Federal Court Grants Reimbursement Claims of Cancer Therapy Provider

On April 4, 2013, the United States District Court for the Western District of Oklahoma granted summary judgment for a provider of a new type of radiation treatment for cancer, and ordered the Secretary of HHS to compute an appropriate payment on multiple reimbursement claims that the provider had submitted to the Centers for Medicare and Medicaid Services (“CMS”).  See Oklahoma ProCure Management, LLC v. Kathleen Sebelius, Secretary of the United States Department of Health and Human Services.

The Secretary had argued that the Court did not have jurisdiction to consider the case because the relevant CMS’ payment methodologies are not subject to judicial review.  The Court asked for briefing and heard oral argument.  The court found that it had jurisdiction and, going beyond the jurisdictional issue to the merits of the case, granted summary judgment in favor of the provider. According to the court,  based on the parties’ submissions it was able to conclude that the Secretary’s decision not to make additional payment to the provider was not supported by substantial evidence. 

Oklahoma ProCure Management (“ProCure”) provides proton therapy treatment to cancer patients; proton therapy is an alternative to X-ray radiation therapy that seeks to expose less healthy tissue to radiation than standard X-ray radiation therapy.  Following treatment of multiple patients, ProCure submitted Medicare reimbursement claims to CMS.  CMS acknowledged that ProCure’s treatments were medically reasonable and necessary for the patients, but it reimbursed ProCure at a rate significantly below what ProCure requested and a small fraction of what commercial payers pay for the treatment. Before going to Federal court, ProCure appealed CMS’ reimbursement decisions through the administrative appeals process and received varying bases of denial.

 The case turned, both within the agency and in federal court, on whether CMS actually had engaged in the detailed, rate-setting decision-making process required under CMS’ regulations. The Federal court found that CMS’ claim that it had engaged in the required process were not supported by substantial evidence and that, in fact, evidence indicated that CMS had not engaged in the required process.

As a practical matter, the case affects not only the reimbursement claims before the court but multiple, additional claims pending within the agency. 

Parrish Law Offices represented ProCure before CMS and before the federal court, and was assisted by local counsel McAfee & Taft.

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