Opinion ID: 409579
Heading Depth: 2
Heading Rank: 2

Heading: Jurisdiction Over the Substantive Claim

Text: 17 Jurisdiction over Appellees' challenge to the Secretary's substantive authority to issue the regulation in question is not as easily decided. The Secretary argues that jurisdiction over this claim is precluded by section 405(h). Alternatively, he maintains that Congress has impliedly precluded all judicial review of such claims by expressly providing for judicial review of some Medicare Act claims without expressly authorizing judicial review of claims such as the present one. However, we find both these arguments unpersuasive and hold that the district court had jurisdiction over Appellees' substantive claim. 18
19 The Secretary's first argument is based on the premise that section 405(h) precludes federal question jurisdiction over claims for which the Medicare Act provides alternative routes of review. The Secretary then maintains that Appellees could have brought the present action under the provisions of 42 U.S.C. § 1395oo and concludes that jurisdiction under section 1331 is precluded. 28 Although we accept the Secretary's first premise, we are unable to agree with his second. Accordingly, we must reject his conclusion. 20 a. The availability of judicial review under section 1395oo. Section 1395oo was enacted in 1972 to provide for review of an intermediary's decision as to the amount of total program reimbursement due to the provider. 29 Under section 1395oo initial review of the intermediary's decision is made by the Provider Reimbursement Review Board (PRRB). 30 A provider dissatisfied with the PRRB's decision then has the right to obtain judicial review of that decision, or of any reversal, affirmance, or modification thereof by the Secretary, by filing a civil action in federal district court. 31 We conclude, however, that this route to judicial review is unavailable to Appellees in the present case. 21 In Humana this court noted that (c)onsideration by the Provider Reimbursement Review Board ... is (confined) to disputes over the amount properly reimbursable. 32 Appellees' substantive claim does not involve a dispute over the amount payable under the Act, nor does it involve Appellees' eligibility for reimbursement. Indeed, Appellees seek no money at all. They merely challenge the method of reimbursement, a concern that is not cognizable under section 1395oo. 22 The Secretary maintains that Appellees' claims are similar to those which we held were precluded by section 405(h) in Humana and in American Association of Medical Colleges v. Califano (AAMC). 33 However, the claims we found precluded in those cases were fundamentally different from that pressed by Appellees in the present litigation. In Humana the plaintiff challenged regulations limiting the amount of reimbursement, a challenge unmistakenly directed at upsetting on the merits the Secretary's determination on an element of cost-reimbursement. 34 We held that such a substantive challenge was precluded by section 405(h) because Humana's fundamental grievance ... centers on the amount of cost-reimbursement ... a subject amenable to Review Board adjudication. 35 In AAMC a group of Medicare providers challenged a regulation fixing limits on hospital in-patient general routine service costs. 36 We held that the district court did not have federal question jurisdiction because section 405(h) precluded jurisdiction over suits seeking eventual realization of provider-cost reimbursement under the Medicare Act. 37 Thus, in both Humana and AAMC the regulations attacked imposed limits on the amount of reimbursement. The issues raised in those cases were directly related to a claim for reimbursement. Appellees' claim, on the other hand, does not directly concern the amount of reimbursement they will receive. As noted above, it concerns the mode of reimbursement. 23 The Secretary further argues that the only reason Appellees are challenging the instruction is that they fear they will incur compliance costs that will not be fully reimbursed, and that therefore, the substantive claim is one seeking eventual realization of provider-cost reimbursement. However, regardless of the Appellees' motivation for bringing this suit, reimbursement is not its ultimate goal. Appellees seek to enjoin the Secretary from changing the method of processing payment claims. Granting the requested relief will not enable Appellees to receive larger reimbursements. As the district court recognized, Appellees do not seek any type of eventual monetary recovery on a reimbursement claim by this action. 38 24 Finally, the Secretary argues that if claims such as the Appellees' were not previously encompassed by the section 1395oo review provisions, they were brought under that section by a 1980 amendment to the Medicare Act. The 1980 amendment allows a provider to obtain judicial review of any action of the fiscal intermediary which involves a question of law or regulations relevant to the matters in controversy whenever the (PRRB) determines ... that it is without authority to decide the question. 39 The Secretary contends that the amendment evidences Congress' intent that claims related in any way to reimbursement disputes be challenged pursuant to section 1395oo rather than under section 1331. However, the legislative history behind the amendment reveals that it was not intended to broaden the scope of issues judicially reviewable under section 1395oo. 40 The 1980 amendment merely permits expedited judicial review of certain issues arising in reimbursement disputes otherwise reviewable under the statute. As explained above, the present claim cannot be characterized as a reimbursement dispute. Therefore, the 1980 amendment does not alter the justiciability of this claim under section 1395oo. 25 Because there is no alternative form of judicial review available to Appellees under the Medicare Act, the Secretary's first argument would appear to fail. However, because that argument is premised on the assumption that section 405(h) precludes only those claims for which the Medicare Act provides an alternative form of judicial review, the Secretary's conclusion would still be correct if section 405(h) barred claims arising under the Medicare Act for which no alternative form of judicial review is available. Thus, we must next determine the scope of section 405(h)'s preclusion. 41 26 b. The scope of section 405(h). In Weinberger v. Salfi 42 the Supreme Court held that section 405(h) precluded the exercise of federal question jurisdiction over a constitutional challenge to various provisions of the Social Security Act. However, the Court found that the challenge could be brought under a separate provision of the Social Security Act, 43 thereby implying that the result might have been different had no alternative form of judicial review been available. 