Board of Trustees of Knox County (Indiana) Hospital v. Sullivan

965 F.2d 558, 1992 U.S. App. LEXIS 14572, 1992 WL 141950
CourtCourt of Appeals for the Seventh Circuit
DecidedJune 25, 1992
DocketNo. 91-2265
StatusPublished
Cited by1 cases

This text of 965 F.2d 558 (Board of Trustees of Knox County (Indiana) Hospital v. Sullivan) 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.

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Board of Trustees of Knox County (Indiana) Hospital v. Sullivan, 965 F.2d 558, 1992 U.S. App. LEXIS 14572, 1992 WL 141950 (7th Cir. 1992).

Opinion

CUMMINGS, Circuit Judge.

Knox County Hospital seeks review of the Secretary’s denial of the Hospital’s Medicare reimbursement adjustment for fiscal year 1984. The Hospital claims that it should have been classified as a rural referral center in 1984 under 42 U.S.C. § 1396ww(d)(5)(C), and is therefore entitled to a higher reimbursement rate for its treatment of Medicare patients in that year.1 Conceding that it does not meet the regulatory definition of a rural referral center in effect in 1984, the Hospital complains that the regulatory definition was contrary to its implementing statute and otherwise arbitrary and capricious. The district court ruled on the pleadings that the Hospital had no standing, or alternatively that the agency’s action was committed to its discretion by law and therefore judicial review was unavailable under 5 U.S.C. § 701(a)(2). We affirm, but on the ground that the regulation in question was consistent with the statute and was not arbitrary or capricious.

I.

The facts are not disputed in this case. The Hospital is a full-service, acute-care hospital with 344 beds located in Vin-cennes, Indiana. It requested reimbursement as a rural referral center in its 1984 cost report filed with Blue Cross and Blue Shield of Indiana, the fiscal intermediary appointed by the defendant pursuant to 42 U.S.C. § 1395h to help process Medicare claims. This request was denied. Under the procedures set forth in 42 U.S.C. § 1395oo, the Hospital appealed to the Provider Reimbursement Review Board, which granted the Hospital’s request for expedit[560]*560ed judicial review pursuant to 42 U.S.C. § 1395oo(f)(l).

The Hospital claimed in district court that the Secretary’s referral center regulation at 49 Fed.Reg. 320 (1984) violated the Medicare statute by denying the Hospital reimbursement as a rural referral center for its 1984 cost year. The rule was allegedly arbitrary and capricious. The Hospital also claimed that the denial of a reimbursement adjustment for the 1984 cost year deprived it of property without due process of law in violation of the Fifth Amendment.2 Among other relief, the Hospital requested a judgment against the defendant in the amount of $711,426.00.

The district court entered judgment on the pleadings in favor of the defendant pursuant to Fed.R.Civ.P. Rule 12(c). The court first concluded that since the Hospital failed to establish that the definition of a rural referral center in the regulation was invalid, it lacked standing to bring suit because it failed to meet this definition. Alternatively, the district court held that judicial review was not proper under 5 U.S.C. § 701(a)(2) because the agency action here was committed to agency discretion.

II.

We can quickly dispose of any contention that the Hospital lacks Article III standing in this case. The Hospital’s claim that it is entitled to reimbursement under the Medicare statute without a doubt presents an injury traceable to the defendant that a favorable decision by the district court would remedy. Article Ill’s requirement that federal courts adjudicate only live cases or controversies is therefore met. Love Church v. City of Evanston, 896 F.2d 1082, 1084-1085 (7th Cir.1990), certiorari denied, — U.S. -, 111 S.Ct. 252, 112 L.Ed.2d 210. The district court’s confusion over the standing issue was a result of a somewhat unusual regulatory structure in effect during 1984, a topic to which we now turn.

In the Social Security Amendments of 1983, Pub.L. No. 98-21, 97 Stat. 165, Congress implemented a new method for reimbursing hospitals participating in Medicare known as the Prospective Payment System (“PPS”). Discarding a system based on reasonable costs of actual services performed, Congress decided that hospitals should be reimbursed according to pre-set rates for various “diagnosis-related groups” (“DRGs”). See generally 42 U.S.C. § 1395ww(d). The PPS tracks cost data (used to calculate the DRG pre-set rates) separately for urban and rural hospitals; therefore, urban hospitals are generally speaking entitled to more reimbursements because of their greater costs. 42 U.S.C. § 1395ww(d)(2)(D). Recognizing that certain hospitals might be entitled to different treatment, Congress authorized several exceptions to the general payment scheme, including the following statutory provision regarding referral centers in effect in 1984:

The Secretary shall provide for such exceptions and adjustments to the payment amounts established under this subsection as the Secretary deems appropriate to take into account the special needs of regional and national referral centers (including those hospitals of 500 or more beds located in rural areas) * * *.

42 U.S.C. § 1395ww(d)(5)(C)(i) (1984).

The following regulation (in effect for fiscal year 1984) implemented the referral center exception:

(g) Referral centers.
(1) Criteria. HCFA [a Health and Human Services (“HHS”) agency] will consider a hospital’s request for a referral center adjustment to the hospital’s prospective payment rates only if the hospital is an acute care hospital that has a provider agreement under Part 489 of this chapter to participate in Medicare as a hospital; and
(i) Is located in a rural area (as defined in § 405.473(b)(6)) and has 500 or more beds available for use; or
(ii) Has an inpatient population such that at least 50 percent of its Medicare pa[561]*561tients are referred from other hospitals or from physicians not on the staff of the hospital. In addition, at least 60 percent of the hospital’s Medicare patients must live more than 25 miles from the hospital, and at least 60 percent of all the services that the hospital furnishes to Medicare beneficiaries must be furnished to beneficiaries who live more than 25 miles from the hospital.
(2) Payments to rural referral centers with 500 or more beds. A hospital that meets the criteria of paragraph (g)(l)(i) of this section will be paid prospective payments per discharge based on the ap plicable urban payment rates as determined in accordance with § 405.473(b)(10) or (c)(6), as adjusted by the hospital’s area wage index.

49 Fed.Reg. 320 (1984), 42 C.F.R. § 405.-476(g).3

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965 F.2d 558, 1992 U.S. App. LEXIS 14572, 1992 WL 141950, Counsel Stack Legal Research, https://law.counselstack.com/opinion/board-of-trustees-of-knox-county-indiana-hospital-v-sullivan-ca7-1992.