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The Provider Reimbursement Review Board ("PRRB") recently published new Rules (the "Rules") governing the PRRB appeals process. The Rules were published in conjunction with the recent final rule issued by the Centers for Medicare and Medicaid Service's ("CMS") that considerably changed the Medicare Part A reimbursement appeal process. The Rules both incorporate changes to the PRRB appeal adopted by CV1S and introduce new requirements, particularly with regard to pre-hearing filings.
The Rules became effective August 21,2008 and apply to all pending and future appeals.
The Rules require providers to use model forms for many filings, which are
included as an appendix. The new forms are:
The model forms for appeal requests incorporate CMS's recently adopted
regulation that requires specific information about each item appealed.
Providers should reference the model forms, as well as Rules 5.4,6-8, to determine what information should be included with the appeal request. The appeal forms also incorporate the regulatory requirement that the provider must certify that there is no other provider under under common ownership or control that has a pending request for a Board hearing on any of the same issues for cost reporting periods that end in the same calendar year. In addition, a provider must certify that none of the appealed issues are pending in any other appeal for the same period, nor have any of the issues been adjudicated, withdrawn or dismissed from any other appeal.
Providers now have the option to enter into a joint scheduling order ("JSO")
rather than submit position papers. Previously, the PRRB established deadlines for the filing of the preliminary and final position papers in its letter acknowledging a hearing request. Under the new rules, the PRRB establishes a preliminary position paper deadline in its acknowledgment letter, but gives the parties the option to enter into a JSO by the same deadline.3 The JSO is a written scheduling plan establishing all pre-hearing due dates (except the final position paper due date), as well as a suggested month and year for a hearing. 4 The JSO must include a description of the resolved, conditionally resolved, and unresolved issues in the appeal and the Rules specify information that must be included for conditionally resolved and unresolved issues.5 The JSO must be signed by both the provider and the fiscal intermediary. 6 The Rules state that the deadlines set in the JSO become the Board deadlines and are subject to sanction for failure to comply, although parties may modify certain due dates through email or faxed signature.7 As stated above, the PRRB has provided a model JSO, "Model Form F," in the appendix to the Rules.
Although the provider still has the option to file a preliminary position paper,
providers should note that the Rules establish new content and documentation
requirements. A provider's preliminary position paper must now include "fully
developed positions" on each issue, include all supporting documentation, and must identify any additional documentation that is required to support its arguments.8 The Rules state that, unless parties can demonstrate good cause, new arguments and and documents not included in the preliminary position paper may be excluded at hearing.9 The preliminary position paper must include a statement indicating how a good faith effort to confer was made in accordance with 42 C.F.R. & 405.1853.10
Final Position Papers will now be due shortly before the hearing. Generally the provider's final position paper will be due 90 days before the scheduled hearing date; the intermediary's final position paper till be due 60 days before the scheduled haring date; and the provider's response ( a new, optional, type of filing) will be due 30 days before the scheduled hearing date.11
The Rules indicate that requests for postponement of a hearing will not be
routinely granted. Specifically, the Rules states that, "representation that a settlement is imminent or probable will not guarantee a postponement. A recent change in representatives or the late filing of a motion will not generally warrant a postponement for either party." 12
Because the Rules impact pending cases, the PRRB has extended the due dates for upcoming position papers. If the PRRB acknowledgement letter in a pending case v/aswas sent prior to August 21,2008, and the upcoming due date(s) for the preliminary or final position paper fall(s) on or after September 1, 2008, the provider's preliminary position paper deadline is extended by four months and the intermediary's preliminary position paper due date is extended by six months. The parties also have the option to enter into a JSO by the new extended deadline for the Provider's preliminary position paper. Due dates for final position papers can be disregarded because they will be reset in the PRRB's notice of hearing.13
Some other minor changes to the Rules that providers should note are:
If you have any questions, please call Mary Susan Philp at (202) 872-6735,
Barbara Straub Williams at (202) 872-6733, Hilton Marcus at (202) 349-4250, or the attorney with whom you usually work.
1. PRRB Rules,
http//www,cms.hhs.gov/PRRBReview/Downloads/PRRBRules2008.pdf2. Medicare Program; Provider Reimbursement Determination and Appeals, 73 Fed. Reg.30, 190 (May 23,2008). Please see PPSV's previous memorandum on the Final rule for further discussion,http://www.ppsv.com/assets/attachments/41.PDF (June 5, 2008).3. PRRB Rules 23.1, 23.3. Parties may also enter into a JSO after filing a preliminary position paper. PRRB Rule 25.4. Commentary to the Rules state that, if the preliminary position papers indicate that further development of information is needed, a JSO should be developed promptly. PRRB Rule 25.4 (Commentary).4. PRRB Rule 23.2.5. PRB Rule 24.16. Id.7. PRRB Rule 23.2, 24.1.C.68. PRRB Rules 25.1, 25.2.9. PRRB Rule 23.3 (Commentary).10. PRRB Rule 25.3. This provision requires the intermediary to "expeditiously attempt" to meet with the provider to resolve factual or legal issues after receiving hearing request and to submit written stipulations setting forth unresolved issues. 42 C.F.R. & 405.1853 (a).11. PRRB Rule 27.112. PRRB Rule 30.3A.13. See Alert, http://www.cms.hhs.gov/PRRBReview/Downloads/PRRBRules2008.pdf14. PRRB Rule 3.3.15. PRRB Rule 3.4.16. PRRB Rule 3.5.
Used with permission of Powers, Pyles, Sutter & Verville, PC, August 28, 2008.
Publication Date: Wednesday, April 22, 2009
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
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