Sebelius v. Auburn Regional Medical Center

Oct 19, 2017 | 0 comments

Oct 19, 2017 | Miscellaneous | 0 comments

Case Analysis Assignment 

Sebelius v. Auburn Regional Medical Center

Subject:

The case was decided by Roberts’s court, with Justice Ruth Bader Ginsburg writing the unanimous opinion for the court. The case was appealed by the Court of Appeals of the District of Columbia Circuit. The case was under docket number 11-1231, and the parties in the case included the petitioner who was Kathleen Sebelius, the Health and Human Services secretary, and the respondent that was Auburn Regional Medical Center. The case was decided on January 22, 2013 (OYEZ, 2012).

Facts

Hospitals always receive compensation based on the number of their patients that are low-income earners from the federal government. The amount of this payment is decided by The Center for Medicare & Medicaid Services (CMS). However, it was revealed that CMS miscalculated the payment between 1993 and 1996, and the hospitals received less than the amount that was due (Cornell University, 2015). A group of hospitals in 2006 filed claims for the full payment with the Provider Reimbursement Review Board (PRRB) for the years between 1987-1994 from the Department of Health and Human Services (Cornell University, 2015). However, the limitations statute for such claims is always 180 days. The hospitals argued that the limitation period should be tolled since CMS unlawfully and unknowingly failed to disclose its error. As a result, the PRRB held that they did not have the power or authority to toll the limitations statutes; hence, the claims were untimely.

The hospitals proceeded to sue in the district courts, but the courts also held that it did not have the jurisdiction since the decision of PRRB was not final. Additionally, the courts held that the relevant statute does not permit the tolling of limitation statutes. The circuit of the District of Columbian US court of appeals reversed, arguing that it did have the jurisdiction because the decision of PRRB was final. Furthermore, it held that it is possible to toll the statute of limitations. In this case, the relevancy and appropriateness to toll were questioned to remand a petition since a rehearing en banc was denied by the court of appeals (Stephanie, 2013).

Statement of the Issue(s):

Can a hospital challenge the reimbursement payments outside the legal deadline for filing as fairness dictates?

Rule of Law:

The dispute of the case is whether a hospital has valid grounds for challenging an underpayment for treating the individuals who are low-income earners under the Medicare Act if the reimbursements are challenged by hospitals after the 180-day deadline has passed. The argument of the petitioner, Sebelius, is that Medicare Act entitles her to determine when the period for filing may be tolled equitably or extended for reasons of fairness since she is the Health and Human service secretary. Additionally, Sebelius argues that the equitable tolling presumption does not apply to the action by an agency (Katie, 2013).

On the other hand, the respondent, Auburn Regional Medical Center, and other hospitals argue that a presumption exists in general for equitable tolling in scenarios of federal deadline filing. Auburn Regional Medical Center and other hospitals maintained that giving the sole authority for a 180-day deadline extension to Sebelius removes the hospital powers of challenging underpayments (OYEZ, 2012). Moreover, this case will interfere and affect many cases of PRRB and its timeliness of hospital reimbursements that treat low-income people.

On behalf of the hospitals, the American Hospital Association filed a brief arguing that the ruling in favor of Sebelius would harm hospital operations. The AHA noted that hospitals serving low-income earners were in a precarious state. Auburn Regional Medical Center remarked that hospitals significantly rely on reimbursements of Medicare in treating the large number of low-income persons who otherwise would be prevented from accessing the medical services. American Hospital Association pointed out that hospitals are reimbursed for only 92% of every spent dollar for Medicare patients on average. They further argued that disallowing tolling of statutes equitably will cheat hospitals out of service payments that are performed faithfully, and this will hurt their ability to serve particularly the vulnerable patients (Cornell University, 2015).

In response, Sebelius argued that allowing tolling of this statute equitably would strain the already PRRB scarce resources unduly, consequently creating claim-backlogs in the agency. Sebelius further iterated that reimbursement payments that were made several years ago would be open for fresh arguments as to why re-evaluations should be done on them (Stephanie, 2013).

According to Sebelius, about 200 hospitals are already filing claims relying upon the decision of the DC circuit. As a result, holding for Auburn Regional Medical Center will jam the courts with the old PRRB decision challenges. This will force the agency to use its scarce resources on court challenges filed too late (Katie, 2013). Sebelius suggests that permitting the court to extend the deadline will automatically slow the whole machinery of the agency, causing the hospitals to continue waiting longer for the reimbursement. Lastly, Sebelius noted that these claims investigations would involve finding records that probably may not be existing and trying to recreate faded memories.

