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 |
|---|---|---|
| 2006-D53 | DePaul Health Center vs. Mutual of Omaha Insurance Company | Whether the Intermediarys adjustment disallowing the consolidation of all of the Providers 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 Intermediarys adjustment of DSH reimbursement based on its determination that the Provider had less than 100 available beds for DSH eligibility purposes was proper. |
| 2006-D52 | Mark Reed Hospital vs. BlueCross BlueShield Association/Noridian Administrative Service | 1. Whether the Intermediarys adjustment to direct nursing costs was proper. 2.Whether the Intermediary properly increased the total patient days to include respite care. |
| 2006-D51 | Gundersen Lutheran Hospital vs. BlueCross BlueShield Association/United Government Services, LLC-WI | Whether the denial of the Providers request for an exception to the end stage renal disease (ERSD) composite rate was in compliance with 42 CFR 413.180(h). |
| 2006-D56 | Sutter Merced Medical Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA | Whether the Intermediary properly disallowed Medicare bad debts. |
| 2006-D55 | Saint Anthonys Health Center vs. BlueCross BlueShield Association/AdminaStar Federal Illinois | Whether the full amount of Providers 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 notices of program reimbursement (NPR). |
| 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 QMBs) and paid under the Medicare Part B fee schedule. |
| 2006-D58 | Wilmington Treatment Center vs. BlueCross BlueShield Association/Cahaba Safeguard Administrators, LLC | Whether the Intermediarys disallowance of Medicare bad debts claimed by the Provider was proper. |
| 2006-D07 | Chicago 98-00 MSA Wage Index Group vs. Mutual of Omaha Insurance Company | N/A |
| 2006-D4 | Omega Hills, Inc. vs. BlueCross Blue Shield Association/AdminaStar Federal-Indiana (formerly Anthem Insurance Company) | Whether the Intermediarys adjustment to owners compensation was proper. |
| 2010-D13 | Royal Coast Rehabilitation Center vs. Blue Cross Blue Shield Association/First Coast Services Options, Inc. | Whether the Intermediarys adjustment disallowing bad debts arising from coinsurance and deductibles for dual eligible Medicare and Medicaid beneficiaries was proper. |
| 2010-D11 | HCA 01 Outpatient Therapy Bad Debts Group vs. Wisconsin Physician Services | Whether the Intermediary properly disallowed reimbursement for the Providers 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 Providers respective cost reporting periods ending 2001. |
| 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 Providers request for EJR over the validity of the provisions of the CMS Ruling CMS-1498-R. |
| 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-D51 | University of Louisville Hospital vs. BlueCross BlueShield Association/National Government Services | Whether the Intermediary properly reducted 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 that the Provider did not meet the written agreement requirement for counting resident time spent in nonprovider settings in 42 C.F.R. 412.105 and 413.86. |
| 2010-D53 | Henry Ford Health System vs. Blue Cross BlueShield Association/National Government Services, LLC | 1. Whether the Intermediary properly determined the Providers 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 in other approved programs, including unaccredited training programs. 2. Whether the Intermediary properly excluded FTEs attributable to time spent by residents in research that was required by the residents approved medical residency programs. |
| 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-D50 | Walter O. Boswell Memorial Hospital vs. Blue Cross /Blue Shield Association/AdminaStar Federal Illinois | 1. Whether the Providers nursing education program qualified as provider-operated. 2. Whether, assuming the Providers nursing education program did not qualify as provider-operated, the Provider is entitled to receive an additional payment to account for services provided to Medicare managed care patients. |
| 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-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 Providers cost reporting period and skilled nursing facilitys Medicare certification date with respect to the reimbursement scheme that should govern payments? |
| 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-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-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 federal fiscal year 2004 wage index for the Norfolk Metropolitan Statistical Area. |
| 2010-D46 | Davies Medical Center vs. BlueCross BlueShield Association/First Coast Service Options, Inc. | Whether the Intermediary properly denied the Providers Tax Equity and Fiscal Responsibilty Act (TEFRA) exception request. |
| 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 Intermediarys calculation of the new program add-on to the Provider FTE cap was improper by virtue of the fact that it omitted time spent by residents in research and scholarly activities. |
| 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-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-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-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-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-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 disproportionate share hospital (DSH) calculation for fiscal year-ending (FYEs) September 30, 2001 through September 30, 2004, was proper. |
| 2011-D13 | Western Medical Center- Santa Ana vs. BlueCross BlueShield Association/First Coast Service Options-CA | Whether it was proper for the Centers for Medicare and Medicaid Service to reduce by two percent the Medicare annual payment update for Western Medical Center - Santa Ana for federal fiscal year 2008. |
| 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-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-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) eligibility and payment determinations, including any impact such would have on capital DSH, was proper. |
| 2011-D9 | 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-D8 | 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, calculated pursuant to the existing regulation, would be decreased if the Provider's proposed manner of calculation is adopted. |
| 2011-D7 | 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-D6 | 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 Providers' 1996 resident cap for purposes of direct graduate medical education and indirect graduate medical education payments. |
| 2011-D5 | 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-D4 | 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-D3 | 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-D2 | 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 furnished during the cost reporting periods at issue. |
| 2011-D1 | 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 associated with rotations to the Providers' outpatient medical office clinics in FYE 12/31/1996, the GME FTE cap base year. |
| 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 Providers Medicare disproportionate share hospital (DSH) calculation for days attributable to patients who received medical assistance through Tennessees Medicaid demonstration project under section 1115 of the Social Security Act. |
| 2010-D37 | Carney Hospital Transitional Care Unit vs. BlueCross BlueShield Association/National Government Services | Whether the Intermediarys denial fo the Providers request for a new provider exemption from the Medicare routine service cost limits for SNFs was proper in light of the standards set forth in St. Elizabeth Medical Center of Boston, Inc. v. Thompson. |
| 2010-D19 | The Leaves, Inc. vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration | Whether the Intermediary improperly reclassified the Providers nursing school costs and related statistics to a non-reimbursable cost center. |
