DSH Management Solutions - 11/16/2006 – CMS stipulates that their prior “black box” Medicare SSI ratio improperly excluded admissions

Analysis and opinion by Robert F. Gricius – President DSH Mgmt Solutions, LLC

Although this ruling ( Oakwood SSI ) nominally concerns itself with the issue of whether the Provider in this case, Oakwood Hospital & Medical Center (Dearborn, Mich.) was entitled to expedited judicial review given its interpretation of the facts and disputes at issue, the more critical precedent setting issue imbedded in this case was CMS’s stipulation that their previous calculation of the Medicare SSI fraction numerator excluded 72 days that should have been included.

The magnitude of the days notwithstanding, the precedent set by the CMS in this case in admitting that any prior “black box” calculation was incorrect cannot be understated. This stipulation represents the first proverbial crack in the dam that has been the “black box” number provided, without supporting detail (until December of 2005).

The ruling goes on to say that there was:
“No statute, regulation or ruling prohibited CMS from reconsidering its calculations or disclosing the number of dual eligibles who also were eligible for SSI.”

What can hospitals do to prepare themselves to take full advantage of this opportunity? Consider the following steps:

Step 1: Immediately request all of the Limited Medpar Data Set files that contain the detail behind the “black box” number published by CMS for all cost reports with a fiscal year ending after 12/8/2004 and amend all open cost reports to include this issue for fiscal years ending prior to 12/8/2004 and request those data sets as well.
  • Although you will find that these detail claims files merely serve to corroborate the summary number published by CMS, it will serve as an invaluable baseline from which you can springboard into identifying SSI days and admits that were dropped by CMS as a result of its flawed process.
  • The timeliness of this step cannot be over emphasized. Although it is true that CMS is now making these data available, under certain circumstances and timeframes, there is no guarantee that future access will be granted. Further, as cost reports move to NPR status, your ability to obtain these data, absent a jurisdictionally proper appeal outstanding, will be severely compromised.
Step 2: Obtain the maximum amount of Medicaid eligibility and Third party liability data that is available from the Title XIX programs in your state(s), regardless of whether the cost report is closed or not.
  • Perform and rigorous and comprehensive data "scrubbing" and quality assurance processes on this "raw" Medicaid eligibility data. Use of these data "as-is" is a recipe for disaster. There are multiple data integrity issues at the hospital, Medicaid and data feeds into Medicaid eligibility data that must be understood and addressed before you can rely on the integrity of these data for an appeal or restatement of any component of the DSH calculation"
  • Work with the Medicaid contracted claims processing vendor to address data anomalies and correct them if available. Remember that this does not have to be a win/lose proposition between the client and Medicaid. Medicaid can gain substantive financial value from improved data quality in the form of higher federal matching funds for DSH funding purposes.
Step 3: Integrate the “scrubbed” Medicaid eligibility data with the CMS Limited Medpar data sets and the hospital database to identify those claims potentially missed or dropped by CMS in its compilation of the SSI subset of the MedPar file.
  • Work collaboratively with the Fiscal Intermediary by providing irrefutable evidence that your analysis has been thorough, is backed up by verifiable data audit trails, and regulatory fiat to reach agreement on days that need to be added to the SSI ratio.
  • Taking this collaborative approach to working with the fiscal intermediary can help expedite the process, preserve your working relationship with the FI and bypass the cost associated with a formal PRRB appeal and potentially, further judicial venues that could result no matter what ruling is issued by the PRRB.

Please contact Bob Gricius at robertgricius@dshmgmtsys.com with any questions or comments on this analysis and recommended process.