Southwest Consulting Associates Blog

Front & Center with SCA President, Michael Newell: Alert 10 In Action

Posted by Michael Newell on Dec 9, 2014 11:45:00 AM

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PRRB Alert 10Thursday November 20, 2014, I testified before the Provider Reimbursement Review Board (PRRB) in a jurisdictional hearing concerning the May 2014 issuance of PRRB Alert 10 that resulted from an adverse decision in the Danbury case. Much has been written about PRRB jurisdiction, and specifically, the Danbury decision and subsequent PRRB Alert 10 – including pieces authored by Southwest Consulting Associates. However, this was the first hearing that I am aware of since the issuance of Alert 10 to delve deeply into specifics of what that alert requires. If there was any question in your mind regarding the shift in the “jurisdictional” ground beneath providers’ feet, I am here to confirm for you that the ground is in fact shifting and the dominos are now falling.


PRRB Alert 10 requires that providers with pending Medicaid eligible days appeals supplement the record by providing:

  • A detailed description of the process that the provider used to identify and accumulate the actual Medicaid paid and unpaid eligible days that were reported on the Medicare cost report;

  • The number of additional Medicaid paid and unpaid eligible days that the provider is requesting to be included in the DSH calculation; and

  • A detailed explanation why the additional Medicaid paid and unpaid eligible days at issue could not have been verified by the state at the time the cost report was filed. If there is more than one explanation or reason, identify how many of these days are associated with each explanation/reason.

First of all, detailed means detailed. This jurisdictional hearing lasted six-hours and my testimony comprised approximately three and one-half of those hours. As this was a case in which I was responsible for the group that prepared and filed the cost report for the subject provider and am now the president of the consulting firm that prepared the revised Medicare DSH analysis, my testimony went to both the process the provider used to compile the data for the cost report as well as the other two points in Alert 10. While the thrust of the legal argument in this case was that the PRRB is attempting to apply 2014 standards to cost reports filed before those standards were properly adopted, there was much to be learned about how this current board is approaching how jurisdiction might be viewed based on a provider’s responsibility when filing a cost report.


The board proffered many detailed questions in an attempt to understand, at the transactional level, how the provider went about the business of identifying, accumulating and reporting Medicaid eligible days for the Medicare DSH calculation. Many more questions went to the issue of “practical impediment” and if there was the existence of a practical impediment (or more than one), which practical impediment applied to which patient and patient day so that the board could ascertain what number of days might be eligible for inclusion upon the successful litigation of the case on the merits.   


The jury is certainly still out regarding the retroactive application of these Alert 10 standards to Medicaid eligible day appeals that were pending prior to its May issuance. However, providers would be wise to take a good look at their process for not only claiming Medicaid eligible days in as-filed cost reports but how they compile the data to be included in as-filed cost reports in general. We will continue to publish commentary on best practices for the compilation of Medicaid eligible days for Medicare DSH purposes as well as share our thoughts on other best practice aspects of cost report filing.  We also plan to publish an update on this PRRB hearing once a decision has been made.

Topics: Medicare DSH Reimbursement, DSH Litigation Environment, Compliance, OPPS

About This Blog

The climate of provider reimbursement is ever-changing and this blog is intended to keep you up-to-date on the latest information regarding:

  • DSH Reimbursement
  • 340B Pharmacy Drug Discount Program
  • Compliance Issues
  • Litigation Surrounding Provider Reimbursement

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