Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-12-05037/USCOURTS-caDC-12-05037-0/pdf.json

Parties Involved:
Kaiser Foundation Hospitals
Appellee
Kathleen Sebelius
Appellant

Document Text:

United States Court of Appeals 

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued November 7, 2012 Decided March 5, 2013 

No. 12-5037 

KAISER FOUNDATION HOSPITALS, DOING BUSINESS AS KAISER 

FOUNDATION HOSPITAL - ANAHEIM, DOING BUSINESS AS 

KAISER FOUNDATION HOSPITAL - BELLFLOWER, DOING 

BUSINESS AS KAISER FOUNDATION HOSPITAL - FONTANA,

DOING BUSINESS AS KAISER FOUNDATION HOSPITAL - HARBOR 

CITY, DOING BUSINESS AS KAISER FOUNDATION 

HOSPITAL - PANORAMA CITY, DOING BUSINESS AS KAISER 

FOUNDATION HOSPITAL - RIVERSIDE, DOING BUSINESS AS 

KAISER FOUNDATION HOSPITAL - SAN DIEGO, DOING BUSINESS 

AS KAISER FOUNDATION HOSPITAL - SUNSET, DOING BUSINESS 

AS KAISER FOUNDATION HOSPITAL - WEST LOS ANGELES,

DOING BUSINESS AS KAISER FOUNDATION 

HOSPITAL - WOODLAND HILLS, 

APPELLEE

v. 

KATHLEEN SEBELIUS, SECRETARY OF THE UNITED STATES 

DEPARTMENT OF HEALTH AND HUMAN SERVICES, 

APPELLANT

Appeal from the United States District Court 

for the District of Columbia 

(No. 1:11-cv-00092) 

USCA Case #12-5037 Document #1423532 Filed: 03/05/2013 Page 1 of 15
2 

Howard S. Scher, Attorney, U.S. Department of Justice, 

argued the cause for appellant. With him on the briefs were 

Stuart F. Delery, Acting Assistant Attorney General, Ronald 

C. Machen Jr., U.S. Attorney, and Michael S. Raab, Attorney. 

R. Craig Lawrence, Assistant U.S. Attorney, entered an 

appearance. 

Jordan B. Keville argued the cause for appellee. With 

him on the brief was Jonathan P. Neustadter. Harry R. Silver

entered an appearance. 

Before: ROGERS, BROWN and KAVANAUGH, Circuit 

Judges. 

 Opinion for the Court filed by Circuit Judge BROWN. 

 

 BROWN, Circuit Judge: The Kaiser plaintiffs (“Kaiser”) 

are a consortium of ten teaching hospitals located in Southern 

California that receive Medicare payments to offset the costs 

associated with training “full-time equivalent” residents and 

intern physicians (“FTEs”). In 1997, Congress capped those 

payments in such a way that the number of FTEs the hospitals 

trained in 1996 would dictate the maximum reimbursement in 

all future years. Although Kaiser and the Health and Human 

Services Secretary (“Secretary”) agree the 1996 data is not 

accurate, the Secretary believes this predicate fact cannot be 

corrected outside the three-year reopening window, 42 C.F.R. 

§ 405.1885.1

 Concluding otherwise, the District Court granted 

Kaiser’s motion for summary judgment and remanded to the 

agency. Kaiser Found. Hosps. v. Sebelius, 828 F. Supp. 2d 

 1

 Technically, the Secretary has adopted the views of the 

Administrator of the Centers for Medicare and Medicaid Services 

(“CMS”). 

USCA Case #12-5037 Document #1423532 Filed: 03/05/2013 Page 2 of 15
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193, 204 (D.D.C. 2011). Unpersuaded by the Secretary’s 

narrow, arbitrarily applied interpretation, we affirm. 

I 

A 

As the District Court explained: 

The Medicare program, established under Title 

XVIII of the Social Security Act and administered 

through CMS, provides federally funded health 

insurance to eligible aged or disabled persons. See 

generally 42 U.S.C. § 1395 et seq. Under the 

program, the Department of Health and Human 

Services “reimburses medical providers for services 

they supply to eligible patients.” Northeast Hosp. 

