969 F. Supp. 2d 38
D.D.C.2013Background
- Five consolidated cases challenge CMS/FI overpayment recoupment under Medicare; three counts per complaint
- Counts I-II challenge FI NPR determinations as final agency actions; Count III challenges PRRB jurisdictional ruling
- Secretary moves to dismiss or grant summary judgment; argues FI determinations are not final APA actions and PRRB jurisdiction is correct
- PRRB previously dismissed appeals for lack of jurisdiction under 42 C.F.R. §§ 405.1801(a)(4), 405.376(j), 401.625; CMS/PRRB decisions are subject to APA review only if final
- Court finds FI overpayments are not final agency decisions; Counts I-II dismissed; review limited to PRRB jurisdiction; Count III affirmed and dismissed
- Settlement with Sun and CMS and bankruptcy judge Walrath retained jurisdiction over related disputes; later recoupment actions pursued against transferees
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Are FI overpayment determinations final agency actions subject to review? | Eagle/ Hope contend finality under APA. | Secretary: FI determinations are not final agency decisions. | Counts I-II dismissed; no APA review |
| May the court review the merits under expedited review after PRRB denies jurisdiction? | Section 1395oo(f)(1) allows expedited review if PRRB lacks authority. | PRRB must assess jurisdiction first; 1395oo(f)(1) not applicable if PRRB lacks authority to decide the issue | Expedited review not available; Count III affirmed as to PRRB jurisdiction |
Key Cases Cited
- Los Angeles Haven Hospice, Inc. v. Sebelius, 638 F.3d 644 (9th Cir. 2011) (section 1395oo(f)(1) involves questions of law in limited contexts)
- Three Lower Counties Community Services v. U.S. Dep’t of Health and Human Servs., 517 F. Supp. 2d 431 (D.D.C. 2007) (PRRB jurisdiction and expedited review standards guidance)
- Cape Cod Hospital v. Leavitt, 565 F. Supp. 2d 187 (D.D.C. 2008) (distinguishes between jurisdiction and authority to decide the merits)
- Good Samaritan Hosp. Regional Medical Center v. Shalala, 85 F.3d 1057 (2d Cir. 1996) (PRRB’s jurisdictional scope and district court review limitations)
- St. Vincent Health Ctr. v. Shalala, 937 F. Supp. 496 (W.D. Pa. 1995) (PRRB jurisdictional limitations and scope of review)
- Hopkins v. Women’s Div. General Bd. of Global Ministries, 284 F. Supp. 2d 15 (D.D.C. 2003) (expedited review and authority to decide the controlling question)
- Bethesda Hosp. Ass'n v. Bowen, 485 U.S. 399 (1988) (administrative review limitations and final decision standards)