John Muir Memorial Hospital, Inc. v. CalifanoJohn Muir Memorial Hospital, Inc. v. Califano
MEMORANDUM OF OPINION
This is a suit for mandamus and declaratory relief brought by plaintiff John Muir
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Memorial Hospital, Inc. (“Muir”), under Title XVIII of the Social Security Act (
In 1965, Congress enacted Title XVIII of the Social Security Act, known as Medicare, to provide federal reimbursement for medical care to the aged and disabled.
1
The program provides hospital insurance benefits to eligible individuals who receive hospital services from specially designated “providers.” Plaintiff Muir operates a hospital as defined by
As a provider, plaintiff is entitled to receive reimbursement from the Secretary for the “reasonable cost” of its hospital services.
See
BCNC, as fiscal intermediary, has no vested interest in the expenditure of the government funds. Its function is merely to determine that the amount of payment accurately reflects the reasonable costs of services rendered to program beneficiaries. Under statute, and because a hospital’s liquidity needs would be impaired if reimbursements were made only once a year, the reimbursement scheme proceeds in two parts. First, the intermediary makes not less than monthly lump sum payments to the provider, based on estimates that are subject to subsequent retroactive adjustment.
See
In 1973, plaintiff began construction of a nine million dollar addition to its existing hospital. This addition increased the number of beds; provided services for intensive care, coronary care, and intermediate care patients; and created substantial space for support services. The project was financed with bank loans and with a long-term mortgage on the hospital’s land and buildings. Plaintiff paid $166,000 in interest on this indebtedness in 1973 and $366,000 in 1974.
Prior to 1973, plaintiff had always ex-pensed its interest costs as they were incurred. However, on its 1973 and 1974 Medicare cost reports, plaintiff treated the interest payments on the construction financing as a capital item. It did so to conform to the accounting procedures set out in the Provider Reimbursement Manual, HIM — 15, § 206, a manual that provides guidance for the implementation of Medicare regulations regarding the reasonable cost of provider services. 3 As a result of *851 using the capitalization method of accounting rather than the expensing method, plaintiff’s net reimbursed costs were $60,-179 less in 1973 and $134,694 less ii) 1974. Defendant BCNC accepted and approved plaintiff’s cost report for 1973 on January 31,1975 and for 1974 on December 23,1975. Plaintiff did not seek administrative review of these decisions. 4
On March 11, 1976, plaintiff requested that BCNC reopen its 1973 and 1974 cost reports to allow recomputation of the interest costs according to the expensing method. 5 BCNC denied this request on March 18, 1976, because plaintiff had not supplied sufficient information. Plaintiff then filed a more complete Amended Request for Reopening the Cost Reports on September 23, 1976. This request was similarly denied by BCNC on November 23, 1976. 6
Having been unable to secure relief from BCNC, plaintiff filed a Request for a Hearing with defendant Provider Reimbursement Review Board (“PRRB”) on February 22, 1977.
7
On April 4, 1977, after BCNC had filed an opposition to plaintiff’s request for a hearing and plaintiff had filed a rebuttal to that opposition, the PRRB determined that it was without jurisdiction to hear plaintiff’s claim. It based this decision on three factors: first, plaintiff did not file its request for a hearing in timely fashion (
Plaintiff seeks two types of relief from this Court. First, plaintiff seeks a declaration and order that defendant BCNC is required to reopen the cost reports for 1973 and 1974 to reflect the expensing, rather than the capitalizing, of the interest costs. In this regard, it contends that Manual Section 206, the regulation requiring capitalizing of interest costs, is invalid, and that
On December 14, 1977, defendants filed a motion to dismiss on the grounds that this Court lacks subject matter jurisdiction over the action and that plaintiff has failed to state a claim upon which relief can be granted. The case was thereafter reassigned to the undersigned judge and the motion to dismiss was heard on June 8, 1978. For the reasons stated below, the Court will grant defendant’s motion.
A.
Federal jurisdiction to review administrative decisions under the Social Security Act is sharply limited by statute.
“The findings and decisions of the Secretary after a hearing shall be binding upon all individuals who were parties to such hearing. No findings of fact or decision of the Secretary shall be reviewed by any person, tribunal or governmental agency except as herein provided. No action against the United States, the Secretary, or any officer or employee thereof shall be brought under section 41 of Title 28 [28 U.S.C. § 1331 ] to recover on any claim arising under this subchapter.”42 U.S.C. § 405(h) (emphasis added).
Although this section by its terms eliminates
Plaintiff’s first claim is based on its allegation that BCNC improperly failed to reopen the 1973 and 1974 cost reports. In bringing this claim, plaintiff is seeking greater reimbursement under the Medicare Act for the “reasonable costs” it incurred in providing hospital services to eligible beneficiaries.
