OAA Decisions

OAA Decisions

Under Section 1878 of the Social Security Act and the regulations at 42 CFR 405.1875, the Administrator of the Centers for Medicare & Medicaid Services has the authority to review decisions rendered by the Provider Reimbursement Review Board and to issue final Agency decisions for the Secretary of the Department of Health and Human Services. If you need a copy of a decision that is not listed on this site, please contact the Office of the Attorney Advisor. Please note that, because of 508 compliance needs, these decisions are not copies of the actual signed Administrator decisions. Copies of the actual signed decisions may be obtained from the Office of the Attorney Advisor.

Decision Number Case Name Issue
2003-D01
Skaggs Community Health Center vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustments reclassifying home health agency (HHA) building rent to the HHA cost center and the elimination of corresponding square footage allocation statistics were proper.
2003-D02
Central Texas Medical Center vs. Blue Cross/Blue Shield Association/Trailblazer Health Enterprises, LLC
Whether the Intermediary's determination that the Provider had less than 100 “beds” for DSH eligibility purposes was proper.
2003-D03
Kaleida Health 97 Ownership of Assets Group vs. Blue Cross and Blue Shield Association/Empire Medicare Services
Whether the Intermediary's adjustments to the Providers' cost reports for FYE 12/31/97 to eliminate the Providers' claimed losses on disposition of assets were proper.
2003-D04
Maple Crest Care Center vs. Mutual of Omaha Insurance Company
Whether the PRRB has jurisdiction over costs unclaimed on the cost report and a request to reclassify costs for which no audit adjustment was made by the Intermediary.
2003-D05
Always Better Care Home Health Providers vs. v. Blue Cross and Blue Shield Association/United Government Services, LLC-CA
Whether the Intermediary's adjustment of start-up costs was proper.
2003-D06
Cardinal Cushing Hospital/Goddard Memorial Hospital vs. Blue Cross/Blue Shield Association/Associated Hospital Services of Maine
Whether there was recognizable loss upon the transfer of assets to Good Samaritan Medical Center from Goddard Memorial Hospital and Cardinal Cushing Hospital that occurred in connection with the consolidation of the two hospitals and the resulting creatio...
2003-D07
Westview Manor vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment disallowing the allocation of general service costs to the ancillary cost centers was proper.
2003-D08
Blue Ridge Rehabilitation Center vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment disallowing the allocation of general service costs to the ancillary cost centers was proper.
2003-D09
Smoky Hill Rehabilitation Center vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment disallowing the allocation of general service costs to the ancillary cost centers was proper.
2003-D10
Christ the King Manor vs. Blue Cross and Blue Shield Association/Veritus Medicare Svcs.
Whether the Intermediary's reclassification of the Staff Development Coordinator salaries was proper.
2003-D11
SNI Home Care, Inc. vs. Blue Cross and Blue Shield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's application of the Salary Equivalency Guidelines (Guidelines) to the Provider's physical therapy costs was proper.
2003-D12
Susquehanna Regional Home Health Services vs. Blue Cross and Blue Shield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment to rent paid by the Provider to a related party was proper.
2003-D14
Ingham Regional Medical Center vs. United Government Services, LLC-WI
Whether the Board has jurisdiction over the calculation of the disproportionate share adjustment where the issue is added to the appeal of an original Notice of Program Reimbursement.
2003-D15
Long Island State Veterans Home vs. Blue Cross and Blue Shield Association/Empire Medicare Services
Whether it was proper for the Intermediary to apply the lower of cost or charges (LCC) principle in calculating the Provider's reimbursement on the Medicare cost report Worksheet E, Part I
2003-D16
BBL 95-99 Observation Bed Days Group vs. Blue Cross Blue Shield Association/Premera Blue Cross/Riverbend Government Benefits Administrator/Trailblazer Health Enterprises
Whether the Intermediaries' determination that the Providers had less than 100 beds for disproportionate share (DSH) eligibility purposes was proper.
2003-D17
Natividad Medical Center vs. Blue Cross Blue Shield Association/United Government Services
Whether the Intermediary's adjustment to the residents count and Graduate Medical Education payments was proper.
2003-D18
Spalding Rehabilitation Hospital vs. Mutual of Omaha Insurance Company
Whether the Intermediary incorrectly determined that the Provider was not entitled to a new provider exemption from the application of the skilled nursing facility for its provider-based skilled nursing facility.
2003-D19
Devon Gables Health Care Center vs. Blue Cross and Blue Shield Association/Blue Cross and Blue Shield of Arizona
Whether the Intermediary properly calculated the Provider's bad debts.
2003-D20
Meriter Hospital vs. Blue Cross and Blue Shield Association/United Government Services, LLC
Whether the Intermediary's determination of the TEFRA exception request was proper.
2003-D21
AllCare Home Health vs. Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment to owner's compensation was proper.
2003-D23
Edinburg Hospital vs. Blue Cross /Blue Shield Association Trailblazer Health Enterprises, LLC
Whether the Intermediary’s determination that the Provider had less than 100 “beds” for DSH eligibility purposes was proper.
2003-D24
Pleasant Care Corporation- California vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment to deny the allocation of social service costs based on departmental gross chargesw as proper.
2003-D25
Southwestern Nursing Home & Rehabilitation Center vs. Blue Cross Blue Shield Association/Veritus Medicare Services
1. Whether the Intermediary's reclassification of Staff Development/Quality Assurance Coordinator salaries was proper. 2. Whether the Intermediary's adjustment allocating social service costs was proper.
2003-D26
LAC & USC Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the Provider's budgeted beds are the most appropriate measure of available beds for purposes of computing the indirect medical education (IME) payment.
2003-D27
Home Town Health Care vs. Blue Cross Blue Shield/Cahaba Government Administrators
1. Whether the Intermediary's adjustment to disallow advertising cost was proper. 2. Whether the Intermediary's adjustment to include Heaven Sent Nursing Services as a non-reimbursable cost center was proper. 3. Whether the Intermediary's adjustment to ...
2003-D29
Standish Community Hospital vs. Blue Cross Blue Shield Association/ United Government Services, LLC
Whether the Intermediary's adjustment to DRG payments was proper.
2003-D30
Patient Care Medical Services, Inc. vs. Blue Cross Blue Shield Association/ United Government Services, LLC
Whether the Intermediary's adjustment to the Per Beneficiary Limit (PBL) calculation was proper.
2003-D31
University Hospital vs. Blue Cross Blue Shield Association/ AdminaStar Federal, Inc.
1. Whether the Intermediary's reclassification of certain administrative costs from ambulatory service areas to the Administrative and General Cost Center was proper. 2. Whether the Intermediary's reclassification of clinic dieticians' salary costs to t...
2003-D32
Texacare, Inc. vs. Cross Blue Shield Association/Palmetto Government Benefits Administrator
Whether the Intermediary's Audit Adjustment #2 which disallowed $108,875 of Administrative and General Costs was proper.
2003-D33
Cardinal Hill Rehabilitation Hospital vs. Blue Cross/Blue Shield Association/AdminaStar Federal
Whether the all inclusive rate allocation methodology was proper.
2003-D34
AHS 96 Related Organization Costs Group vs. Blue Cross Blue Shield Association/Riverbend Government Benefits Administrator
Whether the Intermediary's adjustments disallowing the Providers' claimed losses on disposal of assets due to a change of ownership were proper.
2003-D35
Meridian Hospitals Corporation Group Costs Group vs. Blue Cross Blue Shield Association/Riverbend Government Benefits Administrator
Whether the Intermediary's adjustments disallowing the Providers' claimed losses on disposal of assets due to a change of ownership were proper.
2003-D36
Castle Medical Center vs. Blue Cross /Blue Shield Association/United Government Services, LLC-CA
Whether the Intermediary adjustment to the disproportionate share hospital (DSH) payment was proper.
2003-D37
New Hanover Regional Medical Center & Psychiatric Unit vs. Blue Cross and Blue Shield Association/ Blue Cross and Blue Shield of North Carolina
Whether the Intermediary and HCFA properly determined that the Provider's request for an adjustment to the TEFRA target limits was untimely.
2003-D38
Starke Memorial Hospital vs. Blue Cross Blue Shield Association/AdminaStar Federal
Whether the Intermediary's adjustment to limit reimbursement to the lower of cost or charges for the Provider's distinct part psychiatric unit was proper.
2003-D39
Hemet Valley Convalescent Hospital vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the Intermediary's denial of the Provider's SNF routine service cost limit exception request was proper.
2003-D40
Citrus Health and Rehabilitation Center vs. Mutual of Omaha Insurance
Whether CMS properly denied the Provider's request for an exemption from the Medicare skilled nursing facility (SNF) routine cost limits (RCL) as a new provider under 42 CFR 413.30(e) based on CMS' determination that the exemption request was not timely f...
2003-D41
Collins Health Center vs. BlueCross BlueShield Association/Veritus Medicare Services
Whether the Intermediary's adjustment to remove nursing administration statistics from the ancillary cost centers on worksheet B-1 was proper.
2003-D42
VNA of Rhode Island vs. Blue Cross Blue Shield Association/Associated Hospital Service
Whether the Intermediary's disallowance of the Provider's Spanish and Portuguese interpreter expenses was proper.
2003-D43
Helen Ellis Memorial Hospital vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether the Intermediary's determination of obligated capital was proper.
2003-D44
Wilmac Corporation Group vs. Blue Cross Blue Shield Association/Veritus Medicare Services
Whether the Intermediary's disallowance of liabilities not liquidated timely on the Medicare cost report was proper.
2003-D45
Angeles Home Health Care, Inc. vs. Blue Cross Blue Shield Association/ United Government Services, LLC - CA
Whether the Intermediary's adjustments of Medicare visits to agree with Medicare's Provider Statistical and Reimbursement (PS&R) report were proper.
2003-D46
Pioneer Home Health vs. Blue Cross and Blue Shield Association
Whether the CMS properly denied the Provider's request for an exception to the Medicare HHA routine cost limits due to extraordinary circumstances.
2003-D47
Phelps Memorial Hospital Center vs. BlueCross BlueShield Association/ Empire Medicare Services
Whether the Intermediary's treatment of the Provider's increase in bed size of its exempt rehabilitation unit was proper.
2003-D48
Mercy Home Health vs. Blue Cross /Blue Shield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment to home office cost statements was proper.
2003-D49
Iroquois Memorial Hospital vs. BlueCross BlueShield Association/Adminastar Federal, Inc.
Whether the Provider is entitled to status as a Medicare Dependent Hospital (MDH) for the period of October 1, 2001 through January 14, 2002.
2003-D50
Pleasant Care Corporation Restorative Nursing Aides Group vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment to restorative nurses aides was proper.
2003-D51
Pleasant Care Corporation?Standby Costs Group vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment to standby costs was proper.
2003-D52
Pleasant Care - Pomona vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustments reclassifying the Medical Director cost were proper.
2003-D53
Pleasant Care-Good Samaritan vs. Mutual of Omaha Insurance Company
1. Whether the Intermediary's adjustment to advertising costs was proper. 2. Whether the Intermediary's adjustment to tax penalties was proper.
2003-D54
Pleasant Care - San Joaquin vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustments reclassifying the Medical Director cost were proper.
2003-D55
Pleasant Care – Parkview vs. Mutual of Omaha Insurance Company
1. Whether the Intermediary's adjustment to advertising costs was proper. 2. Whether the Intermediary's adjustments reclassifying Medical Director cost were proper.
2003-D56
Hospital San Francisco, Inc. vs. Cooperativa de Seguros de Vida de Puerto Rico
Whether the Intermediary's adjustments to the Provider's cost report were proper.
2003-D57
Hospital San Francisco, Inc. vs. Cooperativa de Seguros de Vida de Puerto Rico
Whether the Intermediary’s adjustment to bad debts was proper.
2003-D58
Hospital Auxilio Mutuo vs. Cooperativa de Seguros de Vida de Puerto Rico
Whether the Centers for Medicare & Medicaid Services' denial of the Provider's exception request was proper.
2003-D59
Hospital Dr. Pedro J. Zamora vs. Cooperativa de Seguros de Vida de Puerto Rico
Whether the Intermediary's adjustment to the disproportionate share (DSH) computation was proper.
2003-D60
West Valley Home Health, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
1. Whether the Intermediary's adjustment to home office costs was proper. 2. Whether the Intermediary's adjustment disallowing a portion of the auto allowance was proper. 3. Whether the Intermediary's adjustment to travel and lodging costs was proper.
2003-D61
Iron County Community Hospital vs. Blue Cross and Blue Shield/United Government Services
Whether CMS’ determination, concerning the Provider’s end stage renal disease (ESRD) exception request, was proper.
2003-D62
Jeanes Hospital vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment disallowing the Provider's claimed loss on disposal of assets due to a change of ownership was proper.
2003-D63
Forestville Health & Rehabilitation Center, CT Subacute 96 Disallowance of Rental Expenses Group, Subacute Center of Bristol vs. BlueCross BlueShield Association/Empire Medicare Services
1. Whether the Intermediary's adjustment disallowing rental expense was proper. 2. Whether the Intermediary's adjustment disallowing capital related expenditures was proper. 3. Whether the Intermediary's adjustment disallowing interest expense was prope...
2003-D64
St. Joseph Medical Center vs. Blue Cross Blue Shield Association/Blue Cross Blue Shield of Kansas
Whether the Intermediary's determination of loss on consolidation was proper.
2003-D65
Tenet Healthcare Corporation Group Appeals vs. Mutual of Omaha Insurance Company
Whether the Intermediary correctly applied the Medicare lower of cost or charges limit in determining the Medicare payments to the Providers.
2003-D66
Westminster at Lake Ridge vs. BlueCross BlueShield Association/United Government Services, LLC-WI
Whether the intermediary's adjustment disallowing Medicare Part A and Part B bad debt was proper.
2004-D01
HomeCare PRN; HomeCare PRN 96 Allowable Home Office Expenses; and HomeCare PRN 96 Interest Expense vs. Blue Cross and Blue Shield Association/ Associated Hospital Services
Whether the Board has jurisdiction to determine which entity is the proper payee under the terms of a settlement agreement between the Providers and the Intermediary.
2004-D02
Bournewood Hospital vs. Blue Cross BlueShield Association/Associated Hospital Services of Maine
Whether the Intermediary's adjustments to physician stand-by costs in the routine area were correct.
2004-D03
Tri-County Home Health Services, Inc. vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
(1) Whether the Intermediary's adjustment to Board of Director's fees was proper. (2) Whether the Intermediary's adjustment to legal and professional fees was proper. (3) Whether the Intermediary's adjustment to key employee compensation was proper. (4) W...
2004-D04
Proactive Home Care, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment to include private duty nursing costs on the Medicare cost report was correct.
2004-D05
Chippewa Dialysis Services vs. Blue Cross Blue Shield Association/United Government Services, LLC -WI
Whether the Centers for Medicare and Medicaid Services correctly denied the Provider's request for an exception to the end stage renal disease (ESRD) composite rate
2004-D06
Alpena Dialysis Services vs. Blue Cross Blue Shield Association/United Government Services, LLC -WI
Whether the Centers for Medicare and Medicaid Services correctly denied the Provider's request for an exception to the end stage renal disease (ESRD) composite rate.
2004-D07
Northern Michigan Hospital vs. Blue Cross Blue Shield Association/United Government Services, LLC -WI
Whether the Centers for Medicare and Medicaid Services correctly denied the Provider's request for an exception to the end stage renal disease (ESRD) composite rate
2004-D08
Heritage Health Care d/b/a Heritage Villa Nursing Center vs. Mutual of Omaha Insurance Company
Whether the Board has jurisdiction over the recoupment of overpayments appealed from a letter from the Centers for Medicare & Medicaid Services.
2004-D09
Heritage Health Care d/b/a Heritage Villa Nursing Center vs. Mutual of Omaha Insurance Company
Whether the Board has jurisdiction over the recoupment of overpayments appealed from a letter from the Centers for Medicare & Medicaid Services, and the reimbursement effectis less than $10,000
2004-D10
Preferred Home Health Care vs. Blue Cross and Blue Shield Association/Palmetto Government Benefits Administrator
The propriety of reimbursing home health agencies (HHA) under the Medicare program for expenses that the HHA incurs to provide pastoral care to its patients.
2004-D11
Incare Home Health, Inc. vs. Blue Cross Blue Shield Association/Palmetto Government BenefitsAdministrators
(1) Whether the Intermediary's adjustment to Board of Director's fees was proper. (2) Whether the Intermediary's adjustment to routine and non-routine supply costs was proper.
2004-D12
Saginaw General Hospital vs. Blue Cross/Blue Shield Association/United Government Services, LLC
Whether, for the purposes of allocation of administrative and general costs, the Part B physician's compensation and related fringe benefits should be included in total expenses of the private physician practices.
2004-D13
Hunterdon/Somerset 2001 Wage Index Group vs. Riverbend Government Benefits Administrator
Whether expedited judicial review (EJR) is appropriate because the Board cannot grant the remedy sought by the Providers: a change to the Secretary's policies used to calculate wage indices.
2004-D14
Moore Regional Hospital vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's determination disallowing the loss incurred on change of ownership was proper.
2004-D15
LAC + USC Medical Center vs. Blue Cross Blue Shield Association/United Government Services, LLC- CA
Whether the Provider's budgeted beds are the most appropriate measure of available bedsfor purposes of computing the indirect medical education (IME) payment.
2004-D16
Odessa Regional Hospital vs. Mutual of Omaha Insurance Company
Whether the Intermediary's determination that the Provider had less than 100 beds for DSH eligibility purposes was proper.
2004-D17
Hatch Valley Home Health Agency vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's adjustment to the Provider's cost limits was proper.
2004-D18
Woodland Terrace Extended Care Center vs. Blue Cross Blue Shield Association/First Coast Service Options, Inc.
Whether the Intermediary's adjustment reducing the adjusted hourly salary equivalency amount allowed for the services of Physical Therapy Aides was proper.
2004-D19
Twinning Village vs. Blue Cross Blue Shield Association/Veritus Medicare Services
Whether it was proper for the Intermediary to make an adjustment to remove the hours in the ancillary areas used to allocate nursing administration on Worksheet B-1 of the Medicare cost report.
2004-D20
West Virginia Hospital vs. Blue Cross Blue Shield Association/ Trigon Blue Cross and Blue Shield
Whether the Intermediary's adjustment to bond interest expense was proper.
2004-D21
Bates Medical Center vs. Blue Cross Blue Shield Association/Arkansas Blue Cross Blue Shield
Whether the Intermediary's determination of the loss on disposal of assets was proper.
2004-D22
Chestnut Hill Hospital vs. Veritus Medicare Services/Blue CrossBlue Shield Association
Whether the Intermediary's adjustments disallowing direct graduate medical education (GME) and indirect medical education (IME) costs of the interns and residents full-time equivalent counts were proper.
2004-D23
Glenwood Regional Medical Center vs. Mutual of Omaha Insurance Company
Whether CMS' methodology for determining an exception from the RCLs for HB SNFs, as set forth in P.R.M. § 2534.5, was proper.
2004-D24
Visiting Nursing Association of North Central Indiana, Inc. vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's decision to deny the Provider's request for an exception to Medicare’s salary equivalency guidelines for physical therapy services furnished under arrangement were proper.
2004-D25
Tip of Illinois Health Services vs. Blue Cross and Blue Shield Association/Wellmark, Inc.
Whether the Intermediary's application of the Salary Equivalency Guidelines to the Provider's physical therapy costs was proper.
2004-D26
Aroostook Medical Center vs. Blue Cross Blue Shield Association/Associated Hospital Service of Maine
Whether CMS' denial of the Provider's end stage renal disease composite rate exception request was correct based on applicable Medicare law.
2004-D27
Baptist Memorial Medical Center vs. Blue Cross Blue Shield Association/Blue Cross Blue Shield of Arkansas
Whether the Provider met the criteria set forth at § 4004(b) of OBRA 1990 and whether the costs at issue met the definition of clinical training costs.
2004-D29
Carney Hospital (Transitional Care Unit) vs. Blue Cross Blue Shield Association/Associated Hospital Services
Whether the Intermediary's denial of the Provider's request for an exemption from Medicare's routine service cost limits was proper.
2004-D30
Global Home Care, Inc. Blue Cross Blue Shield Association/United Government Services, LLC
Whether the Intermediary's adjustment to the single business tax was proper.
2004-D31
Pocono Medical Home Care, Inc. vs. Blue Cross and Blue Shield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment applying Medicare's Physical Therapy Compensation Guidelines to the Provider's employee physical therapists was proper.
2004-D32
St. Josephs Hospital vs. Blue Cross /Blue Shield Association/Noridian Administrative Services"
Whether the Intermediary's adjustment to the Provider's disproportionate share hospital (DSH) payment was proper.
2004-D33
Genesis 96, 97 Proper Cost Category Group and Genesis 98 Payroll Tax/Workers Compensation Cost Group vs. Blue Cross Blue Shield Association/Veritus Medicare Services
Whether the Provider's Federal Insurance Contributions Act (FICA) payroll costs should be classified to the administrative and general cost center.
2004-D34
Berks Visiting Nurse Association vs. Blue Cross and Blue Shield/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment applying Medicare's Physical Therapy Compensation Guidelines to the Provider's employee physical therapists was proper.
2004-D35
Harborside Hospital--Indianapolis vs. Blue Cross Blue Shield Association/ AdminaStar Federal, Inc.
Whether the Provider was entitled to an exemption from the routine cost limit as a new provider.
2004-D36
Germantown Hospital and Medical Center vs. Mutual of Omaha Insurance Company
Whether the Intermediary's denial of the Provider's loss on disposal of assets was proper.
2004-D37
Clark Regional Medical Center vs. Blue Cross and Blue Shield Assn./AdminaStar Federal - Kentucky
Whether the Provider's non-acute care swing-bed days should be included in the total of Medicaid patient days used in the calculation of the disproportionate share (DSH) hospital payment.
2004-D38
Saint Clares Hospital - Dover vs. Blue Cross Blue Shield Association/ Riverbed Government Benefits
Whether the Intermediary's determination of loss on consolidation was proper.
2004-D39
Angeles Home Health Care, Inc. vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether denied Medicare visits should be included in the total visits count for purposes of apportioning costs to the Medicare program.
2004-D40
Battle Creek Health System and Mercy General Health Partners vs. Blue Cross Blue Shield Association/ United Government Services, LLC
Whether the Intermediary properly concluded that the Provider failed to make reasonable collection efforts and document such efforts with respect to certain claimed bad debts.
2004-D41
Empire 91-94 Medicaid Eligible Days Group vs. Mutual of Omaha Insurance Company
Whether the Intermediary's determination of the disproportionate share hospital (DSH) computation relating to state-only General Assistance Days was proper.
2004-D42
Mesa Vista Hospital vs. Blue Cross Blue Shield Association/United Government Services, LLC--CA
Whether the Intermediary properly eliminated the Providers Medicare bad debts due to the Provider allowing discounts to only non-Medicare patients.
2004-D43
Ochsner Clinic—New Orleans Renal Dialysis Facility and Houma/Bayou Facility vs. Blue Cross Blue Shield Association/ Trispan Health Services
Whether the Intermediary correctly disallowed Medicare bad debts related to amounts not included in the End-Stage Renal Disease (ESRD) composite rate.
2004-D44
Wayne County Hospital vs. Blue Cross Blue Shield Association/ United Government Services, LLC-WI
Whether the Intermediary properly recognized all termination costs as relating to the period ending 8/13/84 rather than allocating costs to prior years and recognizing the additional Medicare reimbursement as a below the line adjustment on the final 8/13/...
2004-D45
Florida Convalescent Centers 97 Therapy Management Fee Group vs. First Coast Service Options, Inc./Blue Cross Blue Shield Association
1. Whether the Intermediary's disallowance of the Provider's therapy management fees was proper. 2. If the Provider's are found to be entitled to a reversal of the Intermediary's disallowance, does the Board have subject matter jurisdiction to determine w...
2004-D46
Spectrum Home Care, Inc. vs. Blue Cross Blue Shield Association/United Government Services
Whether the Intermediary's adjustment to start-up costs was proper.
2005-D01
Fajardo Home Care; Guaynabo Home Care Program; Font Martelo Home Care Program and El Gigante Home Care vs. Blue Cross Blue Shield Association/United Government Services
Whether the Providers' receivable financing was a loan or a sale of assets.
2005-D02
Dialysis Clinic 94 Bad Debt Expense Group vs. Blue Cross Blue Shield Association/Blue Cross and Blue Shield of Georgia
Whether the Intermediary correctly disallowed Medicare bad debts claimed by the Providers on uncollectible deductible and coinsurance amounts pertaining to items and services not included in the End-Stage Renal Disease (ESRD) composite rate.
2005-D03
Twin Rivers Regional Medical Center vs. Blue Cross Blue Shield Association/ Premera Blue Cross
Whether the Provider was entitled to an exemption from the skilled nursing facility routine cost limits for the years ended December 31, 1992, December 31, 1993, and December 31, 1994.
2005-D04
Eastern Maine Medical Center vs. Blue Cross Blue Shield Association/ Associated Hospital Service
Whether CMS' denial of the Provider's end stage renal disease (ESRD) composite rate exception request was correct.
2005-D05
Mercy Healthcare Bakersfield vs. Blue Cross and Blue Shield Association/United Government Services, LLC-CA
Whether CMS partial denial of the Provider's request for an exception to the ESRD composite rates request based on atypical service intensity and patient mix was correct.
2005-D06
Saint Mary's Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC
Whether for the purposes of allocation of administrative and general costs, the Part B physicians' compensation and related fringe benefits should be included in total expenses of the private physician practices.
2005-D07
Capeside Cove Good Samaritan Center vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary was correct in determining that Provider's request for an exception to the Skilled Nursing Facility (SNF) Routine Cost Limit was untimely filed.
2005-D08
Bon Secours Venice Hospital vs. Blue Cross Blue Shield Association/First Coast Service Options, Inc.
Whether the Intermediary's adjustments to interest expense relating to the acquisition of medical records and an assembled work force were proper.
2005-D09
Robert F. Kennedy Medical Center vs. Blue Cross Blue Shield Association/United Government Services, LLC-CA
Whether the Intermediary's adjustment disallowing the Provider's claimed loss on the disposal of assets due to a change of ownership was proper.
2005-D10
Haven Home Health, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Whether the Intermediary's disallowance of owner's accrued salary expense for untimely liquidation was proper. 2. Whether the Intermediary's adjustment to the related party portion of the office supplies and revision of the related party medical supply...
2005-D11
Flagstaff Medical Center and Northern Arizona Homecare-Flagstaff vs. BlueCross BlueShield Association/United Government Services, LLC-CA/BlueCross BlueShield of Arizona
Whether the Intermediary's denial of a request for exception to the Home Health Agency (HHA) per visit cost limits was proper.
