Opinion ID: 768808
Heading Depth: 3
Heading Rank: 3

Heading: Subsection 1395gg(c)

Text: 25
26 Because the only adjustment contemplated by sec. 1395 gg(b) is an adjustment of payments to individuals, no waiver under sec. 1395gg(c) is possible for these providers. Subsection 1395gg(c) explicitly applies only to the waiver of adjustment[s] as provided in subsection (b) of this section. 42 U.S.C. sec. 1395gg(c). The adjustments made to the payments is, as we have stated, an adjustment only to the payments to the individual, and no rights of the providers are implicated by that adjustment. 27 Even if sec. 1395gg(b) could apply to providers, meaning that sec. 1395gg(c) also could apply to providers, the language of sec. 1395gg(c) precludes waiver based on the provider's lack of fault. The waiver clause only applies when an incorrect payment has been made . . . with respect to an individual who is without fault. 6 42 U.S.C. sec. 1395gg(c) (emphasis added). We cannot accept the Providers' argument that individual, in this context, means individual or provider. The language of sec. 1395gg consistently refers to individuals and providers as separate entities. Indeed, in sec. 1395gg(b), Congress specifically refers to providers of services who are without fault, whereas here the reference is to individuals without fault. Thus, individual in sec. 1395gg(c) cannot mean individual or provider. 28
29 The regulations promulgated by the Secretary support the distinction between individual and provider rights. It has long been recognized that courts should accord considerable weight to an executive department's construction of a statutory scheme it is entrusted to administer. See Chevron, U.S.A., Inc. v. Natural Resources Defense Council, 467 U.S. 837, 844 (1984); City of Chicago v. Federal Communications Comm'n, 199 F.3d 424, 429 (7th Cir. 1999). This is particularly true when Congress has specifically delegated authority to the Secretary to construe the statute. See United States v. Morton, 467 U.S. 822, 834 (1984); Batterton v. Francis, 432 U.S. 416, 425 (1977); Haywood v. North Am. Van Lines, 121 F.3d 1066, 1069 (7th Cir. 1997). This statute delegates to the Secretary the authority to prescribe such regulations as may be necessary to carry out the insurance programs under the subchapter that includes sec. 1395gg. See 42 U.S.C. sec. 1395hh(a); St. Francis Hosp. Ctr. v. Heckler, 714 F.2d 872, 878 (7th Cir. 1983). In this case, the Providers have not argued that the Secretary's regulations are contrary to the statute. 7 30 Two aspects of the recoupment regulations confirm the distinction between individual and provider rights outlined above. First, the Secretary has developed two different regulatory schemes for determining and recouping overpayments from individuals and providers. Compare 42 C.F.R. sec.sec. 405.350-59 (individuals) with id. at sec.sec. 405.370-78 (providers). If the overpayment was to an individual, the Secretary may seek an adjustment pursuant to 42 C.F.R. sec. 405.352, which applies [w]here an individual is liable for an incorrect payment. Id. If the Secretary proceeds against the provider, however, she must act pursuant to 42 C.F.R. sec. 405.371(a), which says that: 31 Medicare payments to providers and suppliers, as authorized under this subchapter (excluding payments to beneficiaries), may be-- . . . . 32 (2) Offset or recouped, in whole or in part, by an intermediary or a carrier if the intermediary, carrier, or HCFA has determined that the provider or supplier to whom payments are to be made has been overpaid. 33 Id. The existence of separate regulatory schemes for recoupment from individuals and providers makes it clear that the two acquire separate rights under the statute. 34 In addition, the regulations set forth different waiver procedures for individuals and providers. The provision allowing individuals to seek waivers of overpayments, 42 C.F.R. sec. 405.355, tracks the language of sec. 1395gg(c): 35 (a) The provisions of sec. 405.352 may not be applied and there may be no adjustment or recovery of an incorrect payment . . . in any case where such incorrect payment has been made with respect to an individual who is without fault, or where such adjustment or recovery would be made by decreasing payments to which another person who is without fault is entitled as provided in section 1870(b) of the Act where such adjustment or recovery would defeat the purpose of title II or title XVIII of the Act or would be against equity and good conscience. . . . (b) Adjustment or recovery of an incorrect payment (or only such part of an incorrect payment as may be determined to be inconsistent with the purposes of Title XVIII of the Act) against an individual who is without fault shall be deemed to be against equity and good conscience if the determination that such payment was incorrect was made subsequent to the third year following the year in which notice of such payment was sent to such individual. 36 42 C.F.R. sec. 405.355 (emphasis added). There can be no question that the issue of fault raised here is fault only on the part of the individual, not fault on the part of the provider. See 20 C.F.R. sec. 404.507 ('Fault' as used in 'without fault' (see [20 C.F.R.] sec. 404.506 and 42 C.F.R. sec. 405.355) applies only to the individual.). 37 A different procedure is used for providers who seek to block the recoupment of overpayments. When a recoupment from a provider is sought pursuant to 42 C.F.R. sec. 405.371(a)(2), the intermediary or carrier seeking recoupment must [g]ive the provider or supplier an opportunity for rebuttal in accordance with sec. 405.374. 42 C.F.R. sec. 405.373. Under sec. 405.374, the intermediary or supplier must give notice of when the recoupment will go into effect, and then must give the provider or supplier an opportunity, before the . . . recoupment takes effect, to submit any statement (to include any pertinent information) as to why it should not be put into effect on the date specified in the notice. 42 C.F.R. sec. 405.374. 38 When one compares the waiver procedures for individuals to that for providers, the differences are evident. The procedure for individuals does, in fact, waive rights to recoupment of overpayments to which the Secretary is otherwise entitled; 42 C.F.R. sec. 405.355 prohibits the Secretary from seeking an adjustment or recovery of an incorrect payment . . . with respect to an individual who is without fault. By contrast, the procedure for providers is more appropriately characterized as a remonstrance provision. It identifies the process that the Secretary must follow in seeking recoupment and that the provider must follow in contesting that determination. The procedure, however, does not contain any waiver of the Secretary's rights; the regulations do not set forth circumstances under which the Secretary is prohibited from seeking recoupment. Noticeably absent from the procedure for providers is any discussion of fault on the part of the provider. 39 The existence of separate regulatory recoupment schemes for individuals and providers makes it clear that 42 U.S.C. sec. 1395gg(c)'s waiver provision for an individual who is without fault applies only to individuals. The statute and the regulations consistently differentiate between individuals and providers. As well, the recoupment schemes for individuals and providers bear little resemblance to one another. Therefore, the regulations confirm that waiver of overpayment liability for providers is not contemplated by sec. 1395gg(c).