U.S. Supreme Court to Hear Case on Providers’ PRRB Appeal

The U.S. Supreme Court has granted certiorari in a Medicare reimbursement case that stretches back 25 years. In Auburn Regional Medical Center v. Sebelius (U.S. Court of Appeals, District of Columbia Circuit, 642 F.3d 1145)  the appellate court ruled that the district court erred in ruling that it had no jurisdiction to apply equitable tolling of the statute of limitations to a claim that CMS knowingly and unlawfully withheld funds from providers.

In a lawsuit filed in 2006, the providers alleged that from 1987 through 1994, CMS had incorrectly computed the SSI/Medicare fraction used to calculate providers’ disproportionate share hospital (DSH) adjustment and that the agency failed to disclose or to correct the underpayments. The Provider Reimbursement Review Board (PRRB) ruled that it had no jurisdiction because the claims were untimely; this ruling was a final order for purposes of judicial review.

The district court then ruled that a federal court cannot review a board decision dismissing an appeal that was not timely filed within 180 days of receipt of the notice of program reimbursement (NPR), because such a decision by the board is a “final decision” for purposes of the judicial review provision the provider appeal statute in Section 1878 of the Social Security Act. In addition, the district court concluded that the appeal statute’s 180-day appeal period is not subject to equitable tolling in any circumstance.

The appellate court disagreed, finding that under the Social Security Act equitable tolling, in general, is available. The court added, however, that “whether tolling is appropriate in this particular case, however, is a different question that cannot be answered without further factual development.”

We look forward to following this case in the coming Supreme Court term.