District Memorial Hospital of Southwestern North Carolina, Inc. v. Thompson

261 F. Supp. 2d 378, 2003 U.S. Dist. LEXIS 7996
CourtDistrict Court, W.D. North Carolina
DecidedFebruary 4, 2003
DocketNo. 2:01CV259-C
StatusPublished
Cited by1 cases

This text of 261 F. Supp. 2d 378 (District Memorial Hospital of Southwestern North Carolina, Inc. v. Thompson) 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
District Memorial Hospital of Southwestern North Carolina, Inc. v. Thompson, 261 F. Supp. 2d 378, 2003 U.S. Dist. LEXIS 7996 (W.D.N.C. 2003).

Opinion

MEMORANDUM OF DECISION

COGBURN, United States Magistrate Judge.

This matter is before the Court on the parties’ cross-motions for summary judgment. Having considered the parties’ motions, briefs in support of their motions, and pleadings and having heard oral argument, the Court concludes that Plaintiffs Motion for Summary Judgment is due to be granted, and Defendant’s Motion for Summary Judgment is due to be denied.

I. PROCEDURAL AND FACTUAL BACKGROUND

The facts are not in dispute in this case. Plaintiff District Memorial Hospital of Southwestern North Carolina, Inc. is a rural acute care hospital located in Andrews, North Carolina. Between September 30, 1991 and September 30, 1997, Plaintiff was licensed by the State of North Carolina for sixty to sixty-one acute care beds but staffed and operated forty-nine beds or less. At all times relevant to this dispute, Plaintiffs services were certified under Title XVIII of the Social Securi[380]*380ty Act, 42 U.S.C. § 1395 et seq. (“Medicare”).

In 1983, the United States Congress overhauled the Medicare payment system, which until that time had reimbursed hospitals for the “reasonable cost” of inpatient services rendered to beneficiaries covered by Medicare. See Cabell Huntington Hosp., Inc. v. Shalala, 101 F.3d 984, 985 (4th Cir.1996); Legacy Emanuel Hosp. & Health Ctr. v. Shalala, 97 F.3d 1261, 1262 (9th Cir.1996). This procedure was replaced in 1983, when Congress required the United States Department of Health and Human Services (“the Department”) to implement the prospective payment system (“PPS”), under which hospitals are paid a fixed predetermined rate for each hospital discharge based on the patient’s diagnosis related group. See 42 U.S.C. §§ 1395ww(d)(2), (d)(3); see also Jewish Hosp., Inc. v. Secretary of Health & Human Serv., 19 F.3d 270, 272 (6th Cir.1994) (explaining PPS as establishing a prospectively determined amount per discharge based on costs an efficiently operating hospital should incur to provide quality services based on patient’s diagnosis at time of discharge). This system was initially implemented only for inpatient acute care services; long-term care hospitals, hospitals for children, and rehabilitation or psychiatric units of hospitals were omitted from the system. See 42 U.S.C. § 1395ww(d)(l)(B). Instead, those services continued to be reimbursed on a “reasonable cost” basis.

In establishing this system, however, Congress recognized that low-income Medicare patients generally have poorer health and are costlier to treat than higher-income Medicare patients. H.R.Rep. No. 98-25(1), at 141-42 (1983), reprinted in 1983 U.S.C.C.A.N. 219, 360-61; see also Cabell Huntington, 101 F.3d at 985. Congress, therefore, authorized the Secretary of the Department (“the Secretary”) to disburse additional Medicare funds to hospitals that treat a disproportionate share of low-income patients, but the Secretary initially chose not to formulate the adjustment, known as the disproportionate share (“DSH”) adjustment. See id. at 986. Congress then instructed the Secretary to formulate the adjustment by December 31, 1984, but the Secretary did not publish criteria for the DSH payments until 1986, after several hospitals sought a court order forcing compliance with the congressional mandate. See id.; see also Jewish Hosp., 19 F.3d at 275 (finding hospital’s contention that the Secretary was hostile to concept of DSH adjustment “credible and compelling”). Congress then replaced the criteria published by the Secretary with its own criteria set forth in 42 U.S.C. §§ 1395ww(d)(5)(F). As discussed more fully below, it is the Secretary’s interpretation of a regulation implementing and construing the term, “patient days,” as used in these criteria that is at issue in this case. See 42 U.S.C. § 1395ww(d)(5)(F)(vi)(II).

In 1987, the Centers for Medicare and Medicaid Services (“CMS”), formerly known as the Health Care Financing Administration, which administers the Medicare program, approved Plaintiff as a swing-bed hospital. A “swing-bed” hospital is one which may, when necessary, use acute care beds to provide post-hospital skilled nursing facility (“SNF”) care on a temporary basis.1 See 42 U.S.C. § 1395tt(a)(l) (permitting hospitals to enter into agreement with Secretary under which inpatient hospital facilities may be used for furnishing services of the type which, if furnished by an SNF, would constitute extended care services); see also [381]*381Clark Reg’l Med. Ctr. v. United States Dep’t of Health & Human Servs., 314 F.3d 241, 242 (6th Cir.2002). Thus, a swing-bed hospital may permit acute beds to “swing” temporarily to SNF care and then “swing back” to acute care when the SNF care is complete or the acute care bed is needed. See 42 U.S.C. § 1395tt(d); Clark, 314 F.3d at 242 n. 1. During the time period relevant to this action, however, SNF care provided by a swing-bed hospital was still reimbursed on a “reasonable cost” basis, not under the PPS system used to reimburse acute care services.2 See id.

In its cost reports for fiscal years 1991 through 1997, Plaintiff included its swing bed utilization as “patient days” for purposes of calculating its DSH patient percentage. The Secretary’s intermediary, vested with the responsibility of reimbursing Medicare providers, excluded days of service rendered to patients occupying swing beds when computing Plaintiffs disproportionate patient percentage. As a result of this exclusion, Plaintiff failed to qualify for the DSH adjustment and was denied additional reimbursement. Plaintiff asserts that it was denied $615,697 to which it was entitled under Medicare.

Plaintiff appealed the Notice of Program Reimbursement issued by the intermediary for the years in dispute to the Provider Reimbursement Review Board (“PRRB”) pursuant to 42 U.S.C. § 1395oo. The PRRB reversed the intermediary’s decision and held that Plaintiff was entitled to the DSH adjustment for all cost years under appeal.

The Administrator of CMS (“Administrator”) reviewed the PRRB’s decision and reversed, finding that swing-bed utilization should not be included in calculating a hospital’s patient days for purposes of the DSH adjustment. The Administrator’s decision then became the decision of the Secretary.

On October 29, 2001, Plaintiff filed this action under 42 U.S.C.

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Related

DIST. MEMORIAL HOSP. OF SOUTHWESTERN v. Thompson
261 F. Supp. 2d 378 (W.D. North Carolina, 2003)

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261 F. Supp. 2d 378, 2003 U.S. Dist. LEXIS 7996, Counsel Stack Legal Research, https://law.counselstack.com/opinion/district-memorial-hospital-of-southwestern-north-carolina-inc-v-thompson-ncwd-2003.