2005-D12
NYCHHC 94 TEFRA Target Amount Per Case E/E Group vs. Blue Cross Blue Shield Association/ Empire Medical Services
Whether the Intermediary properly processed the Providers' TEFRA exception request.
2005-D13
Terrebonne Home Care, Inc. vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
Whether the Intermediary denial of the Provider's request for exception to its per-visit cost limits was proper.
2005-D14
Countryside Manor Health Care Center vs. BlueCross BlueShield Association/AdminaStar Federal - Indiana
1. Whether the Intermediary adjustment to disallow a portion of the owners' compensation was proper. 2. Whether the Intermediary adjustment to disallow bad debts was proper
2005-D15
Topanga Terrace vs. BlueCross BlueShield Association/United Government Services, LLC - CA
Whether the Intermediary's denial of the Provider's Routine Cost Limit (RCL) exception request was proper
2005-D16
Hospital Corporation of America (HCA) Providers with Late Notices of Program Reimbursement vs. BlueCross BlueShield Association/Various Intermediaries
What relief is available through appeal to the Provider Reimbursement Review Board for failure of the Intermediary to timely settle the Provider's cost reports, especially where prejudice will result from the failure to settle such cost report.
2005-D17
Hamburg Health Clinic vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the Intermediary's adjustment to physician/owners compensation was proper.
2005-D18
Liberty Village vs. BlueCross BlueShield Association/AdminaStar Federal
1. Whether the Intermediary's adjustment to National Premier Financial Services, Inc., and NPF VI, Inc. Costs/Program Fees was proper. 2. Whether the Intermediary's failure to allow $18,215 of related party depreciation was proper. 3. Whether the Intermed...
2005-D19
Family Home Care, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's adjustment to disallow accrued salaries was proper.
2005-D20
Parkview Memorial Hospital vs. Blue Cross Blue Shield Association/ AdminaStar Federal
1. Whether for purposes of evaluating the Routine Cost Limit (RCL) exception request, the base year per diem amounts should be adjusted to reflect reclassifications made by the Provider.; 2. Whether the Intermediary properly offset the costs for the "priv...
2005-D21
Treyton Oak Towers vs. Blue Cross Blue Shield Association/AdminaStar Federal, Inc.
Whether the Intermediary's adjustment removing the Skilled Nursing Facility (SNF) for purposes of evaluating the Routine Cost Limit (RCL) exception amount was appropriate
2005-D22
Heritage House of Richmond vs. Blue Cross Blue Shield Association/AdminaStar Federal, Inc.
Whether the Intermediary's adjustment to disallow a portion of the owner's compensation was proper.
2005-D25
Brady Home Health Care Services, Inc. vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators
1. Whether the Intermediary's adjustment to remove accrued salaries for owners due to payment not being properly liquidated within 75 days after the close of the cost reporting period was correct. 2. Whether it was proper for the Intermediary to disallow ...
2005-D26
Rogue Valley Medical Center vs. BlueCross BlueShield Association/Medicare Northwest
Whether the Board properly accepted jurisdiction over a new provider exemption; whether the jurisdiction extended to multiple years and whether CMS' denial of the new provider exemption was proper.
2005-D27
Memorial Hospital at Gulfport vs. Blue Cross Blue Shield Association/TriSpan Health Services
Whether the Intermediary's disallowance of Medicare bad debts was proper.
2005-D28
St. Edward Mercy Medical Center vs. BlueCross BlueShield Association/Arkansas Blue Cross & Blue Shield
Whether the Centers for Medicare and Medicaid Service's denial of the Provider's request for new provider exemption was proper.
2005-D29
San Francisco Medical Center vs. Mutual of Omaha Insurance Company
Whether CMS' partial denial of the Provider's request for an exception to the ESRD composite rate based on atypical patient mix was correct.
2005-D30
Community Care Hospital vs. BlueCross BlueShield Association/TriSpan Health Services
Whether the Intermediary properly adjusted the method of reimbursing the Provider, a hospital-based skilled nursing facility (SNF), from cost-based reimbursement to the SNF prospective payment system (PPS).
2005-D31
Roy L. Schneider Hospital vs. Cooperativa de Seguros de Vida de Puerto Rico
Whether CMS' determination to deny a request for an exception to the end stage renal disease(ESRD) composite rate based on a lack of documentation supporting the criteria of the isolated essential facility (IEF) was proper.
2005-D32
CentraState Medical Center vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the Intermediary failed to properly classify certain projects as old capital.
2005-D33
California Nurses Home Health Services vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the Intermediary's adjustment to start-up costs was proper.
2005-D34
Brackenridge Hospital vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the Intermediary properly applied the "Pickle Amendment" in calculating the Provider's Disproportionate Share Hospital (DSH) adjustment.
2005-D35
Mid-City Home Health vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the liabilities claimed by the Provider are reimbursable under the Medicare principles.
2005-D36
University Medical Center vs. BlueCross BlueShield Association/Blue Cross & Blue Shield of Arizona
1. Whether the Intermediary's adjustment, reducing the Provider's IME full-time equivalent (FTE) resident count for time spent by residents in research activities, was proper. 2. Whether the Intermediary's adjustment reducing the Provider's Direct GME an...
2005-D37
VNA Health Care, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustments applying Medicare's salary equivalency guidelines to services performed by the Provider's employee physical and occupational therapists were proper.
2005-D38
Select Specialty Hospital-Houston Heights vs. Mutual of Omaha Insurance Company
Whether the Board properly found jurisidction over the issue of whether the Intermediary erred in denying the Provider a CIB for fiscal year ending August 31, 1999.
2005-D39
Arthur G. James Cancer Hospital vs. BlueCross BlueShield Association/AminaStar Federal - Ohio
Whether the Intermediary's adjustment to disallow the interest paid to Ohio State University Hospitals (OSUH) was proper.
2005-D40
St. Joseph's Health Services of Rhode Island vs. Blue Cross BlueShield Association/BlueCross Blue Shield of Rhode Island
Whether CMS' denial of the Provider's request for an exemption from the SNF RCLs was proper.
2005-D41
St. Rita's Medical Center vs. Blue Cross Blue Shield Association/AdminaStar Federal Ohio
Whether the Board properly accepted jurisdiction of the Provider's request for a hearing on the issue of whether it was entitled to additional disproportionate share (DSH) reimbursement for inpatient hospital days for which patients were eligible for Medi...
2005-D42
Rome Memorial Hospital vs. Blue Cross Blue Shield Association/Empire Medicare Services
Whether the Board properly accepted jurisdiction of the Provider's request for a hearing on the issue of whether it was entitled to additional disproportionate share (DSH) reimbursement for inpatient hospital days for which patients were eligible for Medi...
2005-D43
Pleasant Care 97/98 Payroll Tax Cost Group vs. Mutual of Omaha Insurance Company
Whether the Intermediary should reclassify the Provider's Federal Insurance Contributions Act (FICA) tax expense from the Employee Benefits cost center to the Administrative and General cost center (A&G).
2005-D44
Covenant Shores Health Center vs. BlueCross BlueShield Association/AdminaStar Federal Illinois
Whether CMS' denial of the Provider's request for an exception to the routine cost limits (RCLs) for skilled nursing facilities (SNFs) as a new provider was proper.
2005-D45
UMass Memorial Medical Center vs. BlueCross BlueShield Association/Associated Hospital Service
Whether the Centers for Medicare and Medicaid Services' (CMS) denial of the Provider's request for an exemption to the end stage renal disease (ESRD) composite rate was proper.
2005-D46
Evergreen Hospital Medical Center and SNF vs. BlueCross BlueShield Association/Premera Blue Cross
Whether the Provider was entitled to a "new provider" exemption from Medicare's routime cost limits for its hospital-based skilled nursing facility (SNF).
2005-D47
Alhambra Hospital vs. BlueCross BlueShield Association/United Government Services, LLC - CA
Whether the Intermediary's adjustment excluding dual-eligible patient days associated with the Provider's sub-acute unit from the Provider's DSH percentage was proper.
2005-D48
Long Beach Memorial Hospital vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary's application of the reasonable compensation equivalent limits was proper.
2005-D49
Ashtabula County Medical Center; The Community Hospital; Akron General Medical Center; Lima Memorial Hospital and The Toledo Hospital vs. BlueCross BlueShield Association/AdminiStar Federal, Inc.
Whether the Intermediary's adjustment excluding patient days related to Ohio's Hospital Care Assurance Program (HCAP) from the Providers' disproportionate share (DSH) calculation was proper.
2005-D51
Sun Terrace Health Care Center vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary properly reclassified the Provider's square footage costs for its common areas from the Administrative and General cost center to the Plant Operations, Maintenance and Repair cost center.
2005-D52
Sun City Center 96 Square Foot Allocations vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary properly reclassified the Providers' square footage costs for its common areas from the Administrative and General cost center to the Plant Operations, Maintenance and Repair cost center.
2005-D53
Goleta Valley Community Hospital a/k/a/ Goleta Valley Cottage Hospital vs. BlueCross BlueShield Association/ United Government Services, LLC-CA
Whether the Provider furnished sufficient information to enable CMS to make a decision on the Provider's request for a new provider exemption to Medicare's routine cost limits (RCLs) for skilled nursing facilities (SNFs).
2005-D54
Nix Health Care System vs. BlueCross BlueShield Association/Trailblazer Health Enterprises, LLC
Whether the Intermediary's classification of the Provider's home health agency (HHA) as a 'new provider' for purposes of determining the per-beneficiary limits was proper.
2005-D55
Muhlenberg Hospital Center vs. BlueCross BlueShield Association/Veritus Medicare Services
Whether the Intermediary's adjustment disallowing the Provider's loss on sale of assets was proper.
2005-D56
Central Texas Medical Center vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the observation days and swing bed days should reduce the number of available beds for purposes of calculating the Provider's eligibility for DSH payments.
2005-D57
Central Texas Medical Center vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the observation days and swing bed days should reduce the number of available beds for purposes of calculating the Provider's eligibility for DSH payments.
2005-D58
Central Texas Medical Center vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the observation days and swing bed days should reduce the number of available beds for purposes of calculating the Provider's eligibility for DSH payments.
2005-D59
Central Texas Medical Center vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the observation days and swing bed days should reduce the number of available beds for purposes of calculating the Provider's eligibility for DSH payments.
2005-D60
Mary Immogene Bassett Hospital-OSDF vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the denial of the Provider's request for an exception to the renal dialysis composite rate by CMS was proper.
2005-D61
Erwine's Home Health Care, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment applying the physical therapy salary guidelines to fee-for-service employee compensation was proper.
2005-D62
Shady Lawn Nursing Home vs. BlueCross BlueShield Association/TriSpan Health Services
Whether the Intermediary's adjustment removing the Provider's 'grossing up' of costs and charges for drugs charged to patients was proper.
2005-D63
Colorado Home Care, Inc. vs. BlueCross BlueShield Association/ Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment applying the Adjusted Hourly Salary Equivalency Guidelines or "physical therapy compensation guidelines" to fee-for-service employee compensation was proper.
2005-D64
Alamitos West Convalescent vs. BlueCross BlueShield Association/United Government Services, LLC--CA
Whether the Intermediary's adjustment to allow only a 15% increase in the therapy rate for physical therapy supervisors was proper.
2005-D65
Hill Country Health Services, Inc. vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
Whether the Intermediary properly disallowed interest expense incurred in connection with the Provider's deferred compensation plan.
2005-D67
Rhode Island Hospital vs. BlueCross BlueShield Association/Arkansas BlueCross & BlueShield
Whether the Intermediary's adjustment, reducing the Provider's full-time equivalent (FTE) resident count for purpose of calculating the Indirect Medical Education (IME) adjustment, was proper.
2005-D68
The Manor House at Riverview vs. BlueCross BlueShield Association/AdminaStar Federal-Indiana
1. Whether the Intermediary's adjustment of the square footage statistic for the Physical Therapy department was proper. 2. Whether the Intermediary's adjustment disallowing owners' compensation was proper. 3. Whether the Intermediary's denial of the Rout...
2005-D69
Columbia Montour Home Health Services vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment of accounting fees was proper.
2005-D70
Potomac Home Health Care, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment applying the Salary Equivalency Guidelines or "physical therapy compensation guidelines" to fee-for-service employee compensation was proper.
2005-D71
Potomac Home Health Care, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment applying the Salary Equivalency Guidelines or "physical therapy compensation guidelines" to fee-for-service employee compensation was proper
2005-D72
Saddleback Memorial Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether CMS' denial of the Provider's request for a new provider exemption based upon a finding of an untimely submission in response to a request for additional documentation was proper.
2006-D01
Saint Marys Hospital vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary's denial of the Provider's request for an adjustment to its TEFRA target amount due to untimely filing of the request was proper.
2006-D03
Trenton Psychiatric Hospital vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the Intermediary's adjustments to disallow reimbursement for physician's professional services on a reasonable cost basis was proper.
2006-D04
Omega Hills, Inc. vs. BlueCross Blue Shield Association/AdminaStar Federal-Indiana (formerly Anthem Insurance Company)
Whether the Intermediary's adjustment to owners compensation was proper.
2006-D05
Rush-Presbyterian-St. Lukes Medical Center vs. BlueCross BlueShield Association/AdminaStar Federal
1. Whether the Intermediary's adjustment to the Provider's disproportionate share (DSH) payment was proper. 2. Whether the Intermediary's calculation of the number of interns and residents and the amount of allowable costs for fiscal year 1991 for purpose...
2006-D06
Professional Home Care, Inc., Garvin and Moore Okla. Professional HC 97 Access Infusion Group vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment of the Provider's physical therapy costs was proper.
2006-D07
Chicago 98-00 MSA Wage Index Group vs. Mutual of Omaha Insurance Company
1. Whether Michael Reese Hospital (Reese) failed to exhaust its administrative remedies for a correction to its wage data during the February-March 1998 window for correcting wage data. 2. Whether Reese Hospital nevertheless met the criteria for a correct...
2006-D08
Preferred Management Corporation Group vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustments reallocating key employee and owners bonuses were proper.
2006-D09
Washington County Memorial Hospital vs. BlueCross BlueShield Asssociation/TriSpan Health Services
Whether the Intermediary's computation of the Medicare dependent, small rural hospital (MDH) adjustment, due the Provider for its fiscal year (FY) 2000 cost report decrease in discharges, was correct.
2006-D10
Highland Medical Center vs. Mutual of Omaha Insurance Company
Whether the Intermediary's determination that the Provider had less than 100 beds for purposes of disproportionate share hospital (DSH) eligibility purposes under the inpatient prospective payment system (IPPS) was proper.
2006-D11
St. Joseph Hospital vs. Mutual of Omaha Insurance Company
Whether the denial of the Provider's request for an exception to the renal dialysis composite rate by the Centers for Medicare and Medicaid Services (CMS) was proper.
2006-D12
Immanuel - St. Josephs Hospital vs. Blue Cross Blue Shield Association/Noridian Administrative Services
Whether the Intermediary's adjustment to reduce the unweighted FTE resident count and related adjustment cap for time spent by residents providing services at the Mankato Clinic was proper.
2006-D13
Community Hospital of the Monterey Peninsula vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether for purposes of the Provider's disproportionate share (DSH) adjustment calculation, the Provider is entitled to an increased number of days of care rendered to eligible Medicaid beneficiaries.
2006-D14
Harborside Healthcare-Reservoir vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary properly denied the Provider's new provider exemption request.
2006-D15
Acadian HomeCare, Inc. vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's disallowance of medical director fees was proper.
2006-D16
Dameron Hospital vs. Blue Cross Blue Shield Association/United Government Services, LLC
Whether the Intermediary's disallowance of the Provider's inpatient and outpatient Medicare bad debts was proper.
2006-D17
Alden Court Nursing Home vs. Mutual of Omaha Insurance Company
Whether CMS' denial of the Provider's request for an exception to the routine cost limits for skilled nursing facilities as a provider of atypical services was proper.
2006-D18
The Medical Team vs. Blue Cross Blue Shield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment applying Medicare's Physical Therapy Compensation Guidelines to the Provider's employee physical therapists was proper.
2006-D19
Western Arizona Regional Medical Center vs. Blue Cross Blue Shield Association/Blue Cross Blue Shield of Arizona
Whether the Intermediary's adjustment of the Provider's DSH calculation was based upon a proper interpretation of the Medicare DSH statutes as amended by the BIPA of 2000.
2006-D20
Baystate Medical Center vs. Mutual of Omaha Insurance Company
1. Whether the CMS determination of the Provider's Medicare Part A Supplemental Security Income (SSI) percentage, commonly known as the Medicare fraction component of the disproportionate share (DSH) percentage, is incorrect. 2. Whether the Provider is en...
2006-D21
HCT 94-95 Physical Therapy AHSEA Exception Group vs. Mutual of Omaha Insurance Company
Whether the Intermediary properly denied the Provider's requests for an exception to the Medicare allowable hourly salary equivalency amount for physical therapy.
2006-D22
Saint Anthonys Health Center vs. BlueCross BlueShield Association/ AdminaStar Federal Illinois
Whether CMS' determination of the Provider's Medicare Part A Supplemental Security Income (SSI) percentage, commonly known as the Medicare fraction component of the disproportionate share (DSH) percentage, was proper.
2006-D23
University of Pittsburgh Medical Center (UPMC) - St. Margaret Hospital vs. BlueCross BlueShield Association/ Veritus Medicare Services
Whether the Intermediary's adjustments to the Medicare cost report that disallowed the loss on disposal depreciable assets due to the facility's change of ownership (CHOW) were proper.
2006-D24
Advanced Rehabilitation Services, Inc.; Prospect Rehabilitation Services, Inc. vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the Intermediary's adjustments disallowing the Provider's claimed Medicare Bad Debts, disallowed in a prior year period, were proper.
2006-D25
MGH Home Health vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's application of salary equivalency guidelines to the compensation of physical therapists employed by the Provider on a per visit basis was improper.
2006-D26
Mary Hitchcock Memorial Hospital vs. BlueCross BlueShield Association/Anthem Health Plans of New Hampshire, Inc.
Whether the denial of the Provider's request for an exception to the renal dialysis composite rate by the Centers for Medicare and Medicaid Services (CMS) was proper.
2006-D27
Phoenix Baptist Hospital vs. BlueCross BlueShield Association/BlueCross & BlueShield of Arizona
Whether the Intermediary improperly failed to offset investment losses incurred by the Provider's home office against interest income earned on funds the Provider deposited with a trustee to retire the debt associated with an advance refunding transaction...
2006-D28
Provena St. Joseph Medical Center and Provena United Samaritans Medical Center vs. BlueCross BlueShield Association/AdminaStar Federal Illinois
Whether the Intermediary's adjustment to school of nursing costs was based upon a proper application of the effective date articulated in Section 6205(a)(2) of the Omnibus Budget Reconciliation Act of 1989.
2006-D29
Montefiore Medical Center vs. BlueCross BlueShield Association/Empire Medicare Services
1. Whether the Intermediary's adjustments offsetting rental income received by the Provider for employee housing against both operating and capital costs was proper. 2. Whether the Centers for Medicare & Medicaid Service's methodology for determining the ...
2006-D30
Greenbriar Nursing and Convalescent Center/Guest House of Slidell/Riverland Healthcare Center vs. Blue Cross Blue Shield Association/TriSpan Health Services
Whether the Intermediary's adjustments to reduce the Provider's outpatient therapy costs by 10 percent were proper.
2006-D31
Olive View Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the Provider is entitled to the benefit of the previously granted change in the TEFRA base period for the purpose of applying the TEFRA limit for the Provider's FYE June 30, 1990.
2006-D32
Osteopathic Founders Foundation vs. Blue Cross Blue Shield Association/Blue Cross Blue Shield of Oklahoma
1. Whether closing costs incurred in the sale of a hospital are allowable as a deduction from the sales price to determine gain or loss on the sale. 2. Whether a portion of the sales proceeds received by the Provider from the sale of its hospital should b...
2006-D33
Visiting Nurse Association of Washington, D.C. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment of the Provider's physical therapy costs was proper.
2006-D34
St. David s 89-92 Related Organization Purchased Services Group vs. Blue Cross Blue Shield Association/Trailblazer Health Enterprises, LLC
Whether the Intermediary's denial of the Provider's request for an exception to the related organization principle for calendar years 1989 through 1992 was proper.
2006-D35
East Lake Community Health Center vs. Blue Cross Blue Shield Association/AdminaStar Federal
Whether certain adjustments made by the Intermediary were proper.
2006-D36
Extendicare 99 Uncollect Co-In Dual Elig Group vs. BlueCross BlueShield Association/United Government Services, LLC - WI
Whether the Intermediary properly disallowed bad debts related to uncollectible deductibles and coinsurance arising from therapy services, paid under the Medicare Part B fee schedule, where the Medicare eligible patient was not in a covered Part A stay at...
2006-D37
Lawrence & Memorial Hospital vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary's adjustment to disallow the Connecticut Sales Tax was proper.
2006-D38
St. Vincents Medical Center vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary's adjustment to disallow the Connecticut Sales Tax was proper.
2006-D39
Loma Linda University Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the denial of the Provider's request for an exception to the end stage renal disease (ERSD) composite rate by the Centers Medicare and Medicaid Services (CMS) was proper, or whether it should be deemed to have been approved pursuant to Section 188...
2006-D40
Loma Linda University Kidney Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the denial of the Provider's request for an exception to the end stage renal disease (ERSD) composite rate by the Centers Medicare and Medicaid Services (CMS) was proper, or whether it should be deemed to have been approved pursuant to Section 188...
2006-D41
Comprehensive Home Care, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's disallowance of accrued compensation for the Provider's President/Chief Executive Officer (CEO) and Vice-President/Operations Manager was proper.
2006-D42
Logos Healthcare Rehabilitation, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's adjustment to accounting expense was proper.
2006-D43
Greenwood County Hospital vs. BlueCross BlueShield Association/BlueCross BlueShield of Kansas
Whether the Provider was improperly denied a Medicare low-volume adjustment.
2006-D44
DCH Regional Medical Center vs. BlueCross BlueShield Association/BlueCross BlueShield of Alabama
Whether the Intermediary/Centers for Medicare and Medicaid Service's denial of the request to include additional pension costs as wage-related costs for purposes of the Provider's FY 2004 wage index was proper.
2006-D45
The Milton S. Hershey Medical Center vs. BlueCross BlueShield Association/Veritus Medicare Services
Whether the CMS denial of the Provider's request for an exception to the end stage renal disease (ESRD) composite rates based on atypical service intensity and patient mix was correct.
2006-D46
Sisters of Charity Hospital vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary properly calculated the Provider's indirect medical education (IME) reimbursement.
2006-D47
Rush University Medical Center vs. BlueCross BlueShield Association/AdminaStar Federal Illinois
Whether the Intermediary should have used the aggregation methodology when implementing the updated reasonable compensation equivalent (RCE) limits on compensation paid to Provider's hospital-based physicians.
2006-D48
District of Columbia General Hospital vs. Blue Cross Blue Shield Association/Carefirst of Maryland
Whether the Intermediary's determination of available bed days for the purpose of calculating the Provider's IME payment was accurate.
2006-D49
CT Subacute Corp. 93 Capital Lease Group vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary's adjustments to disallow rental expense as a cost incurred with a related organization were proper.
2006-D50
CT Subacute Corp. 98 Protested Items Group vs. BlueCross BlueShield Association/Empire Medicare Services
Whether the Intermediary's adjustments to disallow rental expense as a cost incurred with a related organization were proper.
2006-D51
Gundersen Lutheran Hospital vs. BlueCross BlueShield Association/United Government Services, LLC-WI
Whether the denial of the Provider's request for an exception to the end stage renal disease (ERSD) composite rate was in compliance with 42 CFR 413.180(h).
2006-D52
Mark Reed Hospital vs. BlueCross BlueShield Association/Noridian Administrative Service
1. Whether the Intermediary's adjustment to direct nursing costs was proper. 2.Whether the Intermediary properly increased the total patient days to include respite care.
2006-D53
DePaul Health Center vs. Mutual of Omaha Insurance Company
Whether the Intermediary's adjustment disallowing the consolidation of all of the Provider's therapy services into a single cost center was proper.
2006-D54
North Okaloosa Medical Center vs. BlueCross Blue ShieldAssociation/First Coast Service Options, Inc.
Whether the Intermediary's adjustment of DSH reimbursement based on its determination that the Provider had less than 100 available beds for DSH eligibility purposes was proper.
2006-D55
Saint Anthonys Health Center vs. BlueCross BlueShield Association/AdminaStar Federal Illinois
Whether the full amount of Provider's exception requests to the skilled nursing facility (SNF) routine service cost limits under 42 CFR 413.40(f) was properly denied because the Provider did not request the exceptions within 180 days of the original Notic...
2006-D56
Sutter Merced Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the Intermediary properly disallowed Medicare bad debts.
2006-D57
Glenwood Park, Inc. vs. BlueCross BlueShield Association/United Government Services, LLC-WI
Whether the Intermediary properly disallowed bad debts claimed for uncollectible deductibles and coinsurance related to therapy services furnished to Medicare beneficiaries dually eligible for Medicare and Medicaid (Qualified Medicare Beneficiaries or QMB...
2006-D58
Wilmington Treatment Center vs. BlueCross BlueShield Association/Cahaba Safeguard Administrators, LLC
Whether the Intermediary's disallowance of Medicare bad debts claimed by the Provider was proper.
2007-D01
Iowa Lutheran Hospital vs. BlueCross/BlueShield Association/Cahaba Government Benefits Administrator
Whether the Intermediary's adjustments to the Medicare cost report that disallowed the loss on disposal depreciable assets resulting from a merger were proper.
2007-D02
JFK- Raritan Bay- Hunterdone 03 Wage Index Group vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether it was proper for the Centers for Medicare and Medicaid Services (CMS) to include the 1999 information for Memorial Medical Center at South Amboy in the 2003 calculation of the Middlesex-Somerset-Hunterdon, New Jersey Metropolitan Statistical Area...
2007-D03
Allegany County Department of Health vs. BlueCross BlueShield Association/United Government Services, LLC - WI
Whether the Intermediary's adjustment to reconcile the fiscal year ending (FYE) 12/31/00 home health agency aide charges to the Provider Statistical & Reimbursement Report was proper.
2007-D04
Central Maine Medical Center, Lewiston, Maine vs. Blue Cross Blue Shield Association/Associated Hospital Services
Whether the Intermediary's denial of the Provider's request for an adjustment to its Tax Equity and Fiscal Responsibility Act (TEFRA) target amount for the fiscal years ending (FYEs) 06/30/96 through 06/30/98 was proper.
