Quality Reimbursement Services, has a 28+ year history of advocating for hospital rights and reimbursements. In addition to cost report and S-10 consulting, disproportionate share, crossover bad debt, SSI Disability Eligibility and 340B services – QRS is possibly best known for its work at the PRRB and in District Court. Whenever QRS sees an injustice or an error by the government that adversely affects US hospitals, a group appeal will be formed. Beginning with the landmark case of Loma Linda Medical Center vs. HHS back in 1992 , QRS has built a sterling reputation for representing client hospitals at the PRRB, District and the Supreme Court. The end result has been over $900 million in court settlements for client hospitals.

There’s still time to join a QRS group appeal.

QRS is compensated entirely on a contingency basis, so it costs hospitals nothing to join a QRS group appeal. QRS pays all up-front and filing costs. If the case is decided in favour of the providers, QRS negotiates a settlement with CMS for client hospitals. If the case is not decided in favour of providers, there is no fee/charge. Following is a brief history of QRS healthcare litigation. Note that QRS is still accepting hospitals who want to join the St. Francis Medical Center v. Azar group appeal. If you are interested in joining this appeal, simply contact us at groupappeals@qualityreimbursement.com.

  • Loma Linda Medical Center vs. HHS

QRS was the lead firm in this 1992 appeal that protested the manner in which SSI percentages were used in calculating DSH reimbursements. Up until this decision, hospitals had no way of knowing how SSI data was applied to their DSH calculations. Success in this appeal made it possible for providers to request their SSI information from CMS via a “Data Use Agreement” (DUA) and receive PSA reports. Providers have since been able to confirm or protest SSI percentages in their DSH calculations and reimbursements.

  • In Re Medicare.

QRS represented over 130 hospitals (out of a total 667 plaintiffs) in this group appeal. The case was concluded in 2008 after more than 4 years of litigation, and resulted in a $666.1 million settlement for providers that participated in the group appeal.

  • Allina v. Sebelius (Allina I).

At issue, was the CMS practice of putting Medicare Advantage (Part C) days, that were eligible for reimbursement, but not paid, in the denominator of the Medicare fraction of the DSH calculation, thereby reducing reimbursement amounts to hospitals. This victory for hospitals in the suit resulted in over $50 million for the over 200 hospitals in the QRS group appeal.

  • Allina Health Services v. Azar (Allina II).

The victory for providers in Allina I was limited to appealable years dating back from the early 1990s through 2004. In the Allina II group appeal, the Medicare Part C issue was carried forward for appealable years 2005 to present. QRS represents over 400 hospitals in this appeal. A supreme court decision that favored the hospitals was rendered in June 2019. However, the court did not directly order CMS to reimburse providers. Rather, the court remanded the case back to CMS, so that CMS could propose a solution that would make the hospitals whole. Total reimbursements are projected to be between $3 Billion and $4 Billion. The CMS proposal could take any number of positions. Stay tuned.

  • Cape Cod v. Sebelius.

Sometimes known as the Rural Floor Budget Neutrality Adjustment (RFBNA) Appeal, this decision in the DC Circuit Court of Appeals, found that CMS knowingly perpetuated an error in factoring the “Rural Floor Budget Adjustment” in calculating PPS payments. QRS represented over 200 hospitals in this group appeal, resulting in $190 million in reimbursements to client hospitals.

  • 2-Midnight Rule.

The 2014 IPPS Final Rule changed the criteria for inpatient admissions, requiring the admitting doctor to determine if the patient needed a hospital stay lasting 2 midnights in order for the patient to qualify as an Inpatient. After being challenged by multiple lawsuits, CMS agreed to reimburse hospitals for shortfalls in 2014, 2015 and 2016 IPPS payments. The 2017 Federal Register increased IPPS payments for all Medicare hospitals by a factor of 0.6% (0.2% per year for each of the three years in dispute). However, in representing over 300 hospitals in this appeal, QRS contends that the increase does not make all client hospitals “whole.” This is because the 0.2% factor was based on 2014 data, and hospitals had fewer inpatients in 2017 than in 2014, so increased payments on a per-patient basis, result in less money for the hospital. Also, QRS believes that hospitals should be reimbursed for interest on lost revenue over the course of payment shortfalls. A decision was reached in favor of providers, but only for lost interest. A settlement is being negotiated for hospitals that appealed this issue.

  • American Taxpayer Relief Act (ATRA) appeal.

With the American Taxpayer Relief Act of 2012, congress directed CMS to recoup $11 billion from hospitals. CMS projected it could recoup the $11 billion by applying an -0.8% rate adjustment for each year between 2014 and 2017 – total of 3.2% reduction. By 2017, ATRA had accrued 3.9%, exceeding its goal by 0.7%. QRS argues on behalf of 330 client hospitals, that CMS acted erroneously by failing to restore the reduction through a 0.7% positive adjustment for 2018. As a result, CMS is recouping from providers more than the $11 billion authorized by ATRA. The QRS group appeal seeks a one-time settlement for client hospitals equal to 0.7% of DRG for FFY 2017, and each year thereafter, that doesn’t account for the correction.

  • 1498R and 1498R1 or “SSI Systemic Errors”

QRS contends that CMS erroneously placed SSI “No Pay” and “Exhausted Days” in the Part A denominator for DSH calculations, thereby reducing payments to DSH hospitals. As a general business practice, QRS appeals this issue for all DSH clients – thereby preserving their rights to appeal the issue if/when the appeal is found in favor of providers. A favorable decision on 1498R has resulted in settlements totaling more than $85 million for 300 QRS Clients. 1498R2 is expected to be settled in 2019.

  • St. Francis Medical Center v. Azar.

Also known as the Predicate Facts/Standardized Amount Appeal, alleges that CMS erroneously calculated the 1981 standardized amounts (Federal rate) by failing to properly account for transfer cases in calculating the Federal rate. CMS used the “Predicate Facts” rule to dismiss any challenges to a rule already in existence. The Saint Francis decision in the DC Court of Appeals, held that “Predicate Facts” cannot be used to shield CMS from errors made in the past, but still affecting providers today. The Saint Francis case also mentioned errors in the cap on the number of full-time (FTE) residents eligible for reimbursement established in a previous year. By knocking-down the “Predicate Facts” rule, providers may appeal this issue as well. QRS organized a group appeal for the 2018 Federal Register, seeking reimbursements for the standardized amount issue – estimated to be 1% of DRG for all cost report years that can still be appealed. And until there is a final decision (if the Supreme Court decides to take the case), QRS will add hospitals to the group and appeal the issue on NPRs as they are released. There are currently 350 hospitals signed-up for this group appeal, and new hospitals may join the appeal up until a final decision is reached. Plans are also in the works to appeal the Predicate Facts/FTE Cap.

Contact Me About Joining QRS Group Appeals