United States v. Erika, Inc., 456 U.S. 201 (1982)

United States v. Erika, Inc.

No. 80-1594

Argued March 1, 1982
Decided April 20, 1982
456 U.S. 201

CERTIORARI TO THE UNITED STATES COURT OF CLAIMS

Syllabus

Part B of the Medicare program, the federally subsidized, voluntary health insurance system for persons 65 or older or who are disabled, supplements Part A, which covers institutional health costs such as hospital expenses, by insuring against a portion of medical expenses excluded from Part A. Under the statute, private insurance carriers are assigned the task of paying Part B claims. If the carrier determines that a claim meets Part B coverage criteria, the claim is paid out of federal funds. Disputed determinations are subject to review in a hearing by the carrier if the disputed amount is $100 or more. The statute also provides for a review by the Secretary of Health and Human Services of determinations of whether an individual is entitled to benefits under Part A or Part B, and of the determination of the amount of benefits under Part A. Persons dissatisfied with the Secretary’s decision are granted the right to additional administrative review, together with the option of judicial review when the dispute relates to their eligibility to participate in either Part A or Part B or concerns the amount of Part A benefits. When respondent distributor of kidney dialysis supplies made sales covered by Part B, the purchasers assigned their Part B claims to respondent. Respondent in turn billed the private insurance carrier, who was required by contract to reimburse 80% of what it determined were "reasonable charges" for the supplies. The carrier interpreted the relevant statute and regulations to define "reasonable charges" to be the catalog price of the supplies as of July 1 of the preceding calendar year. When the carrier refused respondent’s request to make adjustments in this method of reimbursement in order to reflect interim price increases, respondent sought review before one of the carrier’s hearing officers, who upheld the carrier’s decision. Respondent then brought an action against the United States in the Court of Claims, seeking reimbursement on the basis of its current charges. After ruling that the suit was within its jurisdiction under the Tucker Act, the Court of Claims held that the carrier’s calculation of respondent’s allowable charges erred in several respects, and remanded for redetermination of the charges.

Held: The Court of Claims has no jurisdiction to review determinations by private insurance carriers of the amount of benefits payable under Part B of the Medicare program. Pp. 206-211.

(a) In the context of the statute’s precisely drawn provisions, the omission to authorize judicial review of determinations of the amount of Part B awards provide persuasive evidence that Congress deliberately intended to foreclose further review of such claims. Pp. 206-208.

(b) The legislative history confirms that Congress intended to limit review of the Part B awards, which are generally smaller than Part A awards. Pp. 208-211.

225 Ct.Cl. 252, 634 F.2d 580, and 225 Ct.Cl. 273, 647 F.2d 129, revered.

POWELL, J., delivered the opinion for a unanimous court.