| 2010-D28 | Benedictine Hospital vs. BlueCross BlueShield Assocation/National Government Services- New York (formerly Empire Medicare Services) | Whether the Intermediary properly adjusted the Providers 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, 2000. |
| 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 Providers. |
| 2010-D18 | Arden Wood, Inc. vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration | Whether the Intermediary improperly reclassified the Providers nursing school costs and related statistics to a non-reimbursable cost center. |
| 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-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 Providers request for EJR over the validity of the provisions of the CMS Ruling CMS-1498-R. |
| 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-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 vs. BlueCross BlueShield Association/National Government Services-IN/First Coast Service Options | Whether the Board properly granted jurisdiction over the Providers 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 fraction of the disproportionate share adjustment; whether the Board should grant the Providers request for EJR over the validity of the regulations which insulate the Centers for Medicare and Medicaid Services from discovery and the Boards subpoena power; and whether the Board should grant the Providers request for EJR over failure by the Secretary to comply with section 951 of the Medicare Modernization Act. |
| 2010-D39 | Salt Lake Regional Medical Center vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Board had jurisdiction to grant the Providers request for expedited judicial review or EJR over the validity of the provisions of the CMS Ruling CMS-1498-R. |
| 2010-D29 | Hope Horizon Center, Inc. and Homestead Behavioral Clinic, Inc. vs. Blue Cross Blue Shield Association/First Coast Service Options, Inc. | Whether the Intermediarys adjustment disallowing bad debts arising from coinsurance and deductibles for dual eligible Medicare and Medicaid beneficiaries was proper. |
| 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 the numerators of both the Medicaid and Supplemental Security Income (SSI) percentages of the Medicare disproportionate share hospital (DSH) computation for purposes of the Providers fiscal year ended June 27, 1998 (FYE 6/27/98) Medicare cost report. |
| 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 Providers dual eligible bad debts when the Providers does not participate in the Medicaid program. |
| 2010-D21 | Reflections Wellness Center, Inc. vs. Blue Cross Blue Shield Association/First Coast Services Options, Inc. | Whether the Intermediarys 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 Providers 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 request for hearing was filed more than three years after the issuance of the notice of program reimbursement (NPR). |
| 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 Providers indirect medical education or IME reimbursement. |
| 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-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 Providers dual eligible bad debts when the Provider does not participate in the Medicaid program. |
| 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 Providers 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 request for hearing was filed more than three years after the issuance of the notice of program reimbursement (NPR). |
| 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 112% Hospital-Based Peer Group Mean; Toyon 2000 112% Hospital-Based Peer Group Mean; and Toyon 2001 112% Hospital-Based Peer Group Mean vs. BlueCross BlueShield Association/First Coast Service Options, Inc. | Whether CMS methodology for determining the Providers exception to the hospital-based skilled nursing facility cost limits was proper. |
| 2010-D34 | Canon Healthcare Hospice | Whether the Intermediary followed the proper reopening procedures prior to the issuance of the Intermediarys letter dated June 11. 2007 (Notice of Effect of Inpatient Day Limitation and Hospice Cap Amount) recalculating the hospice cap for years ending October 31, 2003 and October 31, 2004, respectively. |
| 2010-D17 | Broadview, Inc. vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration | Whether the Intermediary improperly reclassified the Providers nursing school costs and related statistics to a non-reimbursable cost center. |
| 2010-D16 | Chestnut Hill Benevolent Association vs. Blue Cross/Blue Shield Association/ Riverbend Government Benefits Administration | Whether the Intermediary improperly reclassified the Providers nursing school costs and related statistics to a non-reimbursable cost center. |
| 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-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. BlueCross BlueShield Association National Government Services | Whether the Intermediarys disallowance of the Illinois property tax assessment 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-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 Providers fiscal years 2000 through 2004 Medicare operating and capital disproportionate share hospital (DSH) adjustments by not including the Providers New Jersey Charity Care Program (NJCCP) inpatient days from the calculations of the numerator of the Medicaid proxy. |
| 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-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), the applicable Medicare regulation, 42 C.F.R. Section 405.378, and the Medicare Intermediary Manual (CMS Pub. 13-2) Section 2219. |
| 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-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-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 Medicare and Medicaid. |
| 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-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 calculation. |
| 2009-D6 | Banner Health System 2000 DSH Calculation Group vs. BlueCross BlueShield Association/Noridian Administrative Services (f/k/a BlueCross BlueShield of Arizona) | Whether the Providers State-funded categories of assistance qualify as Medicaid days for purposes of determining the Providers Medicare disproportionate share hospital adjustments (DSH) for the fiscal year 2000. |
| 2009-D2 | 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 average. |
| 2009-D8 | 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 Providers exception to the hospital-based skilled nursing facility cost limits was proper. |
| 2009-D3 | 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)(5)(F)(vi)(II). |
| 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 plans for the fiscal years in contention. |
| 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 plans for the fiscal years at issue. |
| 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 Part B fee schedule. |
| 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-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-D5 | Summer Hill Nursing Home vs. Mutual of Omaha Insurance Company | Whether the Intermediary properly adjusted Medicare bad debts. |
| 2008-D2 | LAC 98 DSH/Non-Federal Low-Income Days Group vs. BlueCross BlueShield Association/National Government Services - CA | 1. Whether the Providers 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 include GR days in the calculation of their disproportionate share percentage was arbitrary and capricious and in violation of law. |
| 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-D29 | St. Francis Regional Medical Center vs. Blue Cross Blue Shield Association/ Blue Cross Blue Shield of Kansas | Whether the Intermediarys adjustments disallowing a loss claimed by St. Francis Regional Medical Center upon its consolidation with St. Joseph Medical Center to form Via Christi Regional Medical Center was proper. |
