Opinion ID: 487477
Heading Depth: 2
Heading Rank: 2

Heading: Alleged Conflict Between 42 U.S.C. Sec. 1395oo(a) and (d)

Text: 22 The D.C. Circuit correctly held that subsections (a) and (d) must be read together. It then held that a literal reading of (d), by which the Board has the power to consider matters not claimed before an intermediary, would conflict with subsection (a), which requires that the provider must be dissatisfied with a final determination of its intermediary before being entitled to Board review. The Court's summary follows: 23 It simply is not plausible to contend that Congress has created a scheme where the provider can claim dissatisfaction and have recourse to an appeal procedure because the intermediary failed to read the provider's mind and anticipate all those things the provider would like to be reimbursed for, even though it did not request them. 24 Athens II, 743 F.2d at 6 (footnote omitted). 25 We understand this argument, but we do not agree. It is perfectly plausible, and apparently agreed by the parties, that in these cases the providers submitted cost reports, the intermediaries made final determinations concerning them, 4 and the providers were dissatisfied with the total reimbursement offered. Section (a) requires that a provider be dissatisfied with the total amount of reimbursement offered by an intermediary, not with the intermediary's reasoning process with respect to any specific costs. Moreover, the providers' failure to claim certain costs at the intermediary level reflects no fault or neglect on them (contrary to the suggestion of the Athens II court); it reflects the fact that any such claim would have been pointless. The intermediary has no authority to deviate from the Medicare Provider Reimbursement Manual. As soon as the providers were before the Board, they made their dissatisfaction regarding specific reimbursement policies known. The language of subsection (a) requires no more, and it does not conflict with subsection (d).