2007-D05
Washington State Medicare DSH Group II vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether patient days related to two Washington State funded programs referred to as MI and GAU should be included in the Medicaid proxy in the Medicare DSH calculation.
2007-D06
Stormont-Vail Health Care vs. BlueCross BlueShield Association/Blue Cross & Blue Shield of Kansas
Whether the Intermediary's revised Notice of Program Reimbursement (NPR) issued on July 25, 2003, that increased the Provider's Disproportionate Share Hospital (DSH) payment, included all Medicaid eligible days that would qualify for inclusion under HCFA ...
2007-D07
St. Joseph Regional Health Center vs. BlueCross BlueShield Association/ TrailBlazer Health Enterprises, LLC
Whether the Intermediary's determination that the Provider should be reimbursed at the rural, as opposed to the urban, inpatient prospective payment system (IPPS) rate for discharges at its Grimes St. Joseph facility was proper.
2007-D08
Marion General Hospital vs. BlueCross BlueShield Association/TriSpan Health Services
Whether the Board may grant jurisdiction for the adjustment included in the Provider's initial Notice of Program Reimbursement (NPR) pursuant to a revised NPR.
2007-D09
Atlantic 97 Residents in Nonhosp. Setting Group; Atlantic Health System 99 IME Group; Atlantic Health System 00 FTE Calc. Grp. Vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the Intermediary properly calculated the Provider's 1996 Indirect Medical Education (IME) base year Full-Time Equivalency (FTE) cap, specifically in regards to residents rotating to nonhospital settings.
2007-D10
St. Benedicts Family Medical Center vs. BlueCross BlueShield Association/ Medicare Northwest
Whether the Provider's physician assistant emergency room availability costs were allowable as Medicare Part A reimbursable expenses.
2007-D11
Foothill Presbyterian Hospital vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the Intermediary's determination of reimbursable Medicaid bad debts for beneficiaries without Medicaid eligibility (non-cross-over beneficiaries) was proper.
2007-D12
El Camino Hospital vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether all of the Provider's outpatient total cost, total charges, and Medicare charges for separately billable End Stage Renal Disease (ESRD) drugs should be reported together on line 56 (drugs charges to patients), on line 57 (renal dialysis), or on a ...
2007-D13
Rush Presbyterian- St. Lukes Medical Center (n/k/a Rush University Med. Ctr.) vs. BlueCross BlueShield Association/AdminaStar Federal-Illinois
1. Whether the Provider's transplant surgery residents should be included in the full-time equivalent (FTE) count for the purposes of both direct graduate medical education (GME) and indirect medical education (IME) reimbursement. 2. Whether the Provider ...
2007-D14
CHI (Catholic Health Initiatives) 1997-2002 Offshore Captive Insurance Groups vs. Mutual of Omaha Insurance Company
Whether the offshore captive investment limitations prescribed in section 2162.2.A.4 of the Provider Reimbursement Manual may properly be applied to disallow all of the premiums paid by the Providers to First Initiatives Insurance, Ltd. for the 1997-2002 ...
2007-D15
P-B Health Home Care Agency, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment to disallow the cost of accrued compensatory time was proper.
2007-D16
Martin Luther King, Jr./ Drew Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA
Whether the Intermediary properly increased the number of available beds used to determine the Provider's indirect medical education (IME) payment.
2007-D17
Hi-Desert Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC - CA (n/k/a National Government Services, LLC-CA)
Whether the Intermediary properly limited the Provider's hospital-based SNF routine cost limit exception amount to costs in excess of 112 percent of its peer group costs, rather than costs in excess of the routine cost limit.
2007-D18
Mesquite Community Hospital vs. BlueCross BlueShield Association/ Highmark Medicare Services
Whether the Intermediary's adjustment of the Provider's Medicare bad debts was proper.
2007-D19
Sewickley Valley Hospital and The Medical Center, Beaver, PA vs. Blue Cross Blue Shield Association/Veritus Medicare Services
Whether the Intermediary's denial of a loss on disposition of assets due to a consolidation of SVH and TMC was proper.
2007-D20
Western Reserve Care System vs. BlueCross BlueShield Association/AdminaStar Federal, Inc.
1. Whether the Intermediary's refusal to include the Provider's cost for contracted perfusionist services in its wage index calculations was proper. 2. Whether the Intermediary erred in refusing to include the Provider's cost for contracted pharmacy servi...
2007-D21
El Centro Regional Medical Center vs. Blue Cross Blue Shield Association/United Government Services, LLC-CA (n/k/a National Government Services, LLC-CA)
Whether the Intermediary properly disallowed the Provider's regular Medicare bad debts.
2007-D22
Alacare Home Health Services vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators
Whether the relevant claims were timely filed by the Provider under 42 CFR 424.44.
2007-D23
Jordan Hospital vs. BlueCross BlueShield Association/Associated Hospital Services
Whether the Intermediary's denial of the Provider's request for a new provider exemption from the routine cost limits (RCLs) was proper.
2007-D24
QRS 96 DSH MediKan Days Group vs. BlueCross BlueShield Association/ BlueCross & BlueShield of Kansas
Whether the Intermediary's adjustment excluding secondary MediKan eligible days from the Provider's Medicare DSH calculation was proper.
2007-D25
Central 99-00 Dixie Diamond Ranch HO Ad. #2 (CIRP) Group; Central 98-99 Dixie Diamond Ranch HO Adj. #9 (CIRP Group) vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's adjustment to include the Dixie Diamond Ranch as an other component on Schedule G of the home office cost statement was proper.
2007-D26
St. Francis Hospital vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Whether the Intermediary properly adjusted the Provider's Medicare bad debts. 2. Whether the Intermediary properly adjusted the Provider's medical benefit plan costs.
2007-D27
North Memorial Health Care vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Provider's fiscal year ending (FYE) 2000 ambulance cost per trip limits were improperly low because the Intermediary improperly applied the 5.8 percent outpatient operating cost reduction and the 10 percent outpatient capital cost reduction to...
2007-D28
Decatur County General Hospital vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrators
Whether the Provider's fiscal years ending (FYEs) 6/30/00 and 6/30/01 ambulance cost per trip limits were improperly low because the Intermediary improperly applied the 5.8 percent outpatient operating cost reduction and the 10 percent outpatient capital ...
2007-D29
Arizona 96-99 DSH Group vs. BlueCross BlueShield Association/ Blue Cross and Blue Shield of Arizona (n/k/a Noridian Administrative Services)
Whether Arizona's State-funded general assistance days qualify as Medicaid days for purposes of determining the Provider's Medicare disproportionate share hospital (DSH) adjustments for the fiscal years ending (FYEs) 1994 through 2000.
2007-D30
Via Christi Regional Medical Center vs. BlueCross BlueShield Association/BlueCross BlueShield of Kansas (n/k/a Wheatlands Administrative Services)
Whether the Intermediarys computation of IME and DGME counts was correct.
2007-D31
Atlantic 97 FTE Cap for IME Calculation Group vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the cost report instructions improperly apply the indirect medical education (IME) FTE cap to discharges prior to October 1, 1997.
2007-D32
John L. Doyne Hospital vs. BlueCross BlueShield Association/United Government Services, LLC (n/k/a National Government Services, LLC)
Whether the Intermediary's determination disallowing post-retirement health benefits costs for a terminated provider was proper.
2007-D33
Bayside Community Hospital vs. Blue Cross Blue Shield Association/Trailblazer Health Enterprises, LLC
Whether the Provider is eligible to receive payment on a reasonable cost basis pursuant to 42 CFR 412.113(c) for certified registered nurse anesthesia services provided in a critical access hospital (CAH).
2007-D34
Sharp Chula Vista Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA (n/k/a National Government Services, LLC-CA)
Whether the Intermediary properly excluded, from the disproporationate share hospital (DSH) Medicaid fraction, the days attribuatable to the labor and delivery portion of the stays of maternity patients who occupied licensed inpatient beds in Labor, Deliv...
2007-D35
Good Samaritan Regional Medical Center/Banner Health 94, 96, 97, 98, 99 DSH Calculation Groups/Samaritan 95 DSH Calculation Group vs. BlueCross BlueShield Association/BlueCross & BlueShield of Arizona
Whether Arizona's State-funded general assistance days qualify as Medicaid days for purposes of determining the Provider's Medicare disproportionate share hospital (DSH) adjustments for the fiscal year in dispute.
2007-D36
VNA of Albany, Inc. vs. BlueCross BlueShield Association/United Government Services, LLC
Whether the Intermediary's adjustment to related party transaction cost was proper.
2007-D37
High Country Home Health Care, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary's disallowance of accrued employee benefit costs that were not liquidated within one year after the end of the Provider's cost reporting period was proper.
2007-D38
St. Gertrude's Health Center vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary's denial of the Provider's request for a new provider exemption from the skilled nursing facility (SNF) routine cost limits (RCLs) was proper.
2007-D39
E.W. Sparrow Hospital vs. BlueCross BlueShield Association/United Government Services, LLC
Whether the Intermediary properly determined the full-time equivalent (FTE) intern and resident count for purposes of computing the Provider's indirect medical education adjustment (IME) and direct graduate medical education (DGME) payment.
2007-D40
Sierra Nevada Memorial Hospital vs. BlueCross BlueShield Association/United Government Services, LLC
Whether the Provider's regular Medicare outpatient bad debts are not allowed until all collection efforts, including those of a collection agency, have ceased.
2007-D41
Newport Bay Hospital vs. Mutual of Omaha Insurance Company
Whether the Intermediary's denial of the Provider's request for an adjustment to its Tax Equity and Fiscal Responsibility Act (TEFRA) target amount was proper.
2007-D42
Carolina Medicorp 1997 Claimed Loss Disallowance Group vs. BlueCross BlueShield Association/Cahaba Safeguard Administrators, LLC
Whether the Intermediary's adjustments disallowing the loss claimed by Medicare Providers on the disposition of assets resulting from the statutory merger of California Medicorp into Presbyterian Health Services Corporation were proper.
2007-D43
Baptist Memorial Hospital vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrators
Whether the Provider is entitled under CMS Program Memorandum (PM) A-99-62 to include Social Security Act, Section 1115 waiver days for the expanded Medicaid populations (a/k/a TennCare) days in the Medicaid component of the disproportionate share hospita...
2007-D44
Tarrant County Hospital District vs. BlueCross BlueShield Association/Trailblazer Health Enterprises, LLC
Whether the Provider timely filed additional information required to entitle it to an exemption from the skilled nursing facility (SNF) routine cost limit under 42 C.F.R. section 413.30(e).
2007-D45
Palmetto General Hospital- SNF vs. Mutual of Omaha Insurance Company
Whether the Centers for Medicare and Medicaid Services (CMS) properly denied the request(s) of the Provider for an exemption from the Routine Service Cost Limits (RCLs) for the fiscal year ended December 31, 1998.
2007-D46
Franklin Square Hospital Transitional Care Unit, Good Samaritan Hospital Comprehensive Care Unit vs. BlueCross BlueShield Association/CareFirst of Maryland, Inc. (n/k/a Highmark Medicare Services)
Whether the Intermediary properly denied requests by Franklin Square and Good Samaritan for New Provider Exemptions from the routine cost limits for fiscal years ending 6/30/97 and 6/30/98.
2007-D47
Texas Senior Care vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
1. Whether the Intermediary properly allocated home office cost from the finalized home office cost statement to the Provider. 2. Whether the Intermediary's adjustment to the salaries, benefits and mileage of the program managers was proper. 3. Whether th...
2007-D48
Spectrum Health-Kent Community Campus vs. BlueCross BlueShield Association/United Government Services, LLC (n/k/a National Government Services, LLC)
Whether the Intermediary and CMS erred in denying the Provider's rate adjustment request made under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA).
2007-D49
Sacred heart Medical Center-Psychiatric vs. BlueCross BlueShield Association/Noridian Administrative Services (f/k/a Medicare Northwest)
1. Whether the exception review process engaged in by the Health Care Financing Administration (HCFA) and the Fiscal Intermediary violated due process and fundamental fairness, including violations of the time limits established by federal regulation and ...
2007-D50
Methodist Hospitals of Memphis vs. BlueCross BlueShield Association/TriSpan Health Services
Whether the Intermediary's adjustment to the Provider's per resident amount (PRA) was proper.
2007-D51
Aroostook Medical Center vs. BlueCross BlueShield Association/Associated Hospital Services of Maine(n/k/a National Government Services-Maine)
Was CMS denial of the end stage renal disease (ESRD) composite rate exception correct based on applicable Medicare law?
2007-D52
Allentown-Bethlehem MSA Wage Index Group vs. BlueCross BlueShield Association/Highmark Medicare Services (f/k/a Veritus Medicare Services)
Whether St. Lukes Hospital's letter of March 8, 2001 requesting corrections to its hospital wage data for its fiscal year ended 6/30/1999 satisfied the requirements established by CMS (then HCFA) set forth in 66 Fed. Reg. 39828 -39871 (Aug 1, 2001) for a ...
2007-D53
St. Francis Hospital vs. BlueCross BlueShield Association/Highmark Medicare Services (f/k/a Veritus Medicare Services)
Whether the Intermediary's application of the reasonable compensation equivalent (RCE) limits was proper.
2007-D54
UPMC-Braddock Hospital vs. BlueCross BlueShield Association/Veritus Medicare Services (n/k/a Highmark Medicare Services)
Whether the Intermediary's adjustments to the Medicare cost report that disallowed the loss on disposal of depreciable assets resulting from a merger were proper.
2007-D55
Covenant Health Care vs. BlueCross BlueShield Association/United Government Services, LLC (n/k/a National Government Services)
Whether the Intermediary's determination of the Full-time Equivalent (FTE) intern and resident count for purposes of computing the Provider's Indirect Medical Education (IME) and direct Graduate Medical Education (GME) adjustments for FYEs June 30, 1999 ...
2007-D56
Innovis Health vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Provider is entitled to Transitional Outpatient Payments (TOPs).
2007-D57
University of Chicago Hospitals & Clinics vs. BlueCross BlueShield Association/National Government Services - Illinois
Whether the time spent by residents conducting research in the Provider's facility as part of an approved residency program should be in the Indirect Medical Education full-time equivalent (FTE) calculation.
2007-D58
MetroWest Medical Center vs. BlueCross BlueShield Association/Associated Hospital Services (n/k/a National Government Services-Maine)
Whether the Provider's Notice of Program Reimbursement (NPR) dated September 24, 2002 was an original or a revised NPR.
2007-D59
Mountains Community Hospital vs. BlueCross BlueShield Association/ National Government Services, LLC - CA
Whether the Intermediary properly required the use of a full years Medicaid days in the Disproportionate Share Hospital (DSH) calculation based on its interpretation of the Benefit Improvements and Protection Act (BIPA) of 2000.
2007-D60
Guam Memorial Hospital Authority vs. BlueCross BlueShield Association/United Government Services, LLC-CA (n/k/a National Government Services-CA)
Whether the Intermediary's adjustment disallowing the Provider's claimed withholding tax expense was proper.
2007-D61
Montefiore Medical Center vs. BlueCross BlueShield Association/National Government Services - NY
Whether the Intermediary improperly limited the Provider's hospital-based Skilled Nursing Facility (SNF) routine cost limit exception amount to costs in excess of 112 percent of its peer group costs rather than costs in excess of the routine cost limit.
2007-D62
Hi-Desert Medical Center vs. BlueCross BlueShield Association/National Government Services, LLC - CA
Whether the Intermediary's determination of non-allowable physician office and vacant space costs was proper.
2007-D63
Saint Mary's Mercy Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC (n/k/a National Government Services)
Whether CMS correctly calculated the Medicare fraction of the disproportionate patient percentage (DPP) for purposes of the DSH payment.
2007-D64
Harbor Healthcare & Rehabilitation Center vs. BlueCross BlueShield Association/Empire Medicare Services (n/k/a National Government Services-NY)
1. Whether the Intermediary's notification of the opening of the Provider's 1996 and 1997 final settled cost reports was timely pursuant to regulatory standards. 2. Whether the sampling methodology used by the Intermediary to disallow charges for the Prov...
2007-D65
Baptist Memorial Hospital vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrators
Whether the Centers for Medicare and Medicaid Services (CMS) properly disallowed the Provider's request for an exception to its Skilled Nursing Facility (SNF) Routine Service Cost Limit (RCL).
2007-D66
Memorial Healthcare Center vs. BlueCross BlueShield Association/ National Government Services, LLC -WI
Whether the Intermediary improperly limited the Provider's hospital-based Skilled Nursing Facility (SNF) routine cost limit exception amount to costs in excess of 112 percent of its peer group costs rather than costs in excess of the routine cost limit.
2007-D67
Rochester 02-03 MSA Wage Index Group vs. BlueCross BlueShield Association/Empire Medicare Services(n/k/a National Government Services-NY)
Whether the Intermediary failed to properly adjust the wage data for Rochester General Hospital used in the calculation of the Federal Fiscal Year (FFY) 2003 Wage Index for The Rochester, New York Metropolitan Statistical Area (MSA).
2007-D68
St. Joseph's Hospital/St. John's Northeast Hospital vs. BlueCross BlueShield Association/Noridian Government Services
Whether the Intermediary's exclusion of certain non-Medicaid general assistance and other state-only funded patient days (General Assistance Days or GADs) from the Provider's Medicaid Proxy was proper based on the instruction contained in Program Memorand...
2007-D69
Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators
Whether the Intermediary's adjustment to accounting expense was proper.
2007-D70
Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators
1. Did the Intermediary improperly reopen the cost report? 2. Was the Intermediary's adjustment to bad debts proper? 3. Was the Intermediary's adjustment to salaries proper?
2007-D71
Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Was the Intermediary's adjustment to Medicare bad debts proper? 2. Were the Intermediary's adjustments to salaries - administrative proper? 3. Was the Intermediary's adjustment to salaries - physical therapy proper? 4. Was the Intermediary's adjustment...
2007-D72
Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators
1. Was the Intermediary's adjustment to bad debts proper? 2. Was the Intermediary's adjustment to salaries proper? 3. Was the Intermediary's adjustment to contracted labor proper?
2007-D73
Logos Healthcare Rehabilitation of South Carolina vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Did the Intermediary improperly reopen the cost report? 2. Was the Intermediary's adjustment to Medicare bad debts proper?
2007-D74
Logos Healthcare Rehabilitation of South Carolina vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Was the Intermediary's adjustment to Medicare bad debts proper? 2-5. Were the Intermediary's adjustments to salaries - administrative, physical therapy, occupational therapy, and speech therapy - proper?
2007-D75
Logos Healthcare Rehabilitation of South Carolina vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Did the Intermediary improperly reopen the cost report? 2. Was the Intermediary's adjustment to salaries - physical therapy proper? 3. Was the Intermediary's adjustment to salaries - speech therapy proper?
2007-D76
Logos Healthcare Rehabilitation of South Carolina vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Was the Intermediary's adjustment to salaries proper? 2. Was the Intermediary's adjustment to contract labor proper?
2007-D77
Logos Healthcare Rehabilitation of Tennessee vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Did the Intermediary improperly reopen the cost report? 2. Was the Intermediary adjustment to contract services - administrative proper? 3-4. Were the Intermediary's adjustment to contract services - speech and occupational therapy proper?
2007-D78
Santa Barbara Cottage Hospital vs. BlueCross BlueShield Association/ National Government Services, LLC - CA
1. Whether the Intermediary improperly disallowed direct graduate medical education (DGME) and indirect medical education (IME) payments with respect to discharge of Medicare beneficiaries who were enrolled in the Medicare + Choice or other Medicare risk ...
2008-D01
Marion General Hospital vs. BlueCross BlueShield Association/National Government Services - Indiana
Whether the rescission of the Provider's approved request for Sole Community Hospital (SCH) status was proper.
2008-D02
LAC 98 DSH/Non-Federal Low-Income Days Group vs. BlueCross BlueShield Association/National Government Services - CA
1. Whether the Providers are entitled to have general relief (GR) days included in the calculation of their disproportionate share percentage to the hold harmless provisions of Program Memorandum A-99-62. 2. Whether the failure to allow the Providers to i...
2008-D03
Bayfront Medical Center vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether the Intermediary's disallowance of the discharges not reflected in the PS&R was proper.
2008-D04
Hallmark Health System, Inc. vs. BlueCross BlueShield Association/National Government Services-Maine (f/k/a Associated Hospital Service)
Whether the Intermediary's determination of the Provider's dental intern and resident count for purposes of calculating its direct and indirect medical education adjustment was accurate.
2008-D05
Summer Hill Nursing Home vs. Mutual of Omaha Insurance Company
Whether the Intermediary properly adjusted the Provider's Medicare bad debts.
2008-D06
Queen of the Valley Hospital vs. BlueCross BlueShield Association/National Government Services, LLC - CA
Whether the Intermediary improperly allowed 0.54 intern and resident FTE for IME purposes on the Provider's fiscal year ending (FYE) December 31, 1996 Medicare cost report.
2008-D07
St. Marys Hospital - Milwaukee vs. BlueCross BlueShield Association/National Government Services, LLC-WI
1. Whether CMS properly calculated the Provider's Medicare disproportionate share hospital (DSH) adjustment by not including 52 patient days from the Supplemental Security Income (SSI) fraction. 2. Whether the Intermediary improperly calculated the Provid...
2008-D08
Visiting Nurse Association of Texas vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's disallowance of $35,390 to remove the portion of Home Health First (HHF) management fees attributable to the cost of a deferred compensation plan for executives was proper.
2008-D09
Medical Park Hospital vs. BlueCross BlueShield Association/Arkansas BlueCross & BlueShield
Whether the Provider's Disproportionate Share Hospital (DSH) adjustment was correctly calculated.
2008-D10
Hackensack University Medical Center vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the Intermediary's adjustments to the Provider's direct graduate medical education and indirect medical education full-time equivalent counts were proper.
2008-D11
Hackensack University Medical Center vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the Intermediary erred by not including patient days attributable to certain patients, who were not eligible for Medicaid but who were given assistance under the New Jersey Charity Care Program (CCP), in the calculation of the Medicaid proxy to de...
2008-D12
Baptist Regional Medical Center vs. BlueCross BlueShield Association/National Government Services - Kentucky
Whether the Intermediary properly adjusted Medicare bad debts accounts considered indigent by the Provider.
2008-D13
Covenant Health System 91, 93-97 DSH/Medicaid Proxy Group vs. Mutual of Omaha Insurance Company
Whether the Intermediary's calculation of the disproportionate share hospital (DSH) payment was proper.
2008-D14
Riverside Center for Jewish Seniors vs. BlueCross BlueShield Association/Highmark Medicare Services
Whether the Intermediary's adjustment to remove Nursing Administration, Medical Records, and Social Services allocation statistics from the Provider's ancillary cost centers on the Medicare cost report were proper.
2008-D15
Allentown Osteopathic Medical Center vs. BlueCross BlueShield Association/Veritus Medicare Services (n/k/aHighmark Medicare Services)
Whether the Intermediary's adjustment, disallowing the loss claimed by the Provider, was proper.
2008-D16
Hillcrest Baptist Medical Center vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
1. Whether capitalized interest that may have been amortized in future years can be expensed in the current year when future cost reports are no longer subject to reopening. 2. Whether the Intermediary's determination of allowable interest expense which d...
2008-D17
Sparrow Health 98-99 IME Managed Care Group vs. BlueCross BlueShield Association/United Government Services
Whether the Providers are entitled to receive additional indirect medical education (IME) and direct graduate medical education (DGME) payments for Medicare managed care enrollees.
2008-D18
Mercy Center for Health Care Services vs. BlueCross BlueShield Association/AdminaStar Federal, Inc.
Whether the Intermediary's adjustment disallowing the loss on disposal of depreciable assets through consolidation was proper.
2008-D19
North Dakota 99-01 Adjustment of FTE GME/IME Group vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary properly disallowed reimbursement for direct graduate medical education (DGME) and indirect medical education (IME) costs in the non-hospital setting by reducing the Provider's full-time equivalent (FTE) resident counts.
2008-D20
HealthEast Woodwinds Hospital vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary's refusal to reimburse the Provider for capital-related costs under the hold harmless methodology was proper.
2008-D21
Vitality Rehab, Inc. vs. Mutual of Omaha Insurance Company
Whether the Intermediary properly disallowed bad debts claimed for uncollectible deductibles and coinsurance amounts related to outpatient therapy services furnished to Medicare beneficiaries dually eligible for Medicare and Medicaid, and paid under the P...
2008-D22
Cooper University Hospital vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator
Whether the Intermediary erred by not including patient days attributable to certain patients, who were not eligible for Medicaid but who were given assistance under the New Jersey Charity Care Program (CCP), in the calculation of the Medicaid proxy to de...
2008-D23
University of Texas M.D. Anderson Cancer Center vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises
1. Whether the Intermediary properly disallowed the Provider's request for an adjustment to the TEFRA rate-of-increase ceiling to account for the cost of new drugs that were not approved in the 1983 base year. 2. Whether the Intermediary properly calculat...
2008-D24
Summit Medical Center vs. BlueCross BlueShield Association/National Government Services, LLC - CA
Whether the TEFRA base year used by the Intermediary to compute a target amount for the Provider's excluded psychiatric unit for the February 28, 1998 and February 28, 1999 cost years was proper.
2008-D25
University of California, Davis Medical Center vs. BlueCross BlueShield Association/National Government Services, LLC - CA
Whether the Intermediary properly corrected the Provider's reported payments, more than three years after the date of the original Notice of Program Reimbursement (NPR).
2008-D26
Loma Linda University Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC - CA (n/k/a National Government Services, LLC-CA)
Whether the payments for indirect medical education (IME) and direct graduate medical education (DGME) was understated as a significant number of managed care days and discharges for inpatient services for Medicare beneficiaries were not included in the c...
2008-D27
Oswego Medical Center vs. BlueCross BlueShield Association/Wheatlands Administrative Services
Whether the Intermediary's adjustment to the Provider's claimed owners compensation was proper.
2008-D28
Quality Lifestyles of Mesa vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators
Whether the Intermediary properly reclassified professional fees from the Administrative and General (A and G) -reimbursable cost center to the A and G-Shared cost center for the cost reporting period ending December 31, 1999.
2008-D29
UPHS 99/ 2000 Medicare Choice Beneficiaries Group vs. Mutual of Omaha Insurance Company
Whether the Provider's reimbursement for indirect medical education (IME) and direct graduate medical education (DGME) for Medicare managed care patients was properly disallowed by the Intermediary for fiscal year 1999 and fiscal year 2000 for failure to ...
2008-D30
Forest Hospital vs. BlueCross BlueShield Association/National Government Services - Illinois
1. Whether the Intermediary properly adjusted Medicare bad debts. 2. Whether the Intermediary properly adjusted the Provider's treatment of asset refiling. 3. Whether the Intermediary properly adjusted public relations and marketing expenses. 4. Whether t...
