Provider Reimbursement Review Board Appeals

PRRB Appeals2018-10-24T19:13:28+00:00

PRRB Appeals

The Provider Reimbursement Review Board, or the PRRB for short, is a panel that is designed to handle reimbursement appeals from providers of Medicare-certified services. This means that if your services are covered by Medicare, and you disagree with the decisions that Medicare makes about how much to reimburse you for services provided, you can take it to the PRRB to dispute the amount.

iStock 671299112 200x300 - PRRB AppealsRecent Review Board Appeals Changes

Significant changes in rules governing Provider Reimbursement Review Board (PRRB) Appeals were promulgated on August 29, 2018. The rules apply to both newly filed and pending appeals; therefore, it is important that providers are well-versed in the rules as they currently stand. The most significant changes to the rules include a newly available opportunity for electronic filing, changes in how papers are to be filed, and allowance of reports to support self-disallowed items from the cost report. The laws surrounding PRRB appeals will likely continue to evolve, and the review process is so complex that most providers choose to seek the counsel of an experienced PRRB appeals attorney to navigate the process.

Hurdles in the PRRB Appeals Process

When reimbursements are made, Medicare service providers must make appeals in accordance with the following requirements:

  • Make the appeal within 180 days.
  • Be absolutely clear about the exact issue.
  • The amount must be at least $10,000 for individual appeals or $50,000 for group appeals.
  • Include a reasonable good faith estimate of cost for services provided.
  • Include an impact calculation.
  • Include a summary of the provider’s legal position.

In other words, protesting the reimbursement you receive for Medicare-covered services requires you to be timely and to thoroughly substantiate your position. This means not only proving the amount reimbursed was unfair or insufficient in some way, but also indicating how that affects you and what laws affect your position.

The PRRB Appeals Hearing

Once your request for a hearing is approved, it works largely like any other court hearing—you have a lawyer represent you, you provide the evidence to back up your claim, and you examine or cross examine witnesses. A report of the hearing and all evidence is made, and the Board reviews that record and makes a decision. Making sure your PRRB appeal is presented properly is absolutely crucial to securing the financial remedy you deserve.

Legal Counsel for PRRB Appeals

Naturally, the entire process, from filing the appeal request through the actual hearing, requires expert legal assistance. The laws governing PRRB appeals are largely stacked against healthcare providers, so without skilled legal counsel, your odds of success are remote. If you are a Medicare service provider and need to dispute Medicare reimbursements, it’s essential to get legal representation from a skilled PRRB appeals attorney.