Advisories
New PRRB Appeals Regulations and Board Rules: Changes limit timeframe for new issues in provider appeals
By
David Volk
09.25.08
The Medicare Program on May 23, 2008, issued the long-awaited final regulations revising the Provider Reimbursement Review Board (PRRB) appeal procedures. They are effective generally for all appeals pending as of, or filed on or after, Aug. 21, 2008. The new regulations have now been followed by completely updated PRRB internal rules.
Probably the most important change in the final regulations, with long-term consequences for providers, is that providers will no longer be able to raise new issues during much of the appeal process. A request to add issues to an appeal must be received by the board no later than 60 days after the expiration of the initial 180-day appeal filing period from the Notice of Program Reimbursement (NPR).
For appeals already pending at the board as of Aug. 21, 2008, the deadline is the later of: (1) 60 days after the expiration of the applicable 180-day appeal period or (2) Oct. 20, 2008. This shortened window of opportunity means that providers should review existing appeals immediately to assure that all identifiable issues have been properly appealed by the due dates. It also means that providers must be much more diligent in identifying issues promptly after receiving an NPR, and appealing those issues with specificity in a timely manner.
In computing deadlines under the final regulations, a provider is presumed to have received the determination to be appealed five days after issuance, unless established to the contrary by a preponderance of the evidence. The date of receipt by the board is the date of delivery if delivered by a nationally recognized courier, or the date stamped “received” at the board, if delivered otherwise, unless established to the contrary by a preponderance of the evidence.
Another important change, effective with cost reporting periods ending on or after Dec. 31, 2008, is that providers will not be granted appeal rights for items unless they were either expressly claimed on a cost report or properly self-disallowed as a protested amount on a cost report.
The new PRRB internal rules, effective August 21, 2008, have numerous changes in the basic processes of pursuing both individual and group appeals, and establish requirements for specificity in identifying issues, amounts in controversy, and jurisdiction. The rules include several suggested forms for appeal requests and other procedural issues. They also revise the group appeal rules, limiting the movement of issues and fiscal years among appeals, and emphasize attention to Common Interest Related Party groups as required.
The appeal regulations (found at 73 Fed. Reg. 30190) and the PRRB rules and subsequent updates and alerts are extensive and should be reviewed carefully for your specific situation.
Probably the most important change in the final regulations, with long-term consequences for providers, is that providers will no longer be able to raise new issues during much of the appeal process. A request to add issues to an appeal must be received by the board no later than 60 days after the expiration of the initial 180-day appeal filing period from the Notice of Program Reimbursement (NPR).
For appeals already pending at the board as of Aug. 21, 2008, the deadline is the later of: (1) 60 days after the expiration of the applicable 180-day appeal period or (2) Oct. 20, 2008. This shortened window of opportunity means that providers should review existing appeals immediately to assure that all identifiable issues have been properly appealed by the due dates. It also means that providers must be much more diligent in identifying issues promptly after receiving an NPR, and appealing those issues with specificity in a timely manner.
In computing deadlines under the final regulations, a provider is presumed to have received the determination to be appealed five days after issuance, unless established to the contrary by a preponderance of the evidence. The date of receipt by the board is the date of delivery if delivered by a nationally recognized courier, or the date stamped “received” at the board, if delivered otherwise, unless established to the contrary by a preponderance of the evidence.
Another important change, effective with cost reporting periods ending on or after Dec. 31, 2008, is that providers will not be granted appeal rights for items unless they were either expressly claimed on a cost report or properly self-disallowed as a protested amount on a cost report.
The new PRRB internal rules, effective August 21, 2008, have numerous changes in the basic processes of pursuing both individual and group appeals, and establish requirements for specificity in identifying issues, amounts in controversy, and jurisdiction. The rules include several suggested forms for appeal requests and other procedural issues. They also revise the group appeal rules, limiting the movement of issues and fiscal years among appeals, and emphasize attention to Common Interest Related Party groups as required.
The appeal regulations (found at 73 Fed. Reg. 30190) and the PRRB rules and subsequent updates and alerts are extensive and should be reviewed carefully for your specific situation.