Dyna Care Home Health, Inc. v. Shalala

35 F. Supp. 2d 1096, 1999 U.S. Dist. LEXIS 1681, 1999 WL 79493
CourtDistrict Court, N.D. Illinois
DecidedFebruary 17, 1999
Docket98 C 0268
StatusPublished

This text of 35 F. Supp. 2d 1096 (Dyna Care Home Health, Inc. v. Shalala) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dyna Care Home Health, Inc. v. Shalala, 35 F. Supp. 2d 1096, 1999 U.S. Dist. LEXIS 1681, 1999 WL 79493 (N.D. Ill. 1999).

Opinion

MEMORANDUM OPINION AND ORDER

ALESIA, District Judge.

Before the court is defendant Donna Sha-lala’s motion for remand. For the following reasons, the court grants defendant’s motion and remands this case to the Secretary of the United States Department of Health and Human Services.

I. BACKGROUND 1

This case arises under Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq., which is commonly referred to as the Medicare Act. Plaintiff Dyna Care Home Health, Inc. (“Dyna Care”) is a corporation which provides home health care services in Illinois, Indiana, and Michigan. Dyna Care participates in the Medicare program as a “provider” of home health services to Medicare beneficiaries. Dyna Care is suing defendant Donna Shalala in her official capacity as Secretary of the United States Department of Health and Human Services (“the Secretary”). The Secretary is the federal officer responsible for the administration of the Medicare program. 2

Under the Medicare program, certain qualified health care providers, such as Dyna Care, may obtain reimbursement from the Secretary for the reasonable costs of treating Medicare patients. To obtain reimbursement, the provider prepares a cost report at the end of its fiscal year. 3 The cost report details the services rendered Medicare patients by the provider during the year and requests reimbursement for those services. 42 C.F.R. § 405.1801(b). The provider then submits the cost report to a “fiscal intermediary,” which acts as an agent of the Secretary and is usually a private entity such as an insurance company. 42 U.S.C. § 1395h.

After receiving the provider’s cost report, the fiscal intermediary audits the report to determine the amount of Medicare reimbursement due for the fiscal year. After determining the amount of reimbursement, the fiscal intermediary issues a Notice of Program Reimbursement (“NPR”), which sets forth the total amount of reimbursement due the provider and individually lists the expenses allowed and disallowed. 42 U.S.C. § 1395h; 42 C.F.R. §§ 421.103; 413.20; 413.60; 405.1803.

If the provider is dissatisfied with the NPR, the provider may appeal to the Provider Reimbursement Review Board (“PRRB”) within 180 days if the amount in controversy is $10,000 or more. 42 U.S.C. § 1395oo(a). The PRRB may affirm, modify, or reverse the fiscal intermediary’s final determination. 42 U.S.C. § 1395oo(d); see also 42 C.F.R. § 405.1841. The PRRB’s decision is final unless the Secretary reverses, affirms, or modifies the decision within sixty days. 42 U.S.C. § 1395oo(f)(l).

*1098 If the provider remains dissatisfied, it may seek review in the appropriate United States District Court within sixty days of the issuance of the final decision, whether that decision comes from the PRRB or the Secretary. 42 U.S.C. § 1395oo(f). In addition, a provider can seek judicial review of any action of a fiscal intermediary involving a question of law or a challenge to a regulation whenever the PRRB determines, on its own motion or by motion of the provider, that it is without authority to decide the question. 42 U.S.C. § 1395oo(f)(l).

In this case, Dyna Care is seeking reimbursement for interest expenses incurred during its fiscal years of 1989-94. The interest expense was interest paid to shareholders of Dyna Care and their relatives who had loaned money to Dyna Care. Under applicable Medicare regulations, interest expense on current indebtedness is an allowable cost if it is deemed to be “necessary and proper.” 42 C.F.R. § 413.153.

The fiscal intermediary denied reimbursement for the interest expense based on its interpretation of subsection (c)(1) of § 413.153. Section 413.153(c)(1), . which is known as the related party borrowing rule, provides that “to be allowable, interest expense must be incurred on indebtedness established with lenders or lending organizations not related through control, ownership, or personal relationship to the borrower.” The fiscal intermediary determined that the regulation on its face precluded Dyna Care from being reimbursed for the interest expense because the loans were made by Dyna Care’s shareholders and their relatives. The fiscal intermediary did not determine whether the interest expenses were otherwise “necessary and proper.”

Dyna Care appealed the fiscal intermediary’s decision on the interest expense for fiscal years 1989-94, along with several other issues related to reimbursement, to the PRRB. In October of 1997, Dyna Care asked the PRRB to authorize expedited judicial review on the issue of “the allowability of related party interest under the regulations.” As a part of the request for expedited judicial review, Dyna Care and the fiscal intermediary stipulated that (1) the fiscal intermediary had disallowed the interest expenses claimed for fiscal years 1989-94 based on the fiscal intermediary’s interpretation of § 413.153(c)(1); (2) the lenders of the loans for which the interest was disallowed during those years were related to Dyna Care through “control, ownership, or personal relationship”; and (3) “the position of the Health Care Financing Administration is clear on its face from the quoted regulation, and it is the parties’ belief that the Board does not have the authority to override or change that regulation.” (Admin. R. at 5-6.)

In November of 1997, the PRRB found that

1. the Board has jurisdiction over the matter for the subject years and, therefore, the Provider was entitled to a hearing before the Board; and
2. based upon the Provider’s assertions, there are no findings of fact for resolution before the Board; and
3. the Board is bound by the applicable existing Medicare law and regulation (42 C.F.R. § 405.1867); and
4.

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35 F. Supp. 2d 1096, 1999 U.S. Dist. LEXIS 1681, 1999 WL 79493, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dyna-care-home-health-inc-v-shalala-ilnd-1999.