42 U.S.C. § 1395oo — Provider Reimbursement Review Board

(a) Establishment: A provider that timely filed a required cost report may obtain a hearing about it before the Provider Reimbursement Review Board, called the “Board.” A hospital receiving payments calculated under section 1395ww(b) or (d), and timely filing the reports needed for those payments, may also obtain a hearing about the payment, except as subsection (g)(2) provides, if (1) the provider (A) is dissatisfied with its fiscal intermediary’s final determination of total program reimbursement for the report period, or with the Secretary’s final determination of a section 1395ww(b) or (d) payment; (B) did not timely receive the intermediary’s final determination after filing a compliant report; or (C) did not timely receive the determination after filing a noncompliant report and then a compliant supplementary report; (2) at least $10,000 is in dispute; and (3) the provider asks for a hearing within 180 days after notice of the intermediary’s or Secretary’s final determination, or, for (B) or (C), within 180 days after notice would have arrived had the determination been timely. (b) Appeals by groups: The same rules apply to a group if every provider would be entitled to a hearing without counting the $10,000 threshold, the dispute has a common factual or legal or regulatory question, and at least $50,000 is disputed in total. (c) Counsel and evidence: At a hearing, the provider may have counsel, introduce evidence, and examine and cross-examine witnesses. The Board may receive evidence even if court evidence rules would exclude it. (d) Board decisions: The decision must rest on the hearing record, including evidence considered by the intermediary and other evidence the Board obtains or receives, and substantial evidence must support it when the whole record is considered. The Board may affirm, change, or reverse the intermediary’s final cost-report determination and revise any matter covered by the report, including against the provider, even if the intermediary did not consider that matter. (e) Rules and regulations: The Board may make rules and procedures that are consistent with this subchapter and the Secretary’s regulations and are needed or appropriate to carry out this section. During a hearing it may administer oaths and affirmations. The subpoena rules in section 405(d) and (e) apply to the Board to the same extent as to the Secretary for Social Security subchapter II matters. (f) Finality, court review, authority determinations, place, and interest: (1) A Board decision becomes final unless, within 60 days after notice to the provider, the Secretary on the Secretary’s own motion reverses, affirms, or changes it. A provider may seek court review of a final Board decision or of the Secretary’s action by filing a civil action within 60 days after notice. A provider may also seek review of a fiscal intermediary action involving a relevant legal or regulatory question if the Board decides it lacks authority to decide that question. The Board may make that decision on its own or at the provider’s request. A provider entitled to a hearing and requesting one may ask the Board to decide its authority and must supply the documents and materials the Board requires. The Board must decide in writing within 30 days after receiving the request and materials. That decision is final and cannot be reviewed by the Secretary. If the Board does not decide within 30 days, the provider may file a civil action within 60 days after the period ends concerning the dispute in the hearing request. The action must be filed in the Federal district where the provider is located, or, for several providers suing together, where the greatest number are located, or in the District of Columbia. It is tried under the applicable Administrative Procedure Act chapter 7 provisions despite other section 405 rules. Providers under common ownership or control, and providers that obtained a group hearing under (b), must appeal or seek review as a group for a matter involving a common issue. (2) When a provider seeks court review, the disputed amount earns annual interest beginning on the first day of the first month after the 180-day period in (a)(3). The rate is the rate on obligations issued for purchase by the Federal Hospital Insurance Trust Fund for the month the action begins. The reviewing court awards the interest to the prevailing party. (3) The interest is not treated as income or cost when reimbursement owed to providers is determined under this chapter. (g) Certain findings not reviewable: (1) The Board or a court may not review a fiscal intermediary’s finding that no payment is available because expenses for the items or services are listed in section 1395y. (2) The Board or a court may not review the determinations and other decisions described in section 1395ww(d)(7), whether under (f) or otherwise. (h) Composition and compensation: The Secretary appoints five Board members without applying title 5 competitive-service appointment rules. Two represent providers. Every member must know the field of provider payment, and at least one must be a certified public accountant. Members receive compensation set by the Secretary, up to the rate specified for GS-18 in title 5, section 5332, at the time of service. Terms last three years, except initial terms may be shorter so terms are staggered. (i) Technical and clerical help: The Board may hire needed technical assistance. The Secretary must also provide secretarial, clerical, and other help the Board needs. (j) “Provider of services”: For this section, the term includes a rural health clinic and a Federally qualified health center. This section does not otherwise define that quoted term.