Your Home Visiting Nurse v. Shalala

• Decision Date: 23 February 1999
• Docket Number: 971489
• Citation: 119 S.Ct. 930,525 U.S. 449,142 L.Ed.2d 919
• Parties: SUPREME COURT OF THE UNITED STATES 119 S.Ct. 930 142 L.Ed.2d 919 YOUR HOME VISITING NURSE SERVICES, INC., PETITIONER v. DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES1489
• Court: U.S. Supreme Court

525 U.S. 449

119 S.Ct. 930

142 L.Ed.2d 919

SUPREME COURT OF THE UNITED STATES

YOUR HOME VISITING NURSE SERVICES, INC., PETITIONER v. DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES

No. 97 1489

February 23, 1999

ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT

Justice Scalia delivered the opinion of the Court.

Under the Medicare Act, Title XVIII of the Social Security Act, 79 Stat. 290, as amended, 42 U.S.C. § 1395 (1994 ed. and Sup. II), et seq., the Secretary of Health and Human Services reimburses the providers of covered health services to Medicare beneficiaries, see §§1395f(b)(1), 1395h, 1395x(v)(1)(A). A provider seeking such reimbursement submits a yearly cost report to a fiscal intermediary (generally a private insurance company) that acts as the Secretary's agent. See 42 CFR § 405.1801(b) (1997). The intermediary analyzes the cost report and issues a Notice of Program Reimbursement (NPR) determining the amount of reimbursement to which the provider is entitled for the year. See §405.1803.

As is relevant here, a dissatisfied provider has two ways to get this determination revised. First, a provision of the Medicare Act, 42 U.S.C. § 1395oo, allows a provider to appeal, within 180 days, to the Provider Reimbursement Review Board (Board) an administrative review panel that has the power to conduct an evidentiary hearing and affirm, modify, or reverse the intermediary's NPR determination. The Board's decision is subject to judicial review infederal district court. §1395oo(f). Second, one of the Secretary's regulations, 42 CFR § 405.1885 (1997), permits a provider to request the intermediary, within three years, to reopen the reimbursement determination.

Petitioner Your Home Visiting Nurse Services, Inc., owns and operates several entities that provide home health care services to Medicare beneficiaries. Petitioner submitted cost reports for the year 1989 to its fiscal intermediary, and did not seek administrative review of the resulting NPRs within 180 days. Within three years, however, it did ask the intermediary to reopen its 1989 reimbursement determination on the ground that "new and material" evidence demonstrated entitlement to additional compensation. The intermediary denied the request. Petitioner sought to appeal that denial to the Board, but the Board dismissed the appeal on the ground that §405.1885 divested it of jurisdiction to review an intermediary's refusal to reopen a reimbursement determination.

Petitioner then brought the instant action in Federal District Court, seeking review of the Board's dismissal and of the intermediary's refusal to reopen. In an unpublished opinion, the District Court agreed that the Board lacked jurisdiction to review the refusal to reopen, and rejected petitioner's alternative contention that the federal-question statute, 28 U.S.C. § 1331 or the mandamus statute, §1361, gave the District Court jurisdiction to review the intermediary's refusal directly. It accordingly dismissed the complaint. The Court of Appeals affirmed. 132 F.3d 1135 (CA6 1997). We granted certiorari. 524 U.S. ___ (1998).

