AHN Homecare, L.L.C. v. Home Health Reimbursement & Health Care Financing Administration (In re AHN Homecare, L.L.C.)

222 B.R. 804, 12 Tex.Bankr.Ct.Rep. 345, 1998 Bankr. LEXIS 778
CourtUnited States Bankruptcy Court, N.D. Texas
DecidedJune 10, 1998
DocketBankruptcy No. 397-81166-RCM-11; Adversary No. 397-3565
StatusPublished
Cited by8 cases

This text of 222 B.R. 804 (AHN Homecare, L.L.C. v. Home Health Reimbursement & Health Care Financing Administration (In re AHN Homecare, L.L.C.)) is published on Counsel Stack Legal Research, covering United States Bankruptcy Court, N.D. Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
AHN Homecare, L.L.C. v. Home Health Reimbursement & Health Care Financing Administration (In re AHN Homecare, L.L.C.), 222 B.R. 804, 12 Tex.Bankr.Ct.Rep. 345, 1998 Bankr. LEXIS 778 (Tex. 1998).

Opinion

MEMORANDUM OPINION

ROBERT MCGUIRE, Chief Judge.

The Secretary of the United States Department of Health and Human Services (“HHS”) filed this motion to dismiss the above-styled adversary filed by AHN Home-care, LLC (“AHN”). By agreement of counsel, the motion was decided on the basis of the pleadings and briefs before the court. Following are the Court’s Findings of Fact and Conclusions of Law pursuant to Bankr.R. 7052.

In considering Defendant’s motion, the Court only considers the pleadings. 5A Charles A. Wright & Arthur R. Miller, Federal Practice & Procedure: Civil 2d § 1356 at 298 (2d ed.1990); Mahone v. Addicks Utility Dist. of Harris Co., 836 F.2d 921, 935 (5th Cir.1988). Federal Rule of Civil Procedure 10(c) and Federal Rule of Bankruptcy Procedure 7010 define pleadings to include written documents which act as exhibits to pleadings. Accord Feder v. MacFadden Holdings, Inc., 698 F.Supp. 47, 50 (S.D.N.Y.1988).

I. Statutory and Regulatory Background

Part A of the Medicare Act, established by Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq., in relevant part provides for payment on behalf of eligible beneficiaries for certain home health services furnished by home health agencies. 42 U.S.C. § 1395d. The Secretary of the United States Department of Health and Human Services (“HHS”) administers the Medicare Program and has delegated this function to the Health Care Financing Administration (“HCFA”), a component of HHS.

A home health agency that meets Medicare certification standards may enter into a provider agreement with HCFA, 42 U.S.C. § 1395ce, and be reimbursed for the reasonable cost of covered services, as determined under detailed statutory and regulatory criteria. 42 U.S.C. §§ 1395f(b), 1395h, 1395x(v); 42 C.F.R. § 413.1 et seq. HHS’s payment scheme pays providers periodically on an interim basis on estimates of the provider’s projected cost for the entire year. 42 C.F.R. § 413.64(b), (e). After interim payments are made, audits are conducted that may reveal any under- or overpayments made to providers. Such under- or overpay-ments are corrected through ongoing adjustments in subsequent Medicare reimbursements. 42 C.F.R. § 405.371(a)(2), 3413.64(e), (h)(7). HHS is allowed to adjust payments to providers as is necessary to properly balance payments to providers. 42 U.S.C. § 1395g(a). The review of the interim payments is conducted by a fiscal intermediary, generally a private insurance company. 42 C.F.R. § 413.20(b), 413.24(f).

Congress has provided an exclusive avenue for judicial review of reimbursement issues effecting providers. Upon an intermediary’s final determination as to the total amount of reimbursement due, a provider may request a hearing with respect to such determinations and obtain a decision from the Provider Reimbursement Review Board. (“PRRB”) 42 U.S.C. § 1395oo(a); 42 C.F.R. § 405.1835. The decision of the Review Board is final unless the HHS reverses, affirms, or modifies the PRRB decision on its own motion within sixty days of the decision. 42 U.S.C. § 1395aa(f)(l). Only after receiving a decision by the PRRB or HHS may the provider obtain judicial review of an adverse decision in a federal district court, 42 U.S.C. § 1395aa(f)(l), pursuant to the applicable provisions of the Administrative Procedure Act, 5 U.S.C. § 701 et seq. See also Homewood Prof'l Care Ctr., Ltd. v. Heckler, 764 F.2d 1242, 1248 (7th Cir.1985). Under Title 42 U.S.C. § 405(h) of the Social Security Act, made applicable to the Medicare Act by 42 U.S.C. § 1395Ü and 42 U.S.C. § 1395oo(f)(l), the findings and decision of HHS are binding and no decisions are reviewable except after administrative exhaustion and a final decision provided for in 42 U.S.C. § 405(g). Bodimetric Health Services, Inc. v. Aetna Life & Cas., 903 F.2d 480, 483 (7th Cir.1990) cert. denied, 498 U.S. 1012, 111 S.Ct. 579, 112 [806]*806L.Ed.2d 584 (1990); Homewood, 764 F.2d at 1247, 1252; In re St. Johns Home Health Agency, Inc., 173 B.R. 238, 243 (Bankr.S.D.Fla.1994).

II. Factual Background

AHN participated in the Medicare program and received reimbursement for services provided to eligible beneficiaries since 1992 when it executed its provider agreement with the HCFA. During the latter part of 1996, AHN was subject to an audit and review. Based on a random sample of 100 claims filed by AHN with the fiscal intermediary Palmetto, HHS determined that 40% of AHN claims were not properly payable under the Medicare program.

In a letter dated April 15, 1997, Palmetto informed AHN that the review resulted in the determination of a $2,420,782 overpayment. Palmetto provided AHN with its administrative appeal rights and offered AHN the opportunity to repay the amount owed in one lump sum or to repay it over an extended period of time, if it could demonstrate that the payback would be made with non-Medicare funds. AHN was unable to do either, so Palmetto informed AHN of its intent to recover the overpayment by “recouping” the amount owed from current interim payments otherwise due AHN. Palmetto began recoupment in late November.

On December 3, 1997, AHN filed for protection under Chapter 11 of the Bankruptcy Code. Palmetto continued to attempt recoupment after the petition date, however, upon discovering its error, Palmetto refunded those monies recouped after the petition date. [HHS Motion to Dismiss, p.

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222 B.R. 804, 12 Tex.Bankr.Ct.Rep. 345, 1998 Bankr. LEXIS 778, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ahn-homecare-llc-v-home-health-reimbursement-health-care-financing-txnb-1998.