| 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-D32 | Sharp Coronado Hospital and HealthCare Center vs. Blue Cross /Blue Shield Association United Government Services, LLC - CA | 1. Whether the Intermediarys calculation of the Providers disproportionate share hospital (DSH) payments, as it pertains to sub-acute unit days was proper; and 2. Whether the Intermediarys calculation of the Providers DSH payments, as it pertains to Medicare Part A exhausted days for dual eligible patients was proper. |
| 2009-D34 | Whidden Memorial Hospital vs. Blue Cross Blue Shield Association | (1) Whether the Intermediarys 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 denied the Providers application for a new provider exemption from the Routine Service Cost Limits or RCLs for its hospital-based skilled nursing facility (SNF). |
| 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-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, nor make a payment |
| 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 Intermediarys adjustments reflected in the revised Notices of Program Reimbursement (NPR), that reduced allowable home office costs, were proper. |
| 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 Providers for, and received, assistance under Georgias Indigent Care Trust Fund (ICTF) should be counted in the number of Medicaid-eligible days in the numerator of the Medicaid fraction used to calculate the Medicare disproportionate share (DSH) payments to the Providers. |
| 2009-D36 | Select Medical 2002-2003 Freestanding New Hospital Capital-Related Costs Groups vs. Wisconsin Physicians Service | Whether the Intermediarys adjustments to the Providers reimbursable capital cost after denying new hospital status 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 improperly computed the numerator of the Medicaid fraction that were used to calculate the Providers disproportionate share hospital (DSH) payments for fiscal years (FYs) 1999, 2000, 2001 and 2002 by excluding inpatient days attributable to individual who received assistance under the Massachusetts Uncompensated Care Pool (MA UCP) for such days. |
| 2009-D37 | Canonsburg General Hospital vs. BlueCross BlueShield Association | Whether CMS methodology for determining the Providers exception to the hospital-based skilled nursing facility (HB-SNF) routine cost limits was proper. |
| 2009-D41 | Kingston Hospital vs. BlueCross BlueShield Association/National Government Services, New York (formerly Empire Medicare Services) | Whether the intermediary properly adjusted the Providers 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 Intermediarys 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. |
| 2007-D1 | Iowa Lutheran Hospital vs. BlueCross/BlueShield Association/Cahaba Government Benefits Administrator | Whether the Intermediarys adjustments to the Medicare cost report that disallowed the loss on disposal depreciable assets resulting from a merger were proper. |
| 2007-D11 | Foothill Presbyterian Hospital vs. BlueCross BlueShield Association/United Government Services, LLC-CA | Whether the Intermediarys determination of reimbursable Medicaid bad debts for beneficiaries without Medicaid eligibility (non-cross-over beneficiaries) was proper. |
| 2009-D1 | Roanoke 93 DSH Medicaid Percentage Group vs. BlueCross BlueShield Association/National Government Services | Whether the Medicaid percentage component of the Providers disproportionate share hospital (DSH) adjustment has been properly computed to contain all Medicaid patient days including Medicaid eligible days. |
| 2009-D10 | Kindred Healthcare 05 Bad Debts vs. Wisconsin Physicians Service (formerly Mutual of Omaha) | Whether the Intermediarys adjustments to disallow Medicare bad debts written off by Kindred Healthcare 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 proper. |
| 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 Providers 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 that were characterized by the Intermediary as labor days. |
| 2009-D13 | Langley Porter Psychiatric Institute vs. BlueCross BlueShield Association/National Government Services - CA | Whether the Intermediarys determination of the Providers direct graduate medical education (DGME) payment was proper. |
| 2009-D15 | St. Josephs Hospital and Health Center vs. BlueCross BlueShield Association/BlueCross BlueShield of Texas | Whether the denial of the Providers request for an exception to the Tax Equity and Fiscal Responsibility Act (TEFRA) rate for its rehabilitation unit was proper. |
| 2009-D17 | Hospice 2009 BNAF Group/Bluegrass 2009 BNAF Group vs. Blue Cross Blue Shield Association/Palmetto Government Benefit Administrators | Should the Provider Reimbursement Review Board (Board) grant expedited judicial review over the question of whether Secretarys 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 Intermediarys 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 Reimbursement (NPR). |
| 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 Providers Medicare Disproportionate Share (DSH) adjustment calculation for the Providers fiscal years ended June 30, 1997, 1998, 1999, and 2000. |
| 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 Intermediarys 10 year delay in implementing the PRRBs case number 91-2673. |
| 2009-D24 | New England Deaconess Hospital vs. Blue Cross/ Blue Shield Association/ National Government Services | Whether the Intermediarys disallowance of the Providers 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 Connecticuts 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 appeal. |
| 2009-D27 | St. Marys Hospital-Milwaukee vs. Blue Cross Blue Shield Association/National Government Services, LLC-WI | Whether the Intermediary improperly calculated the Providers 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 Providers hourly wage rates. |
| 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 Providers disproportionate patient percentage contravenes the statute and regulations |
| 2009-D33 | Cleveland Regional Medical Center vs. Wisconsin Physicians Service | Whether the Intermediarys adjustment of disproportionate share hospital (DSH) reimbursement, based on its determination that the Provider had less than 100 available beds for DSH eligibility purposes. |
| 2009-D4 | Flagstaff Medical Center vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Intermediary properly calculated and applied the Providers ambulance cost per trip limit. |
| 2009-D5 | Mayo Clinic Hospital vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Intermediary used proper cost-to-charge ratios in calculating the Providers outlier payments. |
| 2009-D7 | 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-D9 | St. Luke Community Healthcare vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Intermediarys disallowance of the Providers certified registered nurse anesthetist (CRNA) on-call costs was proper. |
| 2007-D12 | El Camino Hospital vs. BlueCross BlueShield Association/United Government Services, LLC-CA | Whether all of the Providers 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 separate cost center line of the Medicare cost report. |
| 2007-D15 | P-B Health Home Care Agency, Inc. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators | Whether the Intermediary 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 Providers 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 Providers 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 Intermediarys adjustment of the Providers 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 Intermediarys denial of a loss on disposition of assets due to a consolidation of SVH and TMC was proper. |
| 2007-D2 | 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 (MSA) Wage Index. |
| 2007-D20 | Western Reserve Care System vs. BlueCross BlueShield Association/AdminaStar Federal, Inc. | 1. Whether the Intermediarys refusal to include the Providers cost for contracted perfusionist services in its wage index calculations was proper. |