See
In
Califano v. Sanders,
The same result can be. reached by examining the reasoning of
Weinberger v. Salfi,
There is a further reason why this Court declines to review BCNC’s decision not to reopen the 1973 and 1974 cost reports. When Congress amended the Medicare Act in 1972 and 1974, it provided for only limited judicial review. Section 1395oo(f)(l) permits a provider to seek review in the courts only after the Provider Reimbursement Review Board (“PRRB”) has rendered a “final decision.” The PRRB can render a final decision only if the provider has requested a hearing before it within 180 days after receiving notice of the fiscal intermediary’s final determination.
Rather, plaintiff now seeks to circumvent Congress’ intent to limit judicial review by asking this Court to accept jurisdiction directly over BCNC’s refusal to reopen the cost reports. The Supreme Court has recently considered a similar attempt to seek review of HEW’s refusal to reopen a claim for benefits and stated:
“ * * * [A]n interpretation that would allow a claimant judicial review simply by filing — and being denied — a petition to reopen his claim would frustrate the congressional purpose, plainly evidenced in [the judicial review section of the Social Security Act], to impose a 60-day limitation upon judicial review of the Secretary’s final decision on the initial claim for benefits. [Citation omitted.] Congress’ determination * * * is a policy choice obviously designed to forestall repetitive or belated litigation of stale eligibility claims. Califano v. Sanders, supra,430 U.S. at 108 ,97 S.Ct. at 986 .
This Court declines to upset the Congressional policy of limiting judicial review in the instant case and holds that it has no jurisdiction to review BCNC’s refusal to reopen. 11
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Plaintiff’s second claim, based on its assertion that it is entitled to a hearing before the PRRB by virtue of its property interest in adequate and proper reimbursement, appears to be a claim arising under the Medicare Act (and therefore within the bar of
The determination that plaintiff’s constitutional claim arises under the Medicare Act does not conclude the matter. For as plaintiff points out, many courts have suggested that the jurisdictional bar of
In
St. Louis, Daytona Beach,
and
Behlen,
plaintiffs argued not that they had been improperly denied a hearing as in this case, but that the hearing they had been granted was constitutionally defective.
15
In these three cases, plaintiffs had no opportunity to raise their due process claims except in federal court. The PRRB had not yet been established by Congress, so plaintiffs had no administrative forum in which to present their arguments.
Similarly, in Pacemaker, plaintiff was a supplier of medical equipment who claimed he had no opportunity to be heard before HEW. set the allowable rates for his equipment. But there was no opportunity to raise this claim before the agency. No procedures for administrative review had been established. Plaintiff was challenging the deficiencies inherent in the system of review itself.
By contrast, Muir has a constitutional cause of action only because it failed to pursue its administrative remedies. The hospital claims that the PRRB deprived it of its due process rights under the Fifth Amendment by refusing to grant it a hearing on the issues of whether Manual Section 206 was invalid, and if so, whether the cost reports which relied on it could be amended. However, it is clear that plaintiff did have an opportunity to be heard before the PRRB on this issue; the hearing was never held only because plaintiff failed to file a timely request.
Prior to filing its 1973 and 1974 cost reports, plaintiff had been using the ex-pensing method of - computing its interest costs. Presumably, it knew that a shift to the capitalization method would result in its being entitled to less reimbursement. But plaintiff could have avoided this financial loss by challenging the validity or application of Manual Section 206 at the time it filed the costs reports.
Plaintiff could have made this challenge in two ways. First, it could have considered that even though the PRRB probably cannot invalidate a regulation as con
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trary to law, it is fully empowered to grant exceptions to regulations in particular cases.
See
The Court is persuaded by the reasoning in the recent case of
Rhode Island Hospital v. Califano, supra,
“On its face,§ 405(h) seems to preclude federal court jurisdiction over an action in which a Plaintiff has failed to pursue the administrative remedies available under the Act. Here, Plaintiff Hospital has filed to seek any administrative hearing to which it is entitled, as for example under§ 1395oo(a) .” Id. at 707.
See also Weinberger v. Salfi, supra,
In sum, this Court lacks subject matter jurisdiction under
B.
Plaintiff next contends that even if this Court lacks jurisdiction under
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The preclusion of review provision of
In most instances, particularly where a claim for benefits was made or where plaintiffs failed to exhaust their administrative remedies, the courts have included the Mandamus Act within the statutory bars of
Many of the considerations mentioned in the first section of this opinion are persuasive in reaching this decision. This is not a case in which plaintiff can claim that the administrative procedure provides no forum for assertion of its statutory and constitutional claims. Rather, plaintiff had an opportunity to challenge the requirement that it capitalize its interest costs, but chose to forego it. Given that mandamus is an extraordinary remedy, which should be employed only in exceptional circumstances, this Court will not base jurisdiction on it here.