2008-D31
Medical Center of North Hollywood vs. BlueCross BlueShield Association/National Government Services-CA
Whether the Intermediary may recoup an overpayment relative to the Provider's 1987 cost reporting period through a revised Notice of Program Reimbursement (NPR) issued in January 2002.
2008-D32
Port Huron Hospital vs. BlueCross BlueShield Association/National Government Services, LLC - WI
Whether the Provider was required to submit a claim to the Michigan Medicaid program and to obtain a Medicaid remittance advice in order to receive Medicare reimbursement for Part B bad debts relating to services furnished to patients dually eligible for ...
2008-D33
Oak Knoll Health Care Center vs. BlueCross BlueShield Association National Government Services
1. Whether the Provider is entitled to a new provider exemption from the skilled nursing facility (SNF) routine cost limitation (RCL) under 42 C.F.R. Section 413.30(e) for the fiscal year ending (FYE) December 31, 1995. 2. Whether the Intermediary's denia...
2008-D34
Henry Ford Hospital vs. BlueCross BlueShield Association/ National Government Services, LLC -WI
1. Whether the Intermediary properly excluded FTEs attributable to rotations by residents in certain unaccredited training programs. 2. Whether the Intermediary properly excluded IME FTEs attributable to time spent by residents in research that was requir...
2008-D35
St. Vincent Mercy Medical Center vs. BlueCross BlueShield Association/National Government Services - Ohio
1. Whether outpatient observation bed days should be included in the bed count for the purpose of calculating the Provider's indirect medical education or IME reimbursement. 2. Whether to include Medicaid outpatient observation days when determining the P...
2008-D36
Cedars-Sinai Medical Center vs. BlueCross BlueShield Association/National Government Services
Whether the Intermediary may refuse to apply a revised graduate medical education base year average per resident amount to the subsequent cost years that fall outside the three-year reopening period set forth in 42 C.F.R. Section 405.1885.
2008-D37
Beverly Hospital vs. BlueCross BlueShield Association/Associated Hospital Services
1. Whether the Intermediary improperly computed the numerator of the Medicaid fractions that were used to calculate the Provider's disproportionate share hospital (DSH) payments for fiscal years (FYs) 1999, 2000, 2001, and 2002 by excluding inpatient days...
2008-D38
Polyclinic Medical Center vs. Blue Cross Blue Shield Association/ Veritus Medicare Services (n/k/a Highmark Medicare Services)
Whether the Intermediary's adjustments to the Provider's cost report that disallowed the loss on disposal of depreciable assets through consolidation were proper.
2008-D39
Harrisburg Hospital/ Seidle Memorial Hospital vs. Blue Cross Blue Shield Association/Veritus Medicare Services (n/k/a Highmark Medicare Services)
Whether the Intermediary's adjustments to the Provider's cost report that disallowed the loss on disposal of depreciable assets through consolidation were proper.
2008-D40
Marias Medical Center vs. BlueCross BlueShield Association/Blue Cross and Blue Shield of Montana
Whether the Intermediary properly denied reimbursement of the Certified Registered Nurse Anesthetist (CRNA) standby costs.
2008-D41
Munson Medical Center vs. BlueCross BlueShield Association/National Government Services, LLC - WI
Whether the Intermediary correctly limited the Provider's ambulance reimbursement to its charges.
2008-D42
Oakwood Healthcare System 1992-2001 Capital Prosp. Rate Sys. Hosp. Spec. Rate Determination Grp vs. BlueCross BlueShieldAssociation/National Government Services, LLC - WI
Whether as a result of underpayment of Medicare reimbursement during the ten-year transition period of the Capital Prospective Payment System (CPPS), the Providers are entitled to a payment of interest under the Medicare statute, 42 U.S.C. Section 1395g(d...
2008-D43
Tulsa Regional Medical Center vs. BlueCross BlueShield Association/Chisholm Administrative Services (f/k/a Blue Cross of Oklahoma)
Whether the Intermediary properly adjusted the Provider's indirect medical education full-time equivalent (FTE) cap.
2008-D44
Cancer Treatment Center of Tulsa vs. BlueCross BlueShield Association/BlueCross BlueShield of Oklahoma
Whether the Intermediary properly treated the Provider as an acute care prospective payment system (PPS) facility instead of an excluded cancer hospital.
2008-D45
Swedish American Hospital vs. Mutual of Omaha Insurance Company (n/k/a Wisconsin Physicians Service)
Whether the Intermediary's adjustments reducing the 1996 base year IME/GME FTE count for osteopathic and allopathic medicine interns and residents and their effect on the May 31, 1999 through May 31, 2003 FTE counts are correct.
2009-D01
Roanoke 93 DSH Medicaid Percentage Group vs. BlueCross BlueShield Association/National Government Services
Whether the Medicaid percentage component of the Provider's disproportionate share hospital (DSH) adjustment has been properly computed to contain all Medicaid patient days including Medicaid eligible days.
2009-D02
Rochester 2004 MSA Wage Index Group vs. Blue Cross Blue Shield Association/National Government Services -NY
Whether the Intermediary properly determined the Rochester, New York, Metropolitan Statistical Area (MSA) wage index for fiscal year 2004 in a manner that reflected the relative hospital wage level in that geographic area as compared to the national avera...
2009-D03
QRS 1994 DSH Medicare Managed Care and Medicaid Eligible Days Group vs. BlueCross BlueShield Asociation/Noridian Administrative Services
Whether the Intermediary should include dual-eligible, managed care days in the Medicaid proxy in determining Medicare reimbursement for disproportionate share hospital (DSH) payments in accordance with the Medicare statute at 42 U.S.C. Section 1395ww(d)(...
2009-D04
Flagstaff Medical Center vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary properly calculated and applied the Provider's ambulance cost per trip limit.
2009-D05
Mayo Clinic Hospital vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary used proper cost-to-charge ratios in calculating the Provider's outlier payments.
2009-D06
Banner Health System 2000 DSH Calculation Group vs. BlueCross BlueShield Association/Noridian Administrative Services (f/k/a BlueCross BlueShield of Arizona)
Whether the Provider's State-funded categories of assistance qualify as Medicaid days for purposes of determining the Provider's Medicare disproportionate share hospital adjustments (DSH) for the fiscal year 2000.
2009-D07
Pleasant Care Corp. Utilization Review Cost Group vs. Wisconsin Physicians Service (formerly Mutual of Omaha Insurance Company)
Whether the Intermediarys adjustment to utilization review costs was proper.
2009-D08
Quality 89-92 Hospital Based SNF Group vs. BlueCross BlueShield Association/National Government Services, LLC - CA
Whether the Centers for Medicare and Medicaid Services (CMS) methodology for determining the Provider's exception to the hospital-based skilled nursing facility cost limits was proper.
2009-D09
St. Luke Community Healthcare vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary's disallowance of the Provider's certified registered nurse anesthetist (CRNA) on-call costs was proper.
2009-D10
Kindred Healthcare 05 Bad Debts vs. Wisconsin Physicians Service (formerly Mutual of Omaha)
Whether the Intermediary's adjustments to disallow Medicare bad debts written off by the Provider and claimed as worthless after the year end date of the terminating cost report it filed for each skilled nursing facility, due to change of ownership, were ...
2009-D11
Quality Reimbursement Services (QRS)Catholic Healthcare West (CHW) DSH Labor Room Days Groups vs. Blue Cross Blue Shield Association/United Government Services, LLC -CA
Whether the Intermediary improperly disallowed from the calculation of the Provider's Disproportionate Share Hospital (DSH) payments, patient days associated with Medicaid patients who were admitted to the hospital prior to the day of giving birth and tha...
2009-D12
SRI 1987-1994 DSH SSI% Group vs. Blue Cross Blue Shield Association/National Government Services (IL)
Whether the Board has jurisdiction over a challenge to the validity of the Supplemental Security Income percentage under the doctrine of equitable tolling where the appeals were not filed within three years of the issuance of Provider's Notices of Program...
2009-D13
Langley Porter Psychiatric Institute vs. BlueCross BlueShield Association/National Government Services - CA
Whether the Intermediary's determination of the Provider's direct graduate medical education (DGME) payment was proper.
2009-D14
Harrison House of Georgetown vs. Blue Cross Blue Shield Association/Empire Medicare Services (n/k/a National Government Services)
1. Whether the Intermediary's notification of the reopening of the Provider's 1996 cost report was timely pursuant to regulatory standards. 2. Whether the Intermediary's determination to disallow costs for the Provider's contracted therapy services was pr...
2009-D15
St. Josephs Hospital and Health Center vs. BlueCross BlueShield Association/BlueCross BlueShield of Texas
Whether the denial of the Provider's request for an exception to the Tax Equity and Fiscal Responsibility Act (TEFRA) rate for its rehabilitation unit was proper.
2009-D16
Yale-New Haven Health Services Group Appeals vs. BlueCross BlueShield Association/National Government Services
Whether the Intermediary properly disallowed payments for indirect medical education (IME) and direct graduate medical education (DGME) with respect to discharges of Medicare beneficiaries who were enrolled in the Medicare Choice or other Medicare risk ...
2009-D17
Hospice 2009 BNAF Group/Bluegrass 2009 BNAF Group vs. Blue Cross Blue Shield Association/Palmetto Government Benefit Administrators
Should the PRRB grant expedited judicial review over the question of whether the Secretary's elimination of the budget neutrality adjustment factor (BNAF) used in the calculation of hospice payment rates was proper?
2009-D18
Valley Presbyterian Hospital vs. BlueCross BlueShield Association/First Coast Service Options-CA
Whether the Board has jurisdiction over the Intermediary's refusal to reopen cost reports to adjust the Supplemental Security Income percentages where the request for reopening were filed more than three years after the issuance of the Notices of Program ...
2009-D19
St. Cloud Hospital vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Intermediary should have included all general assistance days in the computation of the Provider's Medicare Disproportionate Share (DSH) adjustment calculation for the Providers fiscal years ended June 30, 1997, 1998, 1999, and 2000.
2009-D20
Henry Ford Health System Managed Care GME/IME Payments Group vs. BlueCross BlueShield Association/National Government Services, LLC
Whether the Intermediary properly disallowed payments for indirect medical education (IME) and direct graduate medical education (DGME) with respect to discharges of Medicare beneficiaries who were enrolled in the Medicare + Choice or other Medicare risk ...
2009-D21
Triad 2007 Liability for Periodic Interim Payments to Former Owner Group vs. BlueCross BlueShield Association/Blue Cross Blue Shield of Georgia
Whether the Board has jurisdiction over a challenge to an overpayment recoupment action involving the Provider's liability for erroneous payments made to the former owners of the skilled nursing facilities (SNFs) after the change of ownership.
2009-D22
Mercy Hospital of Pittsburgh (n/k/a University of Pittsburgh Medical Center (UPMC)) vs. BlueCross BlueShield Association/Highmark Medicare Services (formerly Blue Cross of Western Pennsylvania)
Whether interest is due on the continuing underpayments that exist as a result of the fiscal Intermediary's 10 year delay in implementing PRRB Case No. 91-2673.
2009-D23
Jeanes Hospital vs. Wisconsin Physicians Service (Formerly Mutual of Omaha Insurance Company)
Whether the Jeanes Hospital merger was a bona fide sale.
2009-D24
New England Deaconess Hospital vs. Blue Cross/ Blue Shield Association/ National Government Services
Whether the Intermediary's disallowance of the Provider's claim for a loss in connection with its October 1, 1996 statutory merger was proper.
2009-D25
Connecticut 94 thru 98 DSH Group vs BlueCross BlueShield Association National Government Services
Whether the Intermediary properly excluded Connecticut's State-Administered General assistance (SAGA) program days from the Medicare disproportionate share hospital (DSH) calculation for fiscal year-ends (FYEs) 1994 to 1998 for hospitals in this group app...
2009-D26
National DSH Dual Eligible Group Appeal vs. Blue Cross Blue Shield Association/ National Government Services
Whether the Intermediary properly excluded dual eligible patient days from the Medicaid eligible days in determining the Medicaid percentages that were used for the disproportionate share hospital (DSH) adjustment payments.
2009-D27
St. Marys Hospital-Milwaukee vs. Blue Cross Blue Shield Association/National Government Services, LLC-WI
Whether the Intermediary improperly calculated the Provider's Medicare DSH adjustment by excluding 365 Long Term Respiratory Unit (LTRU) patient days from the Medicaid proxy of the DSH calculation.
2009-D28
Lunch Hour Dispute Wage Index Group Appeals vs. BlueCross BlueShield Association/ National Government Services, Inc. -IL (formerly AdminaStar Federal, Inc.)
Whether paid lunch period time should be added to hours used to calculate the Provider's hourly wage rates.
2009-D29
St. Francis Regional Medical Center vs. Blue Cross Blue Shield Association/ Blue Cross Blue Shield of Kansas
Whether the Intermediary's adjustments disallowing a loss claimed by the Provider upon its consolidation with St. Joseph Medical Center to form Via Christi Regional Medical Center was proper.
2009-D30
SRI 1998 DSH Medicare Part C Days Group vs. Blue Cross Blue Shield Association/Noridian Administrative Services
Whether the exclusion of patient days attributable to Medicare+Choice (M+C) enrollees from the Medicaid fraction in calculating the Provider's disproportionate patient percentage contravenes the statute and regulations.
2009-D31
College Station Medical Center Part C Days Group vs. Wisconsin Physicians Service
Whether the Intermediary properly excluded observation bed days for purposes of determining whether the Provider had less than 100 available beds for disproportionate share hospital (DSH) eligibility purposes.
2009-D32
Sharp Coronado Hospital and HealthCare Center vs. Blue Cross /Blue Shield Association United Government Services, LLC - CA
1. Whether the Intermediary's calculation of the Provider's disproportionate share hospital (DSH) payments, as it pertains to sub-acute unit days, was proper. 2. Whether the Intermediary's calculation of the Provider's DSH payments, as it pertains to Medi...
2009-D33
Cleveland Regional Medical Center vs. Wisconsin Physicians Service
Whether the Intermediary's adjustment of disproportionate share hospital (DSH) reimbursement, based on its determination that the Provider had less than 100 available beds for DSH eligibility purposes, was proper.
2009-D34
Whidden Memorial Hospital vs. Blue Cross Blue Shield Association
1. Whether the Intermediary's audit adjustments disallowing the entire loss on the disposition of assets claimed by the Provider, when the Provider corporation merged with another provider corporation, were proper. 2. Whether the Intermediary properly den...
2009-D35
Allina 1995-2003 DSH Dual Eligible Days Group vs. Blue Cross /Blue Shield Association/Noridian Administrative Services
Whether it was proper for the Intermediary to exclude from the Medicaid fraction, patient days associated with patients who were dually eligible for both Medicare and Medicaid, but for which Medicare did not cover the days, nor make a payment.
2009-D36
Select Medical 2002-2003 Freestanding New Hospital Capital-Related Costs Groups vs. Wisconsin Physicians Service
Whether the Intermediary's adjustments to the Provider's reimbursable capital cost after denying new hospital status was proper.
2009-D37
Canonsburg General Hospital vs. BlueCross BlueShield Association
Whether CMS' methodology for determining the Provider's exception to the hospital-based skilled nursing facility (HB-SNF) routine cost limits was proper.
2009-D38
Southwest Consulting 1999-2002 State of MA Uncompensated Care Days Group vs. Blue Cross Blue Shield Association/Associated Hospital Services
Whether the Intermediary properly computed the numerator of the Medicaid fraction that was used to calculate the Provider's disproportionate share hospital (DSH) payments for fiscal years (FYs) 1999, 2000, 2001 and 2002 by excluding inpatient days attribu...
2009-D39
Southwest Consulting 95-01 Disproportionate Share Hospital Georgie Indigent Care Trust Fund vs. Blue Cross Blue Shield Association/Blue Cross Blue Shield of Georgia
Whether the hospital days attributable to individuals who applied to the Provider's for, and received, assistance under Georgia's Indigent Care Trust Fund (ICTF) should be counted in the number of Medicaid-eligible days in the numerator of the Medicaid fr...
2009-D40
National Parkinson Foundation CORF; NPF Rehab of Florida/Pompano NPF Florida North Miami Beach vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether the Intermediary's adjustments reflected in the revised Notices of Program Reimbursement (NPR), that reduced allowable home office costs, were proper.
2009-D41
Kingston Hospital vs. BlueCross BlueShield Association/National Government Services, New York (formerly Empire Medicare Services)
Whether the Intermediary properly adjusted the Provider's direct graduate medical education (DGME) and indirect medical education (IME) full-time equivalent (FTE) count for the fiscal years ended December 31, 2000 and December 31, 2001.
2009-D42
Kindred Hospital-Kansas City; Kindred Hospital-St. Louis vs. Wisconsin Physician Services
Whether the Intermediary's adjustments treating the Management Services Corporation (MSC) pool payments the Providers received as provider refunds, which were offset against the allowable provider tax expense, were proper.
2010-D01
University Hospital vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the Intermediary's determination that the resident time was not spent in the hospital complex was proper and, with respect to some residents, the resident time was adequately documented as occurring in the contested area.
2010-D02
Select Medical 2003-2006 New Hospital Capital-Related Costs Groups vs. Wisconsin Physicians Service (formerly Mutual Of Omaha Insurance)
Whether the Intermediary's adjustments to the Provider's reimbursable capital costs after denying new hospital status was proper.
2010-D03
Crozer-Keystone Hospital Specific 2007 Wage Index Rural Floor Group vs. Blue Cross and Blue Shield Association
Whether the Board properly denied jurisdiction over the issue of whether CMS erred in calculating a budget neutrality adjustment to the Inpatient Prospective Payment System (IPPS) standardized amount to account for the effect of the rural floor on the wag...
2010-D04
Royal Oaks Hospital vs. BlueCross BlueShield Association/TriSpan Health Services
Whether the Intermediary properly declined to establish a per-resident amount (PRA) and full-time equivalent (FTE) cap applicable to Providers graduate medical education (GME) costs.
2010-D05
New Jersey 2000/2001/2002 Charity Care DSH Groups vs. Blue Cross Blue Shield Association/Riverbend Government Benefits Administrator
Whether the Intermediary properly excluded New Jersey Charity Care Program (NJCCP) days from the Medicare disproportionate share (DSH) calculation for fiscal year ending (FYEs) 2000 through 2002 for the hospitals in this group appeal.
2010-D06
Greenville Hospital Center vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administration
Whether the Intermediary's disallowance of resident time spent in didactic activities for purposes of the indirect medical education (IME) adjustment was proper.
2010-D07
Mercy Medical Center vs. Wisconsin Physician Services
Whether the Intermediary improperly calculated the Provider's Medicare disproportionate share hospital (DSH) payment by excluding patient days attributable to hospital inpatients who were eligible for Medicaid and enrolled in Medicare Part A for all or a ...
2010-D08
Autumn Bridge, LLC vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators
1. Whether the Provider has demonstrated that it is entitled to a hearing before the Board because there is $10,000 in controversy. 2. To what extent, if at all, Medicare's $720,991 demand for repayment from the Provider for fiscal year 2006 would be decr...
2010-D09
City of Hope National Medical Center vs. BlueCross BlueShield Association/First Coast Services Option, Inc.
Whether the Provider timely filed its Tax Equity and Fiscal Responsibility Act (TEFRA) exception request.
2010-D10
Genesis Health 96 Salaries of Therapists Group vs. BlueCross and BlueShield Association/First Coast Service Options, Inc.
Whether the Intermediary's deletion of therapy costs from line 25, column 9 of Worksheet B-1 of the Provider's Medicare cost reports is proper and in accordance with Medicare cost reporting practices and procedures.
2010-D11
HCA 01 Outpatient Therapy Bad Debts Group vs. Wisconsin Physician Services
Whether the Intermediary properly disallowed reimbursement for the Provider's uncollected coinsurance and deductible amounts relating to outpatient therapy services, paid under the Medicare Part B fee schedule, and claimed as a bad debt for the Provider's...
2010-D12
Ober Kaler 2005 and 2006 Illinois Provider Tax Groups, Southern Illinois Hospital Services 2005 and 2006 Illinois Provider Tax Groups, Memorial Health System 2005 Illinois Provider Tax Group, Blessing Health System 2005 Illinois Provider Tax Group vs. Blu...
Whether the Intermediary's disallowance of the Illinois property tax assessment was proper.
2010-D13
Royal Coast Rehabilitation Center vs. Blue Cross Blue Shield Association/First Coast Services Options, Inc.
Whether the Intermediary's adjustment disallowing bad debts arising from coinsurance and deductibles for dual eligible Medicare and Medicaid beneficiaries was proper.
2010-D14
Mercy Hospital vs. BlueCross BlueShield Association,First Coast Services Option
Whether the Provider has a right to a hearing on correction of its cost report to reclassify certain nurse expenses.
2010-D15
Affinity Medical Center vs. BlueCross BlueShield Association/National Government Services
Whether the Board has jurisdiction over the resident-to-bed ratio where an alleged error in the filed cost report was discovered by the Provider after the final determination was issued.
2010-D16
Chestnut Hill Benevolent Association vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration
Whether the Intermediary improperly reclassified the Provider's nursing school costs and related statistics to a non-reimbursable cost center.
2010-D17
Broadview, Inc. vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration
Whether the Intermediary improperly reclassified the Provider's nursing school costs and related statistics to a non-reimbursable cost center.
2010-D18
Arden Wood, Inc. vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration
Whether the Intermediary improperly reclassified the Provider's nursing school costs and related statistics to a non-reimbursable cost center.
2010-D19
The Leaves, Inc. vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration
Whether the Intermediary improperly reclassified the Provider's nursing school costs and related statistics to a non-reimbursable cost center.
2010-D20
SD 94/95/96-97 Inpatient Crossover Bad Debts Groups/Sharp HC 97 Inpatient Unproc Crossover Bad Debts Group vs. Blue Cross Blue Shield Association/National Government Services, Inc.
Whether the Providers have been properly paid for bad debts for Medicare deductible and coinsurance amounts associated with Medicaid eligible inpatients for services between May 1, 1994 and June 30, 1998.
2010-D21
Reflections Wellness Center, Inc. vs. Blue Cross Blue Shield Association/First Coast Services Options, Inc.
Whether the Intermediary's adjustment disallowing bad debts arising from coinsurance and deductibles for dual eligible Medicare and Medicaid beneficiaries was proper.
2010-D22
Nazareth Hosptial and St. Agnes Medical Center vs. Blue Cross Blue Shield Association/Noridian Administrative Services
Whether general assistance (GA) days should be added to the numerator of the Medicaid proxy in the disproportionate share (DSH) payment calculation.
2010-D23
Life Care Center of Scottsdale vs. Blue Cross Blue Shield Association/National Government Services, Inc.
Whether the CMS must-bill policy applies to the Provider's dual eligible bad debts when the Provider does not participate in the Medicaid program.
2010-D24
The Queens Medical Center vs. BlueCross BlueShield Association/First Coast Services Options, Inc.-CA
Whether the Intermediary improperly excluded patient days associated with patients who were dually eligible for both the Medicare and Medicaid programs but for such days there was no Medicare Part A payment or coverage available (dual eligible days) from ...
2010-D25
Select Specialty 05 Medicare Dual Eligible Bad Debts Group vs. Blue Cross Blue Shield Association/Wisconsin Physicians Service
Whether the CMS must-bill policy applies to the Provider's dual eligible bad debts when the Providers does not participate in the Medicaid program.
2010-D26
QRS Medicare Part A Title XIX Eligible Patient Days Group I vs. Blue Cross Blue Shield Association/Noridian Administrative Services
Whether Medicaid eligible days for Medicare Part A patients should be considered for inclusion in either the Medicaid fraction or the Medicare Supplemental Security Income percentage of the disproportionate share hospital (DSH) adjustment payments.
2010-D27
Saint Barnabas 2000-2004 DSH Adjustment Groups Appeal And St. Peters University Hospital vs. Blue Cross Blue Shield Association/Riverbend Government Benefits Administrator
Whether the Intermediary underpaid the Provider's fiscal years 2000 through 2004 Medicare operating and capital disproportionate share hospital (DSH) adjustments by not including the Provider's New Jersey Charity Care Program (NJCCP) inpatient days from t...
2010-D28
Benedictine Hospital vs. BlueCross BlueShield Assocation/National Government Services- New York (formerly Empire Medicare Services)
Whether the Intermediary properly adjusted the Provider's family practice residency program direction graduate medical education (DGME) and indirect graduate medical education (IME) full-time equivalent (FTE) count for the fiscal year ending December 31, ...
2010-D29
Hope Horizon Center, Inc. and Homestead Behavioral Clinic, Inc. vs. Blue Cross Blue Shield Association/First Coast Service Options, Inc.
Whether the Intermediary's adjustment disallowing bad debts arising from coinsurance and deductibles for dual eligible Medicare and Medicaid beneficiaries was proper.
2010-D30
Medical College of Georgia Hospital vs. Blue Cross Blue Shield Association/Cahaba Government Benefits Administrators-GA
Whether the Board had jurisdiction over the Provider's appeals of the question of whether the disproportionate share (DSH) adjustment was incorrectly determined due to a significant error in the Supplemental Security Income (SSI) percentage where the requ...
2010-D31
Medical College of Georgia Hospital vs. Blue Cross Blue Shield Association/Cahaba Government Benefits Administrators-GA
Whether the Board had jurisdiction over the Provider's appeals of the question of whether the disproportionate share (DSH) adjustment was incorrectly determined due to a significant error in the Supplemental Security Income (SSI) percentage where the requ...
2010-D32
Clinton Memorial Hospital vs. Blue Cross Blue Shield Association/National Government Services, Inc.
Whether outpatient observation bed days should be included in the bed count for the purpose of calculating the Provider's indirect medical education (IME) reimbursement.
2010-D33
UPMC 2001-2007 DSH Medical Assistance Under State Medicaid Plan Groups vs. Blue Cross Blue Shield Association/Highmark Medicare Services-PA Administrator
Whether days for which patients received charity care in Pennsylvania were required by the Medicare statute to be included in the numerator of the Medicaid proxy of the Medicare DSH calculation.
2010-D34
Canon Healthcare Hospice
Whether the Intermediary followed the proper reopening procedures prior to the issuance of the Intermediary's letter dated June 11, 2007 (Notice of Effect of Inpatient Day Limitation and Hospice Cap Amount) recalculating the hospice cap for years ending O...
2010-D35
Toyon 85-98 112% Hospital-Based Peer Group Mean; Catholic Healthcare West 96-98 112% Hospital-Based Peer Group Mean; Sutter Health 91-99 112% Hospital-Based Peer Group Mean; St. Joseph Health System 92-98 112% Hospital-Based Peer Group Mean; Toyon 1999...
Whether CMS' methodology for determining the Provider's exception to the hospital-based skilled nursing facility (SNF) cost limits was proper.
