Monterey Life Systems, Inc. v. United States

635 F.2d 821, 225 Ct. Cl. 50, 1980 U.S. Ct. Cl. LEXIS 256
CourtUnited States Court of Claims
DecidedAugust 13, 1980
DocketNo. 440-78
StatusPublished
Cited by23 cases

This text of 635 F.2d 821 (Monterey Life Systems, Inc. v. United States) is published on Counsel Stack Legal Research, covering United States Court of Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Monterey Life Systems, Inc. v. United States, 635 F.2d 821, 225 Ct. Cl. 50, 1980 U.S. Ct. Cl. LEXIS 256 (cc 1980).

Opinion

SKELTON, Senior Judge,

delivered the opinion of the court:

This case comes before the court on cross-motions for summary judgment. The plaintiff in this action is Monterey Life Systems, Inc., a Delaware corporation (hereinafter referred to as Monterey Life), which owns 100% of the outstanding stock in nine health care facilities which provide medical services to Medicare beneficiaries. Monter-[53]*53ey Life challenges the government’s refusal to reimburse Monterey Life under the Medicare Act, 42 U.S.C. §§1395, et seq., for a reasonable return on equity capital invested after Monterey Life had acquired 100% of the stock of the nine ongoing medicare facilities. The parties present the following issues for our review: (1) Since Monterey Life acquired 100% of the stock instead of the assets of ongoing medical facilities which provide medical services to Medicare beneficiaries, is Monterey Life entitled to Medicare reimbursement based upon a return on equity capital invested (including goodwill) and a step-up in basis for depreciation of the assets? (2) Was defendant’s action and the Board’s decision in refusing reimbursement arbitrary, capricious, unreasonable and contrary to the Medicare Act? (3) Is defendant collaterally estopped from relitigating Monterey Life’s entitlement to Medicare reimbursement? (4) Has Monterey Life failed to exhaust its administrative remedies? (5) Does Monterey Life have standing to bring this lawsuit?

I. STATUTORY BACKGROUND

The case arises under Title XVIII of the Social Security Act, as amended, 42 U.S.C. §§1395, et. seq., which is commonly known as the Medicare Act (hereinafter referred to as the Act). Congress enacted this program in 1965 to establish the federally funded health insurance program known as Medicare. This Act, which provides for federal reimbursement of medical care for the aged and certain disabled persons, consists of two principal components. Part A (the program involved in the instant case) provides hospital insurance benefits to the elderly (42 U.S.C. §§1395-1395i-2) and Part B concerns a voluntary supplemental medical insurance program, (42 U.S.C. §§1395j-1395w). Coverage under Part A extends to the "reasonable costs” of covered services rendered to beneficiaries by "providers” as defined in 42 U.S.C. §1395x(u). This definition of "providers” includes hospitals and skilled nursing facilities like those whose stock is owned by Monterey Life.

Before a qualified provider may participate in the Medicare program, the Act requires that the provider file an [54]*54agreement with the Secretary of Health, Education and Welfare in which it agrees, among other things, not to bill patients eligible under the Medicare program for covered services. 42 U.S.C. §1395cc. In turn, the Act provides that the provider 'is to be reimbursed by the government for its reasonable cost of providing such services, or, if lower, the customary charges for such services. 42,U.S.C. §1395f(b).

The court in American Medical v. Secretary of Health, Education and Welfare, 466 F. Supp. 605, 609-610 (D.D.C. 1979), thoroughly examined the Medicare rpimbursement program and we refer to a portion of that examination as follows:

“A provider may be reimbursed for servicés rendered to Medicare beneficiaries directly by the Secretar^, or it may appoint as a 'fiscal intermediary’ any qualified public Or private agency to act as the Sécretary’s agent for the purpose of reviewing its claims and administering payments dtie it from the government. If a provider is dissatisfied with the fiscal intermediary’s determination with respect to its claim for cost, it may request a hearing on this matter before the Provider Reimbursement Review Board. 42 U.S.C. §1395oo. The Board’s determination is the final agency action unless the Secretary, on his own motion and within 60 days after the provider of services is notified of the Board’s decision, reverses or modifies the Board’s decision. 42 U.S.C. §1395oo(f)(1). The Secretary has delegated his authority to review the Board’s decisions to the Administrator of the Health Care Financing Administration.
“The Medicare program is structured around the concept of reasonable cost. Under that concept, a provider is to be reimbursed only for the reasonable cost of providing medical services to Medicare beneficiaries. The Medicare statute sets forth only the broadest definitional parameters, requiring reasonable cost to be '. . . . the cost actually incurred, excluding therefrom any part of incurred cost found to be unnecessary in the efficient delivery of needed health , services . . .’. 42 U.S.C. §1395x(v)(1)(A). Beyond this threshold requirement, reasonable cost is . to be determined under regulations promulgated by the Secretary '... . establishing the method or methods to be used, and the items to be included, in determining such costs . . .’. Id. These regulations must, however, take into account the direct and indirect costs necessary in the efficient delivery of [55]*55covered services to Medicare beneficiaries so that such costs will not be borne by non-covered individuals. Conversely, the cost of rendering services to non-covered individuals is not to be borne by the Medicare Insurance Program.
“Pursuant to his statutory authority, the Secretary has promulgated regulations to reimburse providers for their reasonable costs incurred in rendering medical services to Medicare beneficiaries. 42 C.F.R. §§ 405.401-488.”

In this case, based on its acquisition of the stock of the Medicare provider facilities, Monterey Life is seeking reimbursement for the following items under the Secretary’s regulations: (1) A return on equity capital invested and used in the provision of patient care (including goodwill). 42 C.F.R. §405.429; (2) cost related to patient care. 42 C.F.R. §405.451; and (3) depreciation on the fair market value of the assets of each provider as of the date of acquisition of the provider’s stock by Monterey Life. 42 C.F.R. §405.415.

II. FACTS

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Bluebook (online)
635 F.2d 821, 225 Ct. Cl. 50, 1980 U.S. Ct. Cl. LEXIS 256, Counsel Stack Legal Research, https://law.counselstack.com/opinion/monterey-life-systems-inc-v-united-states-cc-1980.