§1395oo — Title 42 The Public Health and Welfare | U.S. Code

Summary

Allows a provider who filed the required cost report to ask for a hearing before a Provider Reimbursement Review Board about that report or about certain hospital payments. A provider can get a hearing if it is unhappy with a final decision by its fiscal intermediary about how much Medicare owes, or with a final decision by the Secretary about payments, or if it did not receive a timely decision after filing a report or a corrected report. The amount in dispute must be $10,000 or more, and the provider must ask for a hearing within 180 days after the notice or, for late decisions, within 180 days after the date the decision should have been received. Groups of providers with the same question can appeal together if each would qualify and the group’s total dispute is $50,000 or more. At the hearing the provider may have a lawyer, present and challenge evidence, and question witnesses. The Board must base its decision on the hearing record, may change the intermediary’s decision, and may make rules for its work. Board decisions are final unless the Secretary changes them within 60 days. Providers can sue in federal court within 60 days after notice of a final Board or Secretary decision. If the Board says it cannot decide a legal question, the provider can ask the Board to rule on that authority and the Board must do so in 30 days; if it does not, the provider may sue within 60 days after that 30-day period ends. If a provider sues, the money at issue earns yearly interest starting the first day of the month after the 180-day appeal period ends. The interest rate equals the rate on obligations bought by the Federal Hospital Insurance Trust Fund in the month the lawsuit begins, and the court awards it to the winner. The Board cannot review items excluded under section 1395y or certain decisions described in section 1395ww(d)(7). The Board has five members (two must represent providers; at least one must be a CPA), serves three-year terms, and gets staff and technical help as needed. "Provider of services" includes rural health clinics and Federally qualified health centers.

Title 42, §1395oo

The Public Health and Welfare — Source: USLM XML via OLRC

(a)Any provider of services which has filed a required cost report within the time specified in regulations may obtain a hearing with respect to such cost report by a Provider Reimbursement Review Board (hereinafter referred to as the “Board”) which shall be established by the Secretary in accordance with subsection (h) and (except as provided in subsection (g)(2)) any hospital which receives payments in amounts computed under subsection (b) or (d) of section 1395ww of this title and which has submitted such reports within such time as the Secretary may require in order to make payment under such section may obtain a hearing with respect to such payment by the Board, if—

(1)such provider—

(A)(i)is dissatisfied with a final determination of the organization serving as its fiscal intermediary pursuant to section 1395h of this title as to the amount of total program reimbursement due the provider for the items and services furnished to individuals for which payment may be made under this subchapter for the period covered by such report, or

(ii)is dissatisfied with a final determination of the Secretary as to the amount of the payment under subsection (b) or (d) of section 1395ww of this title,

(B)has not received such final determination from such intermediary on a timely basis after filing such report, where such report complied with the rules and regulations of the Secretary relating to such report, or

(C)has not received such final determination on a timely basis after filing a supplementary cost report, where such cost report did not so comply and such supplementary cost report did so comply,

(2)the amount in controversy is $10,000 or more, and

(3)such provider files a request for a hearing within 180 days after notice of the intermediary’s final determination under paragraph (1)(A)(i), or with respect to appeals under paragraph (1)(A)(ii), 180 days after notice of the Secretary’s final determination, or with respect to appeals pursuant to paragraph (1) (B) or (C), within 180 days after notice of such determination would have been received if such determination had been made on a timely basis.

(b)The provisions of subsection (a) shall apply to any group of providers of services if each provider of services in such group would, upon the filing of an appeal (but without regard to the $10,000 limitation), be entitled to such a hearing, but only if the matters in controversy involve a common question of fact or interpretation of law or regulations and the amount in controversy is, in the aggregate, $50,000 or more.

(c)At such hearing, the provider of services shall have the right to be represented by counsel, to introduce evidence, and to examine and cross-examine witnesses. Evidence may be received at any such hearing even though inadmissible under rules of evidence applicable to court procedure.

(d)A decision by the Board shall be based upon the record made at such hearing, which shall include the evidence considered by the intermediary and such other evidence as may be obtained or received by the Board, and shall be supported by substantial evidence when the record is viewed as a whole. The Board shall have the power to affirm, modify, or reverse a final determination of the fiscal intermediary with respect to a cost report and to make any other revisions on matters covered by such cost report (including revisions adverse to the provider of services) even though such matters were not considered by the intermediary in making such final determination.

(e)The Board shall have full power and authority to make rules and establish procedures, not inconsistent with the provisions of this subchapter or regulations of the Secretary, which are necessary or appropriate to carry out the provisions of this section. In the course of any hearing the Board may administer oaths and affirmations. The provisions of subsections (d) and (e) of section 405 of this title with respect to subpenas shall apply to the Board to the same extent as they apply to the Secretary with respect to subchapter II.

