The Toledo Hospital v. Donna E. Shalala, Secretary, Department of Health and Human Services

104 F.3d 791
CourtCourt of Appeals for the Sixth Circuit
DecidedMarch 27, 1997
Docket95-3858
StatusPublished
Cited by5 cases

This text of 104 F.3d 791 (The Toledo Hospital v. Donna E. Shalala, Secretary, Department of Health and Human Services) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
The Toledo Hospital v. Donna E. Shalala, Secretary, Department of Health and Human Services, 104 F.3d 791 (6th Cir. 1997).

Opinion

ALAN E. NORRIS, Circuit Judge.

At issue in this case is the validity of the Medicare reaudit regulation, 42 ' C.F.R. §§ 413.86(e)(1)(ii)-(iii). For the following reasons, we conclude that the reaudit regulation is invalid under the guidelines set out by the Supreme Court in Chevron, U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837, 104 S.Ct. 2778, 81 L.Ed.2d 694 (1984).

I. Regulatory Framework

From 1965 to 1986, the Medicare program reimbursed participating hospitals, known as providers, for the reasonable costs incurred in furnishing graduate medical education (“GME”). The Secretary of Health and Human Services (the “Secretary”) delegated the task of administratively determining these costs to fiscal intermediaries. The procedure for determining a provider’s reasonable costs for GME involved several steps. First, providers would submit a cost report to a fiscal intermediary shortly after the end of the reporting year. See 42 C.F.R. § 413.24(f)(2)(i) (1995). The fiscal intermediary would then issue a notice of program reimbursement (an “NPR”). See 42 C.F.R. § 405.1803(a) (1995). A provider dissatisfied with the allowed costs could appeal the intermediary’s determination to the Provider Reimbursement Review Board (the “Board”). See 42 U.S.C. § 1395oo (a)(1); 42 C.F.R. § 405.1835(a) (1995). Judicial review of final decisions of the Board was authorized by 42 U.S.C. § 1395oo (f)(1).

To aid in the audit and review of providers’ claims, the Secretary required each provider to retain records pertaining to its physicians’ compensation, as well as the amount of time each physician devoted to Medicare versus non-Medicare duties. 42 C.F.R. § 405.481(g)(3) (1995), removed, 60 Fed.Reg. 63,124, 63,175 (1995). The Secretary required that such records be retained for at least four years after the end of. each cost reporting period to which the allocation applies. Id. To further ensure the accuracy of the audit process, the Secretary allowed for the reopening of a cost determination within three years of the last administrative action taken with respect to the year in question. See 42 C.F.R. § 405.1885(a) (1995).

In April of 1986, Congress enacted the Comprehensive Omnibus Budget Reconciliation Act of 1986 (the “Act”), Pub.L. No. 99-272, 1986 U.S.C.C.A.N. (100 Stat.) 82. Among the changes adopted, the Act converted GME reimbursements from a pass-through basis to a per-resident reimbursement indexed to a base year. Section 9202(a) of that act amended § 1886 of the Social Security Act, 42 U.S.C. § 1395ww, by, among other things, enacting 42 U.S.C. § 1395ww(h)(2)(A), the current version of which reads as follows: “The Secretary shall determine, for the hospital’s cost reporting period that began during fiscal year 1984, the *794 average amount recognized as reasonable under this subchapter for direct graduate medical education costs of the hospital for each full-time-equivalent resident.” 1986 U.S.C.C.A.N. (100 Stat.) at 171-72 (the “GME amendment”). Section' 9202(a) further provides that the base year 'per-resident average would be adjusted for inflation and used to calculate GME reimbursements for future years. See 42 U.S.C. §§ 1395ww(h)(2)(C)-(D). Section 9202(b) of the Act provides that the amendments in § 9202(a) “shall apply to hospital cost reporting periods beginning on or after July 1, 1985.” 1986 U.S.C.C.A.N. (100 Stat.) at 175.

While the Act was passed in April of 1986, the Secretary waited until September of 1989 to adopt implementing regulations. See 54 Fed.Reg. 40,286, 40,316-17 (1989) (Codified at 42 C.F.R. § 413.86(e)(1)). These regulations first instruct the fiscal intermediaries to verify that the costs allowed for each provider for the base year, fiscal year 1984, are accurate and to exclude any costs improperly allowed in the initial audit. See 42 C.F.R. §§ 413.86(e)(1)(i)-(ii) (1995). The regulations then address GME cost determinations that are. more than three years old and, therefore, are no longer subject to reopening: “If the hospital’s cost report for its GME base period is no longer subject to reopening under § 405.1885 of this chapter, the intermediary may modify the hospital’s base-period costs solely, for purposes of computing the per resident amount.” 42 C.F.R. § 413.86(e)(1)(iii) (1995) (together with 42 C.F.R. § 413.86(e)(1)(ii), the “reaudit regulation”). Thus, finding that a provider’s 1984 GME costs were too high would not require repayment from the provider for that year if the reaudit occurred after the end of the reopening period. Because many providers had disposed of their records for 1984 after having retained the documents for the requisite four-year period, the Secretary allowed providers who no longer had their 1984 records to submit information from subsequent years as evidence of the number of residents and the percentage of time - dedicated to Medicare activities for the base year. See 55 Fed.Reg. 35,990, 36,063-64 (1990).

II. Facts

Plaintiff, The Toledo Hospital (the “Hospital”), uses the calendar year as its fiscal year. Accordingly, its base year for purposes of the Medicare regulations ended on December 31, 1984. On February 26, 1986, a fiscal intermediary issued the NPR for 1984, recognizing that the Hospital was entitled to $5,867,-705 in reasonable GME costs. The Hospital did not appeal that finding to the Board, and the three-year reopening period for the 1984 determination ended on February 26, 1989. Under the four-year record-keeping requirement, the Hospital was required to retain its physician compensation records for 1984 until December 31,1988.

Pursuant to the reaudit regulations adopted in September of 1989, a fiscal intermediary began a reaudit of the Hospital’s base year in late 1990.

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