44 Since Salfi the various courts of appeal have grappled with the issue of whether section 405(h) precludes federal question jurisdiction when no alternative form of judicial review is available. 45 Every court that has considered the issue has agreed that section 405(h) should be read so as to permit some avenue of judicial review for constitutional claims. 46 However, the result has not been so harmonious when the same courts have considered the effect of section 405(h) on otherwise non-reviewable statutory claims. 27 Three circuit courts have held that section 405(h) precludes all federal courts from exercising jurisdiction over claims arising under the Medicare Act even when no alternative form of judicial review is available. 47 Two courts of appeals have held that section 405(h) precludes the exercise of federal question jurisdiction over claims for which no alternative form of judicial review is available, but only after concluding that the Court of Claims had jurisdiction over such claims. 48 Finally, two circuit courts, the Sixth and the Second, along with the Court of Claims, have held that section 405(h) is not a bar to claims arising under the Medicare Act when there is no alternative form of judicial review available. 49 We agree with the district court that the view espoused by the Sixth and Second Circuits and the Court of Claims is the correct one. 28 We start with the well established principle that an agency bears a heavy burden of overcoming the strong presumption that Congress did not mean to prohibit all judicial review of an agency decision. 50 Thus, only upon a showing of 'clear and convincing evidence' of a contrary legislative intent should the courts restrict access to judicial review. 51 We conclude that the Secretary has failed to meet this heavy burden. 29 First, the Secretary has cited no legislative history which indicates that Congress intended to preclude jurisdiction over claims for which there was no alternative form of judicial review. Indeed, section 405(h) was incorporated into the Medicare Act only to the extent it was applicable. 52 (T)he entire thrust of the section is to prevent claimants who seek judicial review of their claims for benefits from bypassing the specific procedural requirements provided by Congress in the various acts. 53 Thus, (t)he subsection does not have a meaningful application in a case where no statutory review mechanism is available. 54 30 Second, precluding review of claims like the present one does not further the policy which led Congress to incorporate section 405(h) into the Medicare Act. As the Eighth Circuit noted, Congress adopted section 405(h) because permitting 31 (j)udicial review of the amount of all Medicare payments would bring the courts into the complex interplay between physician and hospital in ascertaining the appropriate medical charges for technical services .... These charges are subject to extensive and complicated statutory guidelines and regulations.... Determining the proper amount of these charges is a matter peculiarly suited to determination by a specialized agency. 55 32 These concerns are not present when actions like the present one are brought to challenge secretarial action unrelated to reimbursement disputes. 56 Finding no clear and convincing evidence to the contrary, we conclude that Congress, by incorporating section 405(h) into the Medicare Act to the extent applicable, did not intend to preclude judicial review of claims for which no alternative form of judicial review was available. Accordingly, we reject the Secretary's argument that section 405(h) precludes jurisdiction in the present case.
33 In his reply brief the Secretary argues that even if jurisdiction is not precluded by section 405(h), it is nevertheless barred in view of Congress' express delineation of the kinds of claims which may be reviewed under the Medicare Act. Relying on United States v. Erika, Inc., 57 the Secretary maintains that since Congress expressly made certain types of cases reviewable under the Medicare Act, issues not reviewable under section 1395oo are not reviewable at all. A review of the Supreme Court's decision in Erika, however, indicates that the case does not support the Secretary's point of view. 34 In Erika a physician brought a claim for reimbursement under Part B of the Medicare Act. That part of the Act provides for judicial review of the Agency's determination concerning the physician's eligibility for payments, but does not contain a provision permitting review of the Agency's determination of the amount of reimbursement. The Supreme Court noted that Congress had provided judicial review for both eligibility and amount determinations under Part A of the Medicare Act, but had provided for judicial review of only eligibility determinations under Part B. 58 The Court also examined statements from the legislative history of the Medicare Act and subsequent amendments which clearly indicated an intent to restrict the appealability of amount determinations under Part B. 59 In the face of these expressions of legislative intent (which) unambiguously support our reading of the statutory language, the Court concluded that judicial review of amount determinations under Part B of the Act was precluded. 60 35 The reasoning utilized by the Supreme Court in Erika does not apply to the present claim which was brought under Part A of the Medicare Act. As noted earlier, the general presumption is in favor of judicial review. 61 In Erika the government overcame this presumption by presenting clear and convincing evidence that Congress intended to preclude judicial review. The Secretary argues that the precisely drawn review provisions of Part A, 62 coupled with the omission of an express provision of judicial review for claims like the present one, provides the requisite clear and convincing evidence of Congressional intent to preclude judicial review. However,  '(t)he mere fact that some acts are made reviewable should not suffice to support an implication of exclusion as to others. The right to review is too important to be excluded on such slender and indeterminate evidence of legislative intent.'  63 Where, as here, the statutory language and legislative history is devoid of even the slightest intimation that Congress intended to preclude judicial review over the issues raised by Appellees, the mere fact that other types of issues are expressly reviewable under the Medicare Act does not constitute the clear and convincing evidence needed to overcome the presumption in favor of judicial review. Therefore, we reject the Secretary's second argument, and hold that the district court properly exercised its jurisdiction in the present case. 36