Adams House Health Care v. Heckler

817 F.2d 587, 1987 U.S. App. LEXIS 6340, 17 Soc. Serv. Rev. 709
CourtCourt of Appeals for the Ninth Circuit
DecidedMay 18, 1987
DocketNos. 85-1512, 86-1872
StatusPublished
Cited by12 cases

This text of 817 F.2d 587 (Adams House Health Care v. Heckler) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Adams House Health Care v. Heckler, 817 F.2d 587, 1987 U.S. App. LEXIS 6340, 17 Soc. Serv. Rev. 709 (9th Cir. 1987).

Opinion

BEEZER, Circuit Judge:

The parties present an unsettled question of statutory construction: may a Medicare provider claim certain costs in a proceeding before the Provider Reimbursement Review Board when the provider included but failed to claim such costs in its annual Medicare cost report? In these consolidated cases, the Board held it had no power to consider reimbursement items not expressly claimed by the providers in their cost reports. The district court remanded both cases, directing the Board to accept jurisdiction over disputes concerning such reimbursement items. We have jurisdiction pursuant to 28 U.S.C. § 1291 and we affirm.

I

BACKGROUND

A. The Medicare Program

The Medicare program is set forth in subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (1982). Part A of the program, under which these cases arise, authorizes federal reimbursement for hospital care provided to the elderly and disabled. 42 U.S.C. § 1395c-1395i-2. Until recently, a health care “provider” (e.g. a hospital) submitted annual cost reports to a “fiscal intermediary” (usually a private insurance company) for review; the fiscal intermediary acted as an agent of the Secretary of Health and Human Services. The intermediary audited the cost report and issued a Notice of Program Reimbursement with an explanation of any audit adjustments or disallowed costs.1 If the provider was not satisfied, the statute provided an avenue of administrative appeal to the Provider Reimbursement Review Board (“Board”) which, since it is central to this case, will be set forth at length below.

B. Adams House, No. 85-1512

The appellants, 82 skilled nursing facilities under common ownership, will be referred to collectively as “Adams House.” In fiscal year 1981, Adams House claimed an allowance for a “reasonable return on equity capital invested and used in the provision of patient care,” pursuant to 42 C. F.R. § 405.429(a)(l)(i) (1983). Following the rules set forth in the Medicare Provider Reimbursement Manual, however, Adams House made no claim relative to assets invested for more than six months, though such assets were listed in the cost report. Later, claiming that the Manual conflicted with the regulations, Adams House filed an appeal with the Board seeking an allowance for these investments. The Board declined review on the ground that it lacked power to consider claims not expressly disclosed to the intermediary in the cost report.

Adams House appealed to the district court pursuant to 42 U.S.C. § 1395oo(f) and both parties moved for summary judgment. Summary judgment was entered in favor of Adams House on October 17, 1984. The case was remanded to the Board, which was ordered to accept jurisdiction. 604 F.Supp. 110, 117 (N.D.Cal.1984).2 The Secretary timely appealed.

[590]*590C. Board of Trustees of Stanford, No. 86-1872

The appellant (“Stanford”) owns and operates the Stanford University Hospital. In fiscal year 1981, Stanford claimed reimbursement for Medicare services rendered, using the “average cost per diem” method set forth in the Medicare Provider Reimbursement Manual. Later, claiming that the Manual’s rules improperly required inclusion of labor and delivery room patient days in the per diem calculation, Stanford filed an appeal with the Board. The Board declined review on the ground that it lacked power to consider claims not expressly disclosed to the intermediary on the cost report.

Stanford appealed to the district court and both parties moved for summary judgment. Summary judgment was entered in favor of Stanford on January 29, 1986. The Secretary timely appealed and this case was consolidated with Adams House for argument.

II

ANALYSIS

We review the district court’s grants of summary judgment de novo. Vance v. Hegstrom, 793 F.2d 1018, 1022 (9th Cir.1986). In other words, we review the Board’s refusals to accept jurisdiction under the same standard as did the district court.

Judicial review of Medicare reimbursement decisions is governed by the Administrative Procedure Act, 5 U.S.C. §§ 701-06 (1982). See 42 U.S.C. § 1395oo (f)(1); Western Medical Enterprises, Inc. v. Heckler, 783 F.2d 1376, 1380 (9th Cir.1986). According to that Act, the courts must set aside any agency action found to be “arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law.” 5 U.S.C. § 706. We defer to an agency when it fills gaps or resolves ambiguities in the statute it administers, but we must reject agency rules that thwart the expressed intent of Congress. See Chevron U.S.A. Inc. v. Natural Resources Defense Council, 467 U.S. 837, 842-45, 104 S.Ct. 2778, 2781-83, 81 L.Ed.2d 694 (1984); Regents of the University of California v. Heckler, 771 F.2d 1182, 1187 (9th Cir.1985).

The central question in this case is whether the Provider Reimbursement Review Board correctly decided that it had no power to consider reimbursement claims not expressly made to a fiscal intermediary in a cost report. Some federal courts have held that the Board’s power is so limited; many of those decisions rely in large part on the thoughtful opinion in Athens Community Hospital, Inc. v. Schweiker, 743 F.2d 1 (D.C.Cir.1984) (“Athens II”). See University of Cincinnati v. Sec’y of Health and Human Services, 809 F.2d 307 (6th Cir.1987); North Broward Hosp. Dist. v. Bowen, 808 F.2d 1405 (11th Cir.1987); Baptist Hospital East v. Sec’y of Health and Human Services, 802 F.2d 860 (6th Cir.1986); Community Hosp. of Roanoke Valley v. Health and Human Services, 770 F.2d 1257 (4th Cir.1985). Other federal courts, including the district court below, have disputed the Board’s narrow view of its powers. See St. Luke’s Hospital v.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Mainegeneral v. HHS
210 F.3d 420 (First Circuit, 2000)
MaineGeneral Medical Center v. Shalala
205 F.3d 493 (First Circuit, 2000)
French Hospital Medical Center v. Shalala
89 F.3d 1411 (Ninth Circuit, 1996)
Adams House Health Care v. Bowen
862 F.2d 1371 (Ninth Circuit, 1988)
Bethesda Hospital Assn. v. Bowen
485 U.S. 399 (Supreme Court, 1988)
Kootenai Hospital District v. Bowen
663 F. Supp. 1061 (N.D. California, 1987)
Catholic Social Services, Inc. v. Meese
664 F. Supp. 1378 (E.D. California, 1987)

Cite This Page — Counsel Stack

Bluebook (online)
817 F.2d 587, 1987 U.S. App. LEXIS 6340, 17 Soc. Serv. Rev. 709, Counsel Stack Legal Research, https://law.counselstack.com/opinion/adams-house-health-care-v-heckler-ca9-1987.