HEARING - U.S. Senate Special Committee on Aging

126
462 6485 New Developments
10,053
There is also no need, as the provider suggests,
to set up a different patient billing
department for the emergency room physicians'
billing services. The revenue offset is designed to
offset those costs incurred by the provider which
are not reimbursable costs related to patient
care pursuant to 42 CFR 405.451. The billing
revenues retained by the provider relate strictly
to the cost incurred in providing the billing
service. This is evidenced by the agreement
between the physicians and the hospital which
provides that payments to the hospital for the
billing services are to be in an amount which has
been determined by the parties to correspond to
the hospital's actual costs.
Accordingly, the decision of the Provider
Reimbursement Review Board that the Intermediary
properly reduced the provider's administrative
costs by the billing revenue received
from the emergency room physicians is
affirmed.
This constitutes the final administrative decision
of the Secretary of Health and Human
Services.
[ 34,619] Hooper v. Harris.
U.S. District Court, District of Connecticut. No. H-80-99 (MJB), May 1, 1985.
Medicare: Inpatient Hospital Rehabilitation Coverage
Medicare Part A coverage-Inpatient hospital rehabilitation coverage.-The earlier
decision of this court-that a 1976 HCFA Bulletin restricting coverage of inpatient hospital
rehabilitation services was a substantive rule and, therefore, should have been published in the
Federal Register-is reaffirmed. The Bulletin applied a restriction to Region I (New England)
intermediaries and hospitals that was not applicable nationwide through the Medicare Intermediary
Manual-this restriction refused coverage of rehabilitation services provided on an inpatient
hospital basis unless the patient's condition otherwise necessitated that the services be rendered on
an inpatient hospital basis. This restriction was used to deny coverage for rehabilitation services
provided in a hospital when such services could have been provided at a lower cost facility insofar as
the patient's condition was concerned, but where the services were unavailable at such lower cost
facilities. IHCFA is ordered to send notices to all affected intermediaries, hospitals, and PROs that
the policies contained in the Bulletin are not to be followed.
See J 1231.73, 13,510.035.
Notices, determinations, and appeals-Court jurisdiction-Exhaustion of administrative
remedies.-Exhaustion of administrative remedies is not required for jurisdiction in a case
involving a procedural challenge to HCFA's method of promulgating restrictions on the provision of
rehabilitation services on an inpatient hospital basis because: (1) plaintiffs were trying to correct a
procedural deficiency collateral to a claim for benefits, (2) pursuing administrative remedies would
b futile, and (3) irreparable injury was demonstrated in that many of the plaintiffs were too old,
sick, and poor to await the conclusion of a lengthy administrative reviewing process.
See 13,540.035.
The earlier decision in this case was reported at 1984-1 Transfer Binder T 33,528.
[Text of Decision]
BLUNIENFELD, District Judge: On November
17, 1983, this court approved Magistrate
Eagan's Recommended Ruling, filed September
21, 1983, on Cross Motions for Summary judgment
in this case, granting the plaintiffs' motion
for summary judgment and denying the defendant's
motion for summary judgment.' On January
5, 1984, the court issued a judgment
declaring Health Care Financing Administration
(HCFA) Region I Bulletin No. 175 invalid.
The motions now before the court, all of which
seek to alter the judgment in some respect, were
also referred to Magistrate Eagan, who filed a
Recommended Ruling (hereinafter referred to as
IThis Recommended Ruhing is a.tached as Appendix A
[see 194-1 Transfer 8inder 133,5281.
Medicare and Medicaid Guide
.1
"the Second Recommended Ruling") on November
21, 1984 .2 The defendant has filed objections
to the Second recommended Ruling, and
the plaintiffs have filed a memorandum in support
of the Second Recommended Ruling.
I. Factual Background
The pertinent facts are set forth in the Magistrate's
Second Recommended Ruling at 2-4, and
are as follows:
The underlying case concerns the HCFA
Region I Bulletin No. 175. The Bulletin establishes
criteria for Medicare coverage of inpatient
hospital rehabilitative services in
addition to criteria set forth in the Medicare
I The Second Recommended Ruling is attached as Appendix
B [omitted by CCHI.
$ 34,619