Supreme Court affirms payment appeal limits
60-day limit on appeals stands
Medicare providers cannot challenge a refusal to reopen a decision to deny payment after the initial 60-day appeals period, according to a Feb. 24 decision by the U.S. Supreme Court.
Medicare providers’ annual reimbursement is based on cost reports they submit to an intermediary, usually an insurance company, designated by the government to determine the appropriate reimbursement.
By law, Medicare providers have 180 days to appeal decisions to deny reimbursement claims to the Provider Reimbursement Review Board. The board’s decision can then be appealed to a federal court within 60 days.
Health care providers also have three years to ask an intermediary to reopen a previous funding decision. But if the intermediary refuses, federal rules say that decision cannot be appealed.
In 1994, Your Home Visiting Nurse Services in Knoxville, TN, asked its designated Medicare intermediary to reopen a 1989 funding decision based on the allegation it was paid less than owners of a competing nursing home for the same services.
Blue Cross and Blue Shield of South Carolina, the designated intermediary, refused to reopen Your Home’s 1989 case, and the Provider Reimbursement Review Board said it lacked the authority to hear the nursing service’s appeal.
Your Home sued, asking a federal judge in Knoxville to either order Blue Cross to reopen the case or require the review board to hear its appeal. The judge ruled against Your Home, and the 6th U.S. Circuit Court of Appeals upheld that ruling. The Supreme Court, in turn, backed the lower courts’ decisions.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content