement results in the Hospices having to repay amounts they never received in the first instance,\u201d the hospices argued. The \u201csequestration methodology is incorrect and constitutes \u2018double dipping\u2019 by requiring hospices to pay back certain funds that they never received,\u201d they contended, according to the decision.<\/p>\n\n\n\n

The PRRB\u2019s decision: <\/strong>\u201cThe Board reviewed the Medicare Contractor\u2019s calculation and disagrees that the Hospices have to pay back amount(s) they never received,\u201d it says.<\/p>\n\n\n\n

Key to the board\u2019s decision is a finding about what constitutes payment, notes veteran consultant Lisa Lapin <\/strong>with Simione in Sturbridge, Massachusetts. \u201cFor hospices that exceed their aggregate cap \u2026 their aggregate cap then becomes the Medicare allowable payment for the 2013 cap year and, therefore, sequestration must be applied to the resulting Medicare allowable payment,\u201d the decision reads.<\/p>\n\n\n\n

\u201cThat sums up everything in a nutshell,\u201d Lapin says.<\/p>\n\n\n\n

How it works: <\/strong>\u201cThe simplest way to analyze sequestration is to apply it to a full cap year and to wait to apply it until the cap year has ended,\u201d the decision explains. \u201cIn this situation, the 2 percent sequestration would be applied to the resulting \u2018amount paid\u2019 after the hospice aggregate cap itself has been applied. More specifically, if the hospice were under its aggregate cap, then the 2 percent would be applied to all the interim hospice payments received for that cap year\u2019s \u2018costs.\u2019 However, if that same hospice exceeded its aggregate cap, then the full amount in excess of its aggregate cap would be an overpayment and the resulting \u2018amount paid\u2019 for \u2018costs\u2019 for the cap year would be its aggregate cap amount (i.e., the cost ceiling for that hospice). This resulting \u2018amount paid\u2019 for \u2018costs\u2019 for the cap year (i.e., the aggregate cap amount) would then be subject to sequestration of 2 percent.\u201d<\/p>\n\n\n\n

If all that accounting talk has left you confused, some examples the board includes may help.<\/p>\n\n\n\n

Example #1: <\/strong>A hospice with a cap of $200,000 and payments of $250,000 would have to repay $50,000 due to the cap. It would receive $200,000 in payments and would be unaffected by the sequestration reduction of 2 percent. Thus, the hospice must repay $4,000 of its $200,000 payment to have its payments reduced by sequestration, as they are for under-cap hospices.<\/p>\n\n\n\n

Example #2: <\/strong>A hospice with the same $200,000 cap and payments of $450,000 would have to repay $250,000 due to the cap. It likewise would receive $200,000 in payments and would be unaffected by the sequestration reduction of 2 percent, so must repay $4,000 of its $200,000 payment to have its payments reduced by sequestration.<\/p>\n\n\n\n

Note that the 2 percent isn\u2019t applied to the hospices\u2019 overall payments, but to the cap amount which is considered the allowable payment.<\/p>\n\n\n\n

The board then walks through how the current cap calculation arrives at that result.<\/p>\n\n\n\n

Do Secret Instructions Imply CMS Is Hiding Something?<\/strong><\/p>\n\n\n\n

But the appealing hospices aren\u2019t taking the decision lying down. \u201cContractors have failed to measure just \u2018the amount of payment made\u2019 in carrying out the calculation,\u201d Daucher and Massey note in online analysis of the decision. \u201cAs appeals have dragged on, contractors have continued to apply this practice year after year.\u201d CMS may have overstated hospice cap demands by more than $100 million as a result, Daucher estimates.<\/p>\n\n\n\n

In addition to including payments never actually made to hospices in the calculation, CMS\u2019s instructions for doing so were \u201csecret,\u201d Daucher and Massey charge in online analysis of the decision. CMS never made the TDL letter public.<\/p>\n\n\n\n

\u201cIf our government can by sleight of hand count as \u2018payment made\u2019 funds never actually paid to providers, then statutory injunctions are no barrier to the whims of bureaucratic officials,\u201d the attorneys blast.<\/p>\n\n\n\n

The hospices in the suit plan to appeal at the federal court level, Daucher says. It is no surprise that the PRRB decision is unfavorable, as he \u201calways thought the PRRB would defend CMS\u2019s action.\u201d<\/p>\n\n\n\n

Daucher also upbraids the extended length of time it took the PRRB to hand down the decision. The delay is \u201cfurther evidence of CMS\u2019s failure to properly fund the appeals systems that providers rely upon to challenge adverse action,\u201d he criticizes.<\/p>\n\n\n\n

Note: The PRRB has yet to post the decision on its website at\u00a0www.cms.gov\/Regulations-and-Guidance\/Review-Boards\/PRRBReview\/List-of-PRRB-Decisions.html<\/a>, but you can see the decision at\u00a0<\/em>https:\/\/www.hospicelaw.com\/wp-content\/uploads\/sites\/251\/2019\/03\/2019-2-28-15-2875GC-Silverado-ProCare-2013-PRRB-Decision.pdf<\/a>.<\/em><\/p>\n\n\n\n

Source- SuperCoder<\/em><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

The math might be against you. If you think it\u2019s unfair that Medicare calculates your hospice aggregate cap using funds you never receive, you\u2019re not alone. But the Provider Reimbursement Review … Continue Reading →<\/a><\/p>\n","protected":false},"author":1,"featured_media":631,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[16,5],"tags":[32,12],"class_list":["post-630","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-hospice","category-reimbursement","tag-capreport","tag-hospice"],"_links":{"self":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/630","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/comments?post=630"}],"version-history":[{"count":1,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/630\/revisions"}],"predecessor-version":[{"id":632,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/630\/revisions\/632"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media\/631"}],"wp:attachment":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media?parent=630"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/categories?post=630"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/tags?post=630"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}