Condado Home Care Program, Inc. v. Cooperativa De Seguros De Vida
Condado Home Care Program, Inc. v. Cooperativa De Seguros De Vida
Opinion of the Court
This is an appeal from a district court’s denial of a petition to review an administrative decision reducing reimbursement to plaintiff Condado Home Care Program, Inc., hereinafter provider, by not recognizing the full amount paid for supplies furnished it by Metropolitan Equipment Sale & Rental, Inc., hereinafter supplier. Full reimbursement was sought pursuant to the Medicare Program, 42 U.S.C. §§ 1395 et seq., but defendant Secretary of Health and Human Services refused because provider and supplier were “related corporations,” and provider had not shown entitlement to the exception provisions, 42 C.F.R. 405.427(d). Specifically, provider failed to show satisfaction of the following portion.
... if the provider demonstrates by convincing evidence to the satisfaction of ... the Health Care Financing Administration ... that a substantial part of [supplier’s] business activity of the type carried on with the provider is transacted with others than the provider and organizations related to the supplier____
The regulations are spelled out with regard to the meaning of a “substantial” part.
Example of Exceptions
The exception was intended to cover situations where goods and services are supplied to the general public and only incidentally are furnished to related organizations. Provider Reimbursement Manual, HIM § 1010.1. (emphasis suppl.)
In respect to this, provider furnished a one sentence statement by supplier’s auditors to the effect that two thirds of supplier’s business was carried on with others than provider, and a sworn statement of supplier’s president that this other business was not with related organizations. Co-defendant Cooperativo de Seguros de Vida, acting as fiscal intermediary pursuant to 42 U.S.C. § 1395h, replied that this was not evidence enough, and that intermediary wished to see supplier’s books. To this, provider’s counsel responded with a great many words, but no substance. Intermedi
Intermediary’s position before the Board was that the evidence submitted was unsatisfactory; that, particularly in light of the fact that provider did 90% of its business with supplier, intermediary wished access to supplier’s books. The Board agreed, on two grounds. One, it held against provider because provider had failed to solicit bids on the open market, and, two, provider had failed to show that “(2) the Supplier only incidentally did business with the Provider.”
The dissenting member pointed out that open bidding was not a requirement. In this he was correct.
We would wonder if it would not have to be ruled as a matter of law that 33% is necessarily more than incidental.
After the Board had decided against it, that should have been the end of the matter. An administrative agency such as this presumably makes a final determination, and court review should be the exception. This appeal, and, particularly, the attempt to introduce constitutional issues, is frivolous.
Affirmed, with double costs, plus a $2,000 attorney’s fee. 28 U.S.C. § 1912; F.R.App.P. 38.
. At the same time, to carry on 90% of one's business with a related organization without attempting to deal with others might, unless there are clear standard prices, legitimately raise eyebrows.
. The district court badly mispoke when it stated that provider’s obligation would be met if "supplier has a significant amount of business with unrelated organizations.”
. Judge Torruella concurs in this decision but is of the opinion that the appeal, although merit-less, does not justify the imposition of double costs or attorneys fees.
Reference
- Full Case Name
- CONDADO HOME CARE PROGRAM, INC. v. COOPERATIVA DE SEGUROS DE VIDA, Secretary of Health and Human Services
- Cited By
- 4 cases
- Status
- Published