642 F.3d 1145 (D.C. Cir. 2011), 10-5115, Auburn Regional Medical Center v. Sebelius

Docket Nº:10-5115.
Citation:642 F.3d 1145
Opinion Judge:GRIFFITH, Circuit Judge:
Party Name:AUBURN REGIONAL MEDICAL CENTER, et al., Appellants v. Kathleen SEBELIUS, Secretary, Department of Health and Human Services, Appellee.
Attorney:Robert L. Roth argued the cause and filed the briefs for appellants. M. Roy Goldberg, Christopher M. Loveland, and Brian M. Daucher were on the brief for amici curiae Hospice Advantage, et al. in support of appellants. Jeffrey A. Lovitky was on the brief for amicus curiae Quality Reimbursement Se...
Judge Panel:Before: HENDERSON and GRIFFITH, Circuit Judges, and WILLIAMS, Senior Circuit Judge.
Case Date:June 24, 2011
Court:United States Courts of Appeals, Court of Appeals for the District of Columbia Circuit
 
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642 F.3d 1145 (D.C. Cir. 2011)

AUBURN REGIONAL MEDICAL CENTER, et al., Appellants

v.

Kathleen SEBELIUS, Secretary, Department of Health and Human Services, Appellee.

No. 10-5115.

United States Court of Appeals, District of Columbia Circuit.

June 24, 2011

Argued Dec. 7, 2010.

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Appeal from the United States District Court for the District of Columbia (No. 1:07-cv-02075).

Robert L. Roth argued the cause and filed the briefs for appellants.

M. Roy Goldberg, Christopher M. Loveland, and Brian M. Daucher were on the brief for amici curiae Hospice Advantage, et al. in support of appellants.

Jeffrey A. Lovitky was on the brief for amicus curiae Quality Reimbursement Services in support of appellants.

Stephanie R. Marcus, Attorney, U.S. Department of Justice, argued the cause for appellee. With her on the brief were Ronald C. Machen Jr., U.S. Attorney, and Mark B. Stern, Attorney. Samantha L. Chaifetz, Attorney, and R. Craig Lawrence, Assistant U.S. Attorney, entered appearances.

Before: HENDERSON and GRIFFITH, Circuit Judges, and WILLIAMS, Senior Circuit Judge.

OPINION

GRIFFITH, Circuit Judge:

Since 1983, Medicare has used a prospective payment system to reimburse hospitals for their inpatient operating costs. These payments are based on predetermined, nationally applicable rates and are subject to various adjustments. One such adjustment is the disproportionate share hospital (DSH) payment, which provides an additional reimbursement to hospitals that serve large numbers of low-income patients. A hospital's DSH payment depends on its " DSH percentage," a figure that the Center for Medicare &

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Medicaid Services (CMS) must calculate. The DSH percentage varies based on the number of Medicare beneficiaries entitled to Supplementary Security Income, a federal low-income supplement established by the Social Security Act.

This case stems from the discovery in an unrelated case that CMS had paid hospitals less than they were due because it had miscalculated the DSH percentage for fiscal years 1993-1996. See Baystate Med. Ctr. v. Leavitt, 545 F.Supp.2d 20 (D.D.C.2008). The appellants in this case, a group of hospitals that receive DSH payments, filed claims with the Provider Reimbursement Review Board (PRRB) in 2006 seeking full payments for the fiscal years 1987-1994. Appellants acknowledged that they filed their claim more than a decade after the deadline for challenging payments, but argued that the limitations period should be equitably tolled because CMS knowingly and unlawfully failed to disclose that the DSH payments had been understated.

The PRRB held that it was without authority to toll the limitations period, making appellants' claim untimely and beyond the jurisdiction of the PRRB. Appellants then filed suit in the district court, which held that it also lacked jurisdiction in this matter because the PRRB's determination was not a " final decision." The district court further held that the statute does not allow for equitable tolling. We take jurisdiction pursuant to 28 U.S.C. § 1291 and reverse and remand.

