On June 25, 2004, CMS published a proposed rule that would substantively amend the regulations governing appeals before the Provider Reimbursement Review Board (PRRB). The rules, as proposed, would make significant changes in the procedures for appeals to the PRRB, including:

Calculating the time period for filing of appeals;
Excluding self-disallowed amounts from appeal, unless they are noted as a protested amount on the cost report;
Prohibiting the addition of issues to the time period ending 240 days after receipt of determination being appealed;
Rules involving the formation of group appeals; and
The conducting of a hearing with only one Board member present.

The Social Security Act, however, requires the agency to finalize proposed rules within three years, unless exceptional circumstances exist. Because of this, CMS recently published notice of an extension for finalizing the PRRB regulations. The agency asserted that the "complexity of the public comments received, and the complex policy and legal issues raised by those comments," constituted exceptional circumstances, requiring the agency to take extra time to consider the rule. The notice, published in the Federal Register on June 22, 2007, extended the timeline for publication of the final rule until June 25, 2008.

Advice: Although CMS has until June 25, 2008, to finalize the proposed rule, it may do so at any time before then. Therefore, providers should take this time to make sure they have added all issues they may want to include in their existing appeals, in order to be prepared for restrictions that are likely to be imposed on the timing of adding new issues to pending appeals. Issues that a provider decides not to appeal can always be withdrawn from the PRRB case at a later time.

Ober|Kaler's Health Law Group represents a broad array of health care clients in various areas including coverage and reimbursement, fraud and abuse, licensing and certification, compliance, and transactional matters. The Payment Group specifically focuses on Medicare and Medicaid payment issues for health care professionals and entities, providing advice and representation concerning reimbursement and related compliance matters important to health care facilities and providers. Our attorneys, many of whom were formerly with the government, have extensive experience in all manner of Medicare issues including PRRB and claims appeals, regulatory compliance, certification and enrollment, Medicaid reimbursement, and developing and implementing corporate compliance plans.

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Payment Matters is intended to periodically provide helpful information about selected current healthcare payment issues. It is not to be construed as legal or financial advice, and the review of this information does not create an attorney-client relationship.