AUBURN REGIONAL MEDICAL CENTER v. Sebelius
642 F.3d 1145
D.C. Cir.2011Background
- Medicare uses a prospective payment system; DSH payments provide extra reimbursement to hospitals serving many low-income patients.
- DSH payment amounts depend on the hospital's DSH percentage calculated by CMS, tied to beneficiaries entitled to SSI.
- Hospitals discovered CMS had understated DSH payments for 1993-1996 in a separate case, Baystate Med. Ctr. v. Leavitt.
- In 2006, hospitals filed PRRB claims for full payments for 1987-1994, acknowledging filing beyond the usual deadline but seeking equitable tolling.
- PRRB dismissed as lacking authority to toll the limitations period; district court agreed PRRB decision was not final and lacked tolling authority.
- The DC Circuit reviews reach whether PRRB dismissal for lack of jurisdiction is a final decision and whether equitable tolling applies under 42 U.S.C. § 1395oo(a).
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Is PRRB's lack-of-jurisdiction dismissal a final decision reviewable? | Auburn contends dismissal was final and reviewable. | Secretary argues dismissal is not a final decision subject to review. | Yes, final and reviewable. |
| Whether equitable tolling applies to Medicare provider claims under §1395oo(a). | Equitable tolling should apply given CMS's concealment of underpayments. | Brockamp rebutts tolling due to complex tax-like temporal provisions. | Presumption of equitable tolling applies; tolling may be appropriate on remand. |
| Does Brockamp-style analysis defeat tolling in the Medicare context? | Medicare timing resembles simpler statutes; tolling should be allowed. | Brockamp controls due to complexity and explicit exceptions. | Brockamp distinctions do not compel rebutting tolling here; tolling possible on remand. |
Key Cases Cited
- Athens Community Hosp., Inc. v. Schweiker, 686 F.2d 989 (D.C.Cir. 1982) (jurisdiction to review PRRB's lack of jurisdiction final decision)
- Baystate Med. Ctr. v. Leavitt, 545 F. Supp. 2d 20 (D.D.C. 2008) (context for miscalculation of DSH payments)
- Cleveland Mem'l Hosp., Inc. v. Califano, 444 F. Supp. 125 (E.D.N.C. 1978) (predecessor on PRRB jurisdiction and final decisions)
- John Muir Memorial Hosp., Inc. v. Califano, 457 F. Supp. 848 (N.D. Cal. 1978) (review limitations when timely appeal not pressed before PRRB)
- Irwin v. Dep't of Veterans Affairs, 498 U.S. 89 (U.S. 1990) (presumption of tolling for private-like actions against the U.S.)
- Menominee Indian Tribe of Wis. v. United States, 614 F.3d 519 (D.C.Cir. 2010) (presumption of equitable tolling in federal statutes of limitations)
- Brockamp v. United States, 519 U.S. 347 (U.S. 1997) (tax refund statute not tolled; analysis of complexity and exceptions)