Loma Linda Community Hospital v. Shalala

907 F. Supp. 1399, 1995 U.S. Dist. LEXIS 18693, 1995 WL 752286
CourtDistrict Court, C.D. California
DecidedDecember 15, 1995
DocketED-CV-940055-RT, ED-CV-940068-RT
StatusPublished
Cited by3 cases

This text of 907 F. Supp. 1399 (Loma Linda Community Hospital v. Shalala) is published on Counsel Stack Legal Research, covering District Court, C.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Loma Linda Community Hospital v. Shalala, 907 F. Supp. 1399, 1995 U.S. Dist. LEXIS 18693, 1995 WL 752286 (C.D. Cal. 1995).

Opinion

TIMLIN, District Judge.

I. INTRODUCTION

Plaintiff Loma Linda Community Hospital (“Loma Linda”) filed separate actions for judicial review of two decisions by Donna Shalala, as Secretary of the United States Department of Health and Human Services (the “Secretary”) regarding Loma Linda’s claims for additional Medicare reimbursement. The two actions have been consolidated.

Both Loma Linda and the Secretary filed motions for summary judgment raising the following question for determination by the court: Did the Secretary act arbitrarily, capriciously, and not in accordance with the law in denying Loma Linda’s claim for additional Medicare reimbursement for three fiscal periods because it served a disproportionate number of low-income patients in these periods? The denial was predicated on the ground that Loma Linda did not meet its burden of disproving the Secretary’s calculation of Loma Linda’s percentage of low-income patients who receive Medicare, which percentage calculation is a prerequisite for reimbursement.

II.

THE UNDERLYING ADMINISTRATIVE HEARINGS

Ordinarily Medicare payments to hospitals are limited to fixed reimbursement amounts, although additional payments may be made to a hospital if it serves a disproportionate number of low-income patients. Low-income patients are defined by statute as those who receive Medicare Part A benefits (hospital coverage) and are eligible for federal Supplemental Security Income (“SSI”). Patients who receive only state supplementation are not defined as low-income patients. But 42 U.S.C. section 1395ww(d)(5)(F)(vi)(I) provides a formula for calculating what percentage of the hospital’s patients during a fiscal period were low-income patients on a month-to-month basis so that a determination can be made whether the hospital qualifies to receive additional Medicare reimbursement.

For three fiscal periods, FPE 8-86, FPE 8-87, and FPE 12-87, Loma Linda’s applications for additional reimbursement because it served a disproportionate number of low income patients were denied by the Secretary through its fiscal intermediary. Loma Linda requested a hearing before the Provider Reimbursement Review Board (“PRRB”) for FPE-86 as provided by statute. 42 U.S.C. section 1395oo(a)(l)(A)(i). At the hearing, Loma Linda claimed that 21.18% of its Medicare patients during this fiscal period were eligible for SSI, thereby qualifying them as low-income patients. Loma Linda presented evidence that it had based these figures upon its patients’ Medi-Cal cards which contain certain codes, “10”, “20”, or “60”, identifying specific patients as aged, disabled, or blind. According to the Medi-Cal Eligibility Handbook, any of these three codes indicate that in addition to Medicare, a patient is eligible *1401 for “SSI/SSP Aid,” a cash assistance program “administered by the Social Security Administration.”

In contrast, the Secretary’s representative at the hearing, Aetna Life Insurance Company (also referred to as “Aetna” or the “Intermediary”) asserted that only 14.77% of Loma Linda’s Medicare patients qualified as low income. 1 Aetna did not produce any evidence in support of these figures, although it purportedly received its calculation from the Health Care Financing Administration (“HCFA”) which in turn received its information from the Social Security Administration (“SSA”).

Prior to the hearing, Loma Linda sought discovery of the data Aetna had used, but discovery was refused on the ground that the Federal Privacy Act, 5 U.S.C. section 552a(b) (“Privacy Act”), precluded identification of the social security numbers or medicare numbers of those patients which the Secretary claimed were eligible for SSI. At the hearing, the PRRB again denied Loma Linda’s request to obtain this information.

On June 24, 1993, the PRRB granted Loma Linda’s appeal and ordered Aetna to use the SSI percentage proffered by Loma Linda. It found that Aetna had not substantiated its figure of approximately 14.77%, but that Loma Linda had provided substantial evidence in support of its calculation. Aetna then requested review by the Administrator of the HCFA. On August 31, 1993, the Administrator issued FPE 8-86 Final Decision reversing the disproportionate share decision of the PRRB.

The Administrator ruled that in order to determine the number of low-income patient days, the preamble to the regulations requires matching data from the Medicare Part A tape bill file with the Social Security Administration’s SSI file. The Administrator also noted that the preamble states that because of the “difficulty hospitals would have identifying their Medicare patients who are also SSI recipients,” the HCFA has taken on “the task (and expense) of determining for each hospital the number of patient days of those dually entitled to Medicare Part A and SSI and have removed this burden from hospitals.” Based upon this prefatory language, the Administrator concluded that the PRRB had improperly accepted Loma Linda’s data and calculations as a “substitute” for the SSI data and percentage on which HCFA and Aetna relied.

The Administrator further ruled that the PRRB improperly imposed a burden upon Aetna to dispute Loma Linda’s calculations when the burden should have been upon Loma Linda to demonstrate that Aetna’s calculation was understated. The Administrator also concluded that Loma Linda had failed to provide any documentation to support its own computations because the MediCal information used by Loma Linda also included patients receiving only state supplementation which would be precluded from the calculation of low income patients and Loma Linda’s records did not reflect Federal SSI eligibility on a month-to-month basis.

Loma Linda then filed its first complaint in this court seeking judicial review of the Administrator’s decision.

Loma Linda’s applications for additional Medicare reimbursement because it served a disproportionate number of low-income patients for fiscal periods FPE 8-87 and FPE 12-87 were also denied. Loma Linda again appealed to the PRRB. For these two periods, Aetna utilized SSI percentages of 14.14% and 13.15%. Loma Linda’s calculated percentages for the same periods were 24.95% and 36.61%. Prior to the PRRB hearing, Loma Linda again sought discovery of the underlying data used by Aetna in compiling the figures that it had obtained from the HCFA. HCFA again refused to produce any documentation to Loma Linda on the basis that such information was protected from disclosure by the Privacy Act. Loma Linda submitted support for its figures, but Aetna provided no substantiation for the numbers it received from the HCFA.

*1402 The PRRB denied Loma Linda’s appeals based upon the Administrator’s June 23,1993 decision concerning FPE 8-86, finding that Loma Linda had not met its burden of disproving the accuracy of Aetna’s calculation.

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Bluebook (online)
907 F. Supp. 1399, 1995 U.S. Dist. LEXIS 18693, 1995 WL 752286, Counsel Stack Legal Research, https://law.counselstack.com/opinion/loma-linda-community-hospital-v-shalala-cacd-1995.