Corp. v. Sebelius, 657 F.3d 1, 2 (D.C. Cir. 2011); see 

generally 42 U.S.C. § 1395 et seq. In order to be 

reimbursed, hospitals must submit an annual cost 

report detailing the expenses they incurred during the 

past fiscal year. See 42 C.F.R. §§ 413.20, 413.24. The 

Secretary has contracted with fiscal intermediaries to 

audit cost reports, determine how much Medicare 

owes each provider, and issue interim payments. See

42 U.S.C. § 1395h; 42 C.F.R. § 405.1803. 

Among other things, Medicare reimburses 

approved teaching hospitals for the direct costs of 

graduate medical education (GME) — e.g., salaries 

and benefits for residents and interns. See 42 C.F.R. 

§ 413.75. The amount of GME reimbursement is 

based in part on the number of FTEs in the hospital’s 

training program. See 42 U.S.C. 

§ 1395ww(d)(5)(B)(ii); 42 C.F.R. § 413.79(d). In 

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1997, Congress imposed a cap on the number of 

FTEs a hospital may include for purposes of 

calculating future GME payment, which is known as 

the “GME FTE cap.” See 42 U.S.C. 

[§] 1395ww(h)(4)(F); 42 C.F.R. § 413.79(c)(2)(i). 

Specifically, for cost-report periods beginning on or 

after October 1, 1997, the hospital’s unweighted FTE 

count — meaning the actual number of FTEs before 

applying statutorily specified weighting factors — 

“may not exceed the number . . . of such full-time 

equivalent residents for the hospital’s most recent 

cost reporting period ending on or before December 

31, 1996.” 42 U.S.C. [§] 1395ww(h)(4)(F). In other 

words, the FTE count a hospital included in its latest 

pre-1997 report would determine its cap (and thereby 

affect its reimbursement) for the indefinite future. 

Hospitals’ pre-1997 reports included only a 

weighted FTE count. See 62 Fed. Reg. 

46,004(V)(I)(2)(a). Because the FTE cap is calculated 

based on the unweighted count, and additional data 

needed to be collected to calculate that figure, the 

caps were not established until the providers’ first 

cost report for the period beginning on or after 

October 1, 1997 — which for [Kaiser] was filed in 

1998. Id. at 46,004, 46,005; see also 42 C.F.R. 

§ 413.79. “FTE count,” therefore, refers to the 

weighted figure provided in the hospitals’ pre-1997 

cost reports, and “FTE cap” refers to the cap 

established thereafter based on the unweighted FTE 

count. 

Once the GME FTE cap is established, the 

intermediary takes it into account when reviewing a 

hospital’s cost reports. See 42 C.F.R. § 413.79. After 

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such review, the intermediary issues a “notice of 

program reimbursement” (NPR) indicating how much 

Medicare owes the hospital for the fiscal year covered 

by the report. See 42 C.F.R. § 405.1803. The hospital 

has 180 days from receipt of the NPR to request a 

review by the Provider Reimbursement Review 

Board (PRRB). See 42 U.S.C. § 1395oo(a). If the 

hospital does not timely appeal the NPR, the cost 

report is considered final. See 42 C.F.R. 

§ 405.1807(c). 

The reimbursement determination may 

nevertheless be reopened — upon a provider’s 

request or at the intermediary’s own initiative — 

within three years of the date of the NPR. . . . Once 

three years has passed, the intermediary’s 

determination is deemed “closed” and can no longer 

be reopened. 

Kaiser, 828 F. Supp. 2d at 195–96.

B 

Before this litigation began, a separate group of Northern 

California-based Kaiser hospitals complained clinic-based 

residents were mistakenly excluded from their “Indirect 

Medical Education” (“IME”) resident FTE count. The PRRB 

agreed these residents should be included, see Kaiser Found. 

Grp. v. Aetna Life Ins. Co., PRRB Dec. No. 96-D50 (Aug. 14, 

1996), and the CMS affirmed, see Kaiser Found. Grp. v. 

Aetna Life Ins. Co., HCFA Administrator Decision (Oct. 21, 

1996) reprinted in [1996–2 Transfer Binder] Medicare & 

Medicaid Guide (CCH) ¶ 44,980. Following suit, the present 

Kaiser plaintiffs requested a similar adjustment in their own 

IME resident FTE count but “did not request a similar 

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adjustment for GME purposes in their 1996 cost reports.” 

Appellant Br. at 14. 

