Gentiva Healthcare Corp. v. Sebelius, No. 12–5179.

• Court: United States Courts of Appeals. United States Court of Appeals (District of Columbia)
• Writing for the Court: GARLAND
• Citation: 723 F.3d 292
• Parties: GENTIVA HEALTHCARE CORPORATION, doing business as Heritage Home Health, Appellant v. Kathleen SEBELIUS, Secretary, U.S. Department of Health and Human Services, Appellee.
• Docket Number: No. 12–5179.
• Decision Date: 23 July 2013

723 F.3d 292

GENTIVA HEALTHCARE CORPORATION, doing business as Heritage Home Health, Appellant
v.
Kathleen SEBELIUS, Secretary, U.S. Department of Health and Human Services, Appellee.

No. 12–5179.

United States Court of Appeals,
District of Columbia Circuit.

Argued May 3, 2013.
Decided July 23, 2013.

[723 F.3d 293]

Appeal from the United States District Court for the District of Columbia (No. 1:11–cv–00438).
Robert L. Roth argued the cause for appellant. With him on the brief was Patric Hooper.

Adam C. Jed, Attorney, U.S. Department of Justice, argued the cause for appellee. With him on the brief were Stuart F. Delery, Principal Deputy Assistant Attorney General, Ronald C. Machen Jr., U.S. Attorney, and Mark B. Stern, Attorney.

Before: GARLAND, Chief Judge, BROWN, Circuit Judge, and SENTELLE, Senior Circuit Judge.

Opinion for the Court filed by Chief Judge GARLAND.

GARLAND, Chief Judge:

Gentiva Healthcare Corporation is a provider of home health-care services. Gentiva contends that the Secretary of Health and Human Services violated the Medicare statute by delegating to an outside contractor the authority to determine whether Gentiva's Medicare reimbursement claims exhibited a “sustained or high level of payment error.” 42 U.S.C. § 1395ddd(f)(3). We conclude that the Secretary reasonably construed the statute to permit such a delegation.

I

The Medicare program is administered by the Secretary of the Department of Health and Human Services (HHS). 42 U.S.C. § 1395kk(a). By statute, the Secretary may “perform any of [her] functions under” the Medicare program “directly, or by contract ..., as the Secretary may deem necessary.” Id. Although the Secretary's functions under the Medicare program are many, this appeal concerns her role in administering the Medicare Integrity Program. Created in 1996, that Program directs the Secretary to “promote the integrity of the medicare program by entering into contracts” with “eligible entities” to carry out specified “activities.” Id.§ 1395ddd(a); see Health Insurance Portability and Accountability Act, Pub.L. No. 104–191, § 202, 110 Stat.1936, 1996 (1996). Included among those activities are the “[r]eview of activities of providers of services” and the “[a]udit of cost reports.” 42 U.S.C. § 1395ddd(b)(1), (2).

At the core of this appeal are amendments to the Medicare Integrity Program that Congress enacted in 2003. See Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub.L. No. 108–173, § 935, 117 Stat.2066, 2407. Under the amended statute, the Secretary may use outside contractors to determine whether the Medicare program has overpaid a health-care services provider. However, “[a] medicare contractor may not use extrapolation to determine overpayment amounts to be recovered ... unless the Secretary determines that ... there is a sustained or high level of payment error.” 42 U.S.C. § 1395ddd(f)(3). The statute further provides that “[t]here shall be no administrative or judicial review ... of determinations by the Secretary of sustained or high levels of payment errors.” Id.

[723 F.3d 294]

In 2007, a Medicare contractor, Cahaba Safeguard Administrators, initiated a review of reimbursement claims that Gentiva submitted to Medicare for home health-care services it provided to patients from July 1, 2005 to November 30, 2006. Cahaba found that 58% of those claims had been at least partially denied by the Medicare program for failure to comply with Medicare coverage requirements. Cahaba also noted that the payments Gentiva received per beneficiary served were high compared to the average payment received by providers in Gentiva's region. Based on these observations, Cahaba determined that Gentiva's claims exhibited a “sustained or high level of payment error.” See Decision of Administrative Law Judge at 16, Appeal of Gentiva Health Services (Apr. 28, 2010) (J.A. 75) (“ALJ Decision”).

Cahaba proceeded to draw a sample of 30 claims. Of these, it initially determined that 26 claims—nearly 87% of the sample—were overpaid. Extrapolating this error rate over all of the relevant claims, Cahaba determined that Medicare had overpaid Gentiva by $4,242,452.10. After Gentiva successfully challenged Cahaba's overpayment determination as to ten of the claims in the sample, Cahaba revised its extrapolation and calculated a lower overpayment principal of $2,112,778.00. See ALJ Decision at 1–2.

Before an HHS Administrative Law Judge (ALJ), Gentiva challenged Cahaba's overpayment determination as to ten more claims in the sample. Gentiva also charged that Cahaba's sampling and extrapolation method was itself invalid. The ALJ agreed with Gentiva that the ten identified claims had not been overpaid and directed that the extrapolation be recalculated accordingly. But the ALJ upheld as valid the statistical sampling and extrapolation methodology that Cahaba used. See ALJ Decision at 20–21.

Gentiva appealed the ALJ's approval of Cahaba's use of extrapolation to the Medicare Appeals Council of HHS' Departmental Appeals Board. Gentiva “advance [d] only one contention” before the Appeals Council: that 42 U.S.C. § 1395ddd(f)(3) barred Cahaba—or any outside contractor—from making the “sustained or high level of payment error” finding that is a prerequisite for using statistical extrapolation to calculate an overpayment amount. Decision of Medicare Appeals Council at 2, In the case of Gentiva Healthcare Corp., Dkt. No. M–11–488 (Jan. 27, 2011) (J.A. 47). Specifically, Gentiva argued that:

because Congress used the terminology ‘a [M]edicare contractor’ and ‘the Secretary’ in the same sentence, it intended that the Secretary herself make a determination of a sustained or high level of payment error and, therefore, the Secretary may not assign or delegate this function to a contractor.

Id. at 2–3. The Appeals Council, however, rejected Gentiva's proposed reading of § 1395ddd(f)(3) as “unduly narrow” in light of § 1395kk(a)'s “broad authority” for the Secretary to perform any of her Medicare functions “directly, or by contract.” Id. at 5 (quoting 42 U.S.C. § 1395kk(a)). The Council concluded that “[t]he Secretary has delegated her authority” to determine that extrapolation is warranted “to a program integrity contractor, and that contractor ... has made a valid determination under the Act.” Id. at 6.

Gentiva challenged the Medicare Appeals...