I

We consider first whether the PRRB's dismissal of appellants' claims for lack of jurisdiction was a " final decision." The Medicare statute grants " [p]roviders ... the right to obtain judicial review of any final decision of the [PRRB] ... by a civil action commenced within 60 days of the date on which notice of any final decision by the [PRRB] ... is received." 42 U.S.C. § 1395 oo (f). There is no question that this appeal was brought within sixty days. The only question is whether the PRRB's decision was final.

To understand the Secretary's argument, a word of explanation is needed about how providers receive Medicare reimbursements and how they can challenge those they think are wrong. Each year, Medicare providers submit cost reports to fiscal intermediaries, who then determine the amount of Medicare reimbursement due, which is announced in a Notice of Provider Reimbursement (NPR). If a provider is dissatisfied, it may appeal that determination to the PRRB but must do so within 180 days of the NPR. 42 U.S.C. § 1395 oo (a). According to the Secretary and the district court, the Board's dismissal of an untimely claim is not a final decision. We fail to see how this could be the case. The district court thought this was our holding in Athens Community Hospital, Inc. v. Schweiker, 686 F.2d 989 (D.C.Cir.1982), but it was not. In Athens, we held that " if the threshold requirements of 42 U.S.C. § 1395oo(f)(1) are met, a court has jurisdiction to review a decision by the PRRB that it lacks jurisdiction to review a determination of the fiscal intermediary." 686 F.2d at 994 (emphasis added). But § 1395 oo (f)(1) only requires that " a civil action [be] commenced within 60 days" of the PRRB's " final decision." It says nothing about the 180-day limitations period.

The Secretary's confusion seems to stem from our reference to John Muir Memorial Hospital, Inc. v. Califano, 457 F.Supp. 848 (N.D.Cal.1978), in Athens. We stated there that " jurisdiction was not available to the court in John Muir because the provider failed to timely file its appeal. Under [§ 1395 oo (f)(1) ], a decision by the PRRB not to hear a case on this basis is,

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by definition, not a ‘ final decision.’ " 686 F.2d at 994 n. 4. The Secretary reads this statement to suggest that a PRRB conclusion that it lacks jurisdiction over an untimely claim is not a final decision subject to judicial review. But that was not our point. In John Muir, the provider, without having appealed the fiscal intermediary's final determination to the PRRB within 180 days, went straight to the district court. It did not go there arguing the PRRB was wrong to deny jurisdiction. Rather, it argued the court could review the intermediary's decision on the merits pursuant to the grant of general federal question jurisdiction under 28 U.S.C. § 1331, even if a timely claim was never pressed before the PRRB. See John Muir, 457 F.Supp. at 852-53. The court disagreed, holding that it could only review cases on the merits that were filed within sixty days of a final decision by the PRRB. See id. The John Muir court did not hold that a dismissal for want of jurisdiction is not a final decision on that issue. And with good reason. Such a dismissal is final in any sense of the word. It is not pending, interlocutory, tentative, conditional, doubtful, unsettled, or otherwise indeterminate. It is done.

Indeed, we took jurisdiction in Athens after explaining that courts have " jurisdiction to review a decision by the PRRB declining to hear a case on the basis of lack of PRRB jurisdiction." 686 F.2d at 993. If it were otherwise, " the PRRB could effectively preclude any judicial review of its decisions simply by denying jurisdiction of those claims that it deems to be non-meritorious." Id. (quoting Cleveland Mem'l Hosp., Inc. v. Califano, 444 F.Supp. 125, 128 (E.D.N.C.1978), aff'd, 594 F.2d 993 (4th Cir.1979)) (internal quotation marks omitted). Accordingly, courts of appeals in comparable situations have consistently understood dismissals for lack of jurisdiction as " final decisions." See id. (analogizing to 28 U.S.C. § 1291, where courts have consistently understood dismissals for lack of jurisdiction as final decisions). This approach accords not only with common...

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