Sebelius v. Auburn Regional Medical Center

Whether the 180-day statutory time limit for filing an appeal with the Provider Reimbursement Review Board from a final Medicare payment determination made by the PRRB is subject to equitable tolling.

In 1983, Medicare began using a “prospective payment system to reimburse hospitals for operating costs based on nationally applicable rates, subject to rate adjustments.” The disproportionate share hospital (DSH) payment allows for additional compensation to hospitals serving large numbers of low-income patients. The DSH percentage is calculated by the Center for Medicare and Medicaid Services (CMS), based on the number of patients using Supplementary Security Income. In an unrelated claim, it was found that CMS had underpaid hospitals from 1993-1996, due to a miscalculation in the relevant hospitals DSH percentage. In 2006 Respondents filed claims with the Provider Reimbursement Review Board (PRRB) seeking full reimbursement for the period of 1987-1994.

Respondents conceded that their claim was outside of the relevant statute of limitations, but argued that the limitation period should be equitably tolled to allow their claim. The PRRB held that it lacked authority to decide Respondent's appeal. The District Court held that the Medicare statute does not authorize equitable tolling.The Court of Appeals for the District of Columbia Circuit reversed holding that the 180 day period for requesting an appeal is subject to equitable tolling.

Petitioner argues that the 180 period is not subject to equitable tolling.