(f)(1)A decision of the Board shall be final unless the Secretary, on his own motion, and within 60 days after the provider of services is notified of the Board’s decision, reverses, affirms, or modifies the Board’s decision. Providers shall have the right to obtain judicial review of any final decision of the Board, or of any reversal, affirmance, or modification by the Secretary, by a civil action commenced within 60 days of the date on which notice of any final decision by the Board or of any reversal, affirmance, or modification by the Secretary is received. Providers shall also have the right to obtain judicial review of any action of the fiscal intermediary which involves a question of law or regulations relevant to the matters in controversy whenever the Board determines (on its own motion or at the request of a provider of services as described in the following sentence) that it is without authority to decide the question, by a civil action commenced within sixty days of the date on which notification of such determination is received. If a provider of services may obtain a hearing under subsection (a) and has filed a request for such a hearing, such provider may file a request for a determination by the Board of its authority to decide the question of law or regulations relevant to the matters in controversy (accompanied by such documents and materials as the Board shall require for purposes of rendering such determination). The Board shall render such determination in writing within thirty days after the Board receives the request and such accompanying documents and materials, and the determination shall be considered a final decision and not subject to review by the Secretary. If the Board fails to render such determination within such period, the provider may bring a civil action (within sixty days of the end of such period) with respect to the matter in controversy contained in such request for a hearing. Such action shall be brought in the district court of the United States for the judicial district in which the provider is located (or, in an action brought jointly by several providers, the judicial district in which the greatest number of such providers are located) or in the District Court for the District of Columbia and shall be tried pursuant to the applicable provisions under chapter 7 of title 5 notwithstanding any other provisions in section 405 of this title. Any appeal to the Board or action for judicial review by providers which are under common ownership or control or which have obtained a hearing under subsection (b) must be brought by such providers as a group with respect to any matter involving an issue common to such providers.

(2)Where a provider seeks judicial review pursuant to paragraph (1), the amount in controversy shall be subject to annual interest beginning on the first day of the first month beginning after the 180-day period as determined pursuant to subsection (a)(3) and equal to the rate of interest on obligations issued for purchase by the Federal Hospital Insurance Trust Fund for the month in which the civil action authorized under paragraph (1) is commenced, to be awarded by the reviewing court in favor of the prevailing party.

(3)No interest awarded pursuant to paragraph (2) shall be deemed income or cost for the purposes of determining reimbursement due providers under this chapter.

(g)(1)The finding of a fiscal intermediary that no payment may be made under this subchapter for any expenses incurred for items or services furnished to an individual because such items or services are listed in section 1395y of this title shall not be reviewed by the Board, or by any court pursuant to an action brought under subsection (f).

(2)The determinations and other decisions described in section 1395ww(d)(7) of this title shall not be reviewed by the Board or by any court pursuant to an action brought under subsection (f) or otherwise.

(h)The Board shall be composed of five members appointed by the Secretary without regard to the provisions of title 5 governing appointments in the competitive services. Two of such members shall be representative of providers of services. All of the members of the Board shall be persons knowledgeable in the field of payment of providers of services, and at least one of them shall be a certified public accountant. Members of the Board shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding the rate specified (at the time the service involved is rendered by such members) for grade GS–18 in section 5332 of title 5. The term of office shall be three years, except that the Secretary shall appoint the initial members of the Board for shorter terms to the extent necessary to permit staggered terms of office.

(i)The Board is authorized to engage such technical assistance as may be required to carry out its functions, and the Secretary shall, in addition, make available to the Board such secretarial, clerical, and other assistance as the Board may require to carry out its functions.

(j)In this section, the term “provider of services” includes a rural health clinic and a Federally qualified health center.

Notes & Related Subsidiaries

Editorial Notes

Amendments

1993—Subsec. (f)(2). Pub. L. 103–66 substituted “the rate of interest on obligations issued for purchase by the Federal Hospital Insurance Trust Fund for the month in which” for “the rate of return on equity capital established by regulation pursuant to section 1395x(v)(1)(B) of this title and in effect at the time”. 1990—Subsec. (j). Pub. L. 101–508, § 4161(b)(4), inserted “a rural health clinic and” after “includes”. Pub. L. 101–508, § 4161(a)(6), added subsec. (j). 1984—Subsec. (c). Pub. L. 98–369, § 2354(b)(39), substituted “inadmissible” for “inadmissable”. Subsec. (e). Pub. L. 98–369, § 2354(b)(40), substituted “and (e)” for “, (e), and (f)”. Subsec. (f)(1). Pub. L. 98–369, § 2351(a)(1), substituted “notification of such determination is received” for “such determination is rendered” in third sentence. Pub. L. 98–369, § 2351(b)(1), inserted “or which have obtained a hearing under subsection (b)” after “common ownership or control” in last sentence. 1983—Subsec. (a). Pub. L. 98–21, § 602(h)(1)(A), inserted provision in introductory text that, except as provided in subsec. (g)(2) of this section, any hospital which receives payments in amounts computed under section 1395ww(b) or (d) of this title and which has submitted such reports within such time as Secretary may require in order to make payment under such section may obtain a hearing with respect to such payment by Board. Subsec. (a)(1)(A). Pub. L. 98–21, § 602(h)(1)(B), (C), designated existing provisions as cl. (i) and added cl. (ii). Subsec. (a)(3). Pub. L. 98–21, § 602(h)(1)(D), substituted “(1)(A)(i), or with respect to appeals under paragraph (1)(A)(ii), 180 days after notice of the Secretary’s final determination,” for “(1)(A)”. Subsec. (f)(1). Pub. L. 98–21, § 602(h)(2), inserted “(or, in an action brought jointly by several providers, the judicial district in which the greatest number of such providers are located)” after “the judicial district in which the provider is located”, and “Any appeal to the Board or action for judicial review by providers which are under common ownership or control must be brought by such providers as a group with respect to any matter involving an issue common to such providers.” Subsec. (g). Pub. L. 98–21, § 602(h)(3), designated existing provisions as par. (1) and added par. (2). Subsec. (h). Pub. L. 98–21, § 602(h)(4), substituted “payment of providers of services” for “cost reimbursement”. 1980—Subsec. (f)(1). Pub. L. 96–499 inserted provision empowering providers of services to obtain judicial review of any action of a fiscal intermediary involving a question of law or

