United States District Court, D. Maine
ORDER ON CROSS MOTIONS FOR JUDGMENT ON THE
Torresen, United States Chief District Judge.
care provider Central Maine Medical Center
(“CMMC”) brought this action against the
Secretary of the U.S. Department of Health and Human Services
(“the Secretary”) challenging the decision of the
Provider Reimbursement Review Board (“PRRB, ” or
“the Board”) denying CMMC's request to add
new issues to the fiscal year 2007 appeal. Pl.'s Mot. for
J. (ECF No. 28). The Secretary filed an opposition and cross
motion for judgment on the Administrative Record. Def.'s
Opp'n and Cross Mot. For J. (ECF No. 29). For the reasons
discussed below, the Secretary's Motion for Judgment on
the Administrative Record is GRANTED and the Plaintiff's
Motion for Judgment on the Administrative Record is DENIED.
STATUTES AND REGULATIONS
Medicare program is a federally funded system of health
insurance for the aged and disabled. See 42 U.S.C. §§
1395 et seq. The Secretary is responsibile for
administering the Medicare program and is authorized to issue
regulations and interpretive rules implementing the statute.
See, e.g., 42 U.S.C. §§ 405(a), 1395hh(a),
and 1395ii. The Secretary has delegated these
responsibilities to the Centers for Medicare & Medicaid
Services (“CMS”). In order to obtain Medicare
reimbursement, a Part A health care provider like CMMC files
an annual cost report with its fiscal intermediary, referred
to as the Medicare Administrative Contractor
(“MAC”). See MaineGeneral Med. Ctr. v.
Shalala, 205 F.3d 493, 496 (1st Cir. 2000); see
also 42 C.F.R. § 413.24(f). The MAC then reviews
“the cost report and issues a Notice of Provider
Reimbursement (NPR), which indicates the reimbursement to
which the provider is entitled.” MaineGeneral Med.
Ctr., 205 F.3d at 494; see also 42 C.F.R.
§ 405.1803. When a provider disagrees with the MAC's
determination, it files an appeal with the PRRB. 42 U.S.C.
§ 1395oo; 42 C.F.R. § 405.1835; MaineGeneral
Med. Ctr., 205 F.3d at 494.
Medicare statute authorizes the PRRB to “make rules and
establish procedures . . . which are necessary or appropriate
to carry out the provisions” of the statute for the
conduct of its appeals. 42 U.S.C. § 1395oo(e); 42 C.F.R.
§ 405.1868(a) (PRRB has the authority to “make
rules and establish procedures. . . to carry out the
provisions of [42 U.S.C. § 1395oo] and of the
regulations in this subpart”). The Code of Federal
Regulations specifically authorizes the PRRB to make rules
regarding its “actions in response to the failure of a
party to a Board appeal to comply with Board rules.” 42
C.F.R. § 405.1868(a). If the provider fails to meet a
requirement established by a Board rule or order, the Board
is empowered to: (1) [d]ismiss the appeal with prejudice; (2)
[i]ssue an order requiring the provider to show cause why the
Board should not dismiss the appeal; or (3) [t]ake any other
remedial action it considers appropriate. 42 C.F.R. §
decision of the PRRB becomes the final administrative
decision after sixty days unless the Secretary, through the
CMS Administrator, elects to review the decision. 42 U.S.C.
§ 1395oo(f)(1). Providers may seek judicial review of
the final decision of the PRRB in a federal district court.
42 U.S.C. § 1395oo(f)(1).
following facts are taken from the Administrative Record and
CMMC's Complaint and are not disputed by the Secretary.
a provider of medical services to beneficiaries of the
federally administered Medicare Program and operates an acute
care hospital in Maine. Compl. ¶¶ 2, 5. On July 17,
2013, CMMC received the MAC's reimbursement decision for
the fiscal year ending June 30, 2007 (“FY 2007”).
