On September 30, 2021, the Provider Reimbursement Review Board (the “Board”) issued a revised set of rules that become effective November 1, 2021. These new and revised rules affect all new and some pending Medicare Part A provider appeals. These rules clarify several aspects of Board appeals and simplify some of the Board’s complex procedures.

The most significant change is the requirement that all submissions to the Board must be made electronically through the Office of Hearings Case and Document Management System (“OH-CDMS”) unless the provider or representative submits a request to the Board for an exemption and the Board grants that request. If an exemption is necessary, a provider or representative may communicate with the Board at a new email address (PRRB@cms.hhs.gov).   In order to file documents electronically, providers or their representatives should register with OH-CDMS in advance of any filing date.

In addition to the shift to electronic filing, the Board adopted several changes that are intended to simplify the appeals process and promote greater disclosure.  The most significant changes are summarized below.

  • If a provider designates a representative, it must do so in a letter on the provider’s letterhead. However, if the provider is under the ownership or control of a parent entity, then the representation letter must be on the parent organization’s letterhead and signed by an authorized official of the parent organization.
  • Similarly, a new rule requires that if a provider is owned or controlled by a parent organization, the appeal request must identify the name and address of the parent organization for the year under appeal. This is a departure from past practice, which identified only the legal entity that had been granted a Medicare provider number.
  • The Board clarified the requirements for appeals of self-disallowed and protested costs, and now requires that the provider specify the disputed item in its cost report in order to preserve the claim for review.
  • A new rule obligates the Medicare Administrative Contractor (“MAC”) to ensure that any evidence the MAC, CMS, or the Secretary considered in making its determination is included in the case record. This new rule may reduce the necessity for discovery requests and delays in resolving appeals.
  • For group appeals, the Board added a new requirement that a group representative must report to the Board that a group is either complete or provide reasons why the group should be held open.
  • A new rule that applies to appeals filed after August 29, 2018 would give providers the option of relying on their preliminary position paper and waive the filing of a final position paper. Providers would have to submit all of their arguments and exhibits with the preliminary position paper, and could elect to submit a rebuttal to the MAC’s position paper. This step would avoid duplicating arguments, and may reduce the number of appeals dismissed based on a failure to file a timely final position paper.
  • The new rules also revise the Board procedures when a party requests expedited judicial review (“EJR”) that involves a challenge to a statute, regulation, or CMS ruling. If a MAC opposes a provider’s request for EJR, then it must now file any jurisdictional challenge within five days of the date that the EJR request is filed.
  • The Board revised its rules governing substantive claim challenges to specify that when any party questions whether a cost report included an appropriate claim for reimbursement, that challenge must be filed no later than the filing deadline for the MAC’s preliminary position paper. If the matter involves a request for EJR, then any substantive claim challenge must be filed within five business days of the EJR request. This would allow for better coordination of proceedings before the Board before any decision to allow the provider to bypass the Board and seek judicial review.

The changes made by the Board in this version of its procedural rules continue the trend of requiring additional specificity and clarity when providers prepare their cost reports, and obligate the MACs to disclose more information earlier in the appeal process. With the adoption of these new rules, providers must plan and consider potential appeal issues during the cost report filing stage to ensure that their appeal rights are protected.

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