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Posts tagged "Medical Assistance"

Nursing Home Medical Assistance Per Diem Payments To Be Denied If Resident's Attending Physician Not An MA Certified Provider

In a Medical Assistance (MA) Bulletin issued April 1, 2016, the Department of Human Services (DHS) stated that effective September 25, 2016, physicians and practitioners who order, refer or prescribe items or services for MA beneficiaries must themselves be enrolled in the MA Program. The Bulletin states that to "track" this requirement, DHS will look to the claim field for the "ordering or referring physician" and the NPI number associated with that physician. If that physician is not on file as an MA provider, then the claim will be denied.

Third Circuit Greenlights Short-Term Medicaid Annuities

The use of Medicaid annuities as planning device has been a hotbed of litigation since the passage of the Deficit Reduction Act of 2005 (DRA). The Pennsylvania Department of Human Services (DHS) has routinely found itself on the losing end of this ongoing battle. In the case of Zahner v. Secretary Pennsylvania Department of Human Services, the United States Court Of Appeals for the Third Circuit addressed the use of short-term annuities as a Medicaid planning device, issuing another decision favoring Medical Assistance (MA) beneficiaries. The Zahner decision has significant implications for the provider community.

Medicaid Enrollment Revalidation Deadline Looming

The Affordable Care Act requires Medicare and Medicaid providers to revalidate their enrollment information, initially by March 24, 2016 and at least every five (5) years thereafter. This process is already underway in Pennsylvania for Medical Assistance providers, and is coordinated through the Office of Long Term Living (OLTL). You can access OLTL's revalidation information here.

Court Issues Significant Medical Assistance Undue Hardship Waiver Decision

In Colonial Park Care Ctr. v. Dep't of Human Services, a decision published on September 21, 2015, the Commonwealth Court of Pennsylvania affirmed the decision of the Bureau of Hearings and Appeals (BHA) imposing a penalty on a nursing facility resident's eligibility for Medical Assistance (MA) benefits due to a transfer of assets for less than fair market value. While the ruling is somewhat predictable and represents a loss for the beneficiary, the decision appears to expand the traditional basis upon which a beneficiary can seek an undue hardship waiver from a penalty period.

Court Holds Responsible Party Provisions are Consistent with Nursing Home Reform Act

In the recent case of Eades v. Kennedy, PC Law Offices, the United States Court of Appeals for the Second Circuit found that provisions of an admission agreement that imposed certain financial obligations on the husband of a nursing home resident did not violate the Nursing Home Reform Act (NHRA), and that the NHRA does not preempt Pennsylvania's indigent support statute. In that case, the daughter and husband of a deceased nursing home resident filed suit against the law firm hired by the nursing home to collect resident's unpaid bill. As part of their claim, the plaintiffs claimed that the responsible party provisions of the admission agreement were unlawful under the NHRA. They further argued that the NHRA preempted Pennsylvania's indigent support statute.

Provider Right to Sue for Adequate Rates in Federal Court Severely Restricted

In Armstrong v. Exceptional Child Center, Inc., the United States Supreme Court found that providers do not have a private right of action under §30(A) of the Medicaid Act to require a state to increase Medicaid payment rates, significantly impacting the ability of providers to sue states in federal court to challenge Medicaid rates. Section 30(A) of the Medicaid Act, often referred to as the "Equal Access Provision," requires states to:

BHA Hearing Delays and Requesting Interim Assistance

Historically, the Bureau of Hearings and Appeals (BHA) has prioritized the scheduling and adjudication of Medical Assistance (MA) eligibility appeals over other types of appeals. Recently, however, beneficiaries and providers have experienced significant delays in the resolution of MA eligibility appeals. In some instances, the BHA is taking several months to schedule hearings on MA eligibility determinations. Generally, the BHA must take "final administrative action" within 90 days of the filing date of the appeal. "Final administrative action" means a decision by the hearing officer. If final administrative action is not taken within 90 days of the filing of the appeal, the Department of Human Services is required to authorize the payment of MA benefits to the provider on behalf of the resident pending the final administrative action. Interim assistance is not subject to restitution absent an affirmative misrepresentation by the beneficiary. In cases where the beneficiary is responsible for delaying the hearing process, the time limit for final administrative action is extended by the length of the delay.

DPW Publishes Case Mix Rates for 2014-2015

On September 20, 2014, the Department of Public Welfare published a notice in the Pennsylvania Bulletin regarding final case mix rates for state fiscal year 2014-2015.  Nursing facilities have received letters detailing their rates for that fiscal year.  Most notably, the budget adjustment factor continues to limit the estimated statewide day-weighted average payment rate for county and nonpublic nursing facilities so that the average payment rate in effect for the fiscal year is limited to the amount appropriated by the state legislature for funding.  For the July, October, in January rates, the base budget adjustment factor is .84265.  At the minimum, providers should review their rate notice letters to determine the cost report years DPW is using to set the facility's case-mix rates.  If the provider has an audit appeal pending for one of its base years, then the best practice would be to file an appeal of the case-mix rate notice to preserve any issue regarding the add-back of costs to the base year and subsequent recalculation of the payment rate.  Providers have 33 days from the date of the letter to file a request for hearing with the Bureau of Hearings and Appeals.

Final PSAE Rules Issued By DPW

On September 13, 2014, DPW issued its final rule addressing Preventable Serious Adverse Events (PSAE) for nursing facilities. The PSAE requirements become effective October 1, 2014, subject to CMS approval of a related state plan amendment.  Once effective, a nursing facility may not seek payment from a resident or a health care payor (including the Medical Assistance Program) for a PSAE (as defined within the regulations) or for any corrective services following a PSAE. Further, a nursing home that discovers it was paid for such services is required to refund such payments to either the resident or the health care payor within 30 days of discovery. Further information on reporting methods, claims and best practices can be found on DPW's website.

Refunds of Resident Trust Accounts

On June 26, 2013, the General Assembly of the Commonwealth of Pennsylvania amended the Probate, Estates, and Fiduciaries Code to allow nursing facilities to disperse up to $10,000 from a resident trust account after the resident's death in certain circumstances. If the deceased resident was a recipient of Medical Assistance benefits, the facility may disperse up to $10,000 from the resident trust account to a licensed funeral director to contribute to burial expenses, regardless of whether a personal representative has been appointed. If the decedent's burial expenses total less than $10,000, then the facility may pay the remaining funds to the decedent's family members, not to exceed $10,000. Preference is given to family members in the following order: spouse, child, parent, then sibling. Previously, facilities could only disperse up to $3,500 from a patient's care account to a licensed funeral director and could not exceed a total of $4,000 after paying the remainder to family members. If a facility makes such a payment, it will be released to the same extent as if the payment had been made to the decedent's personal representative.

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