Strategic Reimbursement Announces Formation of Group Appeal Concerning SSI Portion of Medicare DSH Calculation
Rolling Meadows, June 14 – Strategic Reimbursement today announced the formation Group Appeal 05-1372G titled SRI 1998 DSH MEDICARE SSI GROUP APPEAL. This group appeal concerns the SSI portion of the Medicare Disproportionate Share Hospital (DSH) calculation.
The two components used in the calculation of the Medicare DSH reimbursement amount are the Medicaid percentage and the SSI percentage. The Medicaid percentage has been the subject of various appeals and litigation, resulting in the current environment that allows providers to verify the Medicaid “eligibility” for their patients for purposes of the Medicare DSH adjustment. No such accommodations have been allowed for the SSI percentage.
Until recently, hospitals were required to rely upon the SSI fraction of the DSH formula to be a number that was furnished by the Centers for Medicare and Medicaid Services (CMS). Since the inception of the DSH payment regulations in 1987, the SSI percentage has always represented a large unknown in the calculation of the Medicare DSH payments as CMS would never release their support documentation. Based upon a recent favorable court decision, however, CMS will now release this data and the hospitals have the ability to review the calculation and challenge the accuracy of the SSI fraction used in the calculation of their Medicare DSH payments.
Past analysis of provider SSI information has produced numerous errors, including but not limited to, the following:
- Inconsistent treatment of Medicare beneficiaries who have exhausted their Part A coverage.
- Inconsistent treatment of Medicare beneficiaries who are covered under Medicare Part C.
- Medicare Part A beneficiaries in the SSI percentage who are not included on the Medicare PS&R.
- Medicare beneficiaries who are receiving SSI benefits who are not treated as such in the SSI percentage.
- The use of incorrect HIC numbers for matching SSI recipients.
- The total Medicare days reported in the denominator of the SSI ratio are often incorrect.
For most hospitals, this issue is likely to involve a significant amount of additional Medicare DSH reimbursement and applies to any cost reporting period that is either unaudited or has a PRRB appeal in place.
Once a provider has an appeal before the PRRB, it may request the now-available detailed SSI percentage information under the PRRB’s discovery rules. The delivery of this information usually takes 6 to 9 months. With this information, along with other provider and Medicare information, Strategic Reimbursement will perform all the necessary work and re-calculate the provider’s SSI percentage. With the issue appealed to the PRRB and the corrected data presented to the Fiscal Intermediary, the issue may be administratively resolved without the necessity of a PRRB hearing.
Taking the next step, SRI has formed a group appeal on this issue. The group will be represented by Charles F. MacKelvie of The MacKelvie Law Firm, Chicago, IL and Thomas Conley of Arnstein & Lehr, LLP.
For further information, or to join this group appeal, please contact Virginia Waterstraat, Manager, at vstraat@srinc.org or at 847-259-7373.
About Strategic Reimbursement
Strategic Reimbursement is an employee-owned consulting firm focused exclusively on third party compliance, reimbursement and revenue enhancement for hospitals and other healthcare providers across the country. Founded in 1975, our firm has assisted over 400 hospitals and systems with their most serious reimbursement issues with a variety of payers including Medicare, Medicaid, Tricare/CHAMPUS and managed care.
