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Supplemental Security Income Group Appeal
The Opportunity
The disproportionate share hospital (DSH) statute at 42 U.S.C. § 1395ww(d)(5)(F) utilizes two different "proxies" to determine the "Disproportionate Share Percentage" of indigent patients critical to establishing DSH program eligibility and payment adjustments. The two proxies are added together to calculate the Disproportionate Share Percentage. One proxy, called the "Medicaid proxy" is the number of patient days for patients eligible for medical assistance under a Title XIX (Medicaid) approved state plan, but not entitled to benefits under Medicare Part A, divided by the hospital's total number of patient days. The Medicaid Proxy has already been the subject of various successful appeals that eventually forced CMS in 1997 to include days for which patients were eligible for Medicaid but for which no Medicaid payment was made.

The BHC sponsored Group Appeals focus on the second proxy, called the "Medicare Proxy." This proxy consists of patient days for patients who were entitled to Medicare Part A and entitled to Supplemental Security Income (SSI) benefits, divided by Medicare Part A patient days.

For some time, many hospitals have questioned whether the SSI figure given by the Intermediary/CMS was accurate. There is now considerable evidence to suggest that CMS and Intermediaries have been providing SSI numbers that are very inaccurate and may understate the Medicare Proxy percentage by a substantial margin. This understatement may prevent some hospitals that should receive DSH payments from reaching the indigent care percentage required to be eligible for DSH program payments. In addition, a significant understatement of SSI days would decrease otherwise appropriate DSH payments to existing DSH hospitals up to their cap.

In a recent hearing before the Provider Reimbursement Review Board (PRRB), CMS representatives were compelled to testify as to the methodology used to determine the SSI percentage that is later passed on to hospitals. The testimony revealed many instances where the methodology seemed clearly flawed.

For this project, Baker Healthcare Consulting, Inc. has partnered with the law firm of Hall Render and DataGen, Inc. A HANYS Solutions Company. To determine if an individual hospital is likely to benefit from participation for one or more years, contact Dale Baker for a hospital specific analysis.