John Muir Memorial Hospital, Inc. v. Califano

457 F. Supp. 848, 1978 U.S. Dist. LEXIS 15346
CourtDistrict Court, N.D. California
DecidedSeptember 22, 1978
DocketC-77-1854-CBR
StatusPublished
Cited by19 cases

This text of 457 F. Supp. 848 (John Muir Memorial Hospital, Inc. v. Califano) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
John Muir Memorial Hospital, Inc. v. Califano, 457 F. Supp. 848, 1978 U.S. Dist. LEXIS 15346 (N.D. Cal. 1978).

Opinion

MEMORANDUM OF OPINION

RENFREW, District Judge.

This is a suit for mandamus and declaratory relief brought by plaintiff John Muir *850 Memorial Hospital, Inc. (“Muir”), under Title XVIII of the Social Security Act (42 U.S.C. §§ 1395 et seq.), the Declaratory Relief Act (28 U.S.C. § 2201), and the Fifth Amendment. The action is based on defendants’ refusal to allow plaintiff to reopen its 1973 and 1974 “cost reports” to reflect certain interest payments as expenses rather than as capital items.

In 1965, Congress enacted Title XVIII of the Social Security Act, known as Medicare, to provide federal reimbursement for medical care to the aged and disabled. 1 The program provides hospital insurance benefits to eligible individuals who receive hospital services from specially designated “providers.” Plaintiff Muir operates a hospital as defined by 42 U.S.C. § 1395x(e) and is a “provider” by virtue of having filed an agreement with the Secretary of Health, Education, and Welfare (“HEW”) pursuant to 42 U.S.C. § 1395ec(a)(l).

As a provider, plaintiff is entitled to receive reimbursement from the Secretary for the “reasonable cost” of its hospital services. See 42 U.S.C. §§ 1395f(b)(l), 1395x(v)(l)(A). Plaintiff receives this reimbursement from a private organization that acts as the government’s fiscal intermediary. See 42 U.S.C. § 1395h. 2 The fiscal intermediary between Muir and the Secretary is defendant Blue Cross Association, which has delegated its intermediary duties to defendant Blue Cross of Northern California (“BCNC”), one of its local plan organizations.

BCNC, as fiscal intermediary, has no vested interest in the expenditure of the government funds. Its function is merely to determine that the amount of payment accurately reflects the reasonable costs of services rendered to program beneficiaries. Under statute, and because a hospital’s liquidity needs would be impaired if reimbursements were made only once a year, the reimbursement scheme proceeds in two parts. First, the intermediary makes not less than monthly lump sum payments to the provider, based on estimates that are subject to subsequent retroactive adjustment. See 42 U.S.C. §§ 1395g, 1395x(v)(l)(A)(ii); 20 C.F.R. §§ 405.-402(b)(1), 405.402(b)(2), 405.454. Second, the intermediary makes a final determination as to how much reimbursement is due after the close of the provider’s fiscal year; this determination is based on a cost report filed by the provider. 20 C.F.R. § 405.-405(b). Among the costs for which a provider is entitled to reimbursement is the interest cost on current and capital indebtedness. 20 C.F.R. § 405.419. It is the formula used to calculate these costs in the 1973 and 1974 cost reports that plaintiff ultimately seeks to challenge by bringing this lawsuit.

In 1973, plaintiff began construction of a nine million dollar addition to its existing hospital. This addition increased the number of beds; provided services for intensive care, coronary care, and intermediate care patients; and created substantial space for support services. The project was financed with bank loans and with a long-term mortgage on the hospital’s land and buildings. Plaintiff paid $166,000 in interest on this indebtedness in 1973 and $366,000 in 1974.

Prior to 1973, plaintiff had always ex-pensed its interest costs as they were incurred. However, on its 1973 and 1974 Medicare cost reports, plaintiff treated the interest payments on the construction financing as a capital item. It did so to conform to the accounting procedures set out in the Provider Reimbursement Manual, HIM — 15, § 206, a manual that provides guidance for the implementation of Medicare regulations regarding the reasonable cost of provider services. 3 As a result of *851 using the capitalization method of accounting rather than the expensing method, plaintiff’s net reimbursed costs were $60,-179 less in 1973 and $134,694 less ii) 1974. Defendant BCNC accepted and approved plaintiff’s cost report for 1973 on January 31,1975 and for 1974 on December 23,1975. Plaintiff did not seek administrative review of these decisions. 4

On March 11, 1976, plaintiff requested that BCNC reopen its 1973 and 1974 cost reports to allow recomputation of the interest costs according to the expensing method. 5 BCNC denied this request on March 18, 1976, because plaintiff had not supplied sufficient information. Plaintiff then filed a more complete Amended Request for Reopening the Cost Reports on September 23, 1976. This request was similarly denied by BCNC on November 23, 1976. 6

Having been unable to secure relief from BCNC, plaintiff filed a Request for a Hearing with defendant Provider Reimbursement Review Board (“PRRB”) on February 22, 1977. 7 On April 4, 1977, after BCNC had filed an opposition to plaintiff’s request for a hearing and plaintiff had filed a rebuttal to that opposition, the PRRB determined that it was without jurisdiction to hear plaintiff’s claim. It based this decision on three factors: first, plaintiff did not file its request for a hearing in timely fashion (20 C.F.R. § 405.1841(a)); second, plaintiff did not meet the minimum monetary jurisdictional requirement (20 C.F.R. § 405.-1839(a)); and third, the decision whether to reopen a determination could only be made by the fiscal intermediary that made that determination (20 C.F.R. § 405.1885(c)). Four and one half months after receiving the PRRB's letter, on August 22, 1977, plaintiff filed this lawsuit.

Plaintiff seeks two types of relief from this Court. First, plaintiff seeks a declaration and order that defendant BCNC is required to reopen the cost reports for 1973 and 1974 to reflect the expensing, rather than the capitalizing, of the interest costs.

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Bluebook (online)
457 F. Supp. 848, 1978 U.S. Dist. LEXIS 15346, Counsel Stack Legal Research, https://law.counselstack.com/opinion/john-muir-memorial-hospital-inc-v-califano-cand-1978.