St. Luke's Medical Center v. United States

22 Cl. Ct. 322, 1991 U.S. Claims LEXIS 10, 1991 WL 4800
CourtUnited States Court of Claims
DecidedJanuary 22, 1991
DocketNo. 90-218C
StatusPublished
Cited by2 cases

This text of 22 Cl. Ct. 322 (St. Luke's Medical Center 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
St. Luke's Medical Center v. United States, 22 Cl. Ct. 322, 1991 U.S. Claims LEXIS 10, 1991 WL 4800 (cc 1991).

Opinion

OPINION

NETTESHEIM, Judge.

This case is before the court after argument on defendant’s motion to dismiss for lack of subject matter jurisdiction. Defendant asserts, first, that plaintiff failed to exhaust the available administrative remedies in pursuing its claim for Medicare reimbursement and, second, that by statute a health care provider may obtain initial judicial review of a reimbursement decision solely in a federal district court. Plaintiff opposes on the grounds that its failure to pursue administrative remedies is immaterial and that the statutory limitation on choice of forum is inapplicable to this case.

FACTS

1.‘ Statutory framework

This case involves the right to receive reimbursements pursuant to the Social Security Act of 1935, 49 Stat. 620 (codified as amended at 42 U.S.C. §§ 301-1397Í (1988). The Social Security Act affords “benefits not only to the ‘insured worker in his old age,’ but also to ‘individuals and families when workers retire, become disabled, or die.’ ” Bowen v. Public Agencies Opposed to Social Security Entrapment, 477 U.S. 41, 43, 106 S.Ct. 2390, 2392, 91 L.Ed.2d 35 (1986) (quoting S.Rep. No. 98-13, 83d Cong., 2d Sess., pt. 2, 78 (1983)).

In 1965 Congress amended the Social Security Act of 1935 by adding what is known today as Part A of the Medicare program. Health Insurance for the Aged Act, Pub.L. No. 89-97, 79 Stat. 291 (1965) (codified as amended at 42 U.S.C. §§ 1395c — 1395Í-2 (1988)) [hereinafter “Medicare” or the “program”] 1 Medicare provides indirect hospital insurance benefits to Medicare “beneficiaries,” who are generally the disabled or the elderly. Under the program, disbursements are not paid to individual beneficiaries. Rather, participating hospitals, known as “providers”, are reimbursed for the cost of caring for beneficiaries. A provider routinely receives reimbursements via its “fiscal intermediary” (the “intermediary”),2 an entity which is typically a private insurance company. The intermediary serves as agent to the Secretary of Health and Human Services (the “Secretary”) in reviewing the legitimacy of a provider’s claims for reimbursement. 42 U.S.C. § 1395h.

Providers receive Medicare reimbursements for the lesser of the “reasonable costs” or the providers’ customary charges for hospital services rendered to beneficiaries. 42 U.S.C. § 1395f(b)(l). Section 1395x(v)(l)(A) defines reasonable costs as “the cost actually incurred, excluding therefrom any part of incurred cost found to be unnecessary in the efficient delivery of needed health services____” The program empowers the Secretary, at his discretion, to “provide for the establishment of limits on the direct or indirect overall incurred costs or incurred costs of specific items or services of groups of items or serviced to be recognized as reasonable based on estimates of the costs necessary in the efficient delivery of needed health services.” 42 U.S.C. § 1395x(v)(l)(A). Accordingly, the Secretary, through its delegatee the Health Care Financing Administration (“HCFA”), promulgated regulations concerning requests for reimbursement of “reasonable” costs. 42 C.F.R. § 413.30(a)(1) (1989).

To request such a reimbursement, a provider must submit to its fiscal intermediary a cost report detailing the financial outlay for all services furnished to beneficiaries for the preceding year. 42 C.F.R. § 413.20(b). The intermediary appraises the cost report and issues a notice of program reimbursement (the “NPR”) disclos[324]*324ing the aggregate of reimbursement due the provider and explaining any adjustments the intermediary performed. 42 C.F.R. § 405.1803. If dissatisfied with a NPR, and if the amount in controversy exceeds $10,000.00, a provider may appeal to the Provider Reimbursement Review Board (the “PRRB”), an administrative review panel in the Department of Health and Human Services. 42 U.S.C. § 1395oo(a). The provider must file its appeal within 180 days after receiving notice of the NPR. 42 U.S.C. § 1395oo(a)(3); 42 C.F.R. § 405.1841(a). The Secretary may review sua sponte the PRRB’s finding within 60 days after issuance. 42 U.S.C. § 1395oo(f)(l).

Judicial review under the program as originally enacted, in general, provided little or no express opportunity for judicial review of determinations made by a fiscal intermediary or the Secretary,3 since section 205(h) of the Social Security Act stated: “No findings of fact or decision of the Secretary shall he reviewed by any person, tribunal, or governmental agency except as ... [specified in the Act].” Section 405(h) applied to the Medicare portion of the Social Security Act. 42 U.S.C. § 1395Ü (1988). See, e.g., Trinity Memorial Hospital of Cudahy, Inc. v. Associated Hospital Serv., Inc., 570 F.2d 660, 666-67 (7th Cir.1977); South Windsor Convalescent Home, Inc. v. Mathews, 541 F.2d 910, 914 (2d Cir.1976).4 But see Whitecliff, Inc. v. United States, 210 Ct.Cl. 53, 57-58, 536 F.2d 347, 350-51 (1976), cert. denied, 430 U.S. 969, 97 S.Ct. 1652, 52 L.Ed.2d 361 (1977) (holding judicial review valid of claim arising from 1967 to 1970); accord Dr. John T. MacDonald Found., Inc. v. Califano, 571 F.2d 328, 332 (5th Cir.) (en banc), cert. denied, 439 U.S. 893, 99 S.Ct. 250, 58 L.Ed.2d 238 (1978). Amendments to the program in 1972 created the PRRB and also granted a health care provider a limited opportunity for judicial oversight by allowing review by a court only where the Secretary caused a modification or reversal of an earlier PRRB decision. S.Rep. No. 1065, 93d Cong., 2d Sess. (1974), reprinted in 1974 U.S.Code Cong. & Admin.News 5992, 5995.

In 1974 Congress expanded the judicial review provisions of the program by implementing the following statutory requirements:

Providers shall have the right to obtain judicial review of any final decision of the ...

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22 Cl. Ct. 322, 1991 U.S. Claims LEXIS 10, 1991 WL 4800, Counsel Stack Legal Research, https://law.counselstack.com/opinion/st-lukes-medical-center-v-united-states-cc-1991.