2010-D36
Southwest Consulting 2004 DHS Dual Eligible Days Group; CHI 2004 Dual Eligible Days Group; Caritas Christi Health Care 2004 DSH Dual Eligible Days Group vs. Blue Cross Blue Shield Association/Wisconsin Physician Services/National Government Servs. ME
Whether the Board had jurisdiction to grant the Provider's request for EJR over the validity of the provisions of the CMS Ruling CMS-1498-R.
2010-D37
Carney Hospital Transitional Care Unit vs. BlueCross BlueShield Association/National Government Services
Whether the Intermediary's denial of the Provider's request for a new provider exemption from the Medicare routine service cost limits (RCLs) for skilled nursing facilities (SNFs) was proper in light of the standards set forth in "St. Elizabeth Medical Ce...
2010-D38
King & Spalding Inclusion of Medicare Advantage Days in 2007 SSI Ratios Group/Shands HealthCare Inclusion of Medicare Advantage Days in 2007 SSI Ratios Group/North Shore-Long Island Jewish HS Inclusion of Medicare Advantage Days in 2007 SSI Ratios Group v...
Whether the Board properly granted jurisdiction over the Provider's request for expedited judicial review (EJR) over the question of whether Medicare Part C days should be excluded from the numerator and denominator of the Supplemental Security Income (SS...
2010-D38-R
Allina Health Services, et. al. vs. Sylvia M. Burwell, Secretary, Department of Health and Human Services
Whether enrollees in Medicare Part C are "entitled to benefits" under Part A, as that phrase is used at section 1886(d)(5)(F)(vi)(I) of the Social Security Act, and, therefore, whether these days should be counted in the numerator and denominator of the "...
2010-D39
Salt Lake Regional Medical Center vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether the Board had jurisdiction to grant the Provider's request for expedited judicial review (EJR) over the validity of the provisions of the CMS Ruling CMS-1498-R.
2010-D40
Adventist DSH Waiver Days Group vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether the Intermediary properly exluded expansion wavier days from the Provider's Medicare disproportionate share hospital (DSH) calculation for days attributable to patients who received medical assistance through Tennessee's Medicaid demonstration pro...
2010-D41
Norfolk MSA 2004 Wage Index Group vs. BlueCross BlueShield Association/National Government Services, Inc.-WI
Whether the Intermediary erred in excluding certain contract labor costs, home office costs, and wage-related costs that were claimed by Bon Secours-DePaul Medical Center, Maryview Medical Center, and Mary Immaculate Hospital and used to calculate the fed...
2010-D42
St. Joseph Mercy Hospital-Oakland vs. BlueCross BlueShield Association/National Government Service-WI
Whether the Medicare Proxy component of the disproportionate share hospital (DSH) adjustment must be remanded to the Intermediary without adjudication by the Board pursuant to CMS Ruling 1498-R.
2010-D43
Palmetto General Hospital- Skilled Nursing Facility vs. Wisconsin Physicians Service
In light of the August 29, 2007 Remand Order from the Administrator of the Centers for Medicare and Medicaid Services, what is the proper regulation and manual provision to apply to the facts of this case and what is the relevance of the Provider's cost r...
2010-D44
Southcrest Hospital vs. Wisconsin Physicians Service
Whether the Provider, as a new provider, is entitled to the hold-harmelss payment methodology under the capital prospective payment system beyond the 10-year transition period.
2010-D45
University Medical Center vs. Blue Cross and Blue Shield Association
1. Whether the Intermediary properly excluded resident rotations for research and scholarly activities when calculating the resident full time equivalent (FTE) count for indirect medical education (IME) adjustment purposes. 2. Whether the Intermediary'...
2010-D46
Davies Medical Center vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether the Intermediary properly denied the Provider's Tax Equity and Fiscal Responsibility Act (TEFRA) exception request.
2010-D47
Illinois Masonic Medical Center vs. BlueCross BlueShield Association/ National Government Services, Inc.
Whether the Board has jurisdiction over Medicaid eligible days that were not specifically considered within the implementation of a revised Notice of Program Reimbursement (NPR).
2010-D48
Southwest Consulting DSH SSI Group Appeals- Consolidated Pilot Project vs. Blue Cross Blue Shield Association/ Wisconsin Physician Services
Whether the Board has jurisdiction to grant the Provider's request for expedited judicial review (EJR) over the validity of the provisions of the CMS Ruling CMS-1498-R.
2010-D49
Interim Health Care of Oklahoma City vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrator
Whether the Provider demonstrated that the amount in controversy under 42 C.F.R. 405.1875 was satisfied.
2010-D50
Walter O. Boswell Memorial Hospital vs. Blue Cross /Blue Shield Association/AdminaStar Federal Illinois
1. Whether the Provider's nursing education program qualified as provider-operated. 2. Whether, assuming the Provider's nursing education program did not qualify as provider-operated, the Provider is entitled to receive an additional payment to account...
2010-D51
University of Louisville Hospital vs. BlueCross BlueShield Association/National Government Services
Whether the Intermediary properly reduced the Provider's number of resident full-time equivalents (FTEs) used for purposes of Medicare direct graduate medical education (GME) and indirect graduate medical education (IME) payment based on its contention th...
2010-D52
Southwest Consulting DSH Medicare+Choice Days Group Appeals vs. BlueCross BlueShield Association/NHIC Corp. c/o National Government Services/ Wisconsin Physicians Service, And Noridian Administrative Services
Whether Medicare+Choice (M+C) days should be included in the Medicaid fraction used to calculate the disproportionate share hospital (DSH) adjustment.
2010-D53
Henry Ford Health System vs. Blue Cross BlueShield Association/National Government Services, LLC
1. Whether the Intermediary properly determined the Provider's full-time equivalent (FTE) counts used for purposes of calculating payment for direct graduate medical education (GME) and indirect medical education (IME) based on its exclusion of residents...
2011-D01
Kaiser Foundation Hospitals Southern California 1999-2003 FTE Cap Group Appeals vs. Palmetto GBA/First Coast Service Options
Whether the Intermediary has improperly adjusted the Providers' direct graduate medical education (GME) intern and resident full-time (FTE) counts for their respective fiscal years ended (FTEs) 12/31/1999 through 12/31/2003 by disallowing various FTEs ass...
2011-D02
Penrose/St. Francis Health Services vs. Wisconsin Physicians Service, Inc.
Whether the Intermediary improperly recouped alleged overpayments resulting from an incorrect cost-to-charge ratio (CCR) calculated and applied by the Intermediary to determine outlier payments made to the Provider for inpatient rehabilitation services fu...
2011-D03
Diversicare 05-06 Medicare Bad Debts Group vs. Blue Cross Blue Shield Association/National Government Services, Inc.
Whether the Intermediary's adjustments to the Provider's Medicare bad debts were proper.
2011-D04
Sonoma Valley Health Care District vs. BlueCross BlueShield Association/United Government Services, LLC
Whether the Intermediary's reclassification of clinic meals statistics on Worksheet B-1 from the reimbursable "clinic" cost center to a non-reimbursable cost center was proper.
2011-D05
Unique Care Home Health vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators, LLC
Whether the Provider Statistical and Reimbursement Reports (PS&Rs) used to settle the Provider's cost reports for the fiscal years ended May 31, 1998 and March 17, 1999 were accurate.
2011-D06
UPMC 2003-2006 Count of FTE Resident CIRP Groups vs. BlueCross BlueShield Association/Highmark Medicare Services
Whether the Intermediary/Medicare Administrative Contractor properly calculated the Provider's 1996 resident cap for purposes of direct graduate medical education and indirect graduate medical education payments.
2011-D07
Marian Medical Center vs. Blue Cross Blue Shield Association/National Government Services (n/k/a First Coast Service Options-California)
Whether a loss on disposal of assets is required to be recognized by Medicare as a result of the April 24, 1997 statutory merger of the Provider.
2011-D08
Autumn Bridge LLC vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
1. Whether the Provider demonstrated that it is entitled to a hearing before the Board because there is at least $10,000 in controversy. 2. To what extent, if at all, Medicare's $397,228 demand for repayment from the Provider for fiscal year 2007, calcula...
2011-D09
Various Charity Care/Ohio HCAP DSH Group Appeals vs. Blue Cross Blue Shield Association/National Government Services, Inc.
Whether the Intermediary properly excluded the Ohio Hospital Care Assurance Program (HCAP) days from the Medicare disproportionate share hospital (DSH) calculation.
2011-D10
Indiana DSH-HCI Days Groups I-V vs. BlueCross BlueShield Association/National Government Services, Inc.
Whether the Intermediary's non-inclusion of the Indiana Hospital Care for the Indigent (HCI) program patient days as Medicaid eligible days, whether paid or unpaid, in the calculation of the Medicaid proxy for Medicare Disproportionate Share Hospital (DSH...
2011-D11
Coosa Valley Medical Center vs. BlueCross BlueShield Association/ Cahaba Government Benefits Administrators, LLC
Whether the Centers for Medicare and Medicaid Services reversal of the Provider's rural referral center (RRC) classification was proper.
2011-D12
Various Genesis Health Care Corporation Providers vs. Blue Cross Blue Shield Association/Highmark Medicare Services
Whether the Intermediary properly adjusted the Providers' bad debts, based on reasonable collection efforts and the "must bill" policy, for the fiscal year ended December 31, 2004.
2011-D13
Western Medical Center- Santa Ana vs. BlueCross BlueShield Association/First Coast Service Options-CA
Whether it was proper for CMS to reduce by two percent the Medicare annual payment update for the Provider for federal fiscal year 2008.
2011-D14
Yale New Haven HS 2001-2004 DSH SAGA Days Groups vs. Blue Cross Blue Shield Association/National Government Services, Inc.
Whether the Intermediary's exclusion of days identified by the group as inpatient days attributable to individuals who received medical assistance under the Connecticut State-Administered General Assistance (SAGA) program from the Medicare disproportionat...
2011-D15
Pacific Alliance Medical Center vs. Wisconsin Physician Service
Whether the Provider is entitled to the full market basket update for Federal Fiscal Year ending 2009 under the Reporting Hospital Quality Data for Annual Payment Update Program.
2011-D16
Columbia Memorial Hospital vs. Blue Cross Blue Shield Assn./National Government Services, Inc.
Whether CMS' determination to reduce the Provider's inpatient prospective payment system market basket update for federal fiscal year (FY) 2009 by two (2.0) percentage points was proper.
2011-D17
Charleston Area Medical Center vs. Blue Cross and Blue Shield Association/United Government Services
Whether the provider has a right to a hearing on certain graduate medical education costs and kidney acquisition costs that were not claimed on the cost report.
2011-D18
George Washington University Hospital vs. Wisconsin Physicians Service
Whether the Intermediary properly extrapolated the sample error rate to the population in adjusting Medicaid eligible days.
2011-D19
QRS 1999-2003 DSH Medicare Part C Days Groups vs. BlueCross BlueShield Association/ Noridian Administrative Services, LLC; National Government Services, LLC; TrailBlazer Health Enterprises, LLC; and Wisconsin Physicians Service
Whether Medicare+Choice (M+C) days should be included in the Medicaid fraction used to calculate the disproportionate share hospital (DSH) adjustment.
2011-D20
QRS 1995-1998 DSH Medicare HMO Days Groups vs. Blue Cross Blue Shield Association; Noridian Administrative Services - National Government Services - Trailblazer Health Enterprises
Whether for fiscal years 1995-1998 the Intermediary should include dual-eligible, Medicare health maintenance organization (HMO) patient days in the Medicaid proxy in determining Medicare reimbursement for disproportionate share hospital (DSH) payments in...
2011-D21
McCamey Hospital and Convalescent Center vs. BlueCross BlueShield Association/Trailblazer Health Enterprises, LLC
Whether the Provider is entitled to payment of "fair compensation" pursuant to 42 C.F.R.Section 413.13.
2011-D22
Rankin County Hospital District vs. BlueCross BlueShield Association/Trailblazer Health Enterprises, LLC
Whether the Provider is entitled to payment of "fair compensation" pursuant to 42 C.F.R Section 413.13.
2011-D23
Memorial Hermann Hospital vs. BlueCross BlueShield Association/Trailblazer Health Enterprises, LLC
Whether the Intermediary properly disallowed the loss claimed by Hermann Hospital representing a complete write-off of the book value of its depreciable assets as a result of the merger with the Memorial Hospital System.
2011-D24
QRS 1996 DSH MediKan Days Group vs. Wisconsin Physicians Services
Whether in light of the hold harmless provision of PM A-99-62 and A-01-13, the Intermediary should include all MediKan patient days, primary and secondary, in the Medicaid Proxy used to compute the Provider's disproportionate share hospital (DSH) adjustme...
2011-D25
John L. Doyne Hospital vs. BlueCross BlueShield Association/National Government Services - WI
Whether the Provider's post-retirement health benefit costs are allowable costs in the Provider's terminating cost report under Provider Reimbursement Manual (PRM) Section 2176.
2011-D26
Canon Healthcare Hospice vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administration
Whether a full or partial waiver is permissible for the Provider's hospice inpatient day limitation overpayment for the cap year November 1, 2004 through October 31, 2005.
2011-D27
Kaleida Health vs. BlueCross BlueShield Association/National Government Services
1. Whether the Intermediary's adjustment of the Provider's direct Graduate Medical Education (GME) per resident amount was proper. 2. Whether the Intermediary properly excluded research time the Provider alleges was related to patient care from the FTE re...
2011-D28
Valley Presbyterian Hospital vs. BlueCross BlueShield Association/First Coast Service Options - California
Whether CMS properly reduced the Provider's federal fiscal year (FFY) 2008 inpatient prospective payments system market basket adjust by two (2.0) percentage points.
2011-D29
Memorial Hospital of Salem County vs. BlueCross BlueShield Association/Highmark Medicare Services (formerly Riverbend Government Benefits Administrator)
Whether the Intermediary properly included all appropriate Medicaid eligible days in calculating the Provider's disproportionate patient percentage for purposes of the Medicare disproportionate share hospital (DSH) adjustment under the Prospective Payment...
2011-D30
Universal Health Services, Inc. (UHS) 2004 and 2005 Medicare Bad Debts Still at Agency Group Appeal vs. BlueCross BlueShield Association/HighMark Medicare Services; Wisconsin Physician Service
Whether the Intermediary properly disallowed the Providers' bad debts solely on the ground that accounts related to such bad debts were still pending at outside collection agencies.
2011-D31
George Washington University Hospital vs. BlueCross BlueShield Association/Care First of Maryland, Inc.; Highmark Medicare Services; Wisconsin Physicians Service
Whether the Intermediary's adjustment of the Provider's Medicare bad debts because they were written off while they remained at an outside collection agency, were appropriate.
2011-D32
Exempla Lutheran Medical Center vs. Wisconsin Physician Services
Whether the Intermediary properly disallowed the Provider's entire Medicare disproportionate share hospital (DSH) payment.
2011-D33
Winn Parish Medical Center vs. Wisconsin Physicians Service
Whether the Provider is eligible to be classified and reimbursed as (MDH) for the fiscal years ending (FYEs) 12/31/01, 12/31/02, 12/31/04, 12/31/05, 03/31/07, and 03/31/08.
2011-D34
Sutter 98-99 Managed Care (CIRP) Group vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether the Intermediary properly disallowed payments for indirect medical education (IME) and direct graduate medical education (DGME) payments related to managed care days, discharges, and simulated payments for the fiscal years in contention.
2011-D35
Saints Mary and Elizabeth Medical Centers vs. BlueCross BlueShield Association/National Government Services, Inc.
Whether CMS properly reduced the Provider's Outpatient Prospective Payment System (OPPS) Calendar Year (CY) 2009 market basket update by two (2.0) percentage points.
2011-D36
Southern Christian Medical Center vs. BlueCross BlueShield Association/First Coast Service Options, Inc. - Fl (formerly Cooperativa de Seguros de Vida de Puerto Rico)
Whether the Intermediary improperly excluded certain days attributable to Puerto Rico Medicaid enrollees who were classified by the Administration De Seguros De Salute De Puerto Rico as category six, for which Puerto Rico receives no Federal matching fund...
2011-D37
Partners 2002-2004 DSH Medicare+Choice CIRP Groups vs. BlueCross BlueShield Association/NHIC Corp., c/o National Government Services, Inc.
Whether Medicare+Choice (M+C) days should be included in the Medicaid fraction used to calculate the disproportionate share hospital (DSH) adjustment.
2011-D38
Prosser Memorial Hospital vs. Blue Cross Blue Shield Association/Noridian Administrative Services
Whether the Intermediary's adjustment to the Provider's ambulance service rates was proper.
2011-D39
Baycare 2002 Medicare+Choice Days Group vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether inpatient days for Medicaid-eligible patients who were enrolled in Medicare+Choice (M+C) plan under Part C of the Medicare statute were properly excluded from the numerator of the Medicaid fraction that is used to calculate the disproportionate sh...
2011-D40
UMass Health System 2004 DSH Medicare+Choice Group vs. BlueCross BlueShield Association/NHIC Corp., c/o National Government Services, LLC
Whether inpatient days for Medicaid-eligible patients who were enrolled in Medicare+Choice (M+C) plan under Part C of the Medicare statute were properly excluded from the numerator of the Medicaid fraction that is used to calculate the disproportionate sh...
2011-D41
Strategic Reimbursement/Carondelet/ Resurrection Health Medicare Part C Days-DSH Group Appeals vs. BlueCross Blue Shield Association/National Government Services/Noridian Administrative Services, LLC
Whether Medicare+Choice (M+C) days should be included in the Medicaid fraction used to calculate the disproportionate share hospital (DSH) adjustment.
2011-D42
Memorial Hermann - Memorial City Hospital vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC
Whether the Board has jurisdiction over the issue of whether the provider is entitled to be reimbursed for the interest implicit in the capital lease of the hospital facilities and equipment.
2011-D43
Kingsbrook Jewish Medical Center vs. BlueCross BlueShield Association/National Government Services Inc.
Whether the Provider's cost reimbursement should be computed taking into account the charges included in the Provider's log of late charges which have not been billed to Medicare.
2011-D44
Kingsbrook Jewish Medical Center vs. BlueCross BlueShield Association/National Government Services Inc.
Whether the Provider's cost reimbursement should be computed taking into account the charges included in the Provider's log of late charges which have not been billed to Medicare.
2011-D45
Good Shepherd Rehabilitation Hospital- Bethlehem vs. Blue Cross Blue Shield Association/Highmark Medicare Services -PA
Whether the Intermediary properly reimbusred the Provider based on the blended rate for inpatient rehabilitation facilities (IRF) versus the 100 percent federal prospective payment system (PPS) rate for IRFs.
2011-D46
Borgess Medical Center and Bronson Methodist Hospital vs. Blue Cross Blue Shield Association/National Government Services, Inc.
Whether the Intermediary's adjustment to the direct graduate medical education (GME) and indirect medical education (IME) counts for residents training at the Kalamazoo Center for Medical Studies/Michigan State University (KCMS) nonhospital site clinics w...
2011-D47
DMC Hospitals FFY 2010 Wage Index Pension Group vs. BlueCross BlueShield Association/National Government Services, Inc.
Whether the Intermediary properly disallowed the Providers' pension costs for the fiscal year ended December 31, 2006 in determining the Medicare geographical wage index for federal fiscal year (FFY) 2010.
2012-D01
Hall Render Wage Index Group Appeals vs. BlueCross Blue Shield Association/National Government Services and Wisconsin Physician Services
1. Whether the Fiscal Intermediary and CMS properly determined the Wage Indexes for St. Elizabeth Medical Center; St. Luke Hospital East; St. Luke Hospital West; Mercy Hospital Anderson; University Hospital, Inc.; Jewish Hospital; Mercy Hospital Fa...
2012-D02
L.O. Crosby Memorial Hospital vs. BlueCross BlueShield Association/Pinnacle Business Solutions, Inc.
1. Whether CMS is precluded from recovering the alleged overpayments from the Provider's fiscal year end 12/31/97 and 10/31/98 cost reports due to the Intermediary's issuance of the Notice of Program Reimbursement over ten years after the cost report year...
2012-D03
Lakeland Regional Medical Center vs. BlueCross BlueShield Assocation/National Government Services
Whether the Intermediary's adjustment of the Provider's Medicare bad debts because they were written off while they remained at an outside agency, was proper.
2012-D04
Oakwood Annapolis Hospital vs. BlueCross BlueShield Assocation/National Government Services
Whether the Oakwood Annapolis Family Practice Residency Program, which received provisional accreditation from the Accreditation Council for Graduate Medical Education (ACGME), met the definition of a new program in 2004.
2012-D05
Youngstown-Warren 02 Wage Index vs. BlueCross BlueShield Assocation/National Government Services, Inc.
1. Whether the Fiscal Intermediary erred in refusing to exclude the Provider's bonus or call back hours paid from its Federal Fiscal Year (FFY) 2002 wage index calculations. 4. Whether the Fiscal Intermediary erred in refusing to include the Provider's c...
2012-D06
Lifespan SWC 2003 DSH Medicare+Choice Days Group vs. National Government Services/BlueCross Blue Shield Association
Whether inpatient days for Medicare-eligible patients who were enrolled in a Medicare+Choice (M+C) plan under Part C of the Medicare statute were properly excluded from the numerator of the Medicaid fraction that is used to calculate the disproportionate ...
2012-D07
Alegent Health-Immanuel Medical Center vs. Wisconsin Physicians Service
Whether the Intermediary's adjustments to disallow the Provider's indirect medical education (IME) and direct graduate medical education (DGME) reimbursement for its graduate medical education activities were correct.
2012-D08
Rush University Medical Center vs. BlueCross/Blue Shield Association/National Government Services, Inc. (formerly AdminaStar Federal, Inc.)
1. Whether the Intermediary properly calculated the number of interns and residents for fiscal year (FY) 1993 for purposes of the Provider's direct graduate medical education (DGME). 2-A. Whether the Intermediary's adjustments to the Provider's bed count,...
2012-D09
Rush University Medical Center vs. BlueCross/Blue Shield Association/National Government Services, Inc. (formerly AdminaStar Federal, Inc.)
1. Whether the Intermediary's adjustments to the Provider's bed count, as used for purposes of the indirect medical education (IME) calculation, was proper. 2. Whether, in calculating the Provider's bed count as used for purposes of IME calculation, ther...
2012-D10
Alameda Hospital- SNF vs. BlueCross BlueShield Association/First Coast Service Options, Inc.
Whether the United States District Court's memorandum decision, finding the Secretary's methodology was improper under the precedent established in "Alaska Professional Hunters Association, Inc. v. FAA", also applies to the Secretary's low occupancy adjus...
2012-D11
Doctors Medical Center of Modesto vs. Wisconsin Physicians Service
Whether the Intermediary improperly eliminated all direct medical education and indirect medical education reimbursement for the Provider's family practice residency program for fiscal years ended May 31, 2001 through May 31, 2007.
2012-D12
Research Medical Center vs. Wisconsin Physicians Service
Whether the Intermediary's determination of additional amounts paid to the Provider for nursing and allied health (N&AH) education associated with Medicare+Choice (M+C) enrollees was proper.
2012-D13
Fort Wayne (Indiana) FFY 2002 MSA Wage Index Group vs. BlueCross/Blue Shield Association/National Government Services, Inc. (formerly AdminaStar Federal, Inc.)
Whether the Fiscal Intermediary and the Centers for Medicare and Medicaid Services (CMS) appropriately included certain paid hours not actually worked by Parkview Health System (Parkview) employees for purposes of calculating the federal fiscal year 2002 ...
2012-D14
Norwalk Hospital vs. BlueCross BlueShield Association/National Government Services, Inc.
Whether the Provider Reimbursement Review Board has jurisdiction over the Medicaid eligible days for which there was no adjustment made by the Intermediary within the Notice of Program Reimbursement (NPR).
2012-D15
Canon Health Care Hospice vs. BlueCross BlueShield Association/Palmetto Government Benefits Administration.
Whether a full or partial waiver is permissible for the Provider's hospice inpatient day limitation overpayment for the cap year November 1, 2005 through October 31, 2006.
2012-D16
Alegent Health-Immanuel Medical Center vs. Wisconsin Physicians Service
Whether the Intermediary's adjustments to disallow the Provider's indirect medical education (IME) and direct graduate medical education (DGME) reimbursement for its graduate medical education activities were correct.
2012-D17
Ober Kaler DSH Charity Care Groups vs. BlueCross BlueShield Association/Highmark Medicare Services and Cahaba Government Benefits Administrator
Whether days associated with patients covered under the New Jersey Charity Care Program should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital (DSH) calculation pursuant to § 1886(d)(5)(F)(vi)(II) of the...
2012-D18
Doctors Hospital vs. BlueCross BlueShield Association/CGS Administrators, LLC
Whether the Intermediary properly disallowed Medicare bad debt expense.
2012-D19
HCR Manor Care 1999 Laundry and Central Supply Statistics Group vs. BlueCross BlueShield Association/Highmark Medicare Services
Whether the Intermediary's adjustments to the Laundry and Linen and the Central Service and Supply statistics were proper.
2012-D20
John H. Stroger, Jr. Hospital of Cook County vs. BlueCross BlueShield Association/National Government Services, Inc.
Whether the Intermediary's exclusion of the physician malpractice expense from Worksheets A-8-2 and D-9 of the cost report was proper.
2012-D21
San Joaquin Community Hospital-SNF vs. BlueCross Blue Shield Association/First Coast Service Options, Inc.
Whether the Secretary's failure to reclassify costs in the peer group construction was arbitrary, capricious or plainly erroneous.
2012-D22
Lemuel Shattuck Hospital vs. BlueCross BlueShield Association/National Government Services, Inc.
Whether the allocation of the physician costs between Part A and Part B was proper.
2012-D23
QRS 1991-2006 Colorado DSH/General Assistance Days Group vs. BlueCross BlueShield Association/Trailblazer Health
Whether days associated with patients covered under the Colorado Indigent Care Program (CICP) should be included in the numerator of the "Medicaid proxy" of the Medicare disproportionate share hospital (DSH) calculation pursuant to § 1886(d)(5)(F)(vi)(II...
2012-D24
Swedish American Hospital vs. Wisconsin Physicians Service (formerly Mutual of Omaha Insurance Company)
Whether the Intermediary's adjustments reducing the 1996 base year IME/GME FTE count for osteopathic and allopathic medicine interns and residents and their effect on the May 31, 2004 through May 31, 2007 FTE counts were correct.
2012-D25
Bergen Regional Medical Center vs. BlueCross BlueShield Association/Novitas Solutions, Inc.
Whether the Provider Reimbursement Review Board has jurisdiction over the calculation of the Provider's 1996 Indirect Medical Education Cap Reduction for the redistribution of unused residency slots.
