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PROVIDER REIMBURSEMENT REVIEW BOARD (PRRB) APPEAL SERVICES

 

Since the inception of the Medicare program, the Provider Reimbursement Review Board (PRRB) has reviewed and made judgments on appeals filed by providers concerning final determinations made by fiscal intermediaries. 

 

With more than 25 years of cumulative experience, Hall Consulting Services (HCS) staff has been actively involved in reviewing, analyzing, and documenting PRRB appeal requirements both as fiscal intermediary and consultants.  The PRRB appeal process involves identifying and documenting audit issues, filing Board hearing documents and filing provider position papers on various Medicare reimbursement issues.

 

HCS has directly filed for a number of PRRB appeals for hospital clients in sizes ranging from 125 to 1,500 patient beds.  Appealing issues related to a particular cost report can be a long, time-consuming process that involves a number of deadlines for filing critical documents.

 

Historically, a filed appeal case can take anywhere from three to in excess of five years before a final decision is rendered either by the fiscal intermediary, PRRB, the Centers for Medicare and Medicaid Services (CMS) Administrator and/or the federal courts.


 

Filing Requirements for a Provider for Cost Report Appeal

 

Providers must file their written request for cost report appeal within 180 days of the date of the applicable Notice of Program Reimbursement (NPR) or the final determination letter related to an exception/exemption request. 

 

Provider requests for a cost report appeal must be directed and submitted to the appropriate party based on an estimated reimbursement materiality threshold in dispute as outlined below:

 

  • The estimated issue amount in controversy must be equal to or greater than $10,000

  • For group appeals, the amount in controversy must be equal to or greater than $50,000

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    CMS Issues a Final Rule on PRRB Appeals

     

    On May 23, 2008, the Centers for Medicare and Medicaid Services published a final rule that substantially changed the procedures for appealing a Medicare cost report determination included in a notice of program reimbursement (NPR) before the PRRB.  Many of the revised changes will require providers to improve preparation and filing requirements before and after filing Board appeals. 

     

    Because of the changes in the final rule, providers will need to implement a number of new and updated processes in order to respond to appeal filing requirements.  Providers must identify, document and file all disputed audit issues within the final rule’s stringent guidelines.  The final rule was effective August 21, 2008, with a few exceptions.

     

    Provider Reimbursement Review Broad Rules are Revised

     

    CMS has posted the new PRRB rules on its website.  The new PRRB rules will apply to appeals pending as of August 21, 2008, or filed on or after that date and will supersede the PRRB instructions which were in effect as of March 1, 2002.

     

    The new PRRB rules coincide with CMS’s final rule, which was published in the Federal Register on May 23, 2008.     

     

    Revised Initial Appeal Filing Procedures

     

    The CMS final rule (dated May 23, 2008) and the PRRB rules (effective August 21, 2008) outline a significant number of changes to the PRRB appeal process which will restrict a number of filing options and documentation requirements for providers wishing to file PRRB appeals.

     

    Perhaps the most significant and costly change for providers in the final rule is that there now is a  time limitation on adding issues before the Board.  Under prior PRRB rules, a provider could add issues anytime before the hearing date, which under most circumstances would be several years from the original filing date.

     

    Under the new PRRB rules, appeal issues may only be added to an appeal for a period of up to 240 days after the issuance of the Notice of Program Reimbursement (NPR).  The latter 240 days amount is the result of limiting the time period for adding issues to no later than 60 days after the expiration of the applicable 180 days filing deadline.

     

    Due to the new PRRB rules, providers should make every effort to file all disputed issues in their initial appeal request for hearing.  Additionally, providers should systematically identify, document and finalize all disputed issues as early as possible before and after the fiscal intermediary audit of subject cost report.

     

    Our Services Include the Following:

     

    Review all open Medicare cost reports in order to identify, analyze and document material appeal issues.  An example of potential audit issues include the following:

  • DSH day components

  • - SSI % days

    - Medicaid eligibility days

  • GME/IME – Interns/residents

  • - FTE count

    - GME program review

  • Organ acquisition cost and transplants

  • Medicare Bad Debts

  • Request for exception or exemptions

  • Other key Issues (e.g. legal case effects, CMS clarifications, Medicare regulation changes).          

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    HCS provides services in all facets of PRRB appeal process, which includes but not limited to the following service items:

     

  • Identifying, analyzing, and documenting disputed issues

  • Filing requests for hearing content and related estimated reimbursement amounts in dispute

  • Filing position papers and related documentation

  • Board jurisdiction review

  • Requests for adding “new” issues to individual appeals

  • Review pre-hearing issues and discovery  documents

  • Finalize appeal:

    1. Administration resolution

    2. PRRB hearing

    3. Mediation hearing

     

     

     

    Next Service: Medicare Bad Debt Compilation and Systematic Reviews