Payment Matters

November 1, 2012

Court Rejects Secretary’s Denial of Exhausted Benefit Days in the DSH Medicaid Proxy

By: Thomas W. Coons

As part of the ongoing battle between the Secretary of Health and Human Services and the hospital community, the United States District Court for the District of Columbia has sided with the hospitals. At issue was whether days attributable to a patient who was eligible for both Medicare and Medicaid (dual-eligible) but who had exhausted all of his Medicare hospital coverage (exhausted benefit days) should be counted in the Medicare or the Medicaid fraction of the disproportionate share (DSH) adjustment. The provider maintained that for the days in question the patient had not been entitled to benefits under Medicare Part A and that the days, therefore, were properly included in the Medicaid fraction. The Secretary, however, acting through CMS, took the position that it is the status of the patients, as opposed to the payment for the specific days, that determines whether a patient day is included in the numerator of the Medicaid proxy. The court sided with the provider. Columbia St. Mary’s Hosp. Milwaukee, Inc. v. Sebelius, Case No. 09-2031 (DDC, Oct. 4, 2012) [PDF].

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Proposed Settlement Would Prevent Medicare Denials for Chronically Ill and Disabled Due to Lack of Improvement

By: Carel T. Hedlund

A proposed settlement [PDF] has been reached between CMS and the plaintiffs in a national class action involving the denial of benefits to chronically ill and disabled Medicare beneficiaries. Many of these patients have had skilled nursing and therapy care denied on the grounds that they cannot show a likelihood of improvement or increase in functional capability.

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OIG's 2013 Work Plan - What's Critical for Long-Term Care, Hospice, Home Health Agency and Home and Community-Based Providers?

The Work Plans issued annually by the Department of Health and Human Services, Office of the Inspector General (OIG) give providers insight into what the OIG believes are areas prone to fraud, waste and abuse. This is the second of two articles highlighting provisions in the 2013 OIG Work Plan [PDF], released by the OIG on October 2, 2012, that providers should consider addressing in their compliance plans. The first article summarized Work Plan provisions that relate to hospital and physician providers.

This article focuses on provisions that apply to long-term care and community- based services (HCBS). The summary of these provisions are divided into “new” and “continuing” initiatives based on whether the issue was previously addressed in last year’s Work Plan.

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