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Nature of Suit Code: 151
Nature of Suit: Overpayments under the Medicare Act
Cause of Action: 

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United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued December 7, 2010 Decided June 24, 2011

No. 10-5115

AUBURN REGIONAL MEDICAL CENTER, ET AL.,

APPELLANTS

v.

KATHLEEN SEBELIUS, SECRETARY, DEPARTMENT OF HEALTH 

AND HUMAN SERVICES,

APPELLEE

Appeal from the United States District Court

for the District of Columbia

(No. 1:07-cv-02075)

Robert L. Roth argued the cause and filed the briefs for 

appellants.

M. Roy Goldberg, Christopher M. Loveland, and Brian 

M. Daucher were on the brief for amici curiae Hospice 

Advantage, et al. in support of appellants.

Jeffrey A. Lovitky was on the brief for amicus curiae 

Quality Reimbursement Services in support of appellants.

Stephanie R. Marcus, Attorney, U.S. Department of 

Justice, argued the cause for appellee. With her on the brief 

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were Ronald C. Machen Jr., U.S. Attorney, and Mark B. 

Stern, Attorney. Samantha L. Chaifetz, Attorney, and R. Craig 

Lawrence, Assistant U.S. Attorney, entered appearances.

Before: HENDERSON and GRIFFITH, Circuit Judges, and 

WILLIAMS, Senior Circuit Judge.

Opinion for the Court filed by Circuit Judge GRIFFITH.

GRIFFITH, Circuit Judge: Since 1983, Medicare has used

a prospective payment system to reimburse hospitals for their 

inpatient operating costs. These payments are based on 

predetermined, nationally applicable rates and are subject to 

various adjustments. One such adjustment is the 

disproportionate share hospital (DSH) payment, which

provides an additional reimbursement to hospitals that serve

large numbers of low-income patients. A hospital’s DSH 

payment depends on its “DSH percentage,” a figure that the 

Center for Medicare & Medicaid Services (CMS) must 

calculate. The DSH percentage varies based on the number of 

Medicare beneficiaries entitled to Supplementary Security 

Income, a federal low-income supplement established by the 

Social Security Act. 

This case stems from the discovery in an unrelated case 

that CMS had paid hospitals less than they were due because 

it had miscalculated the DSH percentage for fiscal years 

1993-1996. See Baystate Med. Ctr. v. Leavitt, 545 F. Supp. 2d

20 (D.D.C. 2008). The appellants in this case, a group of 

hospitals that receive DSH payments, filed claims with the 

Provider Reimbursement Review Board (PRRB) in 2006 

seeking full payments for the fiscal years 1987-1994. 

Appellants acknowledged that they filed their claim more than 

a decade after the deadline for challenging payments, but 

argued that the limitations period should be equitably tolled

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because CMS knowingly and unlawfully failed to disclose 

that the DSH payments had been understated.

The PRRB held that it was without authority to toll the 

limitations period, making appellants’ claim untimely and 

beyond the jurisdiction of the PRRB. Appellants then filed 

suit in the district court, which held that it also lacked

jurisdiction in this matter because the PRRB’s determination 

was not a “final decision.” The district court further held that 

the statute does not allow for equitable tolling. We take 

jurisdiction pursuant to 28 U.S.C. § 1291 and reverse and 

remand.

I

We consider first whether the PRRB’s dismissal of 

appellants’ claims for lack of jurisdiction was a “final 

decision.” The Medicare statute grants “[p]roviders . . . the 

right to obtain judicial review of any final decision of the 

[PRRB] . . . by a civil action commenced within 60 days of 

the date on which notice of any final decision by the 

[PRRB] . . . is received.” 42 U.S.C. § 1395oo(f). There is no 

question that this appeal was brought within sixty days. The 

only question is whether the PRRB’s decision was final.

To understand the Secretary’s argument, a word of 

explanation is needed about how providers receive Medicare 

reimbursements and how they can challenge those they think 

are wrong. Each year, Medicare providers submit cost reports 

to fiscal intermediaries, who then determine the amount of 

Medicare reimbursement due, which is announced in a Notice 

of Provider Reimbursement (NPR). If a provider is 

dissatisfied, it may appeal that determination to the PRRB but 

must do so within 180 days of the NPR. 42 U.S.C. 