2013-D01
QRS 1995, 1996, 1998-2007 DSH/Pennsylvania General Assistance Days Group vs. Blue Cross Blue Shield Association/Novitas Solutions, Inc.
Whether Pennsylvania Charity Care Program (e.g., general assistance) days should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital (DSH) calculation pursuant to § 1886(d)(5)(F)(vi)(II) of the Social Secur...
2013-D02
QRS 93-07 DSH/Iowa Indigent Patient/Charity Care (GA) Group vs. Blue Cross Blue Shield Association/Wisconsin Physicians Service
Whether Iowa Charity Care Program days (e.g., general assistance) should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital (DSH) calculation pursuant to § 1886(d)(5)(F)(vi)(II) of the Social Security Act, ...
2013-D03
Maine Medical Center vs. Blue Cross Blue Shield Association/National Government Services
Whether the Intermediary’s exclusion of the crossover bad debts for cost reporting periods ending September 30, 2002 and September 30, 2003 due to a lack of documentation was proper.
2013-D04
The Phoenix Clinic vs. Wisconsin Physician Services
Whether the Intermediary properly removed total costs and total payments.
2013-D05
Maine Coast Memorial Hospital vs. Blue Cross Blue Shield Association/NHIC, Corp. c/o National Government Services, Inc.
Whether Maine Coast Memorial Hospital's request to be designated as a Sole Community Hospital was properly denied.
2013-D06
Mountain State Health Alliance 05 Bad Debt- Passive Collection CIRP Group vs. BlueCross BlueShield Association/Cahaba Government Benefits Administrators, LLC
Whether the Intermediary's adjustments to remove Medicare bad debts from the Providers' cost reports were proper.
2013-D07
HLB Wage Index Pension and Post Retirement Cost Groups- FFY 2007 and 2008 vs. BlueCross BlueShield Association/Palmetto GBA; Palmetto GBA c/o First Coast Service Options, Inc.; Wisconsin Physicians Service and Novitas Solutions, Inc.
Whether the Intermediary improperly eliminated or reduced the pension and postretirement benefit (PRB) costs of the Providers, and the pension costs of the Catholic Healthcare West medical centers (CHW Providers) for the purposes of computing their prospe...
2013-D08
Lima Memorial Hospital vs. BlueCross BlueShield Association/CGS Administrators, LLC
Whether the Intermediary improperly calculated reimbursement for the Provider's skilled nursing facility unit during the skilled nursing facility PPS (prospective payment system) transition period.
2013-D09
Maine Type 6 Medicaid Dual Eligible Days DSH Group
Whether the Intermediary's reopening adjustment to exclude Type 6 Medicaid dual eligible days from the Providers' Medicaid fraction used in the calculation of the disproportionate share hospital adjustment was proper.
2013-D10
QRS 1995, 2001-2002, 2004-2005 Missouri DSH/General Assistance Days Group vs. Blue Cross Blue Shield Association/Wisconsin Physicians Service
Whether days associated with patients “covered” under the Missouri State Plan should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital (DSH) calculation pursuant to §1886(d)(5)(F)(vi)(II) of the Social...
2013-D11
Marion General Hospital vs. BlueCross BlueShield Association/National Government Services, Inc.
Whether the Medicare Administrative Contractor's (MAC) denial of Marion General Hospital's Sole Community Hospital Low Volume Adjustment was proper based on procedural and timing requirements.
2013-D12
Battle Creek MI MSA Fy 2006 Wage Index Group vs. Wisconsin Physicians Service
Whether the Intermediary appropriately included wage data from Trillium Hospital for purposes of calculating the Federal Fiscal year (FFY) 2006 hospital wage index for the Battle Creek, Michigan Metropolitan Statistical Area (MSA).
2013-D13
UMDNJ- University Hospital vs. Blue Cross Blue Shield Association/Cahaba Safeguard Administrators, LLC
Whether the Medicare administrative contractor properly determined that the Provider was not entitled to reimbursement for medical education pass-through costs related to the university’s nursing education and allied health program because the Provider...
2013-D14
St. Francis Hospital, Inc. vs. Blue Cross and Blue Shield Association/Palmetto Government Benefits Administrators
Whether the Intermediary's determination not to increase certain Medicare cost outlier payments was proper, where the outliers were underpaid because of an erroneous overpayment of DSH, which was a factor in the outlier amount calculation and which the MA...
2013-D15
St. Francis Medical Center vs. Wisconsin Physician Services
Whether the Intermediary used the correct number of days when computing the disproportionate share percentage when the cost-reporting periods overlapped April1, 2004.
2013-D16
BB&L 95-03 IME Research FTE Group vs. BlueCross BlueShield Association/Noridian Administrative Services
Whether time spent in research when the residents were assigned to the inpatient prospective payment system portion and/or the outpatient department of the Providers should be included in the full-time equivalent counts (FTE) for indirect medical educatio...
2013-D17
Alpena Dialysis Services vs. vs. Wisconsin Physicians Service
Whether CMS' denial of the Provider's request for an exception to the ESRD composite rate was proper.
2013-D18
Blumberg Ribner 91-99 SNF 112% Peer Mean Group vs. BlueCross BlueShield Association/Palmetto GBA c/o First Coast Service Options
Whether CMS’ methodology for determining the Providers’ exception to the hospital-based SNF routine cost limit was proper.
2013-D19
River Region Medical Center vs. BlueCross BlueShield Association/Novitas Solutions, Inc.
Whether the Intermediary correctly determined the Provider's disproportionate share hospital ("DSH")payment for the fiscal period November 1, 1998 to June 30, 1999
2013-D20
Mountain View Regional Medical Center vs. Wisconsin Physician Services
Whether the Intermediary's determination that the Provider should be reimbursed under the federal rate of the inpatient prospective payment system for capital costs for the fiscal year end 2003 was proper.
2013-D21
QRS UMHC 1991-1996 DSH/Michigan General Assistance Days Group vs. BlueCross BlueShield Association/Wisconsin Physicians Service
Whether days associated with patients “covered” under the Michigan Indigent/Charity Care Program should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital (DSH) calculation pursuant to §1886(d)(5)(F)(vi...
2013-D22
Holy Redeemer Hospital and Medical Center vs. BlueCross BlueShield Association/Highmark Medicare Services
Whether the Intermediary's adjustment disallowing therapy services claims pursuant to a comprehensive medical review was proper.
2013-D23
QRS DSH Florida General Assistance Days Group vs. BlueCross BlueShield Association/First Coast Service Options, Inc.-FL
Whether the Intermediary properly excluded Florida's Charity Care and Low Income days (e.g., general assistance) from the disproportionate share hospital (DSH) calculation.
2013-D25
Medical Professionals for Home Care, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D26
CMK Home Health Agency, Inc. vs. BlueCross BlueShield Association/Palmetto GBA
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D27
Inteli Home Healthcare, Inc. vs. BlueCross BlueShield Association/Palmetto GBA
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D28
Sun City Home Care, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D29
Spectrum Home Care, Inc.vs. BlueCross BlueShield Association/National Government Services
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D30
LivinRite Home Health Services vs. BlueCross BlueShield Association/CGS Administrators, LLC
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D31
All Care Home Health 2012 2% Reduction CIRP Group vs. BlueCross BlueShield Association/CGS Administrators, LLC
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D32
Carinosa Healthcare, Inc. vs. BlueCross BlueShield Association/Palmetto GBA
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D33
MS Healthcare Center, Inc. vs. BlueCross BlueShield Association/Palmetto GBA
Whether the imposition of a 2 percent reduction in the Medicare payments to the home health agency for calendar year (CY) 2012 was proper.
2013-D34
Porter Hospital vs. Blue Cross and Blue Shield Association/National Government Services
Porter Hospital vs. Blue Cross and Blue Shield Association/National Government Services
2013-D35
Cleveland Clinic Hospital vs. BlueCross BlueShield Association/CGS Administrators, LLC
Whether the contractor's decision to exclude certain physician Medicare Part A administrative costs under time study codes L and O from the Provider's fiscal year (FY) 2002 wage index data in calculating the FY 2006 wage index should be reversed.
2013-D36
St. Luke 2001-2007 DSH Inclusion of Title XIX Eligible Days CIRP Group vs. Blue Cross Blue Shield Association/CGS Administrators, LLC
Whether days associated with patients covered under the Kentucky Hospital Care Program (KHCP) should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital (DSH) calculation pursuant to § 1886(d)(5)(F)(vi)(II) ...
2013-D37
Hall Render Pension/Post Retirement Wage Index Appeals FFY 2007 through 2011 vs. BlueCross BlueShield Association/Various
Whether the Fiscal Intermediaries' adjustments to pension costs for the affected providers resulted in erroneous wage indices for the areas where adjustments were made.
2013-D38
Washington General Assistance Days Groups vs. Blue Cross Blue Shield Association/Noridian Administrative Services -WA/AK/Wisconsin Physician Services
Whether patient days associated with the Medically Indigent (MI) and General Assistance/Unemployable (GAU) Programs in Washington State should be included in the numerator of the Medicaid fraction of the Medicare Disproportionate Share Hospital (DSH) paym...
2013-D39
St. Vincent Hospital & Health Center vs. BlueCross BlueShield Association/Wisconsin Physicians Service
Whether the Provider Reimbursement Review Board has jurisdiction over Ambulatory Surgery Costs and Organ Acquisition Costs where the Intermediary made no audit adjustment to the cost report.
2013-D40
Toyon DSH General Assistance Days Groups 1989-2000 vs. BlueCross BlueShield Association
Whether State only eligible (but unpaid) patient days (commonly referred to as General Assistance or GA days), were erroneously excluded from the Medicaid proxy in the Disproportionate Share Hospital (DSH) calculations.
2013-D41
CampbellWilson Nursing Home Days Groups vs. BlueCross BlueShield Association/Novitas Solutions, Inc./CGS Administrators, LLC/Noridian Administrative Services c/o First Coast Service Options, Inc./Wisconsin Physicians Service
Whether CMS properly omitted from the Providers' DSH calculation the patient days of individuals who were Supplemental Security Income ("SSI") recipients but who had the amount of their cash payments reduced to zero while they remained in a nursing home. ...
2013-D42
Health Alliance Hospital vs. BlueCross/BlueShield Association/NHIC Corp., c/o National Government Services, Inc.
Whether the observation bed days for the Provider’s fiscal year ending September 30, 2003 (“FY 2003”) were properly netted from the calculation of the bed count for purposes of qualifying for a disproportionate share hospital (“DSH”) payment, th...
2014-D01
Owensboro Medical Health System vs. Blue Cross Blue Shield Association/CGS Administrators, LLC
Whether medical assistance/general assistance days associated with patients covered under the Kentucky State Plan should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital (DSH) calculation pursuant to § 18...
2014-D02
Hospice Complete, Inc. Hospice Complete, Inc./Southern Care 2008 Hospice Cap CIRP Group vs. BlueCross BlueShield Association/Palmetto GBA
Whether the Providers' cap liability for 2006-2008 should be recalculated in light of Southern Care Hospice's monetary settlement of the qui tam lawsuits filed against it in the United States District Court for the Northern District of Alabama.
2014-D03
Danbury Hospital vs. BlueCross BlueShield Association/National Government Services, Inc
Whether the PRRB has jurisdiction over a claim for Medicaid Eligible Days for which there was no adjustment made by the Intermediary within the Notice of Program Reimbursement.
2014-D04
Canon Health Care Hospice, LLC vs. BlueCross BlueShield Association/Palmetto GBA
Whether the Intermediary erred in calculating the Inpatient Day Limitation over a period greater than 12 months for the Provider's cap year ended October 31, 2008.
2014-D05
Ashton Hall Nursing & Rehabiliation Center vs. BlueCross BlueShield Association/Novitas Solutions, Inc.
Whether the Intermediary's adjustment to disallow Medicare Bad Debts on the Medicare Cost Report was proper.
2014-D06
Accord Health 2005 Crossover Bad Debts Group vs. BlueCross BlueShield Association/Novitas Solutions, Inc.
Whether the Intermediary's exclusion of unbilled crossover bad debts was proper.
2014-D07
Deborah Heart and Lung Center vs. Blue Cross Blue Shield Association
Whether CMS improperly denied the Provider’s request to be reclassified as a rural hospital under section 1886(d)(8)(E) of the Social Security Act and 42 CFR 412.103.
2014-D08
Dana Farber Cancer Institute vs. BlueCross BlueShield Association/NHIC Corp. c/o National Government Services, Inc.and Cahaba Safeguard Administrators, LLC
Whether the Medicare Administrative Contractor (MAC) erred in disallowing certain of the costs associated with Dana Farber Cancer Institute state provider tax expense in the Provider's Fiscal Year 2004 through Fiscal Year 2008 cost reporting periods.
2014-D09
Welch Community Hospital vs. Blue Cross Blue Shield Association/Palmetto GBA
Whether the Intermediary’s adjustment to reclassify Rural Health Clinic (RHC) visits associated with contracted physicians, and the associated full-time equivalents (FTEs), from the cost report Worksheet M-2, line 9 to Worksheet M-2, line 1 was proper.
2014-D10
Eastern Maine Medical Center vs. BlueCross BlueShield Association/NHIC, Corp., c/o National Government Services, Inc.
Whether the Intermediary’s exclusion of certain outside rotations from the Provider’s direct Graduate Medical Education (GME) and Indirect Medical Education (IME) full time equivalent count was proper.
2014-D11
Cooper Hospital/University Medical Center vs. Blue Cross Blue Shield Association/Novitas Solutions, Inc.
Whether a provider's collection effort on inpatient and outpatient bad debts must include personal telephone calls to patients to comprise a reasonable collection effort. 2. Whether the Intermediary incorrectly determined that the regulations affirmativel...
2014-D12
City of Hope National Medical Center vs. BlueCross BlueShield Association/Palmetto Government Benefit Administrators/Cahaba Safeguard Administrators
Whether the Intermediary properly offset investment income against operating and capital-related interest expense for the fiscal years ending September 30, 2004, September 30, 2005, and September 30 2006.
2014-D13
CHS 2004-2006 Medicare Bad Debt Passive Collection CIRP Groups vs. Various
Whether the Intermediary's adjustments to remove the Medicare bad debts claimed by the Provider while the debts were still at the collection agency were proper.
2014-D14
Swedish American Hospital vs. Blue Cross Blue Shield Association/Wisconsin Physicians Service
Whether the Temporary Cap Increase Exception applies to the Provider's 1996 base year IME/GME FTE count for osteopathic and allopathic medicine interns and residents and the caps application to the May 31, 1999 through May 31, 2003 FTE counts.
2014-D15
Unity Healthcare vs. Blue Cross Blue Shield Association/Wisconsin Physicians Service
Whether the Medicare Administrative Contractor (MAC) properly calculated the Medicare dependent hospital volume decrease adjustment (VDA) for the Provider, for fiscal year 2006, by excluding certain variable and semi-fixed costs.
2014-D16
Lakes Regional Healthcare vs. Blue Cross Blue Shield Association/Wisconsin Physicians Service
Whether the Medicare Administrative Contractor (MAC), properly calculated the Medicare dependent hospital volume decrease adjustment (VDA) for the Provider, for fiscal year 2006, by excluding certain variable and semi-fixed costs.
2014-D17
Wyatt, Tarrant & Combs FFY 07 Occupational Mix Adjustment Group vs. Blue Cross and Blue Shield Association/CGS Administrators, LLC
1. Whether the inclusion of surgical technicians, mental health technicians, and heart center recovery technicians in the all-others category instead of the nursing aides, orderlies and attendants category in the Provider's occupational-mix survey was cor...
2014-D18
Methodist Hospital- Southlake; Methodist Hospital-Northlake; Methodist Hospitals, Inc. vs. Wisconsin Physicians Service/Blue Cross Blue Shield Association
Whether the Medicare Administrative Contractor's disallowance of Methodist Hospital's bad debt claims should be reversed.
2014-D19
St. John Health 2004-2005 Bad Debt Moratorium CIRP Group/Hall Render 2005-2006 Bad Debt Moratorium Group vs. BlueCross BlueShield Association/Highmark Medicare Services/Wisconsin Physicians Service
Whether the Intermediary properly disallowed the Providers’ bad debts solely on the ground that accounts related to such bad debts were still pending at outside collection agencies.
2014-D20
Chestnut Hill Benevolent Association/The Leaves, Inc./Arden Wood, Inc./Broadview, Inc. vs. Cahaba Government Benefits Administration/Blue Cross Blue Shield Association
Whether the training offered by the Providers is necessary to enter the specialty of Christian Science nursing in a RNHCI and, therefore, eligible for pass-through reimbursement, or whether the Providers' nurse training program is continuing education tha...
2014-D21
Legacy Hospcie and Palliative Care, LLC vs. CGS Administrators, LLC/Blue Cross and Blue Shield Association
Whether the imposition of a two percent reduction in Legacy Hospice and Palliative Care LLC's Medicare payments for calendar year 2014 was proper.
2014-D22
Cleveland Clinic Florida Hospital vs. Wisconsin Physicians Service
Whether the Intermediary's removal of residents who participated in Colorectal Surgery (fiscal years (FYs) 2002-2006), Internal Medicine (FYs 2004-2006), and Neurology (FYs 2004-2006) programs (collectively, "Programs") from the Provider's Graduate Medica...
2014-D23
Mary Greeley Medical Center vs. Blue Cross Blue Shield Association/Wisconsin Physicians Service
1. Whether the MAC and CMS Regional Office for Region VII evaluated market share for the Provider for the correct geographic area when they denied the Provider’s request for classification as a sole community hospital (SCH) on the grounds that the Provi...
2014-D24
Southwest Ambulatory Behavioral Services, Inc. vs. Novitas Solutions, Inc./Blue Cross and Blue Shield Association
Whether the Intermediary’s adjustment to the allocation of the Provider’s cost was proper.
2014-D25
The Memorial Hospital at North Conway vs. National Government Services, Inc./Blue Cross and Blue Shield Association
Whether the offset of "investment income" up to the amount of interest expense claimed by the Provider for the fiscal year ending June 30, 2007, was proper.
2014-D26
University of Pittsburgh Medical Center (formerly Mercy Hospital of Pittsburgh) vs. Highmark Medicare Services (formerly Blue Cross of Western Pennsylvania/Blue Cross and Blue Shield Association
Whether interest is due the Provider under 42 C.F.R. § 405.378.
2014-D27
Cooper Hospital/University Medical Center vs. Novitas Solutions, Inc./Blue Cross and Blue Shield Association
Whether days associated with patients covered under the New Jersey Charity Care Program should be included in the numerator of the Medicaid proxy of the Medicare disproportionate share hospital ("DSH") calculation pursuant to 42 U.S.C. Section 1395ww(d)(5...
2014-D28
New York City Health and Hospitals Corporation Improper Application of Weighted Discharge Cap CIRP Groups vs. National Government Services/BlueCross BlueShield Association
Whether the Intermediary properly applied the weighted discharge cap to the Providers’ ancillary costs.
2014-D29
Community Hospital of Anaconda vs. Noridian Administrative Services/Blue Cross and Blue Shield Association
Whether the Medicare Administrative Contractor’s disallowance of the Provider’s certified registered nurse anesthetist (CRNA) on-call costs was proper.
2014-D30
HMA 2004-2006 Bad Debt Group Appeals vs. Wisconsin Physicians Service/Blue Cross and Blue Shield Association
Whether the Intermediary properly disallowed the Providers' non-indigent debts for fiscal year ends 2004, 2005, and 2006, for not meeting all applicable regulatory requirements.
2015-D01
OhioHealth 2004 Clark Bed Days Group vs. CGS Administrators/BlueCross BlueShield Association
Whether the Intermediary's application of the Sixth Circuit Court of Appeals' holding in "Clark Regional Medical Center v. U.S. Dept. of Health and Human Servs.", to the determination of the number of available bed days for purposes of calculating the app...
2015-D02
St. Vincent-Randolph Hospital vs. Wisconsin Physician Services/Blue Cross and Blue Shield Association
Whether the Medicare Contractor's disallowance of the interest expense for the Provider’s 2004, 2005, 2006, 2007, and 2008 fiscal years was proper.
2015-D03
Rural Family DGME Group Appeals vs. BlueCross BlueShield Association
1. Was the use of CMS' sequential geography methodology (SGM) for setting the Providers' base year per resident amounts for Medicare reimbursement of certain graduate medical education costs valid and consistent with 42 U.S.C. Section 1395ww(h)(2)(F) and ...
2015-D04
Breckinridge Health, Inc., New Horizons Health Systems, Inc., CAH 2009 Provider Tax Group, CHC 2009 CAH Provider Tax CIRP Group, and ARH CAH Provider Tax CIRP Group vs. National Government Services, Inc./CGS Administrators, LLC/Blue Cross and Blue Shield ...
Whether the Medicare contractor properly offset the Kentucky provider tax assessment for each of the seven hospitals for the fiscal years at issue by the corresponding amount of the Kentucky Medicaid Disproportionate Share Hospital payment that each hospi...
2015-D05
Barberton Citizens Hospital vs. CGS Administrators, LLC/Blue Cross and Blue Shield Association
Whether the PRRB has jurisdiction over the Medicaid eligible days issue in the appeals.
2015-D06
Santa Cruz, CA 03-05 MSA Hospital Wage Index Group vs. Noridian Healthcare Solutions, LLC/Blue Cross and Blue Shield Association
Whether the Medicare Contractor and the CMS properly determined the Provider's Metropolitan Statistical Area Wage Index for Federal Fiscal Year 2004.
2015-D07
Mercy Hospital vs. First Coast Service Options, Inc./Blue Cross and Blue Shield Association
1. Whether the Board has jurisdiction to review the MAC’s determination that the days of patients who were eligible for medical assistance under an approved Medicaid State plan and enrolled in a Medicaid plus Choice plan under Part C of Medicare should ...
2015-D08
QRS CT 2002-2006General Assistance/Charity Care Group; QRS CT 2000 General Assistance/CharityCare Days Group vs. National Government Services/Blue Cross and Blue Shield Association
Whether the exclusion by the Medicare Contractor of days identified as inpatient days attributable to individuals who received medical assistance/general assistance under the Connecticut State Administered General Assistance Program from the Medicaid fra...
2015-D09
Alta Vista Regional Hospital vs. Wisconsin Physician Services/Blue Cross and Blue Shield Association
Whether the Medicare Contractor’s denial of the Provider's request for a sole community hospital volume decrease adjustment payment was proper.
2015-D10
Liberty Healthcare Group, LLC vs. Palmetto GBA/Blue Cross and Blue Shield Association
Whether it was proper to impose a 2 percent reduction in the Medicare payments to the Provider's home health agency located for calendar year 2014.
2015-D11
Fairbanks Memorial Hospital vs. Wisconsin Physician Services/BlueCross BlueShield Association
Whether the Medicare Contractor's calculation of the Provider's volume decrease adjustment amount was determined correctly.
2015-D12
Tehachapi Valley Hospital vs. Noridian Healthcare Solution/Blue Cross and Blue Shield Association
Whether the Medicare Contractor's denial of the Provider's request for a low volume adjustment payment under 42 C.F.R. Section 412.92(e) was proper.
2015-D13
Lutheran Hospital of Indiana vs. Wisconsin Physicians Service/Blue Cross and Blue Shield Association
Whether the Medicare Contractor’s adjustment to remove time for off-site rotations was proper.
2015-D14
Hampton Behavioral Health Center vs. Novitas Solutions, Inc./BlueCross BlueShield Association
Whether the Medicare Contractor improperly disallowed from the calculation of the Provider’s bad debt expense, for the subject fiscal year, bad debts associated with patients whose accounts were not billed to Medicaid prior to the accounts being written...
2015-D16
Sutter Auburn Faith Hospital vs. Cahaba Safeguard Administrators, LLC
Whether the Board has jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustment for the 2006 fiscal year.
2015-D17
Riverside Hospital of Louisiana vs. Cahaba GBA c/o National GovernmentServices
Whether the payment penalty that CMS imposed under the Long-Term Care Hospital Quality Reporting Program to reduce the Provider’s payment update for Fiscal Year 2015 by two percent was proper.
2015-D18
Loma Linda University Medical Center vs. Noridian Healthcare Solutions, LLC
Whether the denial of the Provider’s request for an exception to the end stage renal disease composite rate by CMS was proper.
2015-D19
Loma Linda University Kidney Center vs. Noridian Healthcare Solutions, LLC
Whether the denial of the Provider’s request for an exception to the end stage renal disease composite rate by CMS was proper.
2015-D20
Sutter Auburn Faith Hospital vs. Cahaba Safeguard Administrators, LLC
Whether the Board had jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustment for the 2003 fiscal year.
2015-D21
Wilmington Treatment Center vs. Palmetto GBA
1. Whether the Medicare Contractor’s adjustment to the provider-based physician professional component was proper. 2. Whether the Medicare Contractor’s recoupment of payments related to the denial of inpatient admissions was proper. 3. Whether the Med...
2015-D22
Ochsner Medical Center-Northshore vs. Wisconsin Physicians Service
Whether the reduction of the Provider’s market basket update for federal fiscal year 2015 under the Hospital Inpatient Quality Reporting program was proper.
2015-D23
Medicare Inpatient/Outpatient Unbilled Bad Debts Group Appeals vs. Noridian Healthcare Solutions, LLC
Whether the Providers were required to bill the State Medicaid program and submit a State remittance advice (RA) to the Medicare Contractor (MAC) as a precondition for the Medicare program to pay bad debts for unpaid coinsurance and deductibles for indivi...
2015-D24
Northwest Texas Healthcare System vs. Novitas Solutions, Inc.
Whether the current year bed count and the available bed days were properly recorded for fiscal year 2005, and whether the current year bed count and available bed days and the available bed days used to calculate the prior year intern to resident ratio w...
2015-D25
Faxton-St. Luke's Healthcare vs. National Government Services, Inc.
Whether the MAC’s adjustment to the Provider’s bad debts for indigent patients was proper.
2015-D26
The Phoenix Clinic vs. Wisconsin Physicians Service
1. Whether a community mental health center is a “provider of services” entitled to a hearing before the PRRB under 42U.S.C. § 1395oo. 2. If a CMHC is a “provider of services,” does this finding necessarily implicate other documentation obligati...
2015-D27
Sutter Auburn Faith Hospital vs. Cahaba Safeguard Administrators, LLC
Whether the Board had jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustment for the 2005 fiscal year.
2015-D28
Sutter Auburn Faith Hospital vs. Cahaba Safeguard Administrators, LLC
Whether the Board had jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustment for the 2004 fiscal year for the inpatient rehabilitation facility.
2015-D29
HealthSouth 2006 SSI Percentage Group/HealthSouth 2007 SSI Percentage CIRP Group vs. Cahaba Government Benefits Administrators, LLC
Whether the Board had jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustments for the cost reporting periods at issue for the inpatient rehabilitative facilities.