| 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 Providers 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 Intermediarys denial of the Providers 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 Intermediarys adjustment excluding secondary MediKan eligible days from the Providers 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 Intermediarys 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 Providers Medicare bad debts. 2. Whether the Intermediary properly adjusted the Providers medical benefit plan costs. |
| 2007-D27 | North Memorial Health Care vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Providers fiscal years 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 base year costs utilized to calculate those limits. |
| 2007-D28 | Decatur County General Hospital vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrators | Whether the Providers 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 cost reduction to base year costs utilized to calculate those limits. |
| 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 Arizonas State-funded general assistance days qualify as Medicaid days for purposes of determining the Providers Medicare disproportionate share hospital (DSH) adjustments for the fiscal years ending (FYEs) 1994 through 2000. |
| 2007-D3 | Allegany County Department of Health vs. BlueCross BlueShield Association/United Government Services, LLC - WI | Whether the Intermediarys 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-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 Intermediarys 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, Delivery, Recovery and Postpartum (LDRP) rooms. |
| 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 Arizonas State-funded general assistance days qualify as Medicaid days for purposes of determining the Providers 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 Intermediarys 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 Intermediarys disallowance of accrued employee benefit costs that were not liquidated within one year after the end of the Providers cost reporting period was proper. |
| 2007-D38 | St. Gertrudes Health Center vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Intermediarys denial of the Providers 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 Providers indirect medical education adjustment (IME) and direct graduate medical education (DGME) payment. |
| 2007-D4 | Central Maine Medical Center, Lewiston, Maine vs. Blue Cross Blue Shield Association/Associated Hospital Services | Whether the Intermediarys denial of the Providers 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-D40 | Sierra Nevada Memorial Hospital vs. BlueCross BlueShield Association/United Government Services, LLC | Whether the Providers 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 Intermediarys denial of the Providers request for an adjustment to its Tax Equity and Fiscal Responsibility Act (TEFRA) target amount was 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 hospital (DSH) calculation. |
| 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-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 Providers rate adjustment request made under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). |
| 2007-D5 | 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-D50 | Methodist Hospitals of Memphis vs. BlueCross BlueShield Association/TriSpan Health Services | Whether the Intermediarys adjustment to the Providers per resident amount (PRA) 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 Intermediarys notification of the reopening of the Providers 1996 cost report was timely pursuant to regulatory standards. 2. Whether the Intermediarys determination to disallow costs for the Providers contracted therapy services was proper. |
| 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 Providers Notices of Program Reimbursement. |
| 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 Hospitals letter of March 8, 2001 requesting corrections to its hospital wage data for its fiscal year ended 6/30/1999 (including documentation contained in Exhibit 1-7) satisfied the requirements established by CMS (then HCFA) set forth in 66 Fed. Reg. 39828 -39871 (Aug 1, 2001) for a timely request to the hospitals intermediary to correct any incorrectly reported wage data on its cost report for purposes of the wage data correction process. |
| 2007-D53 | St. Francis Hospital vs. BlueCross BlueShield Association/Highmark Medicare Services (f/k/a Veritus Medicare Services) | Whether the Intermediarys 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 Intermediarys 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 Intermediarys determination of the Full-time Equivalent (FTE) intern and resident count for purposes of computing the Providers Indirect Medical Education (IME) and direct Graduate Medical Education (GME) adjustments for FYEs June 30, 1999 through June 30, 2001 was proper. |
| 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 Providers 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 Providers 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-D6 | Stormont-Vail Health Care vs. BlueCross BlueShield Association/Blue Cross & Blue Shield of Kansas | Whether the Intermediarys revised Notice of Program Reimbursement (NPR) issued on July 25, 2003, that increased the Providers Disproportionate Share Hospital (DSH) payment, included all Medicaid eligible days that would qualify for inclusion under HCFA Ruling 97-2. |
| 2007-D61 | Montefiore Medical Center vs. BlueCross BlueShield Association/National Government Services - NY | Whether the Intermediary improperly limited the Providers hospital-based Skilled Nursing Facilitys (SNFs) 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 Intermediarys determination of non-allowable physician office and vacant space costs was proper. |
| 2007-D63 | Saint Marys 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 Intermediarys notification of the opening of the Providers 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 Providers rehabilitation services was proper. |
| 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 Providers 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 Providers hospital-based Skilled Nursing Facilitys (SNFs) 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. Josephs Hospital/St. Johns Northeast Hospital vs. BlueCross BlueShield Association/Noridian Government Services | Whether the Intermediarys exclusion of certain non-Medicaid general assistance and other state-only funded patient days (General Assistance Days or GADs) from the Providers Medicaid Proxy was proper based on the instruction contained in Program Memorandum A-99-62. (St. Josephs for FYE 1997 through 2000) |
| 2007-D69 | Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators | Whether the Intermediarys adjustment to accounting expense was proper. |
| 2007-D7 | St. Joseph Regional Health Center vs. BlueCross BlueShield Association/ TrailBlazer Health Enterprises, LLC | Whether the Intermediarys 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-D70 | Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators | 1. Did the Intermediary improperly reopen the cost report? (Provider Issue 1); 2. Was the Intermediarys adjustment to bad debts proper? (Provider Issue 2); 3. Was the Intermediarys adjustment to salaries proper? (Provider Issue 3) |
| 2007-D72 | Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/ Palmetto Government Benefits Administrators | Was the Intermediarys adjustment to bad debts proper? 2. Was the Intermediarys adjustment to salaries proper? 3. Was the Intermediarys adjustment to contracted labor proper? |