§ 1395oo(a). According to the Secretary and the district court, 

the Board’s dismissal of an untimely claim is not a final 

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decision. We fail to see how this could be the case. The 

district court thought this was our holding in Athens 

Community Hospital, Inc. v. Schweiker, 686 F.2d 989 (D.C. 

Cir. 1982), but it was not. In Athens, we held that “if the 

threshold requirements of 42 U.S.C. § 1395oo(f)(1) are met, a 

court has jurisdiction to review a decision by the PRRB that 

it lacks jurisdiction to review a determination of the fiscal 

intermediary.” 686 F.2d at 994 (emphasis added). But 

§ 1395oo(f)(1) only requires that “a civil action [be] 

commenced within 60 days” of the PRRB’s “final decision.” 

It says nothing about the 180-day limitations period. 

The Secretary’s confusion seems to stem from our

reference to John Muir Memorial Hospital, Inc. v. Califano, 

457 F. Supp. 848 (N.D. Cal. 1978)), in Athens. We stated 

there that “jurisdiction was not available to the court in John 

Muir because the provider failed to timely file its appeal. 

Under [§ 1395oo(f)(1)], a decision by the PRRB not to hear a 

case on this basis is, by definition, not a ‘final decision.’” 686 

F.2d at 994 n.4. The Secretary reads this statement to suggest 

that a PRRB conclusion that it lacks jurisdiction over an 

untimely claim is not a final decision subject to judicial 

review. But that was not our point. In John Muir, the 

provider, without having appealed the fiscal intermediary’s 

final determination to the PRRB within 180 days, went 

straight to the district court. It did not go there arguing the 

PRRB was wrong to deny jurisdiction. Rather, it argued the 

court could review the intermediary’s decision on the merits 

pursuant to the grant of general federal question jurisdiction 

under 28 U.S.C. § 1331, even if a timely claim was never 

pressed before the PRRB. See John Muir, 457 F. Supp. at 

852-53. The court disagreed, holding that it could only review 

cases on the merits that were filed within sixty days of a final 

decision by the PRRB. See id. The John Muir court did not 

hold that a dismissal for want of jurisdiction is not a final 

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decision on that issue. And with good reason. Such a 

dismissal is final in any sense of the word. It is not pending, 

interlocutory, tentative, conditional, doubtful, unsettled, or 

otherwise indeterminate. It is done. 

Indeed, we took jurisdiction in Athens after explaining 

that courts have “jurisdiction to review a decision by the 

PRRB declining to hear a case on the basis of lack of PRRB 

jurisdiction.” 686 F.2d at 993. If it were otherwise, “the 

PRRB could effectively preclude any judicial review of its 

decisions simply by denying jurisdiction of those claims that 

it deems to be non-meritorious.” Id. (quoting Cleveland 

Mem’l Hosp., Inc. v. Califano, 444 F. Supp. 125, 128 

(E.D.N.C. 1978), aff’d, 594 F.2d 993 (4th Cir. 1979))

(internal quotation marks omitted). Accordingly, courts of 

appeals in comparable situations have consistently understood 

dismissals for lack of jurisdiction as “final decisions.” See id.

(analogizing to 28 U.S.C. § 1291, where courts have 

consistently understood dismissals for lack of jurisdiction as 

final decisions). This approach accords not only with common 

sense but also with the relevant regulations. Cf. 42 C.F.R. 

§ 405.1836(e)(2) (“A Board dismissal decision under 

paragraph (e)(1) [which concerns dismissals for ‘lack of 

Board jurisdiction’] of this section is final and binding on the 

parties. . . .”). We reaffirm, then, that a decision of the PRRB 

denying jurisdiction is a final decision subject to judicial 

review. 

II

The hospitals’ claims, brought over a decade after the 

statute of limitations had expired, may only be heard by the 

PRRB if the limitations period can be equitably tolled. As we 

recently reiterated, “It is hornbook law that limitations periods 

are customarily subject to equitable tolling unless tolling 

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would be inconsistent with the text of the relevant statute.” 

Menominee Indian Tribe of Wis. v. United States, 614 F.3d 

519, 529 (D.C. Cir. 2010) (internal quotation marks omitted).

