By Paige Arnold, J.D.
The PRRB lacks authority to review or mandate revisions of the methodology used by CMS to calculate supplementary security income (SSI), according to a PRRB decision. The PRRP was unable to reverse the Medicare contractors’ reimbursement adjustments ( Hall Render Individual, Optional and CIRP DSH Dual/SSI Eligible Group Appeals—Medicare Fraction v. Wisconsin Physicians Services, PRRB Hearing, Dec. No. 2017-D12, Case Nos. 07-0413, 07-2872G, 09-1830G, 09-1863GC, 12-036GC, 12-0373GC, 12-0412, 13-0140GC, 13-0591, 15-0266, 15-0270, March 28, 2017).
Background. The case brought before the PRRB was a consolidation of multiple appeals by various hospitals. The providers each challenged CMS’ policy of calculating provider reimbursement benefits during the period of 2004 through 2009. Specifically at issue was CMS’ inclusion of only some SSI eligibility categories in the Disproportionate Share Hospital (DSH) formula calculation. Under Medicare, providers that qualify as a DSH receive an additional adjustment in reimbursement for services provided. The DSH formula was calculated using two fractions, the SSI fraction or ratio and the Medicaid fraction. Changes in an individual’s eligibility for SSI benefits and redeterminations of eligibility are regular practice. Over the years, the DSH payment adjustment has been subject to litigation and changes have been made in the process based on the rulings and new regulations. The provider hospitals had received written notice of the calculation process and revisions.
No authority. The PRRB did not make a determination regarding the provider’s argument that additional SSI codes should be included in the data matching process for calculating SSI fractions. The PRRB reasoned that under federal regulations ( 42 C.F.R. Sec. 405.1867) it does not have jurisdiction over such matters because it must comply with the CMS rulings, which describe the calculations and data matching process in detail. The CMS determination as to the data matching process falls within the authority of the CMS, not the PRRB, and CMS’s determinations must stand.