This oversight would haunt Kaiser. For years, Kaiser’s 

intermediary used the inaccurate resident FTE count from the 

1996 cost report coupled with additional data from the 1998 

cost report — the “predicate facts” — to generate artificially 

low GME FTE caps.2

 Kaiser only challenged the errant data 

in its appeal of the intermediary’s handling of the 1999–2003 

cost reporting years. By then, however, the 1996 and 1998 

cost reporting years were “closed.” They had fallen outside of 

the three-year reopening window. 

Accepting as much, Kaiser forswears any direct 

challenge to the 1996 and 1998 cost reports. Although the 

intermediary would have to adjust the total reimbursement for 

the open cost reporting years 1999–2003 using the corrected 

GME FTE cap, nothing, Kaiser maintains, would necessitate 

an adjustment to the total reimbursement from either closed 

reporting period. In other words, Kasier does not believe its 

challenge would have improper retroactive effect because the 

intermediary would not have to reopen any closed cost report. 

See Appellee Br. at 11. 

The intermediary was unconvinced. Any modification of 

the data underlying the 1996/1998 GME FTE cap, it reasoned, 

would constitute a reopening of closed years even if it did not 

affect Kaiser’s final reimbursement determination. See 

Kaiser, 828 F. Supp. 2d at 197. The PRRB agreed with 

Kaiser’s position. See Kaiser Found. Hosps. v. Palmetto 

GBA/First Coast Serv. Options, PRRB Dec. No. 2011-D1 

(Oct. 1, 2010). But the CMS Administrator, after sua sponte

 2

 A higher FTE cap would have allowed Kaiser to claim — 

and presumably obtain — greater reimbursements. 

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review, did not. See Kaiser Found. Hosps. v. Palmetto 

GBA/First Coast Serv. Options, HCFA Administrator 

Decision (Nov. 30, 2010). Because the Administrator’s 

reversal constituted the final decision of the Secretary, see 42 

U.S.C. § 1395oo(f), Kaiser renewed its challenge in the 

District Court. 

Finding in Kaiser’s favor, the District Court granted 

Kaiser’s motion for summary judgment and remanded the 

matter to the agency. See Kaiser, 828 F. Supp. 2d at 204. 

Assuming arguendo that the FTE cap was tied to a specific 

cost report, the court concluded modifying FTE counts in 

closed years did not constitute a “reopening.” The Secretary’s 

interpretation ran afoul of the plain language of the reopening 

regulation, id. at 199–200, and, among other shortcomings, 

contravened recent cases in which the Secretary took contrary 

positions, id. at 200–02. The Secretary appealed. 

On appeal, the agency advances two sets of arguments. 

First, changes to predicate facts in closed years constitute an 

impermissible reopening under § 405.1885. Second, and in 

the alternative, even if the modification of predicate facts in a 

closed year does not itself amount to a reopening, the change 

will necessitate an adjustment of that year’s reimbursement, 

which all parties agree constitutes an impermissible 

reopening. We consider each argument in turn.3

II 

A 

 3

 Like the District Court, we assume arguendo that the cap is 

tied to particular cost reports. Kaiser, 828 F. Supp. 2d at 199. 

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In relevant part, the Secretary’s reopening regulation 

provides: 

A determination of an intermediary . . . may be reopened 

with respect to findings on matters at issue in such 

determination . . . . Any such request to reopen must be 

made within 3 years of the date of the notice of the 

intermediary . . . decision . . . . 

42 C.F.R. § 405.1885(a) (2001).4

 For a provider like Kaiser 

that has filed cost reports pursuant to 42 C.F.R §§ 413.20 and 

413.24(f), “Intermediary determination” is defined as: 

a determination of the amount of total reimbursement due 

the provider, pursuant to § 405.1803 following the close 

of the provider’s cost reporting period, for items and 

services furnished to [Medicare] beneficiaries for which 

reimbursement may be made on a reasonable cost basis 

under Medicare for the period covered by the cost report. 

42 C.F.R. § 405.1801(a). In simpler terms, § 405.1801(a) 

speaks of inputs and outputs — the “items and services 

furnished” and the “amount of total reimbursement due,” 

respectively. 

In Kaiser’s view, the reference to “total amount of 

reimbursement” establishes that “a cost report [is] only . . . 