Regulations

relevant to matters in controversy whenever Board determined that it was without authority to decide such matters in controversy. 1974—Subsec. (f). Pub. L. 93–484 redesignated existing provisions as par. (1), inserted provisions authorizing judicial review for providers of final decisions of Board and judicial review of any affirmance by Secretary, and added pars. (2) and (3).

Statutory Notes and Related Subsidiaries

Effective Date

of 1993 AmendmentAmendment by Pub. L. 103–66 effective Oct. 1, 1993, see section 13503(c)(2) of Pub. L. 103–66, set out as a note under section 1395x of this title.

Effective Date

of 1990 AmendmentAmendment by section 4161(a)(6) of Pub. L. 101–508 applicable to cost reports for periods beginning on or after Oct. 1, 1991, see section 4161(a)(8)(C) of Pub. L. 101–508, set out as a note under section 1395k of this title. Amendment by section 4161(b)(4) of Pub. L. 101–508 applicable to cost reports for periods beginning on or after Oct. 1, 1991, see section 4161(b)(5) of Pub. L. 101–508, set out as a note under section 1395x of this title.

Effective Date

of 1984 Amendment Pub. L. 98–369, div. B, title III, § 2351(a)(2),

July 18, 1984, 98 Stat. 1099, provided that: “The amendment made by paragraph (1) [amending this section] shall be effective with respect to any civil action commenced on or after the date of the enactment of this Act [

July 18, 1984].” Pub. L. 98–369, div. B, title III, § 2351(b)(2),

July 18, 1984, 98 Stat. 1099, provided that: “The amendment made by paragraph (1) [amending this section] shall be effective with respect to any appeal or action brought on or after the date of the enactment of this Act [

July 18, 1984].” Amendment by section 2354(b)(39), (40) of Pub. L. 98–369 effective

July 18, 1984, but not to be construed as changing or affecting any right, liability, status, or interpretation which existed (under the provisions of law involved) before that date, see section 2354(e)(1) of Pub. L. 98–369, set out as a note under section 1320a–1 of this title.

Effective Date

of 1983 AmendmentAmendment by Pub. L. 98–21 applicable to items and services furnished by or under arrangement with a hospital beginning with its first cost reporting period that begins on or after Oct. 1, 1983, any change in a hospital’s cost reporting period made after November 1982 to be recognized for such purposes only if the Secretary finds good cause therefor, see section 604(a)(1) of Pub. L. 98–21, set out as a note under section 1395ww of this title. See, also, section 2351(c) of Pub. L. 98–369, set out as a note below.

Effective Date

of 1974 Amendment Pub. L. 93–484, § 3(b), Oct. 26, 1974, 88 Stat. 1459, provided that: “The amendment made by subsection (a) [amending this section] shall be applicable to cost reports of providers of services for accounting periods ending on or after June 30, 1973.”

Effective Date

Pub. L. 92–603, title II, § 243(c), Oct. 30, 1972, 86 Stat. 1422, provided that: “The

Amendments

made by this section [enacting this section and amending section 1395h of this title] shall apply with respect to cost reports of providers of services, as defined in title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], for accounting periods ending on or after

June 30, 1973.” References in Other Laws to GS–16, 17, or 18 Pay RatesReferences in laws to the rates of pay for GS–16, 17, or 18, or to maximum rates of pay under the General Schedule, to be considered references to rates payable under specified sections of Title 5, Government Organization and Employees, see section 529 [title I, § 101(c)(1)] of Pub. L. 101–509, set out in a note under section 5376 of Title 5. Review of Provider Reimbursement Review Board Decisions Pub. L. 98–369, div. B, title III, § 2351(c),

July 18, 1984, 98 Stat. 1099, provided that: “Notwithstanding section 604 of the Social Security

Amendments

of 1983 (Public Law 98–21) [set out as an

Effective Date

of 1983

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note under section 1395ww of this title]— “(1) the

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made by section 602(h)(2)(A) of that Act [amending this section] shall be effective with respect to any appeal or action brought on or after April 20, 1983; and “(2) the

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made by section 602(h)(2)(B) of that Act [amending this section] shall be effective with respect to any appeal or action brought on or after the date of the enactment of this Act [July 18, 1984].”

§1395oo Provider Reimbursement Review Board

Summary

Title 42, §1395oo

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