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Review of Prior Audited Medicare/ Medicaid Cost Report (Reopening)

 

Since the inception of the Medicare program, the Centers for Medicare and Medicaid Services have allowed providers to reopen the final determinations made by fiscal intermediaries. 

 

With more than 25 years of cumulative experience, Hall Consulting Services (HCS) staff has been actively involved in reviewing, analyzing, and documenting Medicare and Medicaid cost report reopening issues. 

 

Additionally, HCS staff has a broad range of experience in the Medicare and Medicaid cost report reopenings interactions as both fiscal intermediary and consultants.  The reopening process involves identifying audit issues and providing supporting documentation for materially omitted and/or erroneous issues included in fiscal intermediary’s audited cost reports.

 

HCS has directly filed for a number of reopenings on behalf of hospital clients ranging in sizes from 125 to 1,500 patient beds.  Reopening issues related to particular cost reports can be a long, time-consuming process which involves in depth research of potential audit issues and their estimated reimbursement effect.  Our staff of experienced personnel takes our clients' reimbursement issues from inception to completion.

New (Revised) Provider Reimbursement Review Broad (PRRB) Rules for Filing Appeals

 

Due to the changes in the PRRB final rule (effective August 21, 2008), providers now need to implement new and updated processes in order to respond to appeal filing requirements.  It is the provider’s responsibility to protect its appeal rights by filing a cost report appeal within the new regulatory period.  Providers will need to identify, document and file all disputed audit issues within the final rule’s stringent guidelines.  The final rule is effective August 21, 2008, with a few exceptions.

 

Providers are encouraged to assess all controversial or disputed issues to determine if a cost report reopening is the appropriate avenue to process with the fiscal intermediary.  Since reopenings are less formal with fewer restrictions than the PRRB appeal process, providers should take advantage of the reopening process for audit issues which are likely to be resolved with the fiscal intermediary.          

 

Reopenings

 

A provider may request that the intermediary reopen an issue determination if no PRRB appeal was filed on the same issue.  Centers of Medicare and Medicaid Services (CMS) regulations indicate that an intermediary has the discretion to reopen or not reopen an intermediary determination. However, CMS has the authority to direct the intermediary to reopen or not reopen a determination or hearing decision.

 

A request to reopen must be made within three years of the date of the intermediary’s final determination (Notice of Program Reimbursement).  Medicare regulations permit a reopening to be filed in cases where: 1) new and material evidence has been submitted; 2) a clear and obvious error has been made; or 3) a determination is found to be inconsistent with the law.

 

As a result of the new PRRB rules, providers should make every effort to file all disputed issues in their original cost report.  In addition, providers should systematically identify, document and finalize all dispute issues as early as possible before and after the fiscal intermediary audit of subject cost report.

 

HCS Offers the Following Services:

 

  1. Review all open Medicare cost reports in order to identify, analyze and document material reopening issues.  An example of potential audit issues include the following:

 

  • DSH day components:

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    - SSI % days

    - Medicaid eligibility days

  • GME/IME – Interns/residents

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    - FTE count

    - GME program review

  • Organ acquisition cost and transplants

  • Medicare bad debts

  • Request for exception, exemptions or adjustment requests

  • Other key issues (e.g. legal case effects, CMS clarifications, Medicare regulation changes)

  • Outpatient payment issues            

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    1. HCS provides services in all facets of the reopening process which include, but are not limited to the following service items:

     

  • Identifying, analyzing, and documenting omitted or erroneous settled issues

  • Request for reopening for revised issues with the supporting documentation

  • Coordinate the requested documentation for the fiscal intermediary audit review and provide appropriate feedback

  • Finalize the filed reopenings

  • File PRRB appeal, (if necessary and approved by the provider) if the fiscal intermediary reopening resolution is incorrect or unfavorable

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    Next Service: Provider Reimbursement Review Board (PRRB) Appeal Services