Adventist Living Centers, Inc. v. Bowen

881 F.2d 1417, 1989 U.S. App. LEXIS 12255, 1989 WL 91984
CourtCourt of Appeals for the Seventh Circuit
DecidedAugust 10, 1989
DocketNo. 88-2067
StatusPublished
Cited by12 cases

This text of 881 F.2d 1417 (Adventist Living Centers, Inc. v. Bowen) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Adventist Living Centers, Inc. v. Bowen, 881 F.2d 1417, 1989 U.S. App. LEXIS 12255, 1989 WL 91984 (7th Cir. 1989).

Opinion

CUDAHY, Circuit Judge.

In 1981, plaintiff Adventist Living Centers (“ALC”) purchased LaGrange Colonial Manor (“LaGrange”), a provider of skilled nursing services that participates in the Medicare program. Subsequently, ALC became enmeshed in a cost report dispute with its Medicare intermediary about the amount of Medicare reimbursement owed to ALC for depreciation expenses related to assets of the LaGrange facility. ALC commenced this action seeking judicial review of the decision of the Deputy Administrator of the Health Care Financing Administration, who concluded that ALC had overstated its depreciation expense in its 1982 and 1983 cost reports. The district court held that the agency’s determination was supported by substantial evidence and accordingly entered summary judgment in favor of the defendants. We affirm.

I.

A. Medicare Statutory and Regulatory Framework

Before stating the facts, we shall briefly summarize the Medicare regime within which this case arises. The Medicare program, title XVIII of the Social Security Act, 42 U.S.C. section 1395 et seq., provides [1419]*1419publicly-financed health insurance coverage for the aged and disabled. The program is administered, in part, through contractual arrangements with providers of health care services. See 42 U.S.C. § 1395cc. The federal government reimburses providers for the “reasonable costs” of services provided to Medicare beneficiaries through private organizations known as “fiscal intermediaries.” Providers apply for Medicare reimbursement by filing annual “cost reports” with intermediaries. 42 C.F.R. § 405.406(b). The intermediaries serve as administrators of the Medicare program by reviewing claims for reimbursement, making disbursements to providers, auditing records of providers to ensure proper payments and recovering overpayments made to providers. See 42 C.F.R. §§ 421.100(b), (c), (e), (f) and 421.120(e).

Intermediaries reimburse Medicare providers in accordance with standards established by the Medicare statutes, accompanying regulations and interpretive manuals. The regulations specify that depreciation of certain assets is a reimbursable expense. See 42 C.F.R. § 405.415 (1984).1 At the close of its fiscal year, a provider submits to its intermediary a cost report detailing the costs, including depreciation expense, of services provided to Medicare beneficiaries. See 42 C.F.R. § 405.406(b). The intermediary reviews the cost report, makes any appropriate adjustments and computes the amount of Medicare reimbursement owed to the provider. See 42 C.F.R. § 405.1803. If a provider is dissatisfied with the intermediary’s disposition of its claim for reimbursement, it may request a hearing before the Provider Reimbursement Review Board (“PRRB”). See 42 U.S.C. § 1395oo(a). Within 60 days after the provider is notified of the PRRB’s decision, the Secretary of Health and Human Services, through his delegate, the Deputy Administrator of the Health Care Financing Administration (the “Secretary”), may sua sponte reverse, affirm or modify the PRRB’s decision. See 42 U.S.C. § 1395oo(f)(l). If the Secretary’s final decision is adverse to the provider, the provider may obtain judicial review. Id.

B. Facts

On December 4, 1981, ALC2 contracted to purchase the business and assets of La-Grange, a skilled nursing facility, from Co-lianni & Dire Company, Inc. (“Colianni”) for $2,537,500. This purchase price was based on a valuation of $12,500 per bed times 203 beds. The sales contract specified that ALC agreed to purchase all the assets of LaGrange, “including without limitation, goodwill.” Admin. Record at 384. None of the documents memorializing the sale allocated the total purchase price among the individual assets. Following consummation of the sale, Colianni retained C.A. Benson & Associates, Inc. (“Benson”) to conduct a valuation of the assets of the LaGrange facility. Relying on the figures contained in the Benson appraisal, Colianni completed its final 1982 cost report and submitted it, along with the appraisal, to its Medicare intermediary, Blue Cross/Blue Shield of Illinois (“Blue Cross”). The Benson appraisal employed various accounting methodologies, including current reproduction cost and fair market value,3 to allocate the sale price of the LaGrange facility among the separate assets. Relying on the fair market values included in the Benson appraisal, the intermediary assessed Coli-anni’s gain on the sale of the facility and excess depreciation to be recovered by Medicare.

Meanwhile, when ALC completed its own cost reports for fiscal years 1982 and 1983, it included depreciation expenses in connection with the LaGrange assets. In computing its depreciation expense, ALC assigned a total cost of $2,542,000 to the assets based upon their purported fair market val[1420]*1420ue.4 ALC submitted the cost reports to its intermediary, which is also Blue Cross. When reviewing ALC’s cost reports, Blue Cross determined the cost of ALC's depre-ciable assets based upon the fair market values contained in the Benson appraisal rather than the values included in ALC’s cost reports. Applying the fair market methodology, which ascribed $619,500 to non-depreciable goodwill,5 Blue Cross reduced the amount of ALC’s reimbursable depreciation expense by $12,017 for 1982 and $11,320 for 1983.

ALC appealed the intermediary’s adjustments to the PRRB. The PRRB determined that the Benson appraisal was the only appraisal submitted that satisfied Medicare requirements. However, the PRRB disagreed with the intermediary’s use of the fair market value approach contained in the Benson appraisal. Instead, the PRRB concluded that, according to Medicare regulations, current reproduction cost (adjusted for straight-line depreciation to the date of sale) represented the correct valuation for calculating depreciation expense. Relying upon the current reproduction figures furnished in the Benson appraisal, the PRRB held that the proper cost basis of the assets was $2,330,000. The PRRB attributed the $207,500 difference between this figure and the actual purchase price ($2,537,500) to non-depreciable goodwill.

The Secretary reversed the PRRB’s decision sua sponte. The Secretary endorsed Benson’s fair market value approach, thereby aligning himself with the intermediary, and accordingly assigned $619,150 to non-depreciable goodwill. ALC sought judicial review of the Secretary’s decision.

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881 F.2d 1417, 1989 U.S. App. LEXIS 12255, 1989 WL 91984, Counsel Stack Legal Research, https://law.counselstack.com/opinion/adventist-living-centers-inc-v-bowen-ca7-1989.