| 2007-D73 | Logos Healthcare Rehabilitation of South Carolina vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators | Did the Intermediary improperly reopen the cost report?; 2. Was the Intermediarys 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 Intermediarys adjustment to Medicare bad debts proper?; 2-5. Were the Intermediarys 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 Intermediarys adjustment to salaries - physical therapy proper?; 3. Was the Intermediarys 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 Intermediarys adjustment to salaries proper?; 2. Was the Intermediarys 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 Intermediarys 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 plans in fiscal years ending December 31, 1998, 1999, 2000 and 2001. |
| 2007-D8 | Marion General Hospital vs. BlueCross BlueShield Association/TriSpan Health Services | Whether the Board may grant jurisdiction for the adjustment included in the Providers initial Notice of Program Reimbursement (NPR) pursuant to a revised NPR. |
| 2007-D9 | 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 Providers 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 Providers physician assistant emergency room availability costs were allowable as Medicare Part A reimbursable expenses. |
| 2007-D42 | Carolina Medicorp 1997 Claimed Loss Disallowance Group vs. BlueCross BlueShield Association/Cahaba Safeguard Administrators, LLC | Whether the Intermediarys 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-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 the Provider Reimbursement Manual so as to cause the exception request to be deemed approved in full. 2. Whether HCFA and the Fiscal Intermediary improperly denied the Tax Equity and Fiscal Responsibility Act (TEFRA) adjustment in its entirety, when at a minimum Oregon Medical Professional Review Organizations (OMPROs) independent medical review supported a reduced exception amount. 3. Whether HCFA and the Fiscal Intermediary erred in denying the Providers revised TEFRA exception request without correcting the Intermediarys use of an incorrect TEFRA target rate. |
| 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 Providers liability for erroneous payments made to the former owners of the skilled nursing facilities (SNFs) after the change of ownership. |
| 2007-D60 | Guam Memorial Hospital Authority vs. BlueCross BlueShield Association/United Government Services, LLC-CA (n/k/a National Government Services-CA) | Whether the Intermediarys adjustment disallowing the Providers claimed withholding tax expense was proper. |
| 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 Providers 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. |
| 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 Intermediarys adjustment to the salaries, benefits and mileage of the program managers was proper. 3. Whether the Intermediarys adjustment to Dara Stewarts salary and benefits was proper. 4. Whether the Intermediarys reopening was proper. |
| 2007-D71 | Logos Healthcare Rehabilitation Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators | 1. Was the Intermediarys adjustment to Medicare bad debts proper? (Provider Issue 1); 2. Were the Intermediarys adjustments to salaries - administrative proper? (Provider Issue 2); 3. Was the Intermediarys adjustment to salaries - physical therapy proper? (Provider Issue 2); 4. Was the Intermediarys adjustment to salaries - speech therapy proper? (Provider Issue 2); 5. Was the Intermediarys adjustment to salaries - occupational therapy proper? (Provider Issue 2); 6. Was the Intermediarys adjustment to other charges - physical therapy proper? (Provider Issue 3); 7. Was the Intermediarys adjustment to other charges - speech therapy proper? (Provider Issue 3); 8. Was the Intermediarys adjustment to other charges - occupational therapy proper? (Provider Issue 3); 9. Was the Providers request for additional costs for depreciation proper? (Provider Issue 4 and Intermediary Issue 17 in Initial Position Paper) |
| 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 cost reporting periods. |
| 2008-D1 | Marion General Hospital vs. BlueCross BlueShield Association/National Government Services - Indiana | Whether the recission of the hospital approved request for Sole Community Hospital (SCH) status was proper. |
| 2008-D10 | Hackensack University Medical Center vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator | Whether the Intermediary adjustments to the Provider 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 determine the Provider Medicare disproportionate share hospital(DSH) payment for fiscal year 2002. |
| 2008-D13 | Covenant Health System 91, 93-97 DSH/Medicaid Proxy Group vs. Mutual of Omaha Insurance Company | Whether the Intermediarys calculation of the disproportionate share hospital (DSH) payment was proper. |
| 2008-D15 | Allentown Osteopathic Medical Center vs. BlueCross BlueShield Association/Veritus Medicare Services (n/k/aHighmark Medicare Services) | Whether the Intermediarys adjustment, disallowing the loss claimed by Provider, was proper. |
| 2008-D14 | Riverside Center for Jewish Seniors vs. BlueCross BlueShield Association/Highmark Medicare Services | Whether the Intermediarys adjustment to remove Nursing Administration, Medical Records, and Social Services allocation statistics from the Providers ancillary cost centers on the Medicare cost report were 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 Intermediarys determination of allowable interest expense which deducted Hillcrest Medical Tower (HMT)interest from allowable versus total expense is proper.; 3. Whether the Intermediarys adjustment to disallow accrued FICA expense is proper.; 4. Whether the Intermediarys adjustment to the cafeteria revenue offset is proper.; 5. Whether the Intermediarys adjustment to limit bond cost amortization is proper.; 6. Whether the Intermediarys adjustment to disallow debt cancellation costs is proper.; 7. Whether the Intermediarys adjustment to disallow depreciation expense is proper.; 8. Whether the Intermediarys determination that a portion of the 1985 bonds were unnecessary is proper.; 9. Whether the Intermediarys adjustment to disallow accrued zero coupon bond interest expense is proper. |
| 2008-D18 | Mercy Center for Health Care Services vs. BlueCross BlueShield Association/AdminaStar Federal, Inc. | Whether the Intermediarys 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 Providers full-time equivalent (FTE) resident counts. |
| 2008-D20 | HealthEast Woodwinds Hospital vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Intermediarys refusal to reimburse the Provider for capital-related costs under the hold harmless methodology was proper. |
| 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 determine the Providers Medicare disproportionate share hospital (DSH) payment for fiscal year 2000. |
| 2008-D23 | University of Texas M.D. Anderson Cancer Center vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises | 1. Whether the Intermediary properly disallowed the Providers 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 calculated the Providers 1996 reasonable cost that were included in the denominator of the fraction used to determine the payment-to-cost ratio for purposes of the Outpatient Prospective Payment System (OPPS) hold harmless payment. |
| 2008-D24 | Summit Medical Center vs. BlueCross BlueShield Association/National Government Services, LLC - CA | Whether the TEFRA base year used by the fiscal intermediary to compute a target amount for the Providers 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 Providers reported payments, more than three years after the date of the original Notice of Program Reimbursement (NPR). |
| 2008-D27 | Oswego Medical Center vs. BlueCross BlueShield Association/Wheatlands Administrative Services | Was the Intermediarys adjustment to the providers claimed owners compensation proper? |
| 2008-D29 | UPHS 99/ 2000 Medicare + Choice Beneficiaries Group vs. Mutual of Omaha Insurance Company | Whether the Providers 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 file UB-92s in accordance with CMS instruction. |