2015-D30
BMHCC 2004-2006 LIP SSI% CIRP Group vs. National Government Services, Inc.
Whether the Board had jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustment for the Provider for fiscal years 2004, 2005, and 2006.
2016-D01
HCA 00, 02 DSH Medicare + Choice Plan Days, HCA 03 DSH Medicare + Choice Plan Days, HCA 04 DSH Medicare + Choice Plan Days vs. Noridian Healthcare Solutions/ Wisconsin Physicians Service
Whether inpatient days for Medicaid-eligible patients who were enrolled in a Medicare+Choice (M+C) plan under Medicare part C were properly excluded from the numerator of the Medicaid fraction that is used to calculate the disproportionate share hospital ...
2016-D02
Queen of the Valley Medical Center vs. Noridian Healthcare Solutions, LLC
Whether the Board has jurisdiction to review the Medicare Contractor’s determination of the number of Medicaid eligible days included in the numerator of the low-income patient (LIP) adjustment for the 2006 fiscal year.
2016-D03
Grinnell Regional Medical Center vs. Wisconsin Physicians Service
Whether the Medicare Contractor properly denied the Provider's request for a volume decrease payment adjustment.
2016-D04
St. Joseph Hospital of Eureka vs. Noridian Healthcare Solutions
Whether the Board has jurisdiction to review the Medicare Contractor's determination of the low-income patient (LIP) adjustment for the 2007 fiscal year.
2016-D05
BayCare Alliant Hospital vs. First Coast Service Options, Inc.
Whether the payment penalty that CMS imposed under the Long-Term Care Hospital Quality Reporting Program to reduce the Provider’s payment update for FY2015 by two percent was proper.
2016-D06
QRS 1997-1999 Kansas DSH MediKan Days Groups vs. Wisconsin Physicians Service
Whether secondary MediKan days should have been included in the Provider's Medicaid fraction for the Disproportionate Share Hospital (DSH) calculation in the disputed cost reports.
2016-D07
Provena Health 2006 LIP SSI Percentage Calc. Group vs. National Government Services, Inc.
Whether the Board has jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustment for the Providers for the 2006 fiscal years (FYs).
2016-D08
Landmark Hospital of Columbia vs. Wisconsin Physicians Service
Whether the payment penalty that CMS imposed under the Long-Term Care Hospital Quality Reporting Program toreduce the Provider’s payment update for FY2015 by two percent was proper.
2016-D10
New Bedford Rehabilitation Hospital vs. CGS Administrators
Whether the payment penalty that CMS imposed under the Long-Term Care Hospital Quality Reporting Program to reduce the Provider’s payment update for FY2015 by two percent was proper.
2016-D11
University of Louisville Hospital vs. CGS Administrators, LLC
2016-D12
William Beaumont-Royal Oak vs. Wisconsin Physicians Service
Whether the Provider submitted sufficient documentation for its non-Provider-operated nurse clinical training program costs to support pass-through reimbursement for fiscal years (FY s) 2005 and 2006.
2016-D13
Mercy General Hospital vs. Cahaba Safeguard Administrators, LLC
Whether the Medicare Contractor properly calculated the amount of the Provider's exception to the routine cost limitations (RCLs) for hospital-based skilled nursing facilities (or HB-SNFs) by excluding from the calculation those costs that were above the ...
2016-D14
Integris/Deaconess 2005 Non-Provider Setting IME/GME CIRP Group vs. Novitas Solutions, Inc.
Whether the Medicare Contractor’s exclusion of all of the family practice interns and residents for each of the Providers from their respective full-time equivalent (FTE) counts, and the Medicare Contractor’s denial of the associated indirect medical ...
2016-D15
Mid-Delta '03 Hospice Cap Group vs. Palmetto GBA
Whether the Medicare Contractor used the proper date to start the running of the 3-year reopening period for the 2003 hospice cap calculation by CMS for the cap tear ending October 31, 2003.
2016-D16
St. Anthony Regional Hospital vs. Wisconsin Physicians Service
Whether the Medicare Administrative Contractor (MAC), correctly determined the amount of the Sole Community Hospital (SCH) volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the ...
2016-D17
HCA DSH-Colorado State Database Group Appeals vs. Novitas Solutions, Inc.
Whether patient days which the Providers have identified as "inactive" in the Colorado State Medicaid program should be included in the Medicaid proxy that is used in the calculation of the Medicare payment for the disproportionate share hospitals (DSH).
2016-D18
CCT&B 2005-2006 Hurricane Katrina § 1115 Waiver UCP Days Group vs. Novitas Solutions, Inc.
Whether the MAC improperly excluded the inpatient days related to Uncompensated Care Pool (UCCP)services which CMS approved on March 24, 2006, under Hurricane Katrina Multi-State § 1115 demonstration from the Provider's disproportionate share Hospital (D...
2016-D19
Singing River Health System vs. Novitas Solutions, Inc.
Whether the MAC improperly excluded the inpatient days related to Uncompensated Care Pool (UCCP) seivices which CMS approved on March 24, 2006, under Hurricane Katrina Multi-State § 1115 demonstration from the Providers' disproportionate share Hospital (...
2016-D20
UTMD Anderson Cancer Center vs. Cahaba Safeguard Administrators, LLC and Novitas Solutions, Inc.
1. Whether the Provider’s request for adjustments to the TEFRA target amount should be granted. 2. Whether the Medicare Contractor’s adjustment to certain Company P expenses was proper.
2016-D21
Baptist Memorial Hospital-Memphis vs. Cahaba Government Benefits Administrators, LLC c/o National Government Services, Inc.
Whether the Medicare Contractor’s disallowance of the costs for the Providers’s Allied Health Care Management Program (“AHCMP”) was correct.
2016-D22
Select Specialty Medicare Dual Eligible Bad Debts CIRP Groups vs. Novitas Soultions, Inc.
Whether the CMS must-bill policy applies to the Providers’ dual eligible bad debts when the Providers did not participate in the Medicaid Program.
2016-D23
Valeo Home Healthcare Services, LLC vs. CGS Administrators
Whether the Medicare Contractor properly imposed a 2 percent payment reduction upon the Provider for calendar year 2015 for failure to submit quality data as required by the Deficit Reduction Act of 2005.
2016-D24
Texas Specialty Hospital of Lubbock vs. Novitas Solutions, Inc.
Whether the payment penalty that CMS imposed under the Long-Term Care Hospital Quality Reporting Program to reduce the Provider’s update for Fiscal Year 2015 by 2 percent was proper.
2016-D25
LifeCare Hospitals vs. Novitas Solutions, Inc. and Wisconsin Physicians Service
Whether the CMS must-bill policy applies to the Providers’ dual-eligible bad debts when the Providers did not participate in Medicaid.
2016-D26
Toyon 1997-2001 Intern and Resident Research FTE Group vs. Noridian Healthcare Solutions
Whether the Medicare Contractor properly reduced the Provider’s Indirect Medical Education (IME) Full Time Equivalent (FTE) resident counts, for time spent by resident in research activities.
2016-D27
H. Lee Moffitt Cancer Center vs. First Coast Service Options, Inc.
Whether the Medicare Contractor properly calculated the Provider’s payment-to-cost ratio (PCR) for both fiscal years under appeal.
2017-D01
Trinity Regional Medical Center vs. Wisconsin Physician Services
Whether the Medicare Administrative Contractor correctly determined the amount of the Sole Community Hospital volume decrease adjustment in accordance with the regulations and Program instructions per the reugliaton and the Provider Reimbursement Manual.
2017-D02
The Park Associates, Inc. vs. National Government Services, Inc.
Whether the Medicare Contractor’s methodology allocating Park Associates pooled home office costs improperly denied reimbursement to the Providers.
2017-D03
Cornerstone Hospital West Monroe vs. Novitas Solutions, Inc.
Whether the payment penalty imposed by CMS to reduce the Provider's FY 2015 Medicare payment by 2 percent was proper.
2017-D04
Southwest Consulting U Mass Memorial Health Care and Steward Health 2009 DSH CCHIP Section 1115 Waiver Days Groups vs. Novitas Solutions, Inc.
Whether days attributable to patients who were eligible for, and received, assistance through the Massachusetts Commonwealther Care Health Insurance Program, under a CMS approved § 1115 waiver, should be included in the numerator of the Medicaid fraction...
2017-D05
East Texas Medical Center-Athens vs. Novitas Solutions, Inc.
Whether the Provider was assigned to the correct Core Based Statistical Area (CBSA) for the Federal Fiscal Year 2015.
2017-D06
Memorial Hermann Continuing Care Hospital vs. Cahaba Safeguard Administrators, LLC
Whether the Medicare Contractor's adjustment to apply the "must bill" policy to bad debts related to dual eligible Medicare and Medicaid beneficiaries was proper.
2017-D07
Saint Alphonsus Regional Medical Center vs. Noridian Healthcare Solutions, Inc.
Whether the Medicare Contractor’s adjustments disallowing the Provider’s claimed reimbursement for GME and IME costs in the non-hospital setting, by reducing its FTE countbecause these costs were shared with another hospital, was proper.
2017-D08
Greenbrier Behavioral Health vs. Wisconsin Physicians Services
Whether the Provider is eligible for the third year inpatient psychiatric facility prospective payment system transition rate for the cost reporting period beginning on January 1, 2008 and ending on December 31, 2008.
2017-D09
North Sunflower County Hospital vs. Novitas Solutions, Inc.
Whether the CMS "must-bill" policy applies to the Provider's dual eligible unpaid deductible and coinsurance amounts related to the Provider's geropsychiatric program.
2017-D10
Hospice & Palliative Care of Westchester vs. National Government Services, Inc.
Whether the Centers for Medicare & Medicaid Services’ determination that the Provider is subject to a reduced Federal Fiscal Year 2015 Annual Payment Update under the Hospice Quality Reporting Program was proper.
2017-D11
Hall Render Optional and CIRP DSH Dual/SSI Eligible Group Appeals- Medicare Fraction & Hall Render, Individual, Optional and CIRP DSH Dual/SSI Eligible Group Appeals- Medicare Fraction vs. Medicare Administrative Contractors
Whether Medicare Disproportionate Share Hospital reimbursement calculations for the Providers were understated due to the failure of the Centers for Medicare & Medicaid Services and the relevant Medicare administrative contractors to include all supplem...
2017-D12
Hall Render Optional and CIRP DSH Dual/SSI Eligible Group Appeals- Medicare Fraction & Hall Render, Individual, Optional and CIRP DSH Dual/SSI Eligible Group Appeals- Medicare Fraction vs. Medicare Administrative Contractors
Whether Medicare Disproportionate Share Hospital reimbursement calculations for the Providers were understated due to the failure of the Centers for Medicare & Medicaid Services and the relevant Medicare administrative contractors to include all suppleme...
2017-D13
La Cheim School, Inc. vs. Noridian Health Care Solutions
Whether the Providers can claim Medicare and Medicaid crossover bad debts for reimbursement without billing the appropriate state agency.
2017-D14
Portia Bell Hume Behavioral Health & Training Center vs. Noridian Health Care Solution
Whether the Provider can be paid by the Medicare program for certain dual eligible Medicare and Medicaid crossover bad debts without billing and obtaining a remittance advice from the appropriate state Medicaid agency.
2017-D15
Community Health Network Rehabilitation Hospital vs. Wisconsin Physicians Services
Whether the Provider satisfied Inpatient Rehabilitation Facility Quality Reporting Program requirements applicable to it during its first year of Medicare participation such that it would be entitled to the full market basket rate during fiscal year 2015.
2017-D16
West Carroll Memorial Hospital vs. Novitas Solutions, Inc.
Whether the reduction of the Provider's annual payment update for calendar year 2015 under the hospital outpatient quality reporting program was proper.
2017-D17
BBL Direct GME PRA Adj. Group vs. Noridian Healthcare Solutions, LLC
Whether the use of Centers for Medicare and Medicaid Services’ sequential geography methodology for setting the Providers’ base year per resident amounts for Medicare reimbursement of certain graduate medical education costs, which flow through and a...
2017-D18
Vibra Hospital of Fort Wayne vs. Wisconsin Physicians Service
Whether the payment penalty that the Centers for Medicare and Medicaid Services imposed under the Long-Term Care Hospital Quality Reporting Program to reduce the Provider's payment update for Fiscal Year 2015 by 2 percent was proper.
2017-D19
Clarke County Hospital vs. Wisconsin Physicians Service
Whether the Medicare Administrative Contractor improperly disallowed certain home office costs claimed by the Provider, on the grounds that it was not related to the entity that had furnished the services.
2017-D20
Stormont-Vail Healthcare, Inc. vs. Wisconsin Physicians Service
Whether the Provider was the legal operator of Baker University Nursing School pursuant to 42 C.F.R. § 413.85(f)(1) (2008), thus qualifying under the Medicare program for pass-through reimbursement for the reasonable costs of its operation.
2017-D21
Vibra Hospital of Amarillo/Vibra Hospital of Richmond vs. Wisconsin Physicians Service
Whether the payment penalty that the Centers for Medicare and Medicaid Services imposed under the Long-Term Care Hospital Quality Reporting Program to reduce the Provider's payment update for Fiscal Year 2015 by 2 percent was proper.
2017-D22
Mercy Des Moines/Mercy Health Network 2008-2010 Home Office Cost Report Related Party Groups vs. Wisconsin Physicians Service
Whether the Medicare Contractor’s revised determination that the Providers are not related to Mercy Medical Center-Des Moines, and all cost report adjustments stemming from that determination, were appropriate.
2017-D23
Millennium Home Care, LLC vs. Palmetto GBA c/o National Government Services
Whether the Provider should be subject to a 2 percent reduction in home health prospective payment system payments for calendar year 2015 in accordance with 42 C.F.R. § 484.225(i) (2013).
2017-D24
Twin Lakes Regional Medical Center vs. CGS Administrators
Whether CMS' decision to impose a 2 percent reduction to the Market Basket Update for fiscal year 2013, which also resulted in the Provider's ineligibility to participate in the Hospital Value Based Purchasing Program, was proper.
2017-D25
Florida Hospital vs. First Coast Service Options, Inc.
Whether the Medicare Administrative Contractor properly disallowed a portion of the Hospital’s indigent bad debts claimed for the cost reporting periods for fiscal years ending December 31, 2006, December 31, 2007 and December 31, 2008, on the basis tha...
2017-D26
Santa Rosa Memorial Hospital vs. Cahaba Safeguard Administrators, LLC
Whether the Board has jurisdiction to review the Medicare Contractor’s determination of the low-income patient (LIP) adjustment for the Provider for the 2008 fiscal years (FY).
2017-D27
Rochester General Hospital vs. National Government Services, Inc.
Whether the Provider is entitled to a temporary increase in its resident full time equivalent (FTE) count due to the closing of one of the other three hospitals in a medical education training program.
2017-D28
Valley Hospital Medical Center vs. Novitas Solutions, Inc.
Whether the Medicare Contractor’s exclusion of Medicare Advantage/HMO charges and days from the calculation of the direct graduate medical education (DGME) payment for the Provider for its fiscal year ending December 31, 2006 (FY 2006) was proper.
2017-D29
Doctor's Memorial Hospital vs. First Coast Service Options, Inc.
Whether the payment penalty that CMS imposed under the Hospital Inpatient Quality Reporting (IQR) program to reduce the Provider’s payment update for fiscal year 2016 by twenty-five percent of the 2.7 percent Market Basket update was proper
2017-D30
Mercy Medical Center vs. Wisconsin Physicians Service
Whether CMS June 27, 2012 determination that the Provider did not meet the quality reporting program requirements for Fiscal Year 2013 and that its failure to meet these requirements would result in a two percent (2.0%) reduction in the FY 2013 market bas...
2017-D31
Pocohontas Community Hospital vs. Wisconsin Physicians Service
Whether the Medicare Contractor improperly disallowed certain home office costs claimed by the Provider on the grounds that it was not related to the entity that had furnished the services.
2018-D01
Greene County Medical Center vs. Wisconsin Physicians Service
Whether the Medicare Contractor improperly disallowed certain home office costs claimed by the Provider on the grounds that it was not related to the entity that had furnished the services.
2018-D02
Desert Star Home Health vs. Palmetto GBA c/o National Government Services
Whether the Provider should be subject to a two percent reduction to its calendar year 2017 home health market basket percentage increase for failure to meet Home Health Quality Reporting Program requirements in accordance with 42 C.F.R. § 484.225(i).
2018-D03
Hillcrest Specialty Hospital vs. Wisconsin Physicians Service
Whether the CMS “must-bill” policy applies to the Provider’s claimed dual eligible beneficiaries unpaid coinsurance and deductibles when the Provider does not participate in the respective State’s Medicaid program.
2018-D04
Pomerene Hospital (F.K.A. Joel Pomerene Memorial Hospital) vs. CGS Administrators
Whether the Medicare Contractor’s adjustments to the Provider’s Electronic Health Record (EHR) incentive payment based on the exclusion of inpatient days for which the Provider provided covered services to Medicare Advantage (MA) patients is correct.
2018-D05
Kindred 2006-2014 LTCH/SNF Bad Debts CIRP Groups vs. Wisconsin Physicians Service
Whether the CMS “must-bill” policy applies to the Providers’ claimed dual eligible beneficiaries unpaid coinsurance and deductibles when the Providers do not participate in the respective State’s Medicaid program.
2018-D06
HealthEast 2007 Paramed Ed-CPE CIRP Group/ HealthEast 2008 Paramed Ed-CPE CIRP Group vs. National Government Services
"0Whether the Medicare Contractor’s adjustment to the Clinical Pastoral Education (CPE) costs from being reported as an allied health educational activity to an administrative and general expense is correct.
2018-D07
Montgomery General Hospital vs. Palmetto GBA c/o National Government Services
Whether the Medicare Contractor improperly calculated and adjusted the Provider's defined benefit pension plan contribution cost that the Provider claimed on its fiscal year 2007 cost report.
2018-D08
Toyon 2002-2006 LIP SSI Realignment Group vs. Noridian Healthcare Solutions
Whether the Supplemental Security Income (SSI) ratio used to calculate the Medicare Low Income Patient (LIP) adjustment for inpatient rehabilitation facilities (IRFs) accurately reflected the number of patient days corresponding to the IRF cost reporting ...
2018-D09
TLC Health Network- Lake Shore Hospital vs. National Government Services, Inc.
Whether the reduction of the Provider’s Market Basket Update for federal fiscal year 2016 under the Hospital Inpatient Quality Reporting (IQR) Program was proper.
2018-D10
Progressive Health Center, Inc. vs. Novitas Solutions, Inc.
Whether the CMS “must-bill” policy applies to the Provider’s claimed dual eligible beneficiaries unpaid coinsurance and deductibles when the Provider does not participate in the respective State’s Medicaid program.
2018-D11
Progressive Health Center, Inc. vs. Novitas Solutions, Inc.
Whether the CMS “must-bill” policy applies to the Provider’s claimed dual eligible beneficiaries unpaid coinsurance and deductibles when the Provider does not participate in the respective State’s Medicaid program.
2018-D12
St. Anthony Hospital vs. Novitas Solutions, Inc.
Whether the Medicaid days attributable to child and adolescent patients who received services in three of the Provider’s inpatient behavioral health units (namely the ACCENTS Unit, the Human Restoration Unit, and the Positive Outcomes Unit) can be inclu...
2018-D13
Mercy Hospital, Inc. d/b/a/ Carolinas Healthcare System- Pineville vs. Palmetto GBA c/o National Government Services
Whether the full reduction of the Provider’s annual increase factor by 2 percent for fiscal year 2017 for failing to timely submit one of the six required data under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) was proper.
2018-D14
High Ridge House vs. Cahaba GBA c/o National Government Services, Inc.
Whether the Medicare Administrative Contractor improperly reclassified Provider costs related to providing housing free of charge for temporary, on-call and other staff, and for housing leasing at market value to the Director of Christian Science Nursing...
2018-D15
Nassau Suffolk 2007, 2008, 2009 Wage Index Calculation Groups vs. National Government Services, Inc.
Whether the Medicare Contractor should have excluded the aberrant wage index data from Brunswick Hospital Center when calculating the Nassau-Suffolk Core-Based Statistical Area (CBSA) wage index calculations for fiscal years 2007, 2008 and 2009.
2018-D16
St. Joseph's Hospital vs. National Government Services, Inc.
Whether the Provider should be subjected to a reduction of one quarter of the market basket update to the fiscal year 2017 Inpatient Prospective Payment System (IPPS) rates for the failure to meet the Hospital Inpatient Quality Reporting (IQR) Program req...
2018-D17
St. Anthony North Hospital vs. Novitas Solutions, Inc.
Whether the Medicare Contractor improperly reduced the Provider’s adjusted indirect medical education (IME) full time equivalent (FTE) count from 6.48 to zero.
2018-D18
Mountain States Health Alliance 05 Bad Debt- Passive Collection CIRP Group vs. Cahaba Government Benefits Administrators, LLC
Whether the Providers engaged in “reasonable collection efforts” notwithstanding their differential treatment of Medicare and non-Medicare bad debt, in light of the Reed City and St. Francis Board decisions.
2018-D19
Sutter Health 2001-2003 Regular Bad Debts- Collection Agency CIRP Group vs. Noridian Healthcare Solutions
Whether the Providers are entitled to reimbursement of their Medicare bad debts for the fiscal years ending December 31, 2001, 2002 and 2003.
2018-D20
Wyatt FFY 08 Wage Index (Occupational Mix Adjustment) Group vs. CGS Administrators, LLC
1. Whether the inclusion of surgical technicians, mental health technicians, and heart center recovery technicians in the “All other occupations” category instead of the “Nursing aides, orderlies and attendants” category in the Provider’s occupa...
2018-D21
Florida Section 1115 DSH Waiver Days Groups vs. First Coast Service Options
Whether the Low-Income Pool Section 1115 waiver days should be included in the Medicaid fraction of the disproportionate share hospital (DSH) calculations.
2018-D22
Florida Section 1115 LIP Rehab DSH Waiver Days Group vs. First Coast Service Options
Whether the Low-Income Pool Section 1115 waiver days should be included in the Medicaid fraction of the Low Income Patient (LIP) calculations for the inpatient rehabilitative facilities (IRFs).
2018-D23
Momence Meadows Nursing and Rehabilitation Center, LLC vs. National Government Services
Whether the Medicare Administrative Contractor’s adjustment that eliminated $183,879 of claimed Medicare reimbursable bad debts was proper and in accordance with Medicare regulations and the Provider Reimbursement Manual (PRM).
2018-D24
Westchester General Hospital vs. First Coast Service Options
Whether the payment reduction to the market basket update imposed under the Hospital Inpatient Quality Reporting (IQR) program for fiscal year 2015 was proper.
2018-D25
The Mary Imogene Basset Hospital vs. National Government Services, Inc. vs. National Government Services, Inc.
Whether the Provider, as a Sole Community Hospital (SCH), was properly reimbursed for Indirect Medical Education (IME) costs for services provided to Medicare Advantage (MA) patients for the cost reporting years at issue.
2018-D26
Greenwood Leflore Hospital vs. Novitas Solutions, Inc.
Whether the CMS decision to reduce the Provider’s Market Basket Update (MBU) for Fiscal Year (FY) 2017 by twenty-five percent, pursuant to the Hospital Inpatient Quality Reporting program (IQR), was proper.
2018-D27
Central Iowa Healthcare vs. Wisconsin Physicians Service
Whether the Provider is entitled to the full Market Basket Update for the fiscal year 2017.
2018-D28
Providence Sacred Heart Medical Center vs. Noridian Healthcare Solutions,LLC
Whether the MAC properly disallowed reimbursement for direct graduate medical education (GME) and indirect medical education (IME) costs in the non hospital setting by reducing the Provider’s full-time equivalent (FTE) resident counts to exclude residen...
2018-D29
Doctors Hospital of Stark County vs. CGS Administrators
Whether the Medicare Contractor’s adjustments to the Provider’s available beds and bed days and prior-year resident-to-bed ratio for cost reporting periods ending 6/30/2001, 6/30/2002 and 6/30/2003 were proper.
2018-D30
Horizon Home Care & Hospice vs. National Government Services
Whether the imposition of a two percent reduction in the Provider's fiscal year 2016 Medicare payments was proper.
2018-D31
Mary Free Bed Hospital & Rehab Center vs. Wisconsin Physicians Service
Whether the Provider is entitled to the full market basket update for Fiscal Year 2017.
2018-D32
Lightbridge Hospice vs. National Government Services
Whether the imposition of a two percent reduction in the Provider's fiscal year 2016 Medicare payments was proper.
2018-D33
Beaumont Hospital, Wayne (f/k/a Oakwood Annapolis Hospital) vs. Wisconsin Physicians Services
Whether the Provider is entitled to higher direct graduate medical education (DGME) and indirect medical education (IME) full-time equivalent (FTE) resident caps for a new family medicine residents training program.
2018-D34
Northern Utah Healchare d/b/a St. Mark's Hospital vs. Wisconsin Physicians Services
Whether the Provider is entitled to the full Outpatient Prospective Payment System (OPPS) market basket rate for Calendar Year 2015 based on its reported Hospital Outpatient Quality Reporting (HOQR) validation data.
2018-D35
Riverside Methodist Hospital vs. CGS Administrators, LLC
Whether the determination that the Provider failed to meet the validation requirements for the Calendar Year 2015 Hospital Outpatient Quality Reporting (HOQR) Program was proper.
2018-D36
Covenant Medical Center, Inc. vs. Wisconsin Physicians Service
Whether, for purposes of the graduate medical education (GME) payment and indirect medical education (IME) adjustments for FYE’s 06/30/2007, 06/30/2008 and 06/30/2009, the Provider is entitled to count full time equivalent (FTE) residents training in th...
2018-D37
Hospice Care in Westchester and Putnam, Inc. vs. National Government Services
Whether the Centers for Medicare & Medicaid Services’ reduction to the Provider’s Annual Payment Update (APU) for Fiscal Year (FY) 2016 was proper.
2018-D38
North Carolina Baptist Hospital vs. Palmetto GBA c/o National Government
Whether a two percentage point reduction in the Provider’s fiscal year 2017 annual increase factor, due to failure to meet Inpatient Rehabilitation Facility Quality Reporting Program (IRF-QRP) requirements, was proper.
2018-D39
Grace Community Home Health, Inc. vs. National Government Services
Whether the Provider should be subject to a two percentage point reduction to its calendar year 2017 home health market basket percentage increase for failure to meet the Home Health Quality Reporting Program requirements in accordance with 42 C.F.R. § ...
2018-D40
Guardian Homecare LLC vs. CGS Administrators
Whether the imposition of a two percent reduction in the Provider’s Medicare payments for calendar year 2017 was proper.
