Provider Reimbursement Review Board Annual Report: Fiscal Year 1994

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INTRODUCTION

An amendment to the Social Security Act of 1972 created the PRRB and statutorily provides for an administrative review process of reimbursement disputes. The PRRB began operations in FY 1975. Since its creation, there have been only minor changes to the Act relating to the PRRB. This year marks the 20th anniversary of the PRRB.

The independent decision making of the PRRB is supported administratively by the Health Care Financing Administration (HCFA). The Board consists of five members appointed by the Secretary of Health and Human Services (HHS), two of whom must be representatives of providers of service and at least one of whom must be a certified public accountant (CPA). All Board members are to be knowledgeable in the field of payment to providers of services.

The PRRB is the initial finder of fact in the administrative appeals process and is responsible for developing a complete record of the case. The record established at the Board serves as the basis for review by all subsequent administrative and judicial tribunals. During the last FY, PRRB decisions served as the basis for numerous Federal district and circuit court decisions, as well as two cases before the Supreme Court. The Board is bound by laws, regulations, and HCFA rulings, and gives weight to interpretive rules or manual provisions. A provider, in most instances, cannot seek judicial review of a Medicare reimbursement matter until it has received a final decision from the PRRB.

MISSION AND VISION

Congress created the PRRB to furnish providers with an independent forum for resolving payment disputes arising from final determinations (42 U.S.C. 1395oo). Consistent with this purpose, the Board's mission is to adjudicate disputes in a timely manner, maintaining the quality of its decisions along with the Board's independence and integrity. The PRRB makes rules and establishes procedures consistent with the Social Security Act and regulations of the Secretary of HHS to ensure a fair and equitable process. The vision of the PRRB and the Office of Hearings (proposed organizational name of staff) is to promote and …