Heckler v. Community Health Services of Crawford County, Inc.

467 U.S. 51, 104 S. Ct. 2218, 81 L. Ed. 2d 42, 1984 U.S. LEXIS 87, 52 U.S.L.W. 4621
Supreme Court of the United States·Decided May 21, 1984·No. 83-56·Published·Cited by 1,419 cases

Opinions

Justice Stevens

delivered the opinion of the Court.

Under what is recognized for present purposes as an incorrect interpretation of rather complex federal regulations, during 1975, 1976, and 1977 respondent received and expended $71,480 in federal funds to provide health care services to Medicare beneficiaries to which it was not entitled. The question presented is whether the Government is estopped from recovering those funds because respondent relied on the express authorization of a responsible Government agent in making the expenditures.

Under the Medicare program, Title XVIII of the Social Security Act, 79 Stat. 291, as amended, 42 U. S. C. §§ 1395-1395vv, providers of health care services are reimbursed for the reasonable cost of services rendered to Medicare beneficiaries as determined by the Secretary of Health and Human Services (Secretary). § 1395x(v)(l)(A). Providers receive interim payments at least monthly covering the cost of serv[54] ices they have rendered. §1395g(a). Congress recognized, however, that these interim payments would not always correctly reflect the amount of reimbursable costs, and accordingly instructed the Secretary to develop mechanisms for making appropriate retroactive adjustments when reimbursement is found to be inadequate or excessive. § 1395x(v)(l)(A)(ii).1 Pursuant to this statutory mandate, the Secretary requires providers to submit annual cost reports which are then audited to determine actual costs. 42 CFR §§405.454, 405.1803 (1982). The Secretary may reopen any reimbursement determination within a 3-year period and make appropriate adjustments. §405.1885.

The Act also permits a provider to elect to receive reimbursement through a “fiscal intermediary.” 42 U. S. C. §1395h; 42 CFR §421.103 (1982). If the intermediary the provider has nominated meets the Secretary’s requirements, the Secretary then enters into an agreement with the intermediary to have it perform those administrative responsibilities she assigns it. §§421.5, 421.110. These duties include receipt, disbursement, and accounting for funds used in making Medicare payments, auditing the records of providers in order to ensure payments have been proper, resolving disputes over cost reimbursement, reviewing and reconsidering payments to providers, and recovering over-payments to providers. §§421.100(b), (c), (e), (f), 421.120(e). The fiscal intermediary must also “serve as a center for, and communicate to providers, any information or instructions furnished to it by the Secretary, and serve as a channel of communication from providers to the Secretary.” 42 U. S. C. § 1395h(a)(2)(A).

Respondent Community Health Services of Crawford County, Inc. (hereafter respondent), is a nonprofit corporation. In 1966 it entered into a contract with petitioner’s predecessor, the Secretary of Health, Education, and Welfare, to provide home health care services to individuals eligi[55] ble for benefits under Part A of the Medicare program, 42 U. S. C. §§ 1395c to 1395Í-2. Under the contract, respondent received reimbursement through a fiscal intermediary, the Travelers Insurance Cos. (Travelers).

In 1973 Congress enacted the Comprehensive Employment and Training Act (CETA), 87 Stat. 839, codified, as amended, at 29 U. S. C. § 801 et seq. (1976 ed. and Supp. V), and repealed, Pub. L. 97-300, 96 Stat. 1357, authorizing the use of federal funds to provide training and job opportunities for economically disadvantaged persons. In 1975 respondent began participating in the program, which reimbursed it for the salaries and fringe benefits paid to certain of its employees. CETA funds made it possible for respondent to take on additional personnel and to provide additional home health care services.

To prevent what would be in effect double reimbursement of providers’ costs, one of the regulations concerning reasonable costs reimbursable under the Medicare program indicates that grants received by a provider in order to pay specific operating costs must be subtracted from the reasonable costs for which the provider may receive reimbursement.2 [56] After obtaining a CETA grant, respondent’s administrator contacted Travelers to ask whether the salaries of its CETA-funded employees who provided services to patients eligible for Medicare benefits were reimbursable as reasonable costs under Medicare. Travelers’ Medicare manager orally advised respondent that the CETA funds were “seed money” within the meaning of § 612.2 of the Provider Reimbursement Manual, which is defined as “[g]rants designated for the development of new health care agencies or for expansion of services of established agencies,”3 and therefore, even though the CETA employees’ salaries constituted specific operating costs paid by a federal grant, they were reimbursable under the Medicare program.

Relying on Travelers’ advice, respondent included costs for which it was receiving CETA reimbursement in its cost reports, and received reimbursement for those sums amounting [57] to $7,694, $32,460, and $31,326 in fiscal 1975, 1976, and 1977, respectively.4 On several occasions during this period, respondent requested and received from Travelers oral verification of the propriety of this treatment.5 With these additional funds, respondent expanded its annual number of home health care visits from approximately 4,000 in 1974 to over 81,000 in the next three years. Its annual budget increased during that period from about $200,000 to about $900,000.

It is undisputed that correct administrative practice required Travelers to refer respondent’s inquiry to the Department of Health and Human Services for a definitive answer. However, Travelers did not do this until August 7, 1977, when a written request for instructions was finally submitted to the Philadelphia office of the Department’s Bureau of Health Insurance. Travelers was then formally advised that the CETA funds were not “seed money” and therefore had to be subtracted from respondent’s Medicare reimbursement. On October 7,1977, Travelers formally notified respondent of this determination. Travelers then reopened respondent’s cost reports for the preceding three years and recomputed respondent’s reimbursable costs, determining that respondent had been overpaid a total of $71,480.

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Heckler v. Community Health Services of Crawford County, Inc., 467 U.S. 51, 104 S. Ct. 2218, 81 L. Ed. 2d 42, 1984 U.S. LEXIS 87, 52 U.S.L.W. 4621 (1984).

467 U.S. 51 (Heckler v. Community Health Services of Crawford County, Inc.) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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