CMS Ruling 1727-R: Jurisdiction of the PRRB Over Appeals Challenging a Regulation
May 9, 2018:
As a result of the U.S. District Court for the District of Columbia’s holding of Banner Heart Hospital v. Burwell, 201 F. Supp. 3d 131 (D.D.C. 2016), CMS issued a favorable ruling for providers on April 23, 2018. CMS Ruling 1727-R states that “for appeals of cost reporting periods that ended on or after December 31, 2008 and began before January 1, 2016 that were pending or filed on or after April 23, 2018…assuming all other applicable jurisdictional requirements are met, a provider has a right to a Medicare Administrative Contractor (MAC) hearing or a Provider Reimbursement Review Board (PRRB) hearing for an item the provider did not include on its cost report due to a good faith belief that the item was subject to a payment regulation or other policy that gave the MAC no authority or discretion to make payment in the manner the provider sought.” You can find the entire ruling on CMS’s website,https://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/CMS-Rulings-Items/CMS-1727-R.html.
This is great news for those providers that are challenging CMS’s application of the DGME FTE cap in our group appeal. For cost reporting periods that ended on or after December 31, 2008 and began before January 1, 2016, CMS has agreed to not require the provider to protest issues that are challenging a regulation in the cost report filings.
If you are not pursuing this issue with us and would like to learn more about the issue, please find additional information on our website http://gmesolutions.com/gme-cap-penalty/. If you would like to set up a time to discuss the impact of this issue for your hospital, please do not hesitate to contact us.