2018-D41
University Medical Center vs. Wisconsin Physicians Service
Whether the Medicare Administrative Contractor determined Medicare reimbursement for Disproportionate Share Hospital (DSH) payments in accordance with the Medicare statute, 42 U.S.C. § 1395ww(d)(5)(F)(vi). Specifically, whether the numerator of the “Me...
2018-D42
Conway Regional Rehabilitation Hospital vs. Novitas Solutions, Inc.
Whether the reduction of the Provider's Annual Payment Update (APU) for the federal fiscal year 2017 by the Centers for Medicare & Medicaid Services under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) was proper.
2018-D43
QRS 2004-2005 Medicare Part A Title XIX Eligible Patient Days Group III; QRS Empire 2000, 2003-2004, 2006-2007 Medicare Part A Title XIX Eligible Days – No Pay Part A CIRP Group; and QRS 10/1/2004 – 2008 DSH No Pay Part A Group vs. Noridian Healthca...
Whether patient days associated with Medicare Part A, Title XIX eligible patients that were not included in the Supplemental Security Income (SSI) percentage factor of the Medicare Disproportionate Share Hospital (DSH) formula should be included in the Me...
2018-D44
Garden City Hospital vs. Wisconsin Physicians Service
Whether the Provider timely submitted required quality data during the required timeframes, and is entitled to the full Market Basket Update for Fiscal Year 2017.
2018-D45
Faxton-St. Luke's Healthcare vs. National Government Services, Inc.
Whether the Medicare Contractor's disallowance of all bad debt claims for patients deemed indigent is in accordance with the Medicare regulations and manual provisions as described in Centers for Medicare & Medicaid Services’ Provider Reimbursement Manu...
2018-D46
Our Lady of the Lake Regional Medical Center vs. Novitas Solutions, Inc.
Whether the Medicare Contractor's recalculation of the Provider’s per-resident amount was consistent with the law requiring the use of 1998 census region hospital data to determine the cap on the Provider’s recalculated per-resident amount.
2018-D47
Post Acute Medical Specialty Hospital of Texarkana North vs. Novitas Solutions, Inc.
Whether the payment penalty that CMS imposed under the Long-Term Care Hospital Quality Reporting Program to reduce the Provider’s payment update for the federal fiscal year of 2017 by two percent was proper
2018-D48
Providence Health & Services 10/1/2004-12/31/2007 Dual Eligible Days CIRP Group vs. Noridian Healthcare Solutions
Whether patient days associated with Medicare Part A and Title XIX eligible patients that were not included in the SSI percentage factor of the Medicare Disproportionate Share formula should be included in the Medicaid fraction of the Medicare DSH formula...
2018-D49
Akin Gump 2006-2008 Florida Low Income Pool Waiver Days Groups vs. First Coast Service Options, Inc.
Whether days attributable to patients who received assistance under Florida’s Low-Income Pool Medicaid waiver days should be included in the numerator of the Medicaid fraction used to calculate the Providers’ disproportionate share hospital payments....
2018-D50
Pomona Valley Hospital Medical Center vs. Noridian Healthcare Solutions
Whether the Medicare Administrative Contractor properly calculated the Provider’s disproportionate share hospital reimbursement with respect to the Provider’s Supplemental Security Income percentage.
2018-D51
Rice Memorial Hospital vs. National Government Services
Whether the Medicare Administrative Contractor was correct when it calculated the Provider’s volume decrease adjustment (VDA) by prorating the amount of the VDA according to the portion of the year during which the Provider maintained sole community hos...
2018-D52
St. Mary's Regional Hospital vs. National Government Services
Whether the Medicare Administrative Contractor was correct when it calculated the Provider’s volume decrease adjustment (VDA) by prorating the amount of the VDA according to the portion of the year during which the Provider maintained sole community hos...
2019-D01
United Hospital Center vs. Palmetto GBA c/o National Government Services, Inc.
Whether the reduction by one-fourth of the Provider’s fiscal year 2017 Inpatient Prospective Payment System annual payment update for the failure to meet all of the inpatient quality reporting requirements is proper.
2019-D02
The University of Texas Southwestern Medical Center vs. Novitas Solutions, Inc.
Whether the Medicare Contractor’s audit adjustments to remove Medicare Usable Organs (Heart and Kidney) were fair and proper.
2019-D03
St. Helena Hospital- Clearlake vs. Noridian Healthcare Solutions
1. Whether the costs incurred by the Provider for its physician on-call expenses should be allowed for the four cost reporting periods at issue (2005, 2006, 2007, and 2008). 2. Whether the Provider’s costs of meals furnished to outpatients (sometimes re...
2019-D04
Mackey Family Practice, PA vs. Palmetto GBA
Whether the Medicare Contractor's disallowance of the Medicare bad debts claimed by the Provider was proper.
2019-D05
Presence St. Joseph Hospital, Inc. vs. National Government Services
Whether the Medicare Administrative Contractor properly determined the count of full-time equivalent residents, used for the purposes of calculating payments for direct graduate medical education, indirect medical education, and IME capital.
2019-D06
Metroplex Hospital vs. First Coast Service Options, Inc.
Whether the payment penalty under the Hospital Inpatient Quality Reporting Program was properly applied to the Provider.
2019-D07
North Mississippi Medical Center vs.Novitas Solutions, Inc.
Whether the reduction of the Provider’s Annual Payment Update by 2 percent for fiscal year 2017 was proper.
2019-D08
Toyon/Dignity Health/Sutter Health 2012 Inpatient and Outpatient Payment CBSA No. 40900 Wage Data Groups vs. Noridian Healthcare Solutions
Whether the Federal Fiscal Year 2012 wage index factor and capital geographic adjustment factor for Core Based Statistical Area No. 40900 used in the calculation of Medicare inpatient and outpatient prospective payments is properly stated.
2019-D09
Christian Healthcare Center d/b/a Ramapo Ridge vs. Novitas Solutions, Inc.
Whether the Provider is entitled to the full market basket adjustment to its rate for fiscal year 2017.
2019-D10
Minnesota Hospice, LLC vs. National Government Services, Inc.
Whether CMS properly reduced the Provider's annual payment update for Fiscal Year 2018 by 2 percentage points.
2019-D11
Tulsa Hospital vs. Novitas Solutions, Inc.
Whether the Medicare Contractor’s determination to reduce the Providers’ indirect medical education and graduate medical education full-time equivalent resident counts to exclude certain resident rotations in nonhospital clinics was proper.
2019-D12
Dukes Memorial Hospital vs. WPS Government Health Administrators
Whether the Medicare Contractor appropriately disallowed costs to the Provider claimed for physician compensation for emergency room availability services (frequently referred to as “standby services”), administrative/management services, and on-call ...
2019-D13
Rehabilitation Hospital of the Pacific vs. Noridian Healthcare Solutions c/o Cahaba Safeguard Administrators (J-E)
Whether the reduction to the Provider’s Market Basket Update for the fiscal year 2017 under the Inpatient Rehabilitation Facility Quality Reporting Program was proper.
2019-D14
Glenbeigh Health Sources vs. CGS Administrators, LLC
Whether the fiscal year 2018 penalty imposed under the hospital inpatient quality reporting program was proper.
2019-D15
MUSC Medical Center/Medical University Hospital Authority vs. Palmetto GBA c/o National Government Services, Inc.
1. Whether the Medicare Administrative Contractor’s decision to reclassify the costs and statistics out of the paramedical pass-through cost center was proper. This issue applies to the fiscal years ending June 30, 2007 and June 30, 2008. 2. Whether th...
2019-D16
Landmark Hospital of Salt Lake City, LLC vs. Cahaba Gov’t Benefit Administrators, LLC c/o National Gov’t Services, Inc.
Whether the payment penalty that CMS imposed under the Long Term Care Hospital Quality Reporting Program to reduce the Provider’s payment update for Fiscal Year 2017 by 2-percent was proper.
2019-D17
Landmark Hospital of Savannah, LLC vs. Cahaba Gov’t Benefit Administrators, LLC c/o National Gov’t Services, Inc.
Whether the payment penalty that CMS imposed under the Long Term Care Hospital Quality Reporting Program to reduce the Provider’s payment update for Fiscal Year 2017 by 2-percent was proper.
2019-D18
Silverado 2013 Hospice Cap Sequestration CIRP Group/ProCare 2013 Hospice Cap Sequestration CIRP Group vs. National Government Services (J-6)
Whether the Medicare Contractor erred in calculating the hospice aggregate cap overpayments when it included, in “the amount of payment made,” certain funds that were sequestered and never paid to the Providers.
2019-D19
Cottonwod Springs LLC vs. WPS Government Health Administrators
Whether the Provider is entitled to the full market basket adjustment to its Inpatient Psychiatric Facility Prospective Payment System rate for fiscal year 2018.
2019-D20
Silverado 2014 Hospice Cap Sequestration CIRP Group vs. National Government Services
Whether the Medicare Contractor erred in calculating the hospice aggregate cap overpayments when it included, in “the amount of payment made,” certain funds that were sequestered and never paid to the Providers.
2019-D21
RX Home Health Services, Inc. vs. Palmetto GBA
Whether the Provider should be subject to a two percentage point reduction to its Calendar Year 2018 Annual Payment Update for failure to meet Home Health Quality Reporting Program requirements in accordance with 42 C.F.R. § 484.225(i) (2015).
2019-D22
Mariners Hospital vs. First Coast Service Options, Inc.
Whether the Medicare Contractor improperly disallowed costs incurred by the Provider under its service agreements with emergency and anesthesiologist physicians groups for availability, standby, and administrative services furnished to the hospital.
2019-D23
Glendora Community Hospital vs. Noridian Healthcare Solutions c/o Cahaba Safeguard Administrators
Whether the payment penalty imposed by CMS under the Hospital Inpatient Quality Reporting program to reduce the Provider’s payment update for federal fiscal year 2017 by one-fourth of the annual market basket update was proper.
2019-D24
Springs Memorial Hospital vs. Palmetto GBA c/o National Government Services
Whether the Medicare Contractor properly disallowed all costs and removed all therapy charges relating to the Provider’s use of a Therapy and Management Services subcontractor for its Skilled Nursing Facility and Inpatient Rehabilitation Facility units.
2019-D25
Abundant Home Health, LLC vs. Palmetto Government Benefit Administrators, LLC c/o National Government Services, Inc.
Whether the Centers for Medicare & Medicaid Services properly reduced the Provider’s home health market basket percentage increase by two percentage points for Calendar Year 2017.
2019-D26
Novus Health Services, Inc. vs. Palmetto GBA c/o National Government Services
1. Whether the sequestration amount should be included when calculating the aggregate payment made to the Provider, as the reduction in payment through sequestration does not constitute actual Medicare payments made to the Provider. 2. Whether the Medicar...
2019-D27
Henry Ford Allegiance Health vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the per-resident amount for Medicare payment of direct graduate medical education.
2019-D28
Kindred FY 2013 Hospice Cap Sequestration CIRP Group vs. Palmetto GBA c/o National Government Services
Whether the Medicare administrative contractor’s inclusion of the sequestered payments never actually paid to the Providers in its calculation of the Providers’ hospice cap liabilities was improper.
2019-D29
Select Medical 2011 Dual Eligible Bad Debts CIRP Group vs. Novitas Solutions, Inc.
Whether the MAC’s must-bill policy applies to the Providers’ dual eligible bad debts when the Provider did not participate in the Medicaid program.
2019-D30
Southwest Medical Associates Hospice and Palliative Care vs. National Government Services, Inc. (J-6)
Whether the imposition of a two percent reduction in the fiscal year 2018 Medicare payments for the Provider was proper.
2019-D31
Stephens County Hospital vs. Palmetto GBA
Whether the Medicare Administrative Contractor correctly determined the amount of the volume decrease adjustment in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual , CMS Pub. 1...
2019-D32
Stephens County Hospital vs. Palmetto GBA
Whether the Medicare Administrative Contractor (MAC), correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual ...
2019-D33
Trinity Health 2013 Iowa Related Organization Cost Allocation CIRP vs. WPS Government Health Administrators
Whether the Medicare Contractor’s adjustments disallowing the administrative and general costs (A&G) that Mercy Medical Center – Sioux City allocated to the appealing group members (Baum Harmon Mercy Hospital and Oakland Mercy Hospital) were proper.
2019-D34
HMA 2004-2006 Bad Debt Group Appeals vs. Wisconsin Physicians Service/ Federal Specialized Services, Inc.
Whether the Providers engaged in “reasonable collection efforts,” notwithstanding their differential treatment of Medicare and non-Medicare bad debts, in light of the Board’s decisions in Reed City Hosp. v. BlueCross BlueShield Ass’n and St. Fran...
2019-D35
National Jewish Health vs. Novitas Solutions, Inc.
Whether the Provider should be subject to a one-fourth reduction to its Federal Fiscal Year (FFY) 2019 Annual Percentage Update (APU) for noncompliance with the Hospital Inpatient Quality Reporting (IQR) Program requirements.
2019-D36
University of Wisconsin Hospitals and Clinics Authority vs. National Government Services
1: Whether the Medicare Contractor's adjustments, decreasing the Provider's direct Graduate Medical Education (GME) and Indirect Medical Education (IME) Full Time Equivalent (FTE) Caps to a level below the Provider's audited and adjusted fiscal year endin...
2019-D37
Seasons Hospice & Palliative Care of Southern Florida vs. Palmetto GBA c/o National Government Services, Inc.
Whether the Medicare Contractor incorrectly determined the cap year 2012 aggregate cap amount for the Provider when the Medicare Contractor used the patient-by-patient proportional method (proportional method) instead of the streamlined method.
2019-D38
Northeast Regional Medical Center vs. WPS Government Health Administrators
Whether the Provider, as a Sole Community Hospital (SCH), was properly reimbursed for indirect medical education costs for services provided to Medicare Advantage (MA or Part C) patients for the cost reporting period in dispute. In particular, whether the...
2020-D01
Halifax Regional Medical Center vs. Palmetto GBA
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D02
Halifax Regional Medical Center vs. Palmetto GBA
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D03
Vitas Healthcare CY 2013-2015 Hospice Cap Sequestration CIRP Group vs. Palmetto GBA c/o National Government Services
Whether the MAC’s inclusion of sequestered payments in the determination of the Providers’ Cap on Overall Medicare Reimbursement was proper.
2020-D04
Northeast Regional Medical Center vs. WPS Government Health Administrator
Whether the Provider, as a Sole Community Hospital (SCH), was properly reimbursed for indirect medical education costs for services provided to Medicare Advantage (MA or Part C) patients for fiscal year ending May 31, 2009. In particular, whether the Cost...
2020-D05
Brigham and Women’s Hospital vs. National Government Services, Inc.
1. Whether the MAC improperly disallowed the Provider’s reasonable costs for the Ultrasound Allied Health Clinical Training Program (UAHCTP) that is not operated by the Provider. 2. Whether the MAC improperly disallowed the Provider’s reasonable costs...
2020-D06
Woodward Regional Hospital vs. WPS Government Health Administrators
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D07
Woodward Regional Hospital vs. WPS Government Health Administrators
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D08
Bartlett Regional Medical Center vs. WPS Noridian Healthcare Solutions, LLC/ Federal Specialized Services, Inc.
Whether the contributions made by the State of Alaska can be counted as “reasonable cost” by the Provider for purposes of reimbursement under the Medicare Rural Demonstration Project.
2020-D09
Baptist Memorial Hospital Booneville vs. Palmetto GBA
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D10
Baptist Memorial Hospital Booneville vs. Palmetto GBA
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D11
Olympic Medical Center vs. Noridian Healthcare Solutions, LLC
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D12
Lake Region Healthcare Corporation vs. National Government Services, Inc.
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D13
Good Shepherd Hospice of Mid-America, Inc. vs. CGS Administrators
Whether the Medicare Contractor’s amended hospice cap calculation issued pursuant to the Notice of Reopening properly calculated the Provider’s hospice aggregate cap overpayment when it included in “the amount of payment made” certain funds that w...
2020-D14
Ozarks Community Hospital of Gravette vs. Novitas Solutions, Inc.
1. Whether the use of total costs, rather than patient days, as a statistic to allocate home office pooled costs was proper. 2. Whether the use of gross revenues, rather than patient days, as a statistic to functionally allocate business office costs was ...
2020-D15
Innovis Hospital d/b/a Essentia Health Fargo vs. Noridian Healthcare Solutions, LLC
Whether the MAC’s adjustment to reconcile outlier payments was proper and, since the MAC waited 5 years after discovering the error before notifying the Provider, whether the law bars recovery of the overpayment.
2020-D16
St. Vincent Charity Medical Center vs. CGS Administrators
1. Whether the Medicare Contractor’s adjustments for disallowing pass-through costs and managed care payments associated with the Provider’s operation of its pastoral care allied health education program were proper. 2. Whether the Medicare Contractor...
2020-D17
Sentara Healthcare Bad Debt CIRP Groups vs. Palmetto GBA c/o National Government Services
Whether the MAC properly adjusted Medicare bad debt accounts considered indigent by the Providers and claimed as Medicare bad debt. The Board focused its decision-making on whether the asset-test guideline at §312(B) of the PRM must be applied to determi...
2020-D18
Good Shepherd Hospice of Mid-America, Inc. vs. CGS Administrators
Whether the Medicare Contractor’s amended hospice cap calculation properly calculated the Provider’s hospice aggregate cap overpayment when it included in “the amount of payment made” certain funds that were sequestered and never paid to the Provi...
2020-D19
Loyola University Medical Center vs. National Government Services, Inc.
Whether the Medicare Contractor should adjust the direct graduate medical education (GME) cap for the Provider on Worksheet E-3, Part VI of the Provider’s cost reports for fiscal years (FYs) 2006 and 2007, for the addition of new programs.
2020-D20
UHS 2006-2009 Medicare Bad Debts Still At Agency CIRP Group vs. Novitas Solutions, Inc.
Whether the Providers' Medicare bad debts pending at outside collection agencies are allowable.
2020-D21
Encompass Home Health of the West, LLC vs. National Government Services, Inc.
Whether the Medicare Contractor’s reduction to the Provider’s home health prospective payment system (HHA PPS) payments for calendar year (CY) 2018 by two percent was proper.
2020-D22
AnMed Health vs. Palmetto GBA c/o National Government Services, Inc.
Whether the denial of the Provider’s request for sole community hospital (SCH) designation by CMS and the MAC was proper.
2020-D23
Three Rivers Community Hospital vs. Noridian Healthcare Solutions
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2020-D24
Physicians Alliance Hospital vs. WPS Government Health Administrators
Whether the Medicare Contractor’s adjustment to the outlier reconciliation adjustment determination was proper.
2020-D25
Cherokee Regional Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly disallowed administrative and general (A&G) costs allocated to Cherokee by St. Luke’s Regional Medical Center.
2021-D01
Affinis Hospice, LLC vs. Palmetto GBA c/o National Government Services, Inc.
Whether the Medicare Contractor used the correct data and methodology in calculating and applying the “hospice cap” for Cap Years 2013 and 2014.
2021-D02
Berwick Hospital Center vs. WPS Government Health Administrators
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2021-D03
Berwick Hospital Center vs. WPS Government Health Administrators
Whether the MAC correctly determined the amount of the volume decrease adjustment (VDA) in accordance with the regulations and Program instructions per 42 C.F.R. § 412.92(e)(3), and the Provider Reimbursement Manual (PRM), CMS Pub. 15-1 at § 28101.1.
2021-D04
Henry County Health Center vs. WPS Government Health Administrator
Whether the Medicare Contractor improperly disallowed certain related party costs claimed by the Provider based on its determination that the Provider had not incurred the claimed costs.
2021-D05
Palo Pinto General Hospital vs. Novitas Solutions, Inc.
Whether the Provider was entitled to a volume decrease adjustment (VDA) for the Fiscal Year Ended September 30, 2012 (FY 2012) greater than the amount determined by the MAC.
2021-D06
Berwick Hospital Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending June 30, 2015 (FY 2015).
2021-D07
Brownwood Regional Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending September 30, 2007 (FY 2007).
2021-D08
Brownwood Regional Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending September 30, 2012 (FY 2012).
2021-D09
Brownwood Regional Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending September 30, 2013 (FY 2013).
2021-D10
Brownwood Regional Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending September 30, 2014 (FY 2014).
2021-D11
Brownwood Regional Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending September 30, 2015 (FY 2015).
2021-D12
Brownwood Regional Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending September 30, 2016 (FY 2016).
2021-D13
ProHealth Home Care, Inc. vs. National Government Services, Inc.
Whether the two-percentage point reduction to the Annual Percentage Update (APU) of the Provider for Fiscal Year (FY) 2019 was proper.
2021-D14
Hazard ARH Regional Medical Center vs. CGS Administrators, LLC
1. Whether CMS’ decision to reduce the Provider’s Fiscal Year (FY) 2018 Inpatient Psychiatric Facility Prospective Payment System annual payment update (APU) by 2 percentage points was proper. 2. Whether CMS’ decision to reduce the Provider’s Cale...
2021-D15
Lamb Healthcare Center vs. Novitas Solutions, Inc.
Whether the Provider is entitled to a Volume Decrease Adjustment (VDA) for Fiscal Year End September 30, 2012 (FY 2012), greater than the amount determined by the Medicare Contractor.
2021-D16
Jewish Healthcare Center, Inc., d/b/a JHC HomeCare, vs. National Government Services, Inc.
Whether the payment penalty imposed on the Provider’s home health prospective payment system Annual Payment Update (APU) for calendar year (CY) 2019 was proper.
2021-D17
Rolling Plains Memorial Hospital vs. Novitas Solutions, Inc.
Whether the Provider is entitled to a Volume Decrease Adjustment (VDA) for Fiscal Year End September 30, 2010 (FY 2010).
2021-D18
Rolling Plains Memorial Hospital vs. Novitas Solutions, Inc.
Whether the Provider is entitled to a Volume Decrease Adjustment (VDA) for Fiscal Year End September 30, 2012 (FY 2012).
2021-D19
Alta Vista Regional Hospital vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending August 31, 2008 (FY 2008).
2021-D20
Alta Vista Regional Hospital vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending August 31, 2010 (FY 2010).
2021-D21
Rome Memorial Hospital vs. National Government Services, Inc.
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2011 (FY 2011) and whether th...
2021-D22
Serenity One Hospice & Palliative Care vs. Palmetto GBA c/o National Government Services, Inc.
Whether the Medicare Contractor used the correct number of Medicare beneficiaries in calculating the Cap Year 2018 Hospice Cap.
2021-D23
HCR Manor Care 2014 Hospice Cap Overpayment CIRP Group vs. National Government Services, Inc.
Whether the Medicare Contractor’s inclusion of sequestered payments in the determination of the Providers’ cap on overall Medicare reimbursement was proper.
2021-D24
Carthage Area Hospital vs. National Government Services, Inc.
Whether the Provider is entitled to a Volume Decrease Adjustment (VDA) for cost report period ending December 31, 2011 (FY 2011).
2021-D25
Carthage Area Hospital vs. National Government Services, Inc.
Whether the Provider is entitled to a Volume Decrease Adjustment (VDA) for cost report period ending December 31, 2012 (FY 2012).
2021-D26
Oswego Hospital vs. National Government Services, Inc.
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2011 (FY 2011) and whether th...
2021-D27
Universal Health Care / Fletcher, Inc. vs. Palmetto GBA c/o National Government Services, Inc.
Whether the payment penalty imposed by the Centers for Medicare and Medicaid Services (CMS) to reduce the Provider's Fiscal Year (FY) 2019 Medicare payment by two percent was proper.
2021-D28
Scenic Mountain Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2012 (FY 2012).
2021-D29
Scenic Mountain Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2013 (FY 2013).
2021-D30
Scenic Mountain Medical Center vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2014 (FY 2014).
2021-D31
Fremont Area Medical Center vs. WPS Government Health Administrators
Whether the Medicare Administrative Contractor (MAC), properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in in patient discharges that occurred in its cost reporting period ending June 30, 2010 (FY 2010...
2021-D32
Fremont Area Medical Center vs. WPS Government Health Administrators
Whether the Medicare Administrative Contractor (MAC), properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in in patient discharges that occurred in its cost reporting period ending June 30, 2013 (FY 2013...
2021-D33
Fremont Area Medical Center vs. WPS Government Health Administrators
Whether the Medicare Administrative Contractor (MAC), properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in in patient discharges that occurred in its cost reporting period ending June 30, 2015 (FY 2015...
2021-D34
Lake Regional Health System vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending April 30, 2013 (FY 2013).
2021-D35
Lake Regional Health System vs. WPS Government Health Administrators
Whether the Medicare Contractor properly calculated the volume decrease adjustment (VDA) owed to the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending April 30, 2014 (FY 2014).
2022-D01
D. M Cogwell Memorial Hospital vs. Novitas Solutions, Inc.
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2012 (FY 2012).
2022-D02
D. M Cogwell Memorial Hospital vs. Novitas Solutions, Inc.
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2010 (FY 2010).
2022-D03
Hebrew Rehabilitation Center vs. National Government Services, Inc.
Whether the payment penalty imposed under the Long Term Care Hospital Quality Reporting Program (LTCH-QRP), which reduced the Provider’s payment update for Fiscal Year 2019 by two percent, was proper.
2022-D04
Heartland Regional Medical Center (AKA Marion General Hospital/ Marion Memorial) vs. WPS Government Services
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending April 30, 2011 (FY 2011).
2022-D05
Crossroads Community Hospital vs. WPS – Government Administrative Services
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending December 31, 2013 (FY 2013).
2022-D06
Blackwell Regional Hospital vs. Novitas Solutions, Inc.
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending March 31, 2012.
2022-D07
Pitt County Memorial Hospital, dba Vidant Medical Center vs. Palmetto GBA c/o National Government Services, Inc.
Whether the Provider’s disproportionate share hospital (DSH) payment for fiscal year ending September 30, 2009 (FY 2009) should be revised to include additional patient days that were excluded from the numerator of the Medicaid fraction.
2022-D08
Dickinson County Healthcare System vs. WPS Government Health Administrators
Whether the MAC erred in its determination that the Provider did not qualify for the exception to the per-visit upper payment limit (UPL) for rural health clinics (RHCs) for the fiscal years ending December 31, 2015 and December 31, 2016 (FYs 2015 and 201...
2022-D09
Medical Arts Hospital vs. Novitas Solutions, Inc.
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending March 31, 2012.
2022-D10
West Branch Regional Medical Center vs. WPS Government Health Administrators
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending March 31, 2009.
2022-D11
West Branch Regional Medical Center vs. WPS Government Health Administrators
Whether the MAC properly calculated the volume decrease adjustment (VDA) owed the Provider for the significant decrease in inpatient discharges that occurred in its cost reporting period ending March 31, 2010.
2022-D12