Document: 485 U.S. 399 108 S.Ct. 1255 99 L.Ed.2d 460 BETHESDA HOSPITAL ASSOCIATION, et al., Petitionersv.Otis R. BOWEN, Secretary of Health and Human Services. No. 86-1764. Argued Feb. 29, 1988. Decided April 4, Syllabus Under the Medicare program Social Security Act, a qualified provider health care services, in order to obtain reimbursement from Services for its cost providing covered services patients, must submit an annual report fiscal intermediary, usually private insurance company acting as Secretary's agent. The intermediary then audits determines amount due provider. statute, 42 U.S.C. § 1395oo (1982 ed. Supp. III), authorizes appeal Provider Reimbursement Review Board. Board may affirm, modify, or reverse intermediary's decision. Secretary, either on his own motion at provider's request, review matter further, that remains dissatisfied with final decision seek federal district court. In their reports 1980, petitioner providers, apportioning malpractice costs, followed 1979 regulation disallowed certain claims premium costs. Petitioners later filed request hearing before Board, challenging validity seeking costs accordance pre-1979 methodology. Because amounts had been "self-disallowed" however, determined it was without jurisdiction hear petitioners' claims. proceedings regulation, District Court held should have exercised over matter. Appeals reversed. Held: not decline consider challenge ground failed contest regulation's submitted intermediary. plain language (a) demonstrates entertain this action. There is no merit contention right extends only presented because cannot be "dissatisfied" award requested report. submission full compliance unambiguous dictates rules regulations does not, by itself, bar claiming dissatisfaction allowed those regulations. Providers know that, under statutory scheme, confined mere application regulations, power except provide, any attempt persuade do otherwise would futile. While express requires conclusion reached here, also supported design statute whole. Neither nor has authority declare invalid, but, predicate providers judicial action, first determine decide claim involves question law Pp. 403-408. 810 F.2d 558, reversed remanded. KENNEDY, J., delivered opinion unanimous Court. Leonard C. Homer, Baltimore, Md., petitioners. Andrew J. Pincus, New York City, respondent. Justice KENNEDY 1 program, Title XVIII 79 Stat. 291, 1395 seq. are reimbursed reasonable beneficiaries. Each such submits end year agent Secretary. issues Notice Program specifying explaining adjustments. 2 A determination and, circumstances, authorized decisions. provider, United States §§ (a), (d), (f). 3 This case us whether one 4 * Bethesda Hospital Association Deaconess Cincinnati Ohio entities operate hospitals State. joined some 27 other promulgated which We concerned here merits regulation; rather, we issue. 5 petitioners apportionment thereby effected, lexicon "self-disallowance" excess regulation. timely self-disallowed held, essence, condition met, stating grant hearings limited cases "dissatisfied . intermediary," reasoning could when they effected self-disallowance Court, disagreement Board's reasoning, v. Heckler, 609 F.Supp. 1360, 1368 (SD 1985). 6 appealed Sixth Circuit, stated "[w]ere considering issue impression, well different advisability requiring and/or constitutional challenges precedent further administrative regulations." Services, 562 (1987). court found itself bound, prior panel Baptist East 802 860 (1986), where properly "refused exercise who intermediary." supra, 561. granted certiorari, 484 813, 64, 98 28 (1987), resolve conflict among Courts Appeals.1 now reverse. II 7 meaning decides presented. See INS Cardoza-Fonseca, 480 421, 432, n. 12, 107 1207, 1213, 94 434 (1987); Chevron U.S.A. Inc. Natural Resources Defense Council, Inc., 467 837, 842-843, 104 2778, 2781-2782, 81 694 (1984). parties agree addresses circumstances invoke jurisdiction. To extent pertinent states respect if 8 "(1) provider— 9 "(A)(i) total period 10 11 "(2) controversy $10,000 more, "(3) files within 180 days. ." III). 12 contends requirement intermediary" necessarily incorporates exhaustion requirement. view, counter improper, least irregular, manner prohibited correct raise instance presenting 13 strained interpretation offered inconsistent statute. subsection (a)(1)(A)(i), It clear, No expressly mandates futile.2 Thus, stand than bypass clearly prescribed fail all entitled applicable rules. defaults might establish satisfied awarded here. conclude dissatisfaction, incorporating intermediaries. 14 result reach present case, our Cf. Offshore Logistics, Tallentire, 477 207, 220-221, 106 2485, 2493-2494, 91 174 (1986). Section sets forth powers duties once invoked,3 explicitly provides making decision, can "make revisions matters even though were considered determination." allows obtains pursuant revise contested limitation Congress "covered report," is, expense incurred filed, claimed. 15 invalid.4 follow, treats two alike announce regulatory each level; function have. Subsection (f)(1) grants action but make regulations.5 alternatively failure act, triggers review. 16 notes posits "action argues there provides, deviate lacks requisite quite unnecessary. role shaping subject review; not. 17 Finally, proffered notice internally inconsistent. maintain, hand, vital importance other, acknowledge cover letter suffice rule challenge. By objecting protected 18 hold judgment reversed, remanded consistent opinion. 19 so ordered. Compare 558 (CA6 1987) (case below) (finding jurisdiction); North Broward Dist. Bowen, 808 1405 (CA11 (same), cert. pending, 86-1986; Community Roanoke Valley 770 1257 (CA4 1985) (same); Athens Hospital, Schweiker, 222 U.S.App.D.C. 363, 686 989 (1982), modified, 240 1, 743 (1984) Adams House Care 817 587 (CA9 mandatory jurisdiction), 87-443; St. Mary Nazareth Center Department 698 1337 (CA7 1983) denied sub nom. James 464 830, 107, 78 110 (1983), Luke's 325 (CA1 jurisdiction, discretionary), Tallahassee Memorial Regional Medical 815 1435 situation appeals involve regulation), 87-380. CFR 421.100 (1987) (stating pay Part B"); 421.120 (directing shall periodically audit procedures ensure "[c]orrect coverage payment determinations" guarding "proper management funds"); 405.460(a)(2) (1985) ("Reimbursable exceed estimated HCFA [Health Financing Administration] necessary efficient delivery needed services. limits direct indirect overall specific items groups services"). (d) provides: "A based upon record made hearing, include evidence obtained received substantial viewed (including adverse services) "affirm, recognizes allow decisions regard challenged "without question." 3, supra. unless motion, 60 days after notified reverses, affirms, modifies reversal, affirmance, modification civil commenced date received. relevant whenever (on described following sentence) question, sixty notification If section file (accompanied documents materials require purposes rendering determination). render writing thirty receives accompanying materials, fails period, bring (within period) contained hearing. Such brought located (or, jointly several greatest number located) Columbia tried provisions chapter title notwithstanding 405 title. Any common ownership control (b) group involving providers."

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