I

The primary issue in this case is whether the Board has jurisdiction to review a fiscal intermediary's refusal to reopen a reimbursement determination. The regulation that authorizes reopening provides that "[j]urisdiction for reopening a determination rests exclusively with that administrative body that rendered the last determination or decision." 42 CFR § 405.1885(c) (1997). In this litigation, the Secretary defends the position set forth in the Medicare Provider Reimbursement Manual §2926, App. A, ¶B.4 (Sept. 1993): "A refusal by the intermediary to grant a reopening requested by the provider is not appealable to the Board, pursuant to 42 CFR § 405.1885(c) . . . ."1 The Secretary construes the regulation to mean that where, as here, the intermediary is the body that rendered the last determination with respect to the cost reports at issue, review by the Board of the intermediary's refusal to reopen would divest the intermediary of its "exclusiv[e]" "jurisdiction for reopening a determination." Petitioner, on the other hand, contends that "jurisdiction" in §405.1885(c) refers only to original jurisdiction over the reopening question, and not to appellate jurisdiction to review the intermediary's refusal. Even if it should win on this point, however, petitioner would only establish that the Board's otherwise extant appellate jurisdiction has not been excluded; it would still have to establish that the Board's appellate jurisdiction is somewhere conferred. Another regulation, §405.1889, says that an intermediary's affirmative decision to reopen and revise a reimbursement determination "shall be considered a separate and distinct determination" to which the regulations authorizing appeal to the Board are applicable; but it says nothing about appeal of a refusal to reopen. Petitioner must thus establish the Board's appellate jurisdiction on the basis of the unelaborated text of the Medicare Act itself.

Petitioner relies upon 42 U.S.C. § 1395oo(a)(1)(A)(i), which says that a provider may obtain a hearing before the Board with respect to a cost report if the provider "is dissatisfied with a final determination of its fiscal intermediary as to the amount of total program reimbursement due the provider for the period covered by such report ." Petitioner maintains that the refusal to reopen a reimbursement determination constitutes a separate "final determination as to the amount of total program reimbursement due the provider." The Secretary, on the other hand, maintains that this phrase does not include a refusal to reopen, which is not a "final determination . . . as to the amount," but rather the refusal to make a new determination. The Secretary's reading of §1395oo(a)(1)(A)(i) frankly seems to us the more natural but it is in any event well within the bounds of reasonable interpretation, and hence entitled to deference under Chevron v. Natural Resources Defense Council, Inc., 467 U.S. 837,842 (1984).

The reasonableness of the Secretary's construction of the statute is further confirmed by Califano v. Sanders, 430 U.S. 99 (1977), in which we held that §205(g) of the Social Security Act does not authorize judicial review of the Secretary's decision not to reopen a previously adjudicated claim for benefits.2 In reaching this conclusion we relied, in part, upon two considerations: that the opportunity to reopen a benefit adjudication was afforded only by regulation and not by the Social Security Act itself; and that judicial review of a reopening denial would frustrate the statutory purpose of imposing a 60-day limit on judicial review of the Secretary's final decision on an initial claim for benefits. Id., at 108. Similar considerations apply here. The right of a provider to seek reopening exists only by grace of the Secretary, and the statutory purpose of imposing a 180-day limit on the right to seek Board review of NPRs, see 42 U.S.C. § 1395oo(a)(3), would be frustrated by permitting requests to reopen to be reviewed indefinitely.

Finally, we do not think that the Secretary's position is inconsistent with 42 U.S.C. § 1395x(v)(1)(A)(ii), which provides that the Secretary's cost-reimbursement regulations shall "provide for the making of suitable retroactive corrective adjustments where, for a provider of services for any fiscal period, the aggregate reimbursement produced by the methods of determining costs proves to be either inadequate or excessive." Petitioner asserts that the reopening regulations, as construed by the Secretary, do not create a "suitable" procedure for making "retroactive corrective adjustments" because an intermediary's refusal to reopen a determination is not subject to administrative review. In support of this assertion, petitioner decries the "double standard" inherent in a procedure that allows the intermediary to reopen (during the 3-year period) for the purpose of recouping overpayments, but to deny reopening when alleged underpayments are at issue.

This argument fails for two reasons. First, and most importantly, petitioner's construction of §1395x(v)(1)(A)(ii) is inconsistent with our decision in Good Samaritan Hospital v. Shalala, 508 U.S. 402 (1993), in which we held that the Secretary reasonably construed clause (ii) to refer to the year-end reconciliation of monthly payments to providers, see 42 U.S.C. § 1395g with the total amount of program reimbursement determined by the intermediary. Although we did not specifically consider the procedure for reopening determinations after the year's books are closed, we think our conclusion there that clause (ii) refers to the year-end book balancing forecloses petitioner's contention that clause (ii) requires any particular procedure for reopening reimbursement determinations. And...