‘reopened’ . . . where there is a change to the total amount of 

 4

 Although the reopening regulation was amended in 2008, the 

court below “cited to this version without explanation.” Appellant 

Br. at 5 n.3. We agree with the Secretary, however, that the 

“oversight is irrelevant.” Id. The operative language remained the 

same. Compare 42 C.F.R. § 405.1885(a) (2001), with 42 C.F.R. § 

405.1885(a)(1), (b)(2) (2010). 

USCA Case #12-5037 Document #1423532 Filed: 03/05/2013 Page 8 of 15
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Medicare compensation paid to a provider.” Appellee Br. at 

21. In contrast, “reconsideration of predicate factual issues” 

with no effect on closed reimbursements does not reopen the 

report. Id. Meaning, the intermediary will only have reopened 

a “determination” subject to the three-year reopening window 

if it adjusts the output, not the inputs. 

The Secretary, by contrast, believes inputs matter 

independently of the output. In her view, toggling an input 

would constitute a reopening of an “Intermediary 

determination” irrespective of its effect on the output. 

Consequently, any alteration of predicate facts must be done 

within the three-year reopening window. The Secretary 

argues the output language cannot be read without reference 

to the input language since it is “difficult to imagine that the 

‘amount owed’ can in any sense be separated from the data 

upon which it is based.” Appellant Br. at 25, 28. In like vein, 

the Secretary also maintains that § 405.1801(a)’s crossreference to 42 C.F.R. § 405.1803 is suggestive because the 

latter’s requirement of notice “[e]xplain[ing] the 

intermediary’s determination of total program reimbursement 

due,” id. § 405.1803(a)(1)(i), “will necessarily refer to the 

data (or predicate facts) upon which the total reimbursement 

is based.” Appellant Br. at 25. 

The Secretary thinks her interpretation is entitled to 

deference under Bowles v. Seminole Rock & Sand Co., 325 

U.S. 410 (1945), and its progeny. We disagree. Although 

courts will normally give “controlling weight” to an agency’s 

interpretation of its own regulations, Thomas Jefferson Univ. 

v. Shalala, 512 U.S. 504, 512 (1994) (internal quotation 

marks omitted), deference is unmerited where the 

interpretation is “plainly erroneous or inconsistent with the 

regulation . . . .” Ass’n of Private Sector Colls. & Univs. v. 

Duncan, 681 F.3d 427, 442 (D.C. Cir. 2012) (internal 

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quotation marks and citations omitted). Believing the 

Secretary’s interpretation to be inconsistent with her own 

regulations, we decline the invitation to defer. 

 To start, we think the plain language of § 405.1801(a)(1), 

which defines “determination of an intermediary,” a phrase 

that appears in the reopening regulation, too suggestive to 

ignore. Where the term “determination” is both spatially 

proximate to — and logically bound with — “total 

reimbursement,” an output, the mere mention of inputs in a 

separate, subsequent clause does not automatically render 

those inputs material to the definition.5

 Indeed, contextual 

clues lead us to believe that the reference to inputs is more 

likely illustrative than essential. Consider, for example, the 

structure of § 405.1801(a), which consists of four contextdependent definitions of “Intermediary determination.” When 

speaking of “a hospital that receives payments for inpatient 

hospital services under the prospective payment system,” the 

phrase is defined as: 

a determination of the total amount of payment due the 

hospital, pursuant to § 405.1803 following the close of the 

hospital’s cost reporting period, under that system for the 

period covered by the determination. 

42 C.F.R. § 405.1801(a)(2). But for the descriptive final 

clause, the operative language in this provision and 

§ 405.1801(a)(1) would be functionally indistinguishable. 

 5

 Both parties agree that the “total reimbursement” is 

“material” because any effort to adjust this figure would necessarily 

constitute a reopening of an intermediary determination. Their 

dispute turns instead on whether the intermediary’s toggling of the 

inputs would, on its own, do the same. This is what we mean when 

we speak of materiality — an intermediary action capable of 

triggering § 405.1801(a)(1) and, in turn, the reopening provision. 

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Compare id. § 405.1801(a)(1) (“a determination of the 

amount of total reimbursement due the provider), with id. 

§ 405.1801(a)(2) (“a determination of the total amount of 

payment due the hospital”). This is by no means dispositive 

indicium of the agency’s intent, but we do think it suggestive. 

