New Provider Reimbursement Review Boards Appeal Process

The Centers for Medicare and Medicaid Services ("CMS") has recently promulgated new regulatory provisions governing the Provider Reimbursement Review Board's ("PRRB") appeal process. For those of you who have had an opportunity to review the new regulations it is apparent that these revisions are far reaching and signal a fundamental shift away from the current procedures by which appeals are filed and subsequently adjudicated.

As a courtesy, CampbellWilson felt it necessary to provide a brief outline of a few of the relevant changes as well as provide you the links to the relevant documents that will significantly impact hospital reimbursement in the near future.

Of note, the new rules will take effect August 21, 2008 for all existing and new appeals. A major point that should not get lost about this date is that if you currently have an appeal filed with the PRRB, you will have 60-days from the effective date of this regulation to add any new issues to the appeal. If these new potential issues are not added, it appears that you will have foreclosed this right. The following highlights can be reviewed at 73 Fed. Reg. 101, 30190 (May 23, 2008) at the PRRB's website at Instructions for the Provider Reimbursement Review Board:

Filing the Appeal

• The PRRB has requested that new appeals be filed using MODEL FORMS that are available on their website.
• The filing date is the date the PRRB receives the appeal request. A post-mark date will no longer suffice as the filing date. We recommended that if you are close to a deadline, use a reliable overnight delivery service.
• When filing the initial appeal request, all supporting documentation is required. If it is not available, a satisfactory explanation is required.
• If the issue includes multiple components (i.e., DSH-Medicaid Days), you have to identify and appeal each component.

Adding Issues Once the Appeal is Active

• The Provider will have 60-days from the 180-day deadline (based on the NPR date) to add additional issues to an existing appeal. If the 60-days window is missed, additional issues will be denied.

Group Appeals

• Commonly owned or controlled providers appealing the same issue within the same cost reporting year must file a Mandatory group appeal.

Timeline

• The Provider and the Intermediary can agree to a prehearing schedule via a Joint Scheduling Order ("JSO") or follow the schedule as dictated by the PRRB. This JSO cannot be used for delay purposes and has to be filed very early in the appeal process.

Position Papers

• Unless good cause is shown, a provider cannot put forth new arguments or documents not included in the Preliminary Position Paper ("PPP").
• When filing your PPP, include only the first page of the paper, the preliminary documentation list (exhibits) and a statement that a "good faith effort to confer was made in accordance with 42 C.F.R. §405.1853."
• Final Position Papers ("FPP") are due 90 days prior to the hearing. If it determined that the scope of the argument was expanded, the PRRB has the authority to exclude all related evidence and documentation.
• It is only necessary to submit one (1) complete copy of the FPP to the PRRB. If the appeal proceeds to hearing, you will need to submit five (5) additional copies to the PRRB 3-5 days prior to the hearing.

Witness Designation

• Witnesses must be designated 30 days prior to the hearing date.

One last point. Beginning with cost reports filed on or after December 31, 2008, providers will be required to identify all potentially appealable items by protesting or "self-disallowing" the same on the filed cost report. Failure to do so will result in the provider being precluded from appealing these issue when the cost report is NPR'd.

As mentioned above, this article is not intended to provide an in-depth review of the new rules, rather it is designed to highlight a few of the many significant changes that will take effect August 21, 2008, or with cost reports filed on or after December 31, 2008. We strongly recommend that you and your staff conduct a thorough review of the new Federal regulations and the PRRB guidelines associated with the same. CampbellWilson will be conducting training for those clients that request the same in the immediate future. In the meantime, we will be available to answers any questions you may have, assist with current appeals, assist with new appeals, or provide general cost report guidance.

For more information, contact us at 800.723.6492 to speak to one of our experienced consultants or log onto our website for more information: info@campbellwilson.com.

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