Opinion ID: 417775
Heading Depth: 3
Heading Rank: 2

Heading: Part A and Woodcrest

Text: 32 We see no significant difference in the Part A procedures under which Woodcrest's reimbursement claims were determined here. 7 The structure--the Secretary relying on carriers or other intermediaries to review reimbursement claims--was the same; the initial decisionmaking processes of the carriers were parallel; and the appellate procedures were not materially different. 33 Part A of the Medicare Program provides that if any group or association of providers wishes to have its Part A payments made through a public or private agency or organization such as Travelers and nominates such an agency or organization for this purpose, the Secretary is authorized to enter into an agreement providing for the determination by the agency or organization of payments to be made to the providers. 42 U.S.C. Sec. 1395h(a). Thus, just as Part B claimants request reimbursement from the carrier on the basis of their expenditures for services, Part A providers such as Woodcrest seek reimbursement from the fiscal intermediary on the basis of the cost of their services. See 42 C.F.R. Sec. 405.453(f) (1981). 34 Within a reasonable time after receipt of a Part A provider's cost report, the intermediary analyzes the report, undertakes any necessary audit of the report, and furnishes the provider and any related organization of the provider a notice that reflects the intermediary's determination of the amount of reimbursement; if the intermediary's determination differs from the claim submitted, the notice states the reasons for the difference. See id. Sec. 405.1803. Thus, just as Part B carriers determine whether claims are for reasonable amounts for medically necessary services and are otherwise covered by Part B, the Part A intermediaries determine whether and to what extent the providers' claims are for reasonable costs that are reimbursable under Part A. 35 Finally, the appeal procedure for claims of Part A providers differs from the appeal procedure for Part B beneficiaries in that the preliminary step of a written appeal to an employee of the carrier is omitted. If a Part A provider is dissatisfied with the intermediary's claim determination, and the amount in dispute is at least $1,000, the provider is entitled immediately to request a hearing before a hearing officer, or a panel of such officers. See id. Sec. 405.1811(a). These appellate officers are appointed by the intermediary; they must have had no prior role in the decision, and they must be persons knowledgeable in the field of health care reimbursement. Id. Sec. 405.1817. The appellate procedures permit the parties to conduct prehearing discovery, id. Sec. 405.1821, to call and cross-examine witnesses, id. Sec. 405.1825, and to present documentary evidence and arguments, id. Sec. 405.1823. The hearing officers are required to make a de novo determination of the claims after inquir[ing] fully into all of the matters at issue and ... receiv[ing] into evidence the testimony and any documents which are relevant and material to such matters. Id. Sec. 405.1819. The officers are empowered to call for such additional evidence as they deem relevant and material. Id. The hearing officers render a written decision, id. Sec. 405.1831, and unless they decide to reopen their determination, see id. Sec. 405.1885(a), the decision is final and binding upon all parties to the hearing .... Id. Sec. 405.1833. Neither the statute nor any regulation makes provision for further review of the hearing officer's decision as to such claims. 36 These procedures seem adequately designed to provide a fair opportunity for providers to obtain full and meaningful review of the carriers' determinations, and Schwartz has pointed out to us no respect in which they are unfair. 8 The availability of procedures for the prehearing discovery of evidence, the opportunity to present all relevant and material evidence, to cross-examine witnesses, and to present all pertinent arguments to hearing officers knowledgeable in the health care reimbursement field, together with the obligation imposed on those officers to make a full-scale inquiry and de novo determination, provide adequate safeguards against the risk that the carrier has made an erroneous initial determination. 9 We do not regard the difference between these appellate procedures and those for Part B beneficiaries as material. It is true that the availability under Part B of an initial appeal to an employee of the carrier, prior to the final appeal to a hearing officer, automatically increases the chance of a favorable decision on the claim. But this initial appeal is limited to the presentation of written materials, and its omission under Part A seems insignificant beside the expansive opportunities before the final hearing panel. We note, finally, that there was no suggestion in McClure that the Court's conclusion as to the adequacy of the Part B procedures turned upon the opportunity to make a written presentation to a carrier employee or even upon the fact that two appellate steps, rather than one, were available. In short, we conclude that the procedures followed by Travelers in determining Woodcrest's claims and the fact that there was no further review of the appellate panel's decision did not deprive Schwartz of due process.