In general, “the same rebuttable presumption of equitable 

tolling applicable to suits against private defendants should 

also apply to suits against the United States,” Irwin v. Dep’t of 

Veterans Affairs, 498 U.S. 89, 95-96 (1990), and the 

presumption of equitable tolling is not disturbed by the fact 

that Medicare is a government benefits program, see, e.g.,

Scarborough v. Principi, 541 U.S. 401, 422 (2004).1

The district court rejected equitable tolling on the ground 

that “plaintiffs have proffered nothing suggesting that . . . 

Congress intended to authorize equitable tolling for provider 

claims.” Auburn Reg’l Med. Ctr. v. Sebelius, 686 F. Supp. 2d 

55, 70 (D.D.C. 2010). Subsequently, Menominee made clear 

that the appropriate inquiry is just the opposite: whether there 

was good reason to think Congress did not want equitable 

tolling.

 1 We have also required that the injury be “of a type familiar to 

private litigation.” Menominee, 614 F.3d at 529 (quoting Chung v. 

DOJ, 333 F.3d 273, 277 (D.C. Cir. 2003)). Following the Supreme 

Court’s recent decision in Holland v. Florida, 130 S. Ct. 2549 

(2010), it is not entirely clear how similar the claim must be to 

“private litigation” for equitable tolling to apply. The Court in 

Holland applied the presumption of equitable tolling to a 

limitations period in the Antiterrorism and Effective Death Penalty 

Act without first identifying a private-litigation equivalent, stating 

simply that “a nonjurisdictional federal statute of limitations is 

normally subject to a ‘rebuttable presumption’ in favor ‘of 

equitable tolling.’” Id. at 2560. In any event, the contours of that 

requirement need not be determined now, as this case is “of a type 

familiar to private litigation” because it is analogous to a contract 

claim. 

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This presumption in favor of equitable tolling holds here. 

The statute specifies that “[a]ny provider of services which 

has filed a required cost report within the time specified in 

regulations may obtain a hearing with respect to such cost 

report . . . if . . . such provider files a request for hearing 

within 180 days after notice of the intermediary’s final 

determination.” 42 U.S.C. § 1395oo(a). This language is 

similar to other statutes that have been held to permit 

equitable tolling. See Menominee, 614 F.3d at 529-31 (finding 

equitable tolling permissible where statute required all claims 

to “be submitted within 6 years after the accrual of the 

claim”); see also Irwin, 498 U.S. at 94-96 (finding equitable 

tolling permissible where statute stated that “[w]ithin thirty 

days of receipt of notice of final action. . . an employee . . . 

may file a civil action”); Kirkendall v. Dep’t of Army, 479 

F.3d 830, 837-42 (Fed. Cir. 2007) (en banc) (finding equitable 

tolling permissible where statute provided that “within 60 

days after the date on which [the complaint] is filed, the 

complainant may elect to appeal . . . except that in no event 

may any such appeal be brought . . . before the 61st day after 

the date on which the complaint is filed”). 

The Secretary argues that the presumption is rebutted 

here, relying upon United States v. Brockamp, 519 U.S. 347 

(1997). In Brockamp, the Supreme Court found that the 

statute of limitations for filing tax refund claims, IRC § 6511, 

cannot be equitably tolled. But the Court in Brockamp did so

by pointing to a number of factors not present here. First, the 

Court observed that ordinarily, “limitations statutes use fairly 

simple language,” citing as an example 42 U.S.C. § 2000e16(c), which provides that a suit must be filed “[w]ithin 90 

days of receipt of notice of final [EEOC] action.” 519 U.S. at 

350. By contrast, the Court reasoned, the language in IRC 

§ 6511 is “not simple,” but instead “sets forth its limitations in 

a highly detailed technical manner,” id., and “reiterates its 

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limitations several times in several different ways,” id. at 

351.2

 2 IRC § 6511 begins by stating that a “[c]laim for . . . refund . . . of 

any tax . . . shall be filed by the taxpayer within 3 years from the 

time the return was filed or 2 years from the time the tax was paid, 

whichever of such periods expires the later, or if no return was filed 

. . . within 2 years from the time the tax was paid.” IRC § 6511(a). 

It reiterates that “[n]o credit or refund shall be allowed or made 

after the expiration of the period of limitation prescribed . . . unless 

a claim for . . . refund is filed . . . within such period.” Id.