| 2008-D3 | Bayfront Medical Center vs. BlueCross BlueShield Association/First Coast Service Options, Inc. | Whether the Intermediarys disallowance of the discharges not reflected in the PS&R was proper. |
| 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 Providers treatment of asset relifing.; 3. Whether the Intermediary properly adjusted public relations and marketing expenses.; 4. Whether the Intermediary properly adjusted officers life insurance and wind down expenses. |
| 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 Providers 1987 cost reporting period through a revised Notice of Program Reimbursement (NPR) issued in January 2002. |
| 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 Intermediarys denial of the Providers request to be reimbursed the transitional period rate for SNFs under 42 C.F.R. Section 413.340(e) for the cost reporting year ended December 31, 1999, was proper. |
| 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 required by the residents approved medical residency programs; 3. Whether the Intermediary properly excluded FTEs attributable to resident leave time when it is taken during rotations in which the resident is conducting reserarch.; 4. Whether the Intermediary properly excluded from the FTE cap, FTes attributable to time spent by residents in new programs. |
| 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 Providers indirect medical education or IME reimbursement; 2. Whether to include Medicaid outpatient observation days when determining the Providers disproportionate share hospital or DSH eligibility and payment. |
| 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 Providers disproportionate share hospital (DSH) payments for fiscal years (FYs) 1999, 2000, 2001, and 2002 by excluding inpatient days attributable to individuals who were both eligible for medical assistance under an approved Medicaid State plan and enrolled in a Medicare +Choice (M+C) plan for such days.; 2. Whether the Intermediary improperly computed the numerators of the Medicaid fractions that were used to calculate the Providers DSH payments for FYs 1999, 2000, 2001 and 2002 by excluding inpatient days attributable to individuals who allegedly received assistance under the Massachusetts Uncompensated Care Pool for such days.; 3. Whether the Intermediary improperly computed the Medicaid fraction that was used to calculate the Providers DSH payment for fiscal year 2002 by i) excluding from the numerator inpatient days attributable to individuals who were in a labor and delivery room at the census-taking hour and who had not previously occupied a routine bed and ii) including such days in the denominator.; 4.Whether the Medicare/Supplemental Security Income (SSI) fraction that was used to calculate the Providers DSH payment for FY 1999 should be recalculated, or, in the alternative, whether the Medicare SSI fraction should be revised. |
| 2008-D38 | Polyclinic Medical Center vs. Blue Cross Blue Shield Association/ Veritus Medicare Services (n/k/a Highmark Medicare Services) | Whether the Intermediarys adjustments to the Providers 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 Intermediarys adjustments to the Providers cost report that disallowed the loss on disposal of depreciable assets through consolidation were proper. |
| 2008-D4 | Hallmark Health System, Inc. vs. BlueCross BlueShield Association/National Government Services-Maine (f/k/a Associated Hospital Service) | Whether the Intermediarys determination of the Providers dental intern and resident count for purposes of calculating its direct and indirect medical education adjustment was accurate. |
| 2008-D41 | Munson Medical Center vs. BlueCross BlueShield Association/National Government Services, LLC - WI | Whether the Intermediary correctly limited the Providers ambulance reimbursement to its charges. |
| 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 Providers indirect medical education full-time equivalent (FTE) cap? |
| 2008-D45 | Swedish American Hospital vs. Mutual of Omaha Insurance Company (n/k/a Wisconsin Physicians Service) | Whether the Intermediarys 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. |
| 2008-D6 | 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 Providers fiscal year ending (FYE) December 31, 1996 Medicare cost report. |
| 2008-D7 | St. Marys Hospital - Milwaukee vs. BlueCross BlueShield Association/National Government Services, LLC-WI | 1. Whether CMS properly calculated the Providers 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 Providers Medicare DSH adjustment by excluding 366 Long Term Respiratory Unit (LTRU) patient days from the Medicaid proxy of the DSH calculation. |
| 2008-D8 | Visiting Nurse Association of Texas vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators | Whether the Intermediarys 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-D9 | Medical Park Hospital vs. BlueCross BlueShield Association/Arkansas BlueCross & BlueShield | Whether the Providers Disproportionate Share Hospital (DSH) adjustment was correctly calculated. |
| 2010-D4 | 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-D10 | Genesis Health 96 Salaries of Therapists Group vs. BlueCross and BlueShield Association/First Coast Service Options, Inc. | Whether the Intermediarys deletion of therapy costs from line 25, column 9 of Worksheet B-1 of the Providers Medicare cost reports is proper and in accordance with Medicare cost reporting practices and procedures. |
| 2010-D2 | Select Medical 2003-2006 New Hospital Capital-Related Costs Groups vs. Wisconsin Physicians Service (formerly Mutual Of Omaha Insurance) | Whether the Intermediarys adjustments to the Providers reimbursable capital costs after denying new hospital status was proper. |
| 2010-D5 | 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-D1 | University Hospital vs. BlueCross BlueShield Association/TrailBlazer Health Enterprises, LLC | Whether the Intermediarys 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-D6 | Greenville Hospital Center vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administration | Whether the Intermediarys disallowance of resident time spent in didactic activities for purposes of the indirect medical education (IME) adjustment was proper. |
| 2010-D9 | 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-D3 | 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 wage index. |
| 2010-D7 | Mercy Medical Center vs. Wisconsin Physician Services | Whether the Intermediary improperly calculated the Providers 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 part of the period at issue. |
| 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 accordance with the Medicare statute at 42 U.S.C. Section 1395ww(d)(5)(F)(vi)(II). |
| 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 Providers disproportionate share hospital (DSH) adjustment. |
| 2011-D25 | John L. Doyne Hospital vs. BlueCross BlueShield Association/National Government Services - WI | Whether the Providers post-retirement health benefit costs are allowable costs in the Providers 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 resident count for direct Graduate Medical Education (GME) and Indirect Medical Education (IME). |
| 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 share hospital (DSH) payment. |
| 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 share hospital (DSH) payment. |
| 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 was proper. |
| 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. |
| 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 System (PPS) for inpatient operating and capital costs for the fiscal year ended (FYE) December 31, 2001. |
| 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 funds in computing the fraction reflecting the percentage of inpatients who were entitled to medical assistance under an approved state plan (the Medicaid fraction) for purposes of the Medicare disproportionate share hospital calculation. |
