By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On June 15, 2022, the U.S. Supreme Court said the federal government improperly cut more than $1 billion a year in Medicare reimbursements to hospitals. This came in a ruling that limits regulators’ power to control what the program pays for certain drugs. In this case, the Supreme Court justices sided unanimously with a group of hospitals suing over drug reimbursement rates for facilities that serve low-income communities. In writing for the court, Justice Brett Kavanaugh said the U.S. Department of Health and Human Services (HHS) improperly calculated reimbursement rates using a methodology Congress authorized for use only in limited circumstances.
Were the Reimbursement Cuts Unlawful?
The Supreme Court overturned a lower court’s 2020 decision that HHS had the authority to reduce the yearly Medicare reimbursement rates for a group of hospitals serving low income communities. Click here to view the July 31, 2020 decision.
The high court found the U.S. Court of Appeals for the District of Columbia Circuit erred in 2020 when it allowed the HHS to reduce Medicare payments, by roughly $1.6 billion, for outpatient drugs that had helped subsidize the operations of the hospitals. The Supreme Court’s decision did not extend so far as to undermine HHS authority, but only stated how the agency acted unlawfully in accordance with its varying rates for hospitals under the 340B Drug Pricing Program.
“In short, the statute allows HHS to set reimbursement rates based on average price and affords the agency discretion to ‘adjust’ the price up or down. But unless HHS conducts a survey of hospitals’ acquisition costs, HHS may not vary the reimbursement rates by hospital group,” Justice Kavanaugh wrote in the ruling.
Regulating Reimbursement Rates Under the 340B Program.
Under Medicare, health care providers get reimbursed by the government for expenses, including medications used in hospital outpatient departments. Previously, hospitals had been getting reimbursed at a rate based on the average price of the drugs. However, in 2018, the HHS, under then-President Donald Trump, cut payments for outpatient drugs by 28.5% to hospitals receiving money under the 340B program.
The department found that reimbursements were too high because these hospitals obtain the drugs from manufacturers at a deep discount, an issue that also resulted in excessive patient co-payments. Additionally, the resulting cut dealt “a crushing blow to providers that were already operating on razor-thin margins and to the vulnerable populations they serve,” the hospitals told the justices in a court filing.
Justice Brett Kavanaugh wrote for the court that “absent a survey of hospitals’ acquisition costs,” the HHS “may not vary the reimbursement rates for 340B hospitals. The HHS’s 2018 and 2019 reimbursement rates for 340B hospitals were therefore contrary to the statute and unlawful.”
Click here to read the Supreme Court’s Opinion in the case, American Hospital Association v. Becerra, 20-1114.
Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, Medcaid audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
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Stohr, Greg. “Supreme Court Sides With Hospitals on Medicare Reimbursement.” Bloomberg Law. (June 15, 2022). Web.
Chung, Andrew. “U.S. Supreme Court faults Medicare cuts to hospitals for outpatient drugs.” Reuters. (June 15, 2022). Web.
Gresko, Jessica. “High court rules against government on drug reimbursement.” Associated Press. (June 15, 2022). Web.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law is an attorney with The Health Law Firm, which has a national practice. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, Florida 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.
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