§ 6511(b)(1). It again states that “[i]f the claim was filed by the 

taxpayer during the 3-year period . . . the amount of the credit or 

refund shall not exceed the portion of the tax paid within the period, 

immediately preceding the filing of the claim, equal to 3 years plus 

the period of any extension of time for filing the return . . . .” Id.

§ 6511(b)(2)(A). Later, § 6511 provides that “[i]f the claim was not 

filed within such 3-year period, the amount of the credit or refund 

shall not exceed the portion of the tax paid during the 2 years 

immediately preceding the filing of the claim.” Id. § 6511(b)(2)(B). 

As the Brockamp Court noted, the tax code also “reemphasizes the 

point when it says that refunds that do not comply with these 

limitations ‘shall be considered erroneous,’ and specifies 

procedures for the Government’s recovery of any such ‘erroneous’ 

refund payment.” 519 U.S. at 351 (citations omitted).

Also unlike the statute at issue here, IRC § 6511 “sets 

forth explicit exceptions to its basic time limits,” id., 

including special time-limit rules for “refunds related to 

operating losses, credit carrybacks, foreign taxes, selfemployment taxes, worthless securities, and bad debts.” Id. at 

351-52. In the detailed landscape of exceptions before the 

Court in Brockamp, there was no reference to equitable 

tolling—a fact the Court found particularly conspicuous given 

that “[t]ax law . . . is not normally characterized by casespecific exceptions reflecting individualized equities.” Id. at 

352. These reasons, “taken together, indicate[d] . . . that 

Congress did not intend courts to read other, unmentioned, 

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open-ended ‘equitable’ exceptions into the statute that it 

wrote.” Id.

The statute in this case is different enough from the one 

in Brockamp for us to conclude that the presumption of 

equitable tolling has not been rebutted. First, the language in 

§ 1395oo resembles the “fairly simple language” in § 2000e16(c) that the Brockamp Court said clearly allowed equitable 

tolling. Compare 42 U.S.C. § 1395oo(a) (allowing “any 

provider of services which has filed a required cost report 

within the time specified in regulations [to] obtain a hearing . 

. . if . . . such provider files a request for hearing within 180 

days after notice of the intermediary’s final determination”) 

with id. § 2000e-16(c) (stating that a suit must be filed 

“[w]ithin 90 days of receipt of notice of final [agency] 

action”). Second, although the statute of limitations here has a 

“good cause” exception that lasts no longer than three years, 

that exception is in the regulations, not the statute, see 42 

C.F.R 405.1841(b) (2007), and does not bear on whether 

Congress rebutted the presumption of equitable tolling by 

enacting a complex set of exceptions to the statute of 

limitations. In any event, that one exception is unlike the 

numerous “highly technical” exceptions in the Internal 

Revenue Code, and is not “reiterate[d] . . . several times in 

several different ways.” Brockamp, 519 U.S. at 350-51. 

Furthermore, contrary to the Secretary’s suggestions, the 

Court’s focus in Brockamp was not the complexity of tax law 

per se, but rather the complexity of the provisions governing 

whether and when a claim could be filed. Menominee, 614 

F.3d at 530 (“[F]ocus on the regulatory scheme as a whole is 

misplaced. The Brockamp Court did not concern itself with 

the complexity of the Tax Code as a whole, but the 

complexity of the time limitations found in § 6511.”). It is 

true that as a general matter, the Medicare statute, like the 

Internal Revenue Code, is quite complex. But unlike the tax 

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code, the Medicare statute does not create a detailed Jenga 

tower of deadlines and exceptions that equitable tolling might 

topple. Rather, its timing scheme is straightforward and 

readily amenable to tolling.

Given that the factors emphasized in Brockamp do not 

apply to the facts presented here, and without any other 

reasons for rebutting the presumption of equitable tolling, we 

find that equitable tolling is available under § 1395oo(a). 

Whether tolling is appropriate in this particular case, however,

is a different question that cannot be answered without further 

factual development. That question is for the district court on 

remand.

Appellants also raise alternative arguments about the 

availability of mandamus and general federal question 

jurisdiction in the event that equitable tolling is not available. 

Given our disposition, we need not reach those arguments 

today.

III

For the foregoing reasons, we reverse and remand for 

further proceedings consistent with this opinion.

So ordered.

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