Medicare Appeals & Reopenings


We help organizations review and challenge their Medicare Cost Reports
to correct underpayments, file appeals or reopenings when appropriate, and secure the reimbursement they are entitled to while staying compliant.

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Expert Cost Report Reopenings

There are a number of reasons a hospital might request a cost report reopening. Unlike cost report appeals, reopenings are pursued in relation to issues previously settled at the Provider Reimbursement Review Board (PRRB) or at the direction of Centers for Medicare & Medicaid Services (CMS). Although cost report reopenings are at the Medicare Administrative Contractor’s (“MAC”) discretion, Besler Holdings’ specialists have experienced success in pursuit of cost report reopenings on behalf of hospitals.

The specialists at Besler Holdings have worked extensively with MACs for more than 20 years. Our experience has allowed us to cultivate sound relationships with the MACs. This working relationship allows Besler Holdings to clearly articulate a hospital’s needs to the teams responsible for addressing them.

In addition to utilizing reopenings to address settled issues, another avenue a hospital can pursue to increase their reimbursement is through SSI Rebasing. Besler Holdings and its channel partner, Keyzer, Shelby and Associates, Inc., have the expertise in SSI policies helping to shape them and ensuring hospitals benefit from the latest changes.

The financial implications of SSI Rebasing can be substantial. The numerator of the Medicare fraction includes SSI days; therefore, a higher number of SSI days may translate directly into greater DSH payments. For hospitals with fiscal years that do not align with the federal fiscal year, rebasing ensures that the calculation includes all relevant patient days that occurred during their actual fiscal period. Our supporting processes promote efficiency and provide for success in the pursuit of SSI Rebasing.

We are well-versed in handling complex reopening matters, ensuring hospitals receive proper reimbursement. Contact us to learn more about our Medicare Cost Report Reopenings and Rebasing.

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Medicare Cost Report Appeals

Proper Medicare reimbursement is crucial for hospitals. It fuels their ability to provide high-quality care, invest in cutting-edge technology, and attract skilled staff. The complexities of Medicare cost reporting, however, can lead to adjustments and a decrease in reimbursement, thus threatening financial stability.

Hospitals facing cost report underpayments often embark on a challenging Medicare appeals process. Stringent deadlines, precise discrepancy documentation, and well-supported arguments are all essential for success. However, navigating the legalities, reimbursement calculations, and intricate Medicare regulations can be overwhelming.

Besler Holdings’ experienced specialists alleviate this burden, simplifying hospital cost report appeals. 

Don’t let Medicare reimbursement complexities hinder your ability to deliver exceptional care. Team up with Besler Holdings for a proactive approach to ensure your hospital receives its deserved Medicare reimbursement.

Contact us to learn more about our Medicare Cost Report Appeals services.

Medicare Cost Report Appeals & Reopenings FAQs

What is the difference between a Medicare Cost Report appeal and a Medicare Cost Report Reopening?

  • A Medicare Cost Report Appeal is a formal challenge to a final determination (i.e. NPR, Federal Register, failure to timely issue NPR, etc.) that typically is brought before the Board (PRRB) under 42 CFR 405.1809–405.188.
  • A Medicare Cost Report Reopening is an administrative reconsideration of the NPR by the MAC or CMS under 42 CFR 405.1885, usually based on new and material evidence or clear error, and is discretionary.

When should our hospital consider an appeal instead of a reopening?

  • Use an appeal when you disagree with an audit adjustment or CMS policy interpretation and want to preserve formal rights and potential PRRB review.
  • Use a reopening when you identify missed reimbursable items (for example, Medicare bad debt, DSH related days, or IME/GME cost allocations) and want a faster, administrative correction within the three-year window.

What are the basic filing deadlines we need to track?

  • Medicare Cost Report Appeals: Generally, 180 days from the final determination you are appealing.
  • Medicare Cost Report Reopenings: Generally, three years from the NPR date, with no time limit when there is fraud or similar fault.

What are the minimum dollar thresholds to appeal a Medicare Cost Report?

  • MAC Appeals: Typically, $1,000–$9,999 in controversy for an individual hospital.
  • PRRB Appeals: At least $10,000 in controversy for an individual appeal or $50,000 in aggregate for a group appeal.

What issues are commonly appealed or reopened?

  • DSH: Inclusion/exclusion of Medicaid days, Medicare Advantage (Part C Days), or Medicare SSI ratios that materially impact DSH payments.
  • Medicare Bad Debt: Disallowances related to collection effort, timing of write off, crossover claims, or dual eligible cost sharing.
  • Standardized Amount: Miscalculation and/or improper budget neutrality adjustments.
  • IME/GME: Resident rotations or bed ratio.

Can we request a Medicare Cost Report Reopening and still file a Medicare Cost Report Appeal?

  • Yes. A reopening request does not extend or pause the 180-day appeal deadline, so many hospitals file both to preserve rights.
  • If the MAC offers to reopen an issue that is already appealed, make sure any appeal withdrawal is documented; PRRB rules allow possible reinstatement with written evidence if the MAC later fails to act.

What should be included in a Medicare Cost Report appeal submission?

  • Identification of the specific audit adjustments or issues (by worksheet/line/column and adjustment number), the amount in dispute, and the corrected calculation as applicable.
  • A concise explanation of why the MAC’s determination is incorrect, supported by CMS regulations, manuals, PRRB precedent, and detailed workpapers (for example, DSH day listings, bad debt logs, IME/GME calculations).

What should be included in a Medicare Cost Report reopening request?

  • A clear description of the issue(s) to be reopened plus supporting documentation that qualifies as new and material evidence or clearly demonstrates error.
  • Quantified financial impact.

Who can submit appeals and reopening requests on behalf of the hospital?

  • The hospital is the party to the cost report and must sign or authorize submissions.
  • A signed authorization letter on hospital letterhead is required when a third-party representative files a reopening request or appeal on a hospital’s behalf.

Can we appeal directly from a CMS rule (Federal Register) instead of waiting for an NPR?

  • Yes, certain policy issues—such as DSH or IME methodology changes—can be appealed directly from a Federal Register notice if they meet PRRB jurisdiction requirements.
  • This type of appeal is useful when the dispute is about the underlying CMS rule rather than the MAC’s application of that rule in a single cost report.

Can we challenge a MAC’s refusal to reopen our Medicare Cost Report?

Generally, no. Hospitals do not have a separate appeal right when a MAC denies or declines a reopening request.

What are practical best practices for managing Medicare Cost Report Appeals and Medicare Cost Report Reopenings?

  • Maintain robust cost report workpapers, DSH and bad debt detail, and contemporaneous documentation so you can support issues years later during appeal or reopening.
  • Build a tracking calendar for NPR dates, 180-day appeal deadlines, and three-year reopening expirations, and prioritize issues with the highest reimbursement impact relative to the effort and legal risk.

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