A.R. 383. On January 13, 2014, the PRRB received two appeals
for CMMC, filed by two different representatives, each
challenging a different part of the FY 2007 reimbursement
decision. Compl. ¶¶ 13-14. One appeal was filed by
Healthcare Reimbursement Systems (“HRS”), which
had an issue-specific representation letter from CMMC dated
January 25, 2012, authorizing HRS to challenge the
“Rural Floor Budget Neutrality Adjustments.” A.R.
321, 323-326, 385, 387. The other appeal, filed by Verrill
Dana LLP (“Verrill Dana”), which had a general
letter of representation from CMMC dated January 8, 2014,
sought review of the MAC's determination of
“Medicare Bad Debts.” Supp. A.R. 1.
January 16, 2014, the PRRB acknowledged CMMC's two
appeals and combined the issues into one case, docketed as
Appeal No. 14-1712. A.R. 323. The PRRB informed HRS and
Verrill Dana by email that two separate appeals of the FY
2007 decision had been filed for CMMC by two different
representatives and that the PRRB considered Verrill Dana to
be the authorized representative for CMMC. A.R. 323. Both HRS
and Verrill Dana acknowledged receipt of that determination.
A.R. 319-321. The PRRB also observed that “[y]ou are
responsible for pursuing your appeal in accordance with the
Board's Rules.” A.R. 313.
letter to the PRRB dated March 12, 2014, HRS asserted that it
was the designated representative and submitted a request to
add issues to Appeal No. 14-1712. A.R. 69. The letter
enclosed two Model Form Cs; each Model Form C listed three
additional issues for the FYE June 30, 2007. A.R. 59, 61. On
the second page of each of the Model Form Cs, is a
“Certification” page requiring three
certifications were all signed by Phil Morissette, CMMC's
Chief Financial Officer. A.R. 60, 62. The Model Form C in a
section entitled “Representative Information”
asks: “Are you the representative on file for this
individual appeal?” The response “No” is
selected on both forms. A.R. 59, 61. Directly below the
representation question, the Form states:
“NOTE: If you are not the
representative on file or who established this
appeal, then you must attach an authorization letter
signed by an official of the provider.” A.R. 59, 61. No
authorization letter was attached.
same day, March 12, 2014, CMMC sent a letter to the PRRB with
the reference line stating “Appointment of Designated
Representative” and “FYE June 30,
2008-2009.” A.R. 204. The letter stated Ms. Corinna
Goron of HRS was its designated representative for the fiscal
years ending June 30, 2008-2009 for both individual and group
appeals. A.R. 204. The letter was on CMMC letterhead and
signed by Morissette, but did not reference any case or
appeal number. A.R. 204.
April 10, 2014, the PRRB denied HRS's request to add new
issues because “Board Rule 5.1 indicates ‘there
may be only one case representative per appeal' ”
and Verrill Dana, not HRS, was the authorized representative
for CMMC's Appeal No. 14-1712, for the June 30, 2007,
fiscal year. A.R. 54-55. The PRRB explained that the new
letter of representation appointing HRS was for FYE June 30,
2008 and 2009, not FYE June 30, 2007-which was the year under
appeal. A.R. 54. The letter concluded with a reminder that
the “Provider is responsible for adhering to all
previously established deadlines per the Board's
Acknowledgement and Critical Due Dates Notice dated January
16, 2014.” A.R. 55. The PRRB sent a copy of the denial
to HRS and Verrill Dana. A.R. 54.
April 30, 2014, HRS requested reconsideration of the
PRRB's denial of its request to add new issues in Appeal
No. 14-1712. A.R. 51. HRS asserted that it had “been
formally designated as the Representative for the Provider
with respect to Fiscal Year End June 30, 2007.” A.R.
51. It also argued that if the denial was “influenced
by a belief that HRS was attempting to add issues without
Verrill Dana's or the Provider's knowledge, ”
CMMC had signed the certifications after “it was agreed
by all Parties that HRS would take over as the representative
of record.” A.R. 51. The request for ...