A functional explanation for the inclusion of the “items and 

services” language — to differentiate among contexts — cuts 

against the Secretary’s a priori argument that the mere 

presence of the input clause is itself proof of its materiality.6

 

Even assuming § 405.1801 could bear the Secretary’s 

strained interpretation, the reopening regulation cannot. Under 

§ 405.1885(a), an intermediary determination can “be 

reopened with respect to findings on matters at issue in such 

determination” if challenged within the three-year window. 

As the Eighth Circuit explained in HealthEast, “[i]t would 

make no sense to say that an intermediary determination . . . 

could be reopened ‘with respect to’ predicate factual 

questions that do not alter the total reimbursement amount.” 

HealthEast Bethesda Lutheran Hosp. & Rehab. Ctr. v. 

Shalala, 164 F.3d 415, 418 (8th Cir. 1998). It is only when 

alteration of the “matters at issue” could change the total 

reimbursement determination that it “make[s] sense to say 

that a determination could be reopened ‘with respect to’ 

them.” Id. This interpretation, the court concluded, “is the 

 6

 The Secretary’s argument regarding the intervening citation 

to § 405.1803 suffers from the same conceptual shortcomings. That 

provision is entirely procedural. It identifies the steps the 

intermediary must take to issue a determination but offers no 

insight as to what constitutes a reopening. Again, the Secretary has 

proffered nothing to convince us that the mere reference to inputs 

somehow imbues them with independent, material significance. 

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only interpretation logically consistent with the regulatory 

language.” Id. 7 We concur. 

Nor do we believe Regions Hospital v. Shalala, 522 U.S. 

448 (1998), compels a contrary result. The issue before the

Court in that case was a narrow one: did Congress intend “to 

prohibit the Secretary from ensuring an accurate GME baseyear amount by reauditing a provider’s statement of 1984 

GME costs for past errors, outside the Secretary’s three-year 

reopening window.” Id. at 457. Having found ambiguity in 

the relevant statutory language at Chevron Step One, the 

Court proceeded to determine the reasonableness vel non of 

the Secretary’s reaudit regulation. See id. at 457–60. 

“The key point of Regions,” the Secretary contends, “is 

the validity of the reaudit regulation; without that regulatory 

authority the reaudit of the [closed] cost reports would have 

been barred by the reopening regulation.” Reply Br. at 26. 

The inferential argument might be restated thusly: the 

agency’s decision to promulgate a reauditing provision is 

proof that reopening regulation does not, by its own terms, 

allow modification of predicate facts in closed years. We 

 7

 The Secretary in HealthEast agreed. With language mirroring 

Kaiser’s own, the Secretary concluded that § 405.1801(a) — the 

very provision at issue here — “did not apply” to closed year loans 

“because the regulation limits reopening only with respect to 

‘intermediary determinations,’ which are defined as the final 

determinations of the amount a hospital will be reimbursed.” 

HealthEast, 164 F.3d at 417. “Since the amounts of the 

reimbursements for the [closed year] interest payments were not 

disturbed, the Secretary argued, the ‘intermediary determination’ 

was not improperly reopened.” Id. The PRRB likewise agreed in 

Edgemont Hospital v. Mutual of Omaha Insurance Co., PRRB Dec. 

No. 95-D34 (Apr. 6, 1995), a decision the Secretary did not reverse 

sua sponte. 

USCA Case #12-5037 Document #1423532 Filed: 03/05/2013 Page 12 of 15
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disagree. At most, Regions and its analogue in this Court, 

Administrators of Tulane Educational Fund v. Shalala, 987 

F.2d 790 (D.C. Cir. 1993), stand only for the proposition that 

the Secretary acted reasonably in promulgating a reauditing 

regulation in light of statutory silence. We fail to see how the 

Secretary’s decision to announce its policy through 

rulemaking — a potentially pragmatic decision on the 

Secretary’s part8

 — would necessarily foreclose the agency 

from interpreting the reopening regulation to the same effect. 

The Secretary is not unfamiliar with this argument, 

having made it as recently as 2009. Citing Regions, the 

Secretary indicated that “even if the intermediary had 

reaudited and revised the IME FTE determination made in the 

1996 base year cost report — and it did not — the Supreme 

Court has already held that such reauditing and revision is 

reasonable.” Hillcrest Riverside, Inc. v. Sebelius, No. 09-cv00018, Memorandum of Points and Authorities in Support of 

Defendant’s Cross-Motion for Summary Judgment and 

Opposition to Plaintiff’s Motion for Summary Judgment at 19 

n.9 (D.D.C. Oct. 2, 2009). Seeing no reason to depart from the 

Secretary’s recent wisdom, we hold that the reopening 

regulation allows for modification of predicate facts in closed 

years provided the change will only impact the total 

reimbursement determination in open years. 

