Irvine Medical Center v. Tommy G. Thompson, Secretary of the Department of Health & Human Services

275 F.3d 823
CourtCourt of Appeals for the Ninth Circuit
DecidedJanuary 4, 2002
Docket3-3026
StatusPublished
Cited by19 cases

This text of 275 F.3d 823 (Irvine Medical Center v. Tommy G. Thompson, Secretary of the Department of Health & Human Services) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Irvine Medical Center v. Tommy G. Thompson, Secretary of the Department of Health & Human Services, 275 F.3d 823 (9th Cir. 2002).

Opinions

Opinion by Judge CANBY; Dissent by Judge PREGERSON.

CANBY, Circuit Judge:

This is a consolidated appeal brought by Medicare service providers against the Secretary of the Department of Health and Human Services (“Secretar/’)- The plaintiffs contend that the Secretary acted unlawfully in repealing a regulation that had allowed providers to carry forward reasonable costs disallowed in a particular fiscal period to succeeding fiscal periods. In both actions, the district courts awarded summary judgment to the Secretary, on the ground that the repeal was based on a permissible interpretation of the underlying Medicare statute. We conclude that the repeal did not contravene a clearly expressed congressional mandate, was not based on an unreasonable interpretation of the Medicare statute, and was not an arbitrary or capricious agency action within the meaning of the Administrative Procedure Act, 5 U.S.C. § 706(2)(A). We accordingly affirm the judgments of the district courts.

Statutory Background1

The Medicare program, established by Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq., provides payment for medical care for the aged and disabled. Eligible beneficiaries receive medical care from “providers,” which are medical care facilities that have entered into agreements with the Secretary to furnish care, and the providers are then reimbursed by the Medicare program. Part A of the Medicare program authorizes payments for institutional care provided primarily on an inpatient basis. See 42 U.S.C. §§ 1395c-1395i-4. Part B of the program authorizes payments primarily for outpatient services and durable medical equipment. See id. §§ 1395j-1395w-4.

Medical care facilities, such as plaintiffs, receive reimbursement under Part A or Part B (or both) from a “fiscal intermediary,” such as Mutual of Omaha, that functions as the Secretary’s agent in making payment on covered claims. At the close of each fiscal year, a provider must submit a “cost report” to the fiscal intermediary showing the costs it has incurred, and the appropriate portion of such costs to be allocated to the Medicare program during the fiscal period covered by the cost report. 42 C.F.R. §§ 413.20, 413.24.

When it was originally enacted in 1965, the Medicare program reimbursed providers on the basis of their “reasonable costs” for both inpatient and outpatient services. In 1972, Congress amended the Medicare Act to impose a limit on Medicare payments, restricting the annual reimbursement to a provider’s aggregate reasonable costs or aggregate customary charges, whichever is lower. See Soc. Sec. Amendments of 1972, P.L. 92-603, § 233, codified at 42 U.S.C. § 1395f(b). The purpose of the amendment was to prevent Medicare from paying more for services than the provider was charging its non-Medicare patients. This restriction, known as the “lower of costs or charges” principle (“LCC”), applied to reimbursement for services under both Part A (inpatient) and Part B (outpatient). It is the LCC principle of the Medicare statute that is implicated in this appeal.

The effect of the LCC restriction was to limit the amount of reimbursement so that, [827]*827if a provider’s customary charges were less than its reasonable costs, Medicare would reimburse only the provider’s charges, not its costs that were in excess of customary charges. Congress provided an exception to this limitation for providers that furnish services free of charge or at nominal charge to the public. Such public providers would continue to receive reimbursement of full reasonable costs. See 42 U.S.C. § 1395f(b)(2).

In their reports on the 1972 amendments, both the House and Senate committees explained the rationale for the LCC restriction and the single exception for public providers. Both reports also contain an additional paragraph in which the committees acknowledged the potential negative effect of the restriction on institutions experiencing higher than normal costs for a limited period of time. The House Committee Report (like the Senate Committee Report) stated:

[Y]our committee recognizes the desirability of permitting a provider that was reimbursed under the medicare ... pro-gramo on the basis of charges in a fiscal period to carry unreimbursed allowable costs for that period forward for perhaps two succeeding fiscal periods. Should charges exceed costs in such succeeding fiscal periods, the unreimbursed allowable costs carried forward could be reimbursed to the provider along with current allowable costs up to the limit of current charges.

H.R. Rep. No. 92-231, at 102 (1971), reprinted in 1972 U.S.C.C.A.N. 4989, 5088; see also S.Rep. No. 92-1230, at 203 (1971) (using virtually identical language).

This admonition was not lost on the Secretary. In 1974, the Secretary issued a regulation implementing the LCC restriction. 39 Fed. Reg. 16,882 (May 10, 1974), adding a new section 20 C.F.R. § 405.455(now set forth as amended at 42 C.F.R. § 413.13). Under subsection (d) of this regulation, an established provider whose allowable costs exceeded its charges in one fiscal period could carry those un-reimbursed costs forward for two succeeding years. A new provider could carry forward unreimbursed costs for five years.

In 1986, the Secretary published notice of a proposed rule to eliminate the carry-forward provision. 51 Fed. Reg. 33,074 (Sept. 18, 1986). The Secretary promulgated the final regulation in 1988, eliminating the carry-forward provision entirely, effective for fiscal periods beginning on or after April 28, 1988. 53 Fed. Reg. 10,077 (Mar. 29,1988), 42 C.F.R. § 413.13.

Factual Background

Plaintiffs in this case are nine Medicare health care providers that suffered an LCC disallowance for costs in excess of charges in a reporting year occurring after the LCC carry-forward provision was repealed. Eight of the nine plaintiffs fit within the agency’s definition of “new provider” in the year in which they suffered the LCC disallowance. See 42 C.F.R. § 413.13(a) (1999). Under the former carry-forward provision, the eight new providers would have been entitled to carry their unreimbursed costs forward for five years, and the ninth plaintiff would have been entitled to do so for two years. Plaintiffs filed appeals with the Provider Reimbursement Review Board (“PRRB”) challenging the validity of the repeal. Pursuant to plaintiffs’ requests, the PRRB determined that it lacked the authority to decide the issue of the validity of the repeal.

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Bluebook (online)
275 F.3d 823, Counsel Stack Legal Research, https://law.counselstack.com/opinion/irvine-medical-center-v-tommy-g-thompson-secretary-of-the-department-of-ca9-2002.