Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Civil Remedies Division |
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IN THE CASE OF | |
Lancaster Community Hospital Transitional Care Unit, |
DATE: May 21, 2001 |
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Health Care Financing Administration
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Docket No.C-00-275
Decision No. CR774 |
DECISION | |
DECISION DISMISSING REQUEST
FOR HEARING I dismiss the hearing request filed on behalf of Lancaster
Community Hospital Transitional Care Unit (TCU, Petitioner) pursuant to
42 C.F.R. � 498.70(b) because Petitioner does not have a right to a hearing.
I find that Petitioner had no right to a hearing inasmuch as the Health
Care Financing Administration (HCFA) made no adverse initial or reconsideration
determination in this case concerning the Medicare certification status
of the Petitioner. The determination that HCFA made involved the classification
of the reimbursement status of the Petitioner. Moreover, HCFA did not
consent to granting Petitioner a hearing in this matter. I. Background and material facts On February 7, 2000, Petitioner requested a hearing of
the HCFA's December 8, 1999 reconsideration determination to sustain its
denial of provider-based designation for Medicare payment purposes for
Petitioner. Lancaster Community Hospital (Hospital) is a Medicare
certified acute-care hospital. In December 1996, a skilled nursing facility
(SNF), known as the Lancaster Community Hospital Transitional Care Unit,
began operating on the hospital grounds. TCU was licensed and separately
certified as a Medicare SNF effective December 16, 1996. TCU ceased operations
as a SNF on October 1, 1998. In August 1999, Petitioner asked HCFA to
retroactively designate TCU as provider-based with the Hospital for the
period TCU was in operation. By notice dated August 18, 1999, HCFA denied
the application. Petitioner asked HCFA to reconsider its determination,
but HCFA on December 8, 1999, confirmed the denial. On September 13, 2000, I ordered the parties to submit
briefs and show cause why this matter should not be dismissed pursuant
to 42 C.F.R. � 498.70(b) because Petitioner does not have a right to a
hearing. Both parties filed their responses. II. Issues, findings of fact and conclusions of law
The issue in this case is whether I have the authority to hear and decide Petitioner's February 7, 2000 request for hearing, challenging HCFA's reimbursement classification determination that Petitioner is not a provider-based facility as Petitioner contends. Because I find that I do not have authority to hear and decide this case, I decline to address the substantive issue raised of whether Petitioner satisfies HCFA's criteria for provider-based reimbursement status. B. Finding of fact and conclusion of law I make the following finding of fact and conclusion of
law to support my decision, set forth in bold below. I then discuss my
finding in detail.
This case raises the identical issue as has been heard
and decided in Metropolitan Methodist Hospital, DAB CR574 (1999),
aff'd, DAB No. 1694 (1999); Specialty Hospital of Southern
California - La Mirada, DAB CR630 (1999), aff'd, DAB No.
1730 (2000), and most recently Comprehensive Mental Health Center of
Baton Rouge , DAB CR709 (2000); Comprehensive Mental Health Center
of Alexandria, DAB CR710 (2000); and Comprehensive Mental Health
Center of Monroe (Comprehensive), DAB CR711 (2000), aff'd,
DAB No. 1774 (2001). The findings and conclusions made there are equally
applicable to this matter and I reach the same result. Under the Medicare program, a "provider-based" reimbursement
status may have important reimbursement implications for a participating
facility. Essentially, a provider-based facility is one which has been
found to be an integral part of another provider so that the other provider
may claim reimbursement for the services that are provided by the integrated
facility as if those services were given by the provider itself. Comprehensive
Mental Health Center at 3. However, a determination made prior to
January 10, 2001 by HCFA as to how to classify a provider for purposes
of reimbursement is not a determination which gives a party dissatisfied
with that determination hearing and appeal rights before me.(1) As was pointed out clearly in Comprehensive, the
Social Security Act (Act) and implementing regulations which applied as
of the date HCFA took its classification action against Petitioner allowed
a prospective provider a right to a hearing to challenge only a determination
as to whether it qualified to participate in Medicare as a provider of
services. 42 C.F.R. � 493.3(b)(1). These regulations did not confer a
hearing right on a provider dissatisfied with the way in which HCFA classified
it for reimbursement purposes. Comprehensive at 6. The facts of
this case are indistinguishable from the previous cases in that what is
at issue here is the reimbursement classification status of Petitioner
and not a determination of provider participation status. "Provider certification"
is the act of determining whether a prospective provider meets the conditions
of participation in Medicare which specify the requirements for the quality
of care, health and safety of the facility's residents which each facility
must meet in order to be certified. "Reimbursement classification" is
the act of determining how a certified provider will be reimbursed for
the services that it provides. It is undisputed that Petitioner was at all times certified
to participate in Medicare. The only issue in dispute involves whether
HCFA should have considered it to be a "provider-based" facility. As Judge Kessel pointed out in Comprehensive, an
administrative law judge's authority to hear and decide cases is limited
to that which has been delegated to her by the Secretary. Since the Secretary
has not delegated authority to hear and decide reimbursement classification
determinations that were made by HCFA prior to January 10, 2001, I may
not hear and decide this case. The Departmental Appeals Board affirmed
his determination. Comprehensive Mental Health Care Center of Baton
Rouge, Comprehensive Mental Health Care Center of Alexandria;
Comprehensive Mental Health Care Center of Monroe, DAB No. 1774
(2001). The appellate panel determined, inter alia, that an "initial
determination" under section 498.3(b) refers to the matters provided for
in that section of the regulations only. Id. at 8. The panel went
further to conclude that the petitioners were not "dissatisfied with HCFA's
determinations with respect to whether they qualify to provide services
as [a skilled nursing facility], but are dissatisfied with the HCFA's
determinations with respect to whether they are free-standing or provider-based,
a matter not listed in section 498.3(b)." Id. Based on the foregoing, I dismiss Petitioner's hearing request because I have no authority to hear and decide this matter. |
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JUDGE | |
Marion T. Silva Chief Administrative Law Judge |
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FOOTNOTES | |
1. Effective January 10, 2001, the regulatory definition of an "initial determination" was amended. Pursuant to that amendment, 42 C.F.R. � 498.3(b)(2) now provides that an initial determination by HCFA shall include: [w]hether a prospective department of a provider, remote
location of a hospital, satellite facility, or provider-based entity qualifies
for provider-based status under � 413.65 of this chapter, or whether such
a facility or entity currently treated as a department of a provider,
remote location of a hospital, satellite facility, or a provider-based
entity no longer qualifies for that status under � 413.65 of this chapter. 65 Fed. Reg. 58,919 (2000); 65 Fed. Reg. 18,434, 18,549 (2000). The final regulations specifically state that this provision is to be effective January 10, 2001 and do not provide for retroactive application. | |