Engagement

An acute care hospital was denied LTCH conversion by the intermediary. After the provider made numerous attempts to demonstrate that it met the requisite length of stay and compliance with the 15% rule that was applicable to HWH's we were asked to intervene as the intermediary refused to examine the issue any further.

Method

We re-priced all claims for the cost reporting period to determine that there was a $2.3 million reimbursement impact of the LTCH designation denial. We reported this amount as a protested item on the acute care hospital cost report. When the intermediary removed the protested item and issued the NPR, we filed a PRRB appeal. After TFG completed discovery, we prepared the final position paper and personally met with the intermediary's appeals coordinator to identify areas of agreement and establish a good rapport. When the actual PRRB hearing date was scheduled we encouraged the client to engage legal counsel for representation at the actual hearing because the case may have ultimately been resolved in district court. Legal counsel then analyzed our final position paper and identified strengths and weaknesses in our position. We worked diligently with legal counsel to reach a settlement with the intermediary without going to hearing.

Results

Two weeks before hearing, the intermediary agreed to reverse their position and grant LTCH designation. We then re-priced the claims using the updated cost to charge ratio and PS&R data and discovered that the actual reimbursement impact was $2.5 million. Legal counsel and the intermediary drafted the settlement agreement and the case was resolved with the provider receiving approximately $2.5 million. The positive outcome of this case resulted from a team effort by the provider, TFG, and legal counsel combined with an intermediary appeals coordinator that acted in accordance with applicable regulation.