AHA: CMS should overturn mid-build denials issued to PBDs

CMS should rescind denials recently issued to certain off-campus provider-based departments (PBD) that applied for the mid-build exception under the 21st Century Cures Act, the AHA said in a March 25 letter to CMS. The agency released audit results and denials to these facilities in January.

Under an exception created by the 21st Century Cures Act, CMS allowed off-campus PBDs that met certain requirements to continue to be paid under the OPPS if the department was mid-build at the time the Bipartisan Budget Act of 2015 was enacted. New off-campus PBDs were to be paid under an “applicable payment system,” which CMS determined was the Medicare Physician Fee Schedule (MPFS). For off-campus PBD services, the MPFS pays approximately 40% of the OPPS rate.

Of the 334 organizations that applied for the mid-build exception, CMS determined that only 132 met the requirements and 202 failed to do so. Under the 21st Century Cures Act, mid-build exception audit determinations are final and cannot be appealed.

The AHA contends that the denials are inappropriate because CMS failed to meet the statutory deadline for conducting and releasing audit results. According to the 21st Century Cures Act, CMS may deny a mid-build exception application if the agency completed its audit of the applicant by December 31, 2018. Because CMS did not notify audited organizations until two years after the deadline, it failed to meet the deadline, according to the AHA.

The AHA also argues that the audit findings and denials are incorrect based on Medicare Administrative Contractors’ misinterpretation of what the statute requires and the documentation submitted by organizations.