Anaheim Memorial Hospital v. Shalala

130 F.3d 845, 97 Daily Journal DAR 14499, 97 Cal. Daily Op. Serv. 8888, 1997 U.S. App. LEXIS 33505, 1997 WL 731402
CourtCourt of Appeals for the Ninth Circuit
DecidedNovember 26, 1997
DocketNos. 96-55724, 96-55796
StatusPublished
Cited by4 cases

This text of 130 F.3d 845 (Anaheim Memorial Hospital v. Shalala) 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
Anaheim Memorial Hospital v. Shalala, 130 F.3d 845, 97 Daily Journal DAR 14499, 97 Cal. Daily Op. Serv. 8888, 1997 U.S. App. LEXIS 33505, 1997 WL 731402 (9th Cir. 1997).

Opinion

TASHIMA, Circuit Judge:

In French Hosp. Med. Ctr. v. Shalala, 89 F.3d 1411 (9th Cir.1996) (“French Hospital ”), we held that the reopening of a Medicare cost report entitles the provider to appeal only the “issue” on which the report had been reopened. On these consolidated appeals, we face the question which logically follows: How broad is the “issue” that was reopened?

I. BACKGROUND

A. The Statutoiy and Regulatory Framework

The Medicare statute, Title XVIII of the Social Security Act, Pub.L. No. 89-97, 79 Stat. 291 (1965) (codified as amended at 42 U.S.C. § 1395 to 1395eec (1991 & Supp. 1997)), creates a federally funded health insurance program for the elderly and disabled. The statute provides that the Secretary of Health and Human Services (the “Secretary”) will reimburse health care providers for services provided to Medicare patients. A hospital may participate in the Medicare program as a provider by entering into a provider agreement with the Secretary. 42 U.S.C. § 1395h; 42 C.F.R. § 421.103 (1996).

Reimbursement to a provider is normally handled by a “fiscal intermediary.” 42 U.S.C. § 1395h(a). A provider seeking reimbursement submits an annual cost report to the fiscal intermediary, 42 C.F.R. §§ 413.20(a)-(b) & 413.24(f), which then audits the report, determines the reimbursable amount, and issues an initial Notice of Amount of Medicare Program Reimbursement (“NPR”) for the relevant fiscal year. 42 C.F.R. § 405.1803.

During the periods at issue in this case, Medicare paid the lower of a provider’s “customary charges” or the “reasonable cost” of furnishing covered services. 42 U.S.C. § 1395f(b)(1). The statute authorizes the Secretary to set up cost limits” that help define reasonable costs. 42 U.S.C. § 1395x(v)(l)(A). Pursuant to this statutory authorization, the Secretary, acting through the Health Care Financing Administration (the “HCFA”), established cost ceilings called “routine cost limits” (“RCL”). 46 Fed. Reg. 33637, 33639-40 (June 30, 1981) (concerning the fiscal years in question). Providers were not normally reimbursed for costs incurred in excess of the RCL.

The RCL is derived from a number of factors, including: (1) a database consisting of a large set of Medicare cost reports; (2) a market basket index of goods and services purchased by hospitals; (3) determinations of separate labor-related and non-labor components of hospital costs; (4) a hospital wage index; (5) a geographic classification system; (6) inflation factors; (7) cut-off points for determining mean costs; (8) separate adjustments for medical education costs, the cost-of-living in Alaska and Hawaii, and the beginning date of a hospital’s cost reporting period; and (9) an upward adjustment for hospitals located in states with lower than the national average of covered days of care (“CDCA factor”). 46 Fed.Reg. 33637, 33639-40 (June 30, 1981); 45 Fed.Reg. 41868-80 (June 20, 1980); 44 Fed.Reg. 31806, 31810 (June 1, 1979). See also 42 C.F.R. § 413.30(a)(2), (c)-(f) (describing procedure for deriving the RCL).

After the fiscal intermediary issues an initial NPR, the provider may appeal any aspect of the reimbursement to the Provider Reimbursement Review Board (the “PRRB” or “Board”), if the amount in controversy is at least $10,000 ($50,000 for a group appeal), and if the hearing request is submitted within 180 days of the initial NPR. 42 U.S.C. § 1395oo(a), (b). The PRRB has discretion to extend the 180-day appeal period for good cause if an extension is requested within three years of the initial NPR. 42 C.F.R. § 405.1841(b). If these jurisdictional prerequisites are fulfilled and the PRRB has the authority to decide the matter at issue, 42 C.F.R. § 405.1867, the PRRB may hold a [848]*848hearing and issue a decision. The Secretary’s delegate, the HCFA Administrator (the “Administrator”), may then review the PRRB’s decision, either sua sponte or upon request. 42 C.F.R. § 405.1875. The Administrator must promptly notify the parties if he intends to review the PRRB’s decision, and he must render his final decision within 60 days of the PRRB’s decision. 42 U.S.C. § 1395oo(f)(1); 42 C.F.R. § 405.1875(d) & (g).

The Medicare statute also creates a process known as “expedited judicial review” (“EJR”). If the PRRB decides that it has jurisdiction over an appeal but lacks the authority to decide the controlling question of law, it may grant an EJR. 42 U.S.C. § 1395oo(f)(1). The provider then has 60 days to seek judicial review of the legal issue in question. 42 U.S.C. § 1395oo(f)(1).

If a provider does not timely appeal the initial NPR, its cost report for that fiscal year is considered closed. Under certain circumstances, however, a closed cost report can be reopened. 42 C.F.R. § 405.1885. When an NPR is reopened and a revision is made, that revision is considered “a separate and distinct determination or decision,” i.e., it is a new final decision, subject to the appeal rights discussed above. 42 C.F.R. § 405.1889.

B. French Hospital

We first confronted the regulations governing the reopening of an NPR in French Hospital, 89 F.3d 1411. In that case, the fiscal intermediary reopened an initial NPR seven years after it was issued in order to reclassify the provider’s malpractice insurance costs as an administrative and general cost. Id. at 1413. After that reopening, the provider pursued an appeal to the PRRB challenging the RCL formula on the grounds that the wage index in the RCL was flawed and that the CDCA factor was inaccurate. Id. at 1414.

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130 F.3d 845, 97 Daily Journal DAR 14499, 97 Cal. Daily Op. Serv. 8888, 1997 U.S. App. LEXIS 33505, 1997 WL 731402, Counsel Stack Legal Research, https://law.counselstack.com/opinion/anaheim-memorial-hospital-v-shalala-ca9-1997.