Reimbursement:
Tough Luck On Incorrect Payment Limits, PRRB Says
Published on Thu May 20, 2004
You're at the mercy of your FI's errors.
A New Mexico home health agency had to eat $60,000 thanks to an intermediary mistake, and that's fine by the Provider Reimbursement Review Board.
Salem-based Hatch Valley Home Health Agency received its cost limits for the year ended April 30, 1997 from then-intermediary New Mexico Blue Cross Blue Shield. But when regional home health intermediary Palmetto GBA took over and audited Hatch Valley's cost report, it found NM-BCBS had incorrectly based the cost limits on a rural area when Hatch Valley was located in a designated urban area.
Accordingly, Palmetto lowered the cost limits and made the $60,000 adjustment, according to an April 29 PRRB decision, Hatch Valley Home Health Agency v. Blue Cross Blue Shield Association Palmetto Government Benefits Administrators (No. 2004-D17).
Hatch Valley argued in its PRRB appeal that it wasn't given sufficient notice of its cost limits - 30 days before the relevant cost reporting period began. Additionally, the Omnibus Budget Reconciliation Act of 1993 froze HHAs' cost limits for the time period in question. Hatch Valley contended its cost limits, even though they were incorrect, should have been frozen as well.
Finally, the agency says it wasn't at fault for the cost limit overpayment. Because the overpayment was incurred on behalf of Medicare beneficiaries, Hatch Valley shouldn't have to repay the funds based on a regulation that sometimes lets beneficiaries off the hook when they aren't at fault for mistaken expenditures.
But the PRRB shoots down all of Hatch Valley's arguments. "Manual instructions" on the 30-day requirement "cannot grant rights to a provider that are inconsistent with program regulations," the Board insists. Likewise, the OBRA "freeze cannot be used to legitimize program payments that are otherwise inconsistent with program rules, i.e., improper payments."
And the without-fault forgiveness of overpayments applies only to beneficiaries, not Medicare providers, the Board concludes.
The PRRB isn't without sympathy, however. Hatch Valley "was unjustly prejudiced and has likely suffered financial harm as a result of errors by its initial intermediary," the decision says. "While the Board would like to remedy this situation, it has not been granted authority to provide equitable relief."
Hatch Valley appears to no longer be in operation. The HHA and its administrator Antoinette Turner could not be reached for comment.