See Haneke v. Sec’y of HEW,
The United States Court of Appeals for the District of Columbia Circuit was faced with a similar problem in
Assoc, of Amer. Medical Colleges v. Califano, supra,
In none of the cases cited by plaintiff did this Court find a failure to pursue the review procedures set out in the Social Security Act. In
Ryan v. Shea, supra,
By contrast, plaintiff in the case at bar might well have received the relief it sought had it pursued its administrative remedies. Certainly it would have received a hearing. At the hearing, the PRRB would have considered the right of plaintiff to expense its interest costs. After the PRRB’s decision, the Secretary of HEW was empowered to consider plaintiff’s claims as well. Even if neither the Secretary nor the PRRB granted the requested relief, at least the matter could have been considered — in accordance with the statutory review procedure — aided by the complete administrative record evidencing the agency’s thoughts on plaintiff’s claim.
In conclusion, this Court lacks subject matter jurisdiction over plaintiff’s lawsuit under
Accordingly, IT IS HEREBY ORDERED that defendant’s motion to dismiss is granted.
IT IS HEREBY FURTHER ORDERED that counsel for defendant shall prepare a form of judgment in accordance with this Memorandum of Opinion and submit it to the Court for execution within ten (10) days of the date hereof.
Notes
. Pub.L.No. 89-97, 79 Stat. 291, as amended;
. Providers who do not wish to deal with the private intermediaries may seek reimbursement directly from the Secretary.
. Section 206 provides:
“Frequently, providers may borrow funds to construct facilities or to enlarge existing facilities. Usually, construction of facilities will extend over a long period of time, during which interest costs on the loan are incurred. Interest costs incurred during the period of con *851 struction must be capitalized as a part of the cost of the facility. The period of construction is considered to extend to the date the facility is put into use for patient care.
“If the construction is an addition to an existing facility, interest incurred during the construction period on funds borrowed to construct the addition must be capitalized as a cost of the addition. After the construction period, interest on the loan is allowable as an operating cost. * * * ”
. In 1972, Congress established the Provider Reimbursement Review Board (“PRRB”) and gave it jurisdiction to grant providers a hearing with respect to cost reports in cases where the provider was dissatisfied with the final determination of a fiscal intermediary as to the amount of total program reimbursement due.
. Plaintiff made this request in light of the decision in
Saint Francis Memorial Hospital v. Weinberger,
. The letter from BCNC stated in part:
“We regret that we must deny your cost report reopening request. To do otherwise would require a finding on our part that HIM-15, Section 206 was invalid and that the capitalization of interest expense during construction constitutes a material error in the final settlements for 1973 and 1974. We are unable to agree with you on either of these points.”
. The PRRB was established by Public Law No. 92-603, 86 Stat. 1420, adopted October 30, 1972 (
. “The provisions * * * of subsections * * * (h) * * * 0f
. Because
. Plaintiffs Request for a Hearing was filed on February 22, 1977, over a year after the second cost report was approved and two years after the first was approved. Furthermore, plaintiff cannot claim it is sufficient that the Request was filed within 180 days after BCNC denied the request for reopening, because a denial of a reopening request is not a “final determination * * * as to the amount of total program reimbursement due.”
. To rule otherwise would be to render a decision that a cost report can never be closed, for it would allow a provider to obtain a substan *854 tive review of its cost report merely by filing a request for reopening, or repeated requests for reopening, at any time after the cost report had been filed.
. In
Salfi,
although the Court read
“Any individual, after any final decision of the Secretary made after a hearing to which he was a party, irrespective of the amount in controversy, may obtain a review of such decision by a civil action commenced within sixty days after the mailing to him of notice of such decision or within such further time as the Secretary may allow * * *.”
Because the named plaintiffs had received a final decision from the Secretary, the Court held that
Jurisdiction in this case cannot be predicated on
. In most instances, courts that have held
. This Court also takes note of the Seventh Circuit’s decision to “reject the position taken in * * *
St. Louis University
holding that
. In
Daytona Beach,
plaintiffs also alleged that the method used to determine how much money would be recouped due to their “overutilization” of services violated due process.
. This hearing would be conducted pursuant to the regulations contained at
. “The district courts shall have original jurisdiction of any action in the nature of mandamus to compel an officer or employee of the United States or any agency thereof to perform a duty owed to the plaintiff.”
. The only statutes that it excluded were several special purpose jurisdictional grants of no relevance here.
See Weinberger v. Salfi, supra,