Your Home Visiting Nurse Services, Inc. v. Shalala
Headline: Medicare appeals narrowed as Court upholds rule barring review of an intermediary’s refusal to reopen reimbursement decisions, making it harder for home‑health providers to challenge late payment denials.
Holding: The Court held that an administrative appeals panel cannot review a fiscal intermediary’s refusal to reopen a Medicare reimbursement determination, and that federal court review and mandamus relief are generally unavailable.
- Makes it harder for providers to challenge late Medicare reimbursement denials.
- Prevents administrative board review of an intermediary’s reopening refusal.
- Blocks direct federal-court review of reopening denials.
Summary
Background
A company that runs home‑health services submitted its 1989 Medicare cost reports and missed the 180‑day window to appeal the initial reimbursement notices. Within three years it asked the private fiscal intermediary (the company that handles payments for the government) to reopen the decision, claiming new evidence. The intermediary refused. The provider then tried to get the federal administrative appeals panel (the Provider Reimbursement Review Board) to review that refusal, but the Board dismissed the case, and lower courts affirmed.
Reasoning
The Court considered whether a rule saying that “jurisdiction for reopening ... rests exclusively with that administrative body that rendered the last determination” means the Board can review an intermediary’s refusal to reopen. The Justices found the Secretary’s reading reasonable: a refusal to reopen is not itself a new final dollar determination that the Board reviews. The Court relied on prior decisions recognizing that reopening is granted by regulation and is generally an agency discretion, and noted that allowing review of reopenings would undercut the law’s time limits for appeals. The Court also held that federal‑court review under the general federal‑question law is barred by a Medicare provision that limits suits, and that mandamus relief fails because the reopening rule is permissive, not mandatory.
Real world impact
The decision leaves fiscal intermediaries free to deny reopening requests without administrative appeal to the Board and blocks direct federal‑court review. Providers must either appeal within the original 180‑day period or rely on the intermediary’s discretionary reopening, which is not guaranteed.
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