Your Home Visiting Nurse Services, Inc. v. Shalala

PETITIONER: Your Home Visiting Nurse Services, Inc.
RESPONDENT: Shalala
LOCATION: Kimberley Thompson's Apartment

DOCKET NO.: 97-1489
DECIDED BY: Rehnquist Court (1986-2005)
LOWER COURT: United States Court of Appeals for the Sixth Circuit

CITATION: 525 US 449 (1999)
ARGUED: Dec 02, 1998
DECIDED: Feb 23, 1999

ADVOCATES:
Diana L. Gustin - Argued the cause for the petitioner
Lisa Schiavo Blatt -
Lisa S. Blatt - Argued the cause for the respondent

Facts of the case

Your Home Visiting Nurse Services, Inc. provides home health care services to Medicare beneficiaries. Under the Medicare Act, providers seeking reimbursement for covered health services submit a yearly cost report to a fiscal intermediary, usually a private insurance company. The intermediary then issues a Notice of Program Reimbursement (NPR) determining the provider's reimbursement. The Act allows the provider up to 180 days to appeal a reimbursement determination to the Provider Reimbursement Review Board. The provider also has up to three years to ask the intermediary to reopen a determination of the Board. Your Home Visiting Nurse submitted cost reports for 1989 to its intermediary and did not appeal the reimbursement decision. However, within three years Your Home Visiting Nurse asked its intermediary to reopen its 1989 reimbursement determination on the ground that "new and material" evidence demonstrated entitlement to additional compensation. The intermediary denied the request. Your Home Visiting Nurse appealed the denial to the Board, which dismissed the appeal on the ground that lacked it jurisdiction to review an intermediary's refusal to reopen a reimbursement determination. Your Home Visiting Nurse then brought action in Federal District Court, seeking review of the Board's dismissal and of the intermediary's refusal to reopen. The District Court agreed that the Board lacked jurisdiction to review the refusal to reopen. Moreover, it rejected Your Home Visiting Nurse's contention that the federal-question statute or the mandamus statute gave the District Court jurisdiction to review the intermediary's refusal directly. Subsequently, the court dismissed the complaint. The Court of Appeals affirmed.

Question

Can Medicare-reimbursed health care providers appeal a fiscal intermediary's refusal to reopen previous reimbursement decisions?

Media for Your Home Visiting Nurse Services, Inc. v. Shalala

Audio Transcription for Oral Argument - December 02, 1998 in Your Home Visiting Nurse Services, Inc. v. Shalala

William H. Rehnquist:

We'll hear argument next in Number 97-1489, Your Home Visiting Nurse Services v. Donna E. Shalala.

We'll wait just a minute.

Ms. Gustin.

Diana L. Gustin:

Mr. Chief Justice, and may it please the Court:

Petitioner is here today to complain about an insurance company.

In this case the insurance company is a fiscal intermediary serving as the agent for the Government, reviewing medicare cost reports, making determinations about allowable cost, and also making decisions about whether or not the cost report may be reopened.

In this case, the petitioner, a home health agency, discovered new and material evidence after the initial period for requesting appeal, and therefore made a request for a reopening of the cost report.

The intermediary, the insurance company, denied the request to reopen, considered this a final determination, and then we filed an appeal for review of that final agency action at the Provider Reimbursement Review Board.

The review board declined to accept the case, stating it did not have jurisdiction to review the refusal to reopen.

The district court upheld the jurisdictional decision of the board and the Sixth Circuit also upheld the district court, which brings us here today.

We would like to begin with the statement that there is a presumption that there will be judicial review of final agency action, and this presumption is noted in the Court's decision of Bowen v. Michigan Academy of Family Physicians, where the Court's opinion started with saying, we begin with a strong presumption that Congress intends judicial review of administrative action.

William H. Rehnquist:

Well, but you had one round of judicial... of administrative review here, didn't you, with the right to appeal to the district court?

Diana L. Gustin:

We had an opportunity, a chance to make a request for an appeal, but based upon the information that we had at that time, an appeal was not sought, but when we discovered new and material evidence which we believe shows that the intermediary violated its own regulations, upon discovery of the new and material evidence, we believe that gives us the right to request the reopening, and if that reopening is unlawfully withheld, we sought review, and so it's the review of the refusal, which is final agency action, which we are seeking.

Antonin Scalia:

Ms. Gustin, you know, there has to be an end to litigation at some point, and I thought the normal rule is, when there's a final judgment, you can come back and say, you know, there are new circumstances, but whether to open for that reason is discretionary.

The Administrative Procedure Act has an exception for judicial review for matters committed to agency discretion by law, and I have always thought that it's committed to agency discretion whether to reopen a closed case.

They always can, but I don't think anybody has a right to it.

Diana L. Gustin:

Well--

Antonin Scalia:

And if they decide not to, that's the end of the matter.

Diana L. Gustin:

--Your Honor, in this Court's decision in ICC v. Brotherhood of Locomotive Engineers, which was decided in 1977, this Court held that a refusal to reopen which was based upon new and material evidence should have some sort of review, because otherwise--

Ruth Bader Ginsburg:

Ms. Gustin, the statute in that case provided for removal.

I mean, for reopening.

Diana L. Gustin:

--That is--

Ruth Bader Ginsburg:

Here, as I understand it, the statute says nothing.

The statute says, get your act together in 180 days.

The Secretary then said, yeah, I'll provide for reopening, but it's going to be just this one shot, no review.

Diana L. Gustin:

--Well--

Ruth Bader Ginsburg:

So how can you compare a case where Congress said, you have a right to reopen, to a case where Congress made no such provision.

Diana L. Gustin:

--Well, first of all, I think that there is a statutory provision within the medicare statute which requires reopening.

Ruth Bader Ginsburg:

And which one is that?

Diana L. Gustin:

And that would be section 1395x(v)(1)(A), clause (ii).