Application
The argument of Sebelius that administrative law principles prevent intervention by the judiciary

Sebelius argues that the 180-day deadline cannot be applied by equitable tolling since the administrative regulations that govern extensions are neither capricious nor arbitrary. She stated that, as the secretary, she only permits extensions after the 180 days for “good cause” only within three years (OYEZ, 2012). The Petitioner further claimed that the good-cause requirements and the three-year period are not capricious or arbitrary and, therefore, merit courts defense. Furthermore, Sebelius noted that she has unique exclusive discretion over the procedures of administration, preventing any administrative board or a court from adding their own extensions and procedures that could undermine her discretion. From previous cases, it was indicated PRRB held that it has no general power of tolling equitably, and it can enforce its own procedures if they are only consistent with the regulations of the Secretary (Cornell University, 2015).

Also, Sebelius argues that the intention of Congress was not to grant a 180-day deadline equitable tolling. She argues equitable tolling presumption has applied federal court procedures but not administrative agencies procedures. Furthermore, she argues that the powers of the courts to toll the deadlines equitably of tax laws or Title VII does not mean that a court can also toll the deadline of an administrative agency equitably (Stephanie, 2013). According to Sebelius, Congress intended to protect the administrative agencies’ exclusive authority to fashion the regulations for the management of the complex Medicare system. Moreover, she thought that the contention of Auburn relies on a presumption opposing administrative laws principles and argued the congress intended to remove power from the PRRB and secretary. Thus, Congress would have granted the courts explicit power of restraining administrative agencies’ discretion (Katie, 2013).

The argument of Auburn Regional Medical Center that equitable tolling applies to filing the deadline of 180-day

Auburn argues that the filing deadline of 180 days can be extended by the courts for fairness reasons. They argue that this deadline does not define the PRRB authority scope but rather targets the processing of claims. They further contend that the claim processing rule’s purpose is for the promotion of the administration reimbursement smoothly and not to prevent claims of reimbursements (OYEZ, 2012). Auburn further claimed that the filing deadlines in the trading with the suits of the enemy, Title VII discrimination suits, and bankruptcy proceedings are all rules of claim processing similar to the deadline of 180 days in this scenario.

Auburn noted that some law sections about the deadline of 180 days do not characterize the stated deadline as the power limit of PRRB. While pointing to the law language, they argue that the sections use descriptive terms of the individual rights in processing claims and lacks terms used to circumscribe and describe the authority (Cornell University, 2015). Moreover, they further argue that the 180-day deadline language confirms the presumptions of providing tolling equitably. Auburn demands that unless to the contrary there is strong evidence, the intention of the Congress was likely to follow the treating the 180-day deadline tradition as it treats other rules for claim processing and so permit equitable tolling here. Also, it is pertinent to stress the language that indicates deadline rigidity; Auburn pointed out the absence of prohibitive words of a deadline extension, such as the absence of the phrases within subsection (a)(3) like, “in no event.” Lastly, Auburn suggested that tolling equitably is necessary for fulfilling Medicare law’s central purpose to compensate the Medicare centers properly (Stephanie, 2013).

Conclusion

The decision of the Supreme Court determined if the hospitals may make claims of alleged underpayments outside the filling period of 180 days for Medicare payments review if the equitable considerations are all satisfied. The decision was centered on whether or not equitable tolling presumption applies to this deadline in the Medicare Act. The case determined that hospitals could bring forward claims from outside the period requirements for filing if they find discrepancies in the payments that extend to a decade before. This kind of activity can affect the administrative machinery but can also be necessary for the hospitals to continuously offer quality services to individuals who earn low incomes.

Other Opinions

There was no dissenting or concurring opinion in the case since all the nine judges unanimously agreed and their opinions read by Justice Ruth Bader Ginsburg.

Final thoughts

I fully agreed with the decision of the courts since fairness prevailed against the argument of passing a deadline of 180 days for filing. Many implications exist within the healthcare administrations. Many hospitals with payment discrepancies will now start filling for re-evaluations and payments of the reimbursements that were not paid before. Moreover, the health and human services will now be more keen and factual in the future when making payments to avoid errors and court suits

References

Cornell University. (2015). Sebelius V. Auburn Regional Medical Center. Retrieved February 28, 2015, from https://www.law.cornell.edu/supremecourt/text/11-1231

Katie, B. (2013). Bill of Health. (n.d.). Retrieved February 28, 2015, from http://blogs.law.harvard.edu/billofhealth/tag/sebelius-v-auburn-regional-medical-center/

OYEZ. (2012). Sebelius V. Auburn Regional Medical Center. Retrieved February 28, 2015, from http://www.oyez.org/cases/2010-2019/2012/2012_11_1231

Stephanie, K. (2013). JURIST – The Appellate Implications of Sebelius v. Auburn Regional Medical Center. (n.d.).