| 2006-D1 | Saint Mars Hospital vs. BlueCross BlueShield Association/Noridian Administrative Services | Whether the Intermediarys denial of the Providers request for an adjustment to its TEFRA target amount due to untimely filing of the request was proper. |
| 2006-D3 | Trenton Psychiatric Hospital vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator | Whether the Intermediarys adjustments to disallow reimbursement for physicians professional services on a reasonable cost basis was proper. |
| 2006-D5 | Rush-Presbyterian-St. Lukes Medical Center vs. BlueCross BlueShield Association/AdminaStar Federal | 1. Whether the Intermediarys adjustment to the Providers disproportionate share (DSH) payment was proper. 2. Whether the Intermediarys calculation of the number of interns and residents and the amount of allowable costs for fiscal year 1991 for purposes of the Graduate Medical Education (GME) Programs (both for purposes of GME and IME) was proper. 3. Whether the Intermediary properly disallowed expenses relating to the Inn at University Village rather than re-classifying the expenses as investment losses to be offset against investment income. |
| 2006-D13 | Community Hospital of the Monterey Peninsula vs. BlueCross BlueShield Association/United Government Services, LLC-CA | Whether for purposes of the Providers disproportionate share (DSH) adjustment calculation, the Provider is entitled to an increased number of days of care rendered to eligible Medicaid beneficiaries. |
| 2006-D10 | Highland Medical Center vs. Mutual of Omaha Insurance Company | Whether the Intermediarys 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-D12 | Immanuel - St. Josephs Hospital vs. Blue Cross Blue Shield Association/Noridian Administrative Services | Whether the Intermediarys 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-D14 | Harborside Healthcare-Reservoir vs. BlueCross BlueShield Association/Empire Medicare Services | Whether the Intermediary properly denied the Providers new provider exemption request. |
| 2006-D11 | St. Joseph Hospital vs. Mutual of Omaha Insurance Company | Whether the denial of the Providers request for an exception to the renal dialysis composite rate by the Centers for Medicare and Medicaid Services (CMS) was proper. |
| 2006-D15 | Acadian HomeCare, Inc. vs. Blue Cross Blue Shield Association/Palmetto Government Benefits Administrators | Whether the Intermediarys disallowance of medical director fees was proper. |
| 2006-D9 | Washington County Memorial Hospital vs. BlueCross BlueShield Asssociation/TriSpan Health Services | Whether the Intermediarys 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-D8 | Preferred Management Corporation Group vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators | Whether the Intermediarys adjustments reallocating key employee and owners bonuses were proper. |
| 2006-D6 | Professional Home Care, Inc., Garvin and Moore Okla. Professional HC 97 Access Infusion Group vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators | Whether the Intermediarys adjustment of the Providers physical therapy costs was proper. |
| 2006-D16 | Dameron Hospital vs. Blue Cross Blue Shield Association/United Government Services, LLC | Whether the Intermediarys disallowance of the Providers inpatient and outpatient Medicare bad debts was proper. |
| 2006-D18 | The Medical Team vs. Blue Cross Blue Shield Association/Cahaba Government Benefit Administrators | Whether the Intermediarys adjustment applying Medicares Physical Therapy Compensation Guidelines to the Providers 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 Intermediarys adjustment of the Providers DSH calculation was based upon a proper interpretation of the Medicare DSH statutes as amended by the BIPA of 2000. |
| 2006-D17 | Alden Court Nursing Home vs. Mutual of Omaha Insurance Company | Whether CMS denial of the Providers request for an exception to the routine cost limits for skilled nursing facilities as a provider of atypical services was proper. |
| 2006-D23 | University of Pittsburgh Medical Center (UPMC) - St. Margaret Hospital vs. BlueCross BlueShield Association/ Veritus Medicare Services | Whether the Intermediarys adjustments to the Medicare cost report that disallowed the loss on disposal depreciable assets due to the facilitys change of ownership (CHOW) were 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-D20 | Baystate Medical Center vs. Mutual of Omaha Insurance Company | 1. Whether the CMS determination of the Providers 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 entitled to (a) an order from the Board directing CMS to correct such determination and the Intermediary to implement and pay any additional amounts due the Provider as the result of such correction; or (b) an order from the Board granting other appropriate relief. |
| 2006-D29 | Montefiore Medical Center vs. BlueCross BlueShield Association/Empire Medicare Services | 1. Whether the Intermediarys 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 Services methodology for determining the Providers exceptions to the hospital-based skilled nursing facility cost limits was proper. |
| 2006-D24 | Advanced Rehabilitation Services, Inc.; Prospect Rehabilitation Services, Inc. vs. BlueCross BlueShield Association/Riverbend Government Benefits Administrator | Whether the Intermediarys adjustments disallowing the Providers claimed Medicare Bad Debts, disallowed in a prior year period, were proper. |
| 2006-D28 | Provena St. Joseph Medical Center and Provena United Samaritans Medical Center vs. BlueCross BlueShield Association/AdminaStar Federal Illinois | Whether the Intermediarys 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-D30 | Greenbriar Nursing and Convalescent Center/Guest House of Slidell/Riverland Healthcare Center vs. Blue Cross Blue Shield Association/TriSpan Health Services | Whether the Intermediarys adjustments to reduce the Providers outpatient therpay costs by 10 percent were proper. |
| 2006-D26 | Mary Hitchcock Memorial Hospital vs. BlueCross BlueShield Association/Anthem Health Plans of New Hampshire, Inc. | Whether the denial of the Providers request for an exception to the renal dialysis composite rate by the Centers for Medicare and Medicaid Services (CMS) was proper. |
| 2006-D21 | HCT 94-95 Physical Therapy AHSEA Exception Group vs. Mutual of Omaha Insurance Company | Whether the Intermediary properly denied the Providers requests for an exception to the Medicare allowable hourly salary equivalency amount for physical therapy. |
| 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-D22 | Saint Anthonys Health Center vs. BlueCross BlueShield Association/ AdminaStar Federal Illinois | Whether CMS determination of the Providers Medicare Part A/Supplemental Security Income (SSI) percentage, commonly known as the Medicare fraction component of the disproportionate share (DSH) percentage, was proper. |
| 2006-D25 | MGH Home Health vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators | Whether the Intermediarys application of salary equivalency guidelines to the compensation of physical therapists employed by the Provider on a per visit basis was improper. |
| 2006-D49 | CT Subacute Corp. 93 Capital Lease Group vs. BlueCross BlueShield Association/Empire Medicare Services | Whether the Intermediarys adjustments to disallow rental expense as a cost incurred with a related organization were proper. |
| 2006-D37 | Lawrence & Memorial Hospital vs. BlueCross BlueShield Association/Empire Medicare Services | Whether the Intermediarys 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 Providers 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 1881(b)(7) of the Act. |
| 2006-D44 | DCH Regional Medical Center vs. BlueCross BlueShield Association/BlueCross BlueShield of Alabama | Whether the Intermediary/Centers for Medicare and Medicaid Services denial of the request to include additional pension costs as wage-related costs for purposes of the Providers FY 2004 wage index was proper. |
