Rocky Mountain Health Maint. Org., Inc. v. Price

297 F. Supp. 3d 152
CourtCourt of Appeals for the D.C. Circuit
DecidedMarch 22, 2018
DocketCase No. 17–cv–00242 (APM)
StatusPublished
Cited by2 cases

This text of 297 F. Supp. 3d 152 (Rocky Mountain Health Maint. Org., Inc. v. Price) 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
Rocky Mountain Health Maint. Org., Inc. v. Price, 297 F. Supp. 3d 152 (D.C. Cir. 2018).

Opinion

Amit P. Mehta, United States District Judge

This case concerns how much federal money Plaintiff Rocky Mountain Health Maintenance Organization is entitled to in reimbursement for delivering Medicare services. Plaintiff is a "cost-reimbursed" Health Maintenance Organization ("HMO") that contracts with Defendant, the Secretary of Health and Human Services, to provide hospital, doctor, and patient care services to Medicare beneficiaries who are enrolled in its health care plans. Unlike some HMOs, Plaintiff does not directly deliver patient services to enrollees. Rather, it contracts with physicians and other suppliers for that purpose. Defendant reimburses Plaintiff for the "reasonable cost" of those services using a formula that estimates their total price tag.

The manner in which Plaintiff calculates its federal reimbursement requests is at the heart of this dispute. Defendant takes issue with Plaintiff's inclusion of so-called "carrier-paid claims" within Plaintiff's cost reports that Plaintiff submitted to secure *154final reimbursement. These types of claims are deviations from the norm. Ordinarily, Plaintiff directly pays health care providers for patient care. In a minority of cases, however, the health care provider bills a Medicare contractor, known as a carrier, who processes the claim and pays the provider directly, thus leaving Plaintiff out of the payment process. This latter situation is known as a "carrier-paid claim." Plaintiff included carrier-paid claims in its cost reports for a four-year period, which, according to Defendant, resulted in Plaintiff receiving a roughly $15.75 million windfall. Plaintiff, on the other hand, believes that the controlling Medicare regulation, 42 C.F.R. § 417.560(c) ("the Regulation"), allows the inclusion of carrier-paid claims in its reimbursement calculations. Therefore, Plaintiff asserts, it was entitled to receive the amount in dispute.

In proceedings before the agency, Plaintiff challenged an auditor's decision to reduce Plaintiff's allowed reimbursements by $15.75 million for the four-year period on the ground that carrier-paid claims are not reimbursable. At first, Plaintiff found success. It convinced a panel of two Hearing Officers with the Centers for Medicare & Medicaid Services ("CMS") that its interpretation of the Regulation was the correct one. Defendant, however, appealed the Hearing Officers' decision to the CMS Administrator, who reversed. The CMS Administrator concluded that Defendant's interpretation of the Regulation was sound and therefore Plaintiff had to repay the government for the overpayment. Plaintiff then filed this action challenging the Administrator's determination, contesting both the substance of the decision and the process used to reach it.

For the reasons that follow, the court grants Plaintiff's Motion for Summary Judgment in part and remands this matter to Defendant to resolve two issues that Plaintiff raised during the agency proceedings but which the Administrator did not address: (1) whether the Administrator had the authority to review the Hearing Officers' decision; and (2) whether the Administrator's failure to complete its review within 60 days of the Hearing Officers' ruling caused the Hearing Officers' decision to become final. As a result of the decision to remand this matter, the court declines at this time to consider the parties' remaining contested disputes.

II. BACKGROUND

A. Factual Background

Plaintiff is an HMO that delivers medical services to its enrollees not directly, but through agreements with suppliers, physicians, and physician groups. Joint Appendix, ECF No. 20 [hereinafter JA], at 42.1 Plaintiff's health care plans include both Medicare enrollees and non-Medicare enrollees. Id. at 154. As described below, Plaintiff's coverage of both types of insureds affects its total Medicare reimbursement.

Plaintiff participates in the Medicare program as a cost-reimbursed HMO-one of only about 20 such organizations in the country. Id. at 41; see Pl.'s Mot. for Summ. J., ECF No. 14, Mem. in Supp., ECF No. 14-1 [hereinafter Pl.'s Mem.], at 3-4; Def.'s Cross-Mot. for Summ. J., ECF No. 15, Def.'s Mem. in Supp. [hereinafter Def.'s Mem.], ECF No. 15-1, at 5. As a cost-reimbursed HMO, Plaintiff is entitled by statute to reimbursement for the "reasonable cost" of the covered services it provides to its Medicare beneficiaries. See generally 42 U.S.C. § 1395mm(h) (setting terms for "reasonable cost reimbursement contract[s]"). The Medicare Act defines the "reasonable cost" of reimbursable services, in relevant part, as "the cost actually incurred, *155excluding 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). The "cost actually incurred" is to "be determined in accordance with regulations establishing the method or methods to be used, and the items to be included." Id. The Medicare Act also requires that regulations "provide for the making of suitable retroactive corrective adjustments" in instances where a provider's reimbursement under the methodology is "inadequate or excessive." Id. ; see also 42 C.F.R. § 417.576 (containing rules concerning "final settlement" of payments made to HMOs).

Consistent with the Act, a cost-reimbursed HMO's "cost actually incurred" is determined by a formula. See 42 C.F.R. § 417.560(c). The controlling regulation, 42 C.F.R. § 417.560(c) ("the Regulation"), provides:

Medical services furnished under an arrangement that provides for the HMO ....

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Cite This Page — Counsel Stack

Bluebook (online)
297 F. Supp. 3d 152, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rocky-mountain-health-maint-org-inc-v-price-cadc-2018.