Hennepin County v. Sullivan

883 F.2d 85, 280 U.S. App. D.C. 13, 1989 WL 70483
CourtCourt of Appeals for the D.C. Circuit
DecidedJune 30, 1989
DocketNos. 88-5255 and 88-5256
StatusPublished
Cited by11 cases

This text of 883 F.2d 85 (Hennepin County v. Sullivan) is published on Counsel Stack Legal Research, covering Court of Appeals for the D.C. Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hennepin County v. Sullivan, 883 F.2d 85, 280 U.S. App. D.C. 13, 1989 WL 70483 (D.C. Cir. 1989).

Opinion

HARRY T. EDWARDS, Circuit Judge:

This case presents cross-appeals from a District Court decision denying Hennepin County and Hennepin County Medical Center (collectively ‘HCMC’) immediate reimbursement under the Medicare statute, Ti-tie XVIII of the Social Security Act, 42 U.S.C. section 1395 et seq. (1982 & Supp. V 1987), but remanding the case to the Secretary of Health and Human Services1 (‘HHS’) for further proceedings. In Count I of the complaint below, HCMC alleged that HHS unlawfully denied its request for an exemption (or ‘exception’) from the limitations on reimbursable costs for medical education expenses in the 1980 cost reporting year. In Count II, HCMC alleged, in the alternative, that HHS unlawfully denied it a ‘retroactive corrective adjustment[]’ for these same medical education expenses, pursuant to 42 U.S.C. section 1395x(v)(l)(A)(ii) (Supp. V 1987). The District Court granted summary judgment in favor of HHS on Count I, but granted summary judgment in favor of HCMC on Count II, remanding the case to HHS to determine whether HCMC was entitled to a retroactive corrective adjustment. See Hennepin County v. Bowen, 689 F.Supp. 1 (D.D.C.1988).

We affirm the judgment of the District Court as to Count I; we agree that HHS properly denied HCMC immediate reimbursement under applicable agency regulations. However, we reverse the summary judgment in favor of HCMC on Count II; since HCMC was not entitled to immediate reimbursement under Count I, it cannot be entitled to retroactive reimbursement for these same claims under the same regulation by which it was denied reimbursement in the first instance. Accordingly, we reverse the trial court’s remand of the case to HHS for further proceedings.

There cannot be a retroactive corrective adjustment here because it is clear that, under existing, lawful agency regulations, HCMC was not entitled to any exemption from the limitation on reimbursable costs for medical education expenses. In other words, HCMC has received all that it was due under the law. We reject HCMC’s suggestion that 42 U.S.C. section 1395x(v)(l)(A)(ii) should be read to compel the Government, after the fact, to consider whether, as a matter of ‘fairness,’ claim[15]*15ants should be awarded something more than lawful regulations required. This would amount to a form of retroactive rule-making that was specifically rejected by the Supreme Court in Bowen v. Georgetown Univ. Hosp., 488 U.S. 204, 109 S.Ct. 468, 102 L.Ed.2d 493 (1988). Accordingly, we affirm in part and reverse in part the judgment of the District Court.

I. BACKGROUND

A. STATUTORY AND REGULATORY FRAMEWORK

The Medicare statute, Title XVIII of the Social Security Act, 42 U.S.C. section 1395 et seq. (1982 & Supp. V 1987), through a complex reimbursement process, see Tallahassee Memorial Regional Medical Center v. Bowen, 815 F.2d 1435, 1438-40 (11th Cir.1987), cert. denied, 485 U.S. 1020, 108 S.Ct. 1573, 99 L.Ed.2d 888 (1988), furnishes providers of health care services with reimbursements for certain costs associated with the treatment of the aged and disabled. At the time of the events leading to this litigation, the Medicare statute provided that a health care provider was entitled to reimbursement for the lesser of the reasonable costs of the services as defined under 42 U.S.C. section 1395x(v), or the provider’s customary charge for such services.2 42 U.S.C. section 1395f(b)(l) (1982). The statute defined ‘reasonable costs’ as those ‘cost[s] 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. section 1395x(v)(l)(A); it authorized the Secretary of HHS to establish the methods for determining costs, id.; and it granted the Secretary broad rulemaking authority, see id. Pursuant to this broad authority, the Secretary has established cost limits for reimbursable routine costs, 42 C.F.R. section 405.460; 39 Fed.Reg. 20,-164 (June 6, 1974),3 and a procedure for determining these cost limits, see id. section 405.460(b)(3).

The Secretary also enacted two basic mechanisms for adjustment of cost limits in cases where the general rules do not adequately reimburse the .health care provider’s reasonable costs. First, a provider may seek an exemption from the cost limits under one of the enumerated situations in 42 C.F.R. section 405.460(f) — for example, when excess expenses are attributable to ‘extraordinary circumstances,’ see id. section 405.460(f)(2). An exception is allowed only if the costs are reasonable, attributable to the circumstances specified, separately identified by the provider, and verified by the intermediary.4

Id. section 405.460(f). In this case, HCMC sought reimbursement under section 405.460(f)(4), which allows an exception for health care providers operating an approved graduate medical education program if the provider can demonstrate that, if compared to other providers in its group, it incurs increased costs for items or services covered by limits under this section because of its operation of an approved education program. Id. section 405.460(f)(4).

The additional costs generated by a graduate medical education program include both ‘direct’ and ‘indirect’ costs, but 42 C.F.R. section 405.460(f)(4) refers only to ‘indirect costs.’ ‘Direct costs’ consist of the actual costs of operating an approved educational program, such as resident sti[16]*16pends and teaching costs. ‘Indirect costs’ consist of those operating expenses which are generally higher in teaching hospitals than in non-teaching hospitals. HCMC sought additional reimbursement for indirect costs associated with increased administrative expenses attributable to educating and supervising the residents in the hospital; these expenses included items such as the additional ward clerk and nurse time spent instructing residents on hospital’s procedures. Brief for HCMC at 11-12.

Wholly apart from the regulations covering exemptions from the limitations on reimbursable costs is the provision in 42 U.S.C. section 1395x(v)(l)(A)(ii), which directs the Secretary to establish regulations 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.

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Catron v. Babbitt
955 F. Supp. 627 (W.D. Virginia, 1997)
Hennepin County v. Sullivan
883 F.2d 85 (D.C. Circuit, 1989)

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Bluebook (online)
883 F.2d 85, 280 U.S. App. D.C. 13, 1989 WL 70483, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hennepin-county-v-sullivan-cadc-1989.