| 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 be allocated to medical records and assembled work force assets to determine the amount of gain or loss on the sale. |
| 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 the time therapy services were rendered and provided to patients that were dually eligible for Medicare and Medicaid (Qualified Medicare Beneficiaries or QMBs). |
| 2006-D45 | The Milton S. Hershey Medical Center vs. BlueCross BlueShield Association/Veritus Medicare Services | Whether the CMS denial of the Providers request for an exception to the end stage renal disease (ESRD) composite rates based on atypical service intensity and patient mix was correct. |
| 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 Providers hospital-based physicians. |
| 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-D43 | Greenwood County Hospital vs. BlueCross BlueShield Association/BlueCross BlueShield of Kansas | Whether the Provider was improperly denied a Medicare low-volume adjustment. |
| 2006-D50 | CT Subacute Corp. 98 Protested Items Group vs. BlueCross BlueShield Association/Empire Medicare Services | Whether the Intermediarys adjustments to disallow rental expense as a cost incurred with a related organization were proper. |
| 2006-D42 | Logos Healthcare Rehabilitation, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators | Whether the Intermediarys adjustment to accounting expense was proper. |
| 2006-D48 | District of Columbia General Hospital vs. Blue Cross Blue Shield Association/Carefirst of Maryland | Whether the Intermediarys determination of available bed days for the purpose of calculating the Providers IME payment was accurate. |
| 2006-D34 | St. David s 89-92 Related Organization Purchased Services Group vs. Blue Cross Blue Shield Association/Trailblazer Health Enterprises, LLC | Whether the Intermediarys denial of the Providers request for an exception to the related organization principle for calendar years 1989 through 1992 was proper. |
| 2006-D33 | Visiting Nurse Association of Washington, D.C. vs. BlueCross BlueShield Association/Cahaba Government Benefit Administrators | Whether the Intermediarys adjustment of the Providers physical therapy costs was proper. |
| 2006-D41 | Comprehensive Home Care, Inc. vs. BlueCross BlueShield Association/Palmetto Government Benefits Administrators | Whether the Intermediarys disallowance of accrued compensation for the Providers President/Chief Executive Officer (CEO) and Vice-President/Operations Manager was proper. |
| 2006-D38 | St. Vincents Medical Center vs. BlueCross BlueShield Association/Empire Medicare Services | Whether the Intermediarys adjustment to disallow the Connecticut Sales Tax was proper. |
| 2006-D46 | Sisters of Charity Hospital vs. BlueCross BlueShield Association/Empire Medicare Services | Whether the Intermediary properly calculated the Providers indirect medical education (IME) reimbursement. |
| 2006-D40 | Loma Linda University Kidney Center vs. BlueCross BlueShield Association/United Government Services, LLC-CA | Whether the denial of the Providers 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 1881(b)(7) of the Act. |
| 2012-D16 | Alegent Health-Immanuel Medical Center vs. Wisconsin Physicians Service | Whether the Intermediarys adjustments to disallow the Providers indirect medical education (IME) and direct graduate medical education (DGME) reimbursement for its graduate medical education activities were correct. |
| 2012-D15 | Canon Health Care Hospice vs. BlueCross BlueShield Association/Palmetto Government Benefits Administration. | Whether a full or partial waiver is permissible for the Providers hospice inpatient day limitation overpayment for the cap year November 1, 2005 through October 31, 2006. |
| 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-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 wage index for the Fort Wayne, Indiana, Metropolitan Statistical Area (MSA). |
| 2012-D12 | Research Medical Center vs. Wisconsin Physicians Service | Whether the Intermediarys 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-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 Providers family practice residency program for fiscal years ended May 31, 2001 through May 31, 2007. |
| 2012-D10 | Alameda Hospital- SNF vs. BlueCross BlueShield Association/First Coast Service Options, Inc. | Whether the United States District Courts memorandum decision, finding the Secretarys methodology was improper under the precedent established in Alaska Professional Hunters Association, Inc. v. FAA, also applies to the Secretarys low occupancy adjustment. |
| 2012-D9 | Rush University Medical Center vs. BlueCross/Blue Shield Association/National Government Services, Inc. (formerly AdminaStar Federal, Inc.) | 5-A. Whether the Intermediarys adjustments to the Providers bed count, as used for purposes of the indirect medical education (IME) calculation, was proper. 5-B. Whether, in calculating the Providers bed coutn as used for purposes of IME calculation, there should have been a reduction for beds used for observation purposes. 5-C. Whether, for purposes of the Providers intern and resident count for IME, the Intermediary correctly disallowed research rotations for residents participating in an approved medical residency program at hte Provider. |
| 2012-D8 | 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 Providers direct graduate medical education (DGME). 2-A. Whether the Intermediarys adjustments to the Providers bed count, as used for purposes of the indirect medical education (IME) calculation was proper. 2-B. Whether, in calculating the Providers bed count as used for purposes of IME calculation, there should have been a reduction for beds used for observation purposes. |
| 2012-D7 | Alegent Health-Immanuel Medical Center vs. Wisconsin Physicians Service | Whether the Intermediarys adjustments to disallow the Providers indirect medical education (IME) and direct graduate medical education (DGME) reimbursement for its graduate medical education activities were correct. |
| 2012-D6 | 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 share hospital (DHS) payment. |
| 2012-D5 | Youngstown-Warren 02 Wage Index vs. BlueCross BlueShield Assocation/National Government Services, Inc. | 1. Whether the Fiscal Intermedairy erred in refusing to exclue the Providers 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 providers costs for contracted perfusionist services in its FFY 2002 wage index calculations. |
| 2012-D4 | 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-D3 | Lakeland Regional Medical Center vs. BlueCross BlueShield Assocation/National Government Services | Whether the Intermediarys adjustment of the Providers Medicare bad debts because they were written off while they remained at an outside agency, was proper. |
| 2012-D2 | 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 Providers fiscal year end 12/31/97 and 10/31/98 cost reports due to the Intermediarys issuance of the Notice of Program Reimbursement over ten years after the cost report year ends. 2. Whether the Intermediary improperly disallowed bad debts claimed and costs related to the hospitals unduplicated census for fiscal year ends 12/31/97 and 10/31/98. |
| 2012-D1 | 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 Fairfield; Mercy Franciscan Hospital Western Hills; Fort Hamilton Hospital; Christ Hospital; Mercy Franciscan Hospital—Mt. Airy; Mercy Hospital Clermont; and the Cincinnati-Middletown, OH-KY-IN CBSA for Federal Fiscal Year (FFY) 2009. 2. Whether the Fiscal Intermediary and CMS properly determined the Wage Indexes for St. Elizabeth Medical Center and the Cincinnati-Middletown, OH-KY-IN CBSA for Federal Fiscal Year 2009. This was a Medicare Group Appeal involving the FFY 2009 hospital wage index established for St. Elizabeth Medical Center (St. Elizabeth) and for the Cincinnati-Middleton, OH-KY-IN CBSA, and the hospitals using this wage index. |
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