Alexander County Hospital v. Bowen

692 F. Supp. 606, 1988 U.S. Dist. LEXIS 9424, 1988 WL 88031
CourtDistrict Court, W.D. North Carolina
DecidedAugust 24, 1988
DocketNo. C-C-86-501-P
StatusPublished
Cited by2 cases

This text of 692 F. Supp. 606 (Alexander County Hospital v. Bowen) is published on Counsel Stack Legal Research, covering District Court, W.D. North Carolina primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Alexander County Hospital v. Bowen, 692 F. Supp. 606, 1988 U.S. Dist. LEXIS 9424, 1988 WL 88031 (W.D.N.C. 1988).

Opinion

[607]*607MEMORANDUM OF DECISION

ROBERT D. POTTER, Chief Judge.

THIS MATTER is before the Court on cross motions for Summary Judgment by Plaintiffs and Defendant. Arguments on the motions were heard by the Court at Charlotte, North Carolina on July 20, 1988. Carel Hedlund, Ésq. appeared for Plaintiffs and Gerard Keating, Esq. appeared for Defendant. For the reasons stated herein, the Court will grant Plaintiffs’ motion for summary judgment and deny Defendant’s cross-motion for summary judgment.

I. BACKGROUND

A. Parties

Plaintiffs are 54 licensed acute general hospitals which are certified Medicare “providers,” which are appealing as a group from a decision by the Provider Reimbursement Review Board’s (PRRB) dismissal of Plaintiffs’ requests for hearings on their respective cost reports. Defendant is the Secretary responsible for the administration of the Department of Health and Human Services (HHS) including the Medicare Program. The Health Care Financing Administration (HCFA) is the operating component of HHS charged with administration of the Medicare Program.

B. Health Insurance for Aged and Disabled

Congress enacted the Medicare Program in 1965 to subsidize medical care of the elderly. Under the Act, providers of covered services, such as hospitals, are reimbursed for “the lesser of (A) the reasonable cost of such services, as determined under [42 U.S.C.] section 1395x(v) ..., or (B) the customary charges with respect to such services.” 42 U.S.C. § 1395f(b)(l) (1982).

The Secretary of HHS issues regulations by which “reasonable costs” will be calculated. 42 U.S.C. § 1395x(v)(l)(A) (1982). Then, a fiscal intermediary determines the amount of reimbursement due and furnishes the provider a written notice for each cost period. 42 U.S.C. §§ 1395h, 1395g (1982); 42 C.F.R. § 405.1803 (1986).

Up until 1979 all insurance costs, including fire, casualty, accident, and malpractice insurance premiums or contributions to self-insurance funds were included in general and administrative costs and were reimbursed to the hospital on the basis of percentage of medicare utilization of the hospital’s services by the medicare beneficiaries.

In 1979, the Secretary issued regulations which required that malpractice insurance costs be removed from the general and administrative pool of costs and be directly apportioned between Medicare and non-Medicare patients based on the dollar ratio of paid losses. The 1979 regulation has been invalidated by several circuits and district courts, as well as by the Fourth Circuit. Bedford County Memorial Hospital v. Health & Hum. Services, 769 F.2d 1017 (4th Cir.1985).

Having been unsuccessful in sustaining his 1979 Rule, the Secretary proceeded to publish another rule on April 1, 1986 as a final rule with a post-publication comment period. The Secretary stated that the new rule was retroactively “applicable to case reporting periods, beginning on or after July 1,1979.” 51 Fed.Reg. 11194 (1986), 42 C.F.R. § 413.56 (1986).

Under the 1986 Rule, a provider’s malpractice insurance premium costs are divided into two components. The “administrative component,” which accounts for 8.5% of total premium cost, is included in the provider’s general administrative costs, and is apportioned on the basis of the provider’s Medicare utilization rate. See 52 Fed.Reg. 9835 (1987). The “risk component,” which comprises the remaining 91.5% of total premium cost, is apportioned on the basis of a formula that takes into account the individual provider’s Medicare utilization rate as well as the national Medicare malpractice loss ratio and the national Medicare utilization rate.

Before determining whether the 1986 Rule is valid under the Medicare statute, the Court should determine whether the Secretary has the authority to apply the 1986 Rule retroactively. If he does not have authority to apply the rule retroac[608]*608tively, then the Court need not decide whether the Rule is valid since its validity would be irrelevant to the Court’s decision in this case. Plaintiffs here seek reimbursement only for cost years prior to 1986. Of course, the Secretary argues that the Medicare Act, at 42 U.S.C. §§ 1395x(v)(l)(A)(ii) and 1395hh specifically sanctions retroactive rulemaking. We will see if he is correct.

II. ANALYSIS

Title 42, section 1395x(v)(l)(A) provides in pertinent part:

The reasonable cost of any services ... shall be determined in accordance with regulations____
Such regulations shall
(i) take into account both direct and indirect costs of providers of services ..., and
(ii) provide for the making of suitable retroactive corrective adjustments where, for a provider of services for any fiscal period, the aggregate reimbursement produced by the methods of determining costs proves to be either inadequate or excessive.

42 U.S.C. § 1395x(v)(l)(A) (1982).

Notice that the language of the statute is to the effect that the regulations prescribed by the Secretary shall “provide for the making of suitable retroactive adjustments ” (emphasis added). The statute does not bestow on the Secretary any authority to provide for any suitable retroactive regulations. Yet, the Secretary, on page 19 of his Memorandum in support of his cross-motion for summary judgment, states

Given the corrective nature of the 1986 rule and the new rulemaking record, plaintiff cannot show the 1986 rule is arbitrary and capricious. (Citing cases) While the providers can be expected to assert that the 1986 regulation is invalid____

(Emphasis added).

The Secretary, on June 1, 1979, promulgated “the 1979 malpractice rule.” See 44 Fed.Reg. 31,641 (1979), adding 42 C.F.R. §§ 405.452(b)(l)(ii), re-designated as 42 C.F.R. § 405-452(a)(l)(ii) (48 Fed.Reg. 39,-811 (1983)). When the 1979 rule became enmeshed in litigation, and was ultimately found to be invalid by several circuits, the Secretary promulgated the 1986 rule, which effective May 1, 1986 eliminated the 1979 malpractice rule and added 42 C.F.R. § 413.56 (1986) (the 1986 rule) to the Medicare regulations. See 51 Fed.Reg. 11,195-96, adding 42 C.F.R.

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692 F. Supp. 606, 1988 U.S. Dist. LEXIS 9424, 1988 WL 88031, Counsel Stack Legal Research, https://law.counselstack.com/opinion/alexander-county-hospital-v-bowen-ncwd-1988.