Alternatively, we agree with the District Court that the 

Secretary has acted arbitrarily in treating similarly situated 

 8

 A case-by-case approach would have been unwieldy and 

inefficient where the Secretary had “reason to believe some 

‘questionable’ GME costs had been ‘erroneously reimbursed’ to 

providers for their 1984 fiscal year,” Regions, 522 U.S. at 454, and 

was obligated to communicate that shortcoming — as well as all 

new changes in the methodology for Medicare payments — to 

private fiscal intermediaries. 

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parties differently. Kaiser, 828 F. Supp. 2d at 203; see also 

Eagle Broad. Grp., Ltd. v. FCC, 563 F.3d 543, 551 (D.C. Cir. 

2009) (“[A]n agency may not treat like cases differently.” 

(internal quotation marks omitted)); Kreis v. Sec’y of the Air 

Force, 406 F.3d 684, 687 (D.C. Cir. 2005) (“[A]n agency 

must treat similar cases in a similar manner unless it can 

provide a legitimate reason for failing to do so.” (internal 

quotation marks omitted)). HHS routinely championed a 

permissive interpretation of the reopening regulation when 

correction of the predicate facts would have resulted in a 

windfall for the agency, see, e.g., HealthEast, 164 F.3d at 

416, but adopted a contrary view here, where the benefits 

would inure to the provider. At bottom, the Secretary has 

given us no reason to think that this inherently suspicious 

record was the product of reasoned, good faith 

decisionmaking. She has distinguished the cases on their 

facts, but these are distinctions without difference. Whether 

the reimbursement scheme in HealthEast is distinct from the 

one-off “data capture” here, Appellant Br. at 30, for example, 

is an entirely moot point; that fact played an inessential role in 

how the Secretary interpreted the reopening regulation. 

 

B 

The Secretary next argues that “the Medicare Act would 

not allow the intermediary to change the 1996 GME resident 

count . . . without . . . changing the corresponding 

reimbursement amount,” Appellant Br. at 26, which all parties 

concede would constitute a reopening of an “Intermediary 

determination.”

The District Court rejected this claim out of hand, noting 

that the Secretary offered “no legal support for her claim that 

the caps cannot be increased without modifying the total 

reimbursement for closed years, particularly where Plaintiffs 

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have disclaimed such sums.” Kaiser, 828 F. Supp. 2d at 201. 

On appeal, the Secretary attempts to fill the legal void with 

three generic provisions of the Medicare statute that allegedly 

“entitle[] the provider to the reimbursement due under the 

GME . . . formulas.” Appellant Br. at 26.9 

We are unmoved. As a threshold matter, the Secretary 

has failed spectacularly to square this bold claim with — or 

otherwise justify the departure from — HealthEast, Regions, 

and (among others) Tulane. See, e.g., Motor Vehicle Mfrs. 

Ass’n v. State Farm Mut. Auto Ins. Co., 463 U.S. 29, 42 

(1983); E. Ky. Power Co-op, Inc. v. FERC, 489 F.3d 1299, 

1306 (D.C. Cir. 2007) (explaining that an agency “must 

provide reasoned analysis indicating that prior policies and 

standards are being deliberately changed, not casually 

ignored” (internal quotation marks omitted)). Those cases 

assumed alterations to predicate facts would not trigger a 

mandatory reauditing of closed year reimbursements, see, 

e.g., Regions, 522 U.S. at 462, and the Secretary agreed. 

III 

For the foregoing reasons, the decision of the lower court is 

Affirmed. 

 9

 They include 42 U.S.C. §§ 1395ww(h)(1) (“[T]he Secretary 

shall provide for payments for [GME] costs in accordance with [42 

U.S.C. § 1395ww(h)(3)]”), 1395ww(d)(5)(B) (“The Secretary shall 

provide for an additional payment amount for . . . indirect costs of 

medical education.”), and 1395g(a) (“The Secretary shall 

periodically determine the amount which should be paid under this 

part to each provider of services . . . with necessary adjustments on 

account of previously made overpayments or underpayments.”). 

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