Good Samaritan Hospital v. Shalala

124 L. Ed. 2d 368, 7 Fla. L. Weekly Fed. S 354, 113 S. Ct. 2151, 508 U.S. 402, 61 U.S.L.W. 4554, 1993 U.S. LEXIS 4020, 93 Cal. Daily Op. Serv. 4125, 93 Daily Journal DAR 7006
Supreme Court of the United States·Decided June 7, 1993·No. 91-2079·Published·Cited by 529 cases

Opinions

Justice White

delivered the opinion of the Court.

As a means of providing health care to the aged and disabled, Congress enacted the Medicare program in 1965. See Title XVIII of the Social Security Act, 79 Stat. 291, as amended, 42 U. S. C. § 1395 et seq. Under the program, providers of health care services can enter into agreements with the Secretary of Health and Human Services pursuant to which they are reimbursed for certain costs associated with the treatment of Medicare beneficiaries. To operate the program, the Secretary issued regulations imposing limits on the amount of repayment based on a range of factors designed to approximate the cost of providing general routine patient service. The question before us is whether the Secretary must afford the six petitioning hospitals an opportunity to establish that they are entitled to reimbursement for costs in excess of such limits.

I

A

A complex statutory and regulatory regime governs reimbursement, rough description of which is necessary back[405] ground to this case. To begin, Congress has required the Secretary to repay the lesser of the “reasonable cost” or “customary charg[e].” See 42 U. S. C. § 1395f(b)(l). Rather than attempt to define “reasonable cost” with precision, Congress empowered the Secretary to issue appropriate regulations setting forth the methods to be used in computing such costs. See § ISDSxCvXlXA).1

Prior to 1972, the Secretary’s regulations contemplated reimbursement of the entirety of a provider’s services to Medicare patients unless its costs were found to be “substantially out of line” with those of similar institutions. See, e. g., 20 CFR § 405.451(c) (1967).2 In 1972, apparently fueled by concern that providers were passing on inefficient and excessive expenses, see H. R. Rep. No. 92-231, pp. 82-85 (1971); S. Rep. No. 92-1230, pp. 188-189 (1972), Congress amended the statute to specify that “reasonable costs” meant only those “actually incurred, excluding therefrom any part of incurred cost[s] found to be unnecessary in the efficient delivery of needed health services,” 42 U. S. C. § 1395x(v)(l)(A), and to authorize the Secretary — as part of the “methods” of determining costs — to establish appropriate cost limits, see ibid.

Accordingly, the Secretary promulgated regulations, updated yearly and establishing routine cost limits based on factors such as the type of health care provider (hospital, skilled nursing facility, etc.), type of services it rendered, its geographical location, size, and mix of patients treated. See [406] 20 CFR §405.460 (1975). Hospitals are divided in terms of bed size, and of whether they are urban — i. e., located in a Standard Metropolitan Statistical Area (SMSA) — or rural. As of 1979, the labor-related component of provider costs was to be determined by a wage index keyed to the hospital’s location. See, e. g,, 46 Fed. Reg. 33637 (1981).

The regulations generally provide that reimbursable costs must be within the cost limits. The regulations also allow for adjustments to the limits as applied to a provider’s particular claim. A provider classified as a rural hospital can apply for reclassification as an urban one. 42 CFR § 413.30(d) (1992). An exemption from the applicable cost limits can be obtained under certain specified situations— e. g., when excess expenses are due to “extraordinary circumstances,” or when the provider is the sole hospital in a community, a new provider, or a rural hospital with fewer than 50 beds. § 413.30(e). In addition, exceptions are available for, inter alia, “atypical services,” extraordinary circumstances beyond the provider’s control, unusual labor costs, or essential community services. § 413.30(f).3

Two statutory provisions are of central importance to this litigation. First, apparently to protect providers’ liquidity, the statute contemplates a system of interim, advance payments during the year. Specifically, the Secretary “shall periodically determine the amount which should be paid . . . and the provider of services shall be paid, at such time or times as the Secretary believes appropriate (but not less often than monthly) . . . the amounts so determined, with [407] necessary adjustments on account of previously made overpayments or underpayments.” 42 U. S. C. §1395g(a). These interim payments by definition are only approximate ones, based on the provider’s preaudit, estimated costs of anticipated services. See 42 CFR §§ 413.64(e), (f) (1992). Second, the regulations were required to “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)(ii) (clause (ii)).

B

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Good Samaritan Hospital v. Shalala, 124 L. Ed. 2d 368, 7 Fla. L. Weekly Fed. S 354, 113 S. Ct. 2151, 508 U.S. 402, 61 U.S.L.W. 4554, 1993 U.S. LEXIS 4020, 93 Cal. Daily Op. Serv. 4125, 93 Daily Journal DAR 7006 (U.S. 1993).

124 L. Ed. 2d 368 (Good Samaritan Hospital v. Shalala) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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