OPINION AND JUDGMENT
DALTON, District Judge.
Petitioner, South Boston General Hospital (hereinafter South Boston), has brought this action seeking review of a final determination by the Secretary of Health, Education and Welfare (hereinafter the Secretary). Jurisdiction was noted in an opinion by this Court on April 24, 1975. South Boston General Hospital v. Weinberger, 397 F.Supp. 360 (D.C.Va.)
The facts of the case are not in dispute. South Boston is a non-profit provider of Medicare benefits under the Medicare Act, 42 U.S.C. § 1395 et seq., (hereinafter the Act) and is seeking a review of a determination by Blue Cross as agent for the Secretary which (1) reduced the depreciation expenses incurred by South Boston in a sale to a related organization and (2) denied the interest expense paid to the related organization. South Boston has exhausted its administrative remedies. Both sides have moved for Summary Judgment.
Plaintiff seeks reimbursement for costs of services incurred in the efficient delivery of needed health services.
Petitioner makes the following allegations:
The first allegation is clearly erroneous. The entire administration and staff were carried over to the new hospital, and the management remained essentially the same. The proprietary hospital and petitioner are clearly related parties within the meaning of the regulations. The remaining allegations, however, raise important questions and will be dealt with more fully.
APPLICABILITY OF 20 C.F.R. § 405.427
As indicated by its language the thrust of section 405.427 is to avoid self-dealing between related parties in an ongoing relationship in which one of the parties is supplying services, facilities or supplies to the other. The present tense is used throughout the section, indicating the continuing viability of both organizations. Examples of this intent can be found in sub-section (b)(1) where it is stated that the "provider . . . is associated . . . with or has control of or is controlled by the organization furnishing the services, facilities, or supplies." Subsection (b)(2) reads: "when . . . individuals possess significant ownership or equity in the provider and the institution or organization serving the provider."
The Secretary contends that inclusion of the term "facilities" clearly encompasses an outright purchase of an entire facility, as in the case at bar. However, sub-section (c)(2) illustrates the proper interpretation to be given the term "facilities." There the example of a leasing arrangement between related parties of an entire facility is set forth.
The court finds that 20 C.F.R. § 405.427 is not applicable to this controversy. Plaintiff contends that a determination based on this regulation is reversible error. The court expresses no opinion as to that contention because even if true, denial of reimbursement could be based on the related parties doctrine expressed in sections 405.415(g) and 405.419, if those sections are valid. Therefore, the court will address the validity of those sections, which form the statutory basis for denying reimbursement, regardless of the provisions of section 405.427.
DO THE REGULATIONS FURTHER THE PURPOSES OF SECTION 1395x(v)(1)(A) OF THE ACT?
Title 42 U.S.C. § 1395x(v)(1)(A) constitutes the statutory guide for the Secretary in the furtherance of his duty to promulgate regulations governing the items which are reimbursable and the amounts of such reimbursements to providers of needed health services. The overriding consideration is the reimbursement of actual costs, found to be not unnecessary in the efficient delivery of needed health services. The Secretary is directed to assure reimbursement of incurred costs to those providing services to those covered by the insurance program.
Plaintiff admittedly provides services to those covered by the insurance program. Plaintiff is a "provider" under the Act. Furthermore, capital indebtedness is an allowable cost for which reimbursement is available under 20 C.F.R. § 405.419(a); as is depreciation on buildings and equipment pursuant to 20 C.F.R. § 405.415(a). Further, the cost basis on the purchase of a facility as an ongoing operation is the price paid by the purchaser when the purchaser can demonstrate that the sale was a bona fide sale and the price did not exceed the fair market of the facility at the time of the sale. 20 C.F.R. § 405.415(g). These provisions indicate a recognition by the Secretary that interest on capital indebtedness and depreciation, based on the purchase price of a facility, constitute necessary costs incurred in the efficient delivery of needed health services by a qualified provider under the Act.
Because these items of otherwise reimbursable costs were incurred by plaintiff in a transaction with a related party, the Secretary prohibits reimbursement absolutely. Section 405.415(g) requires proof that the purchase of the facility was a bona fide sale in order to use the purchase price as the cost basis for depreciation purposes, but because the transaction was between related parties, such proof is rendered impossible, notwithstanding the fact that the transaction may be identical to or more advantageous than one between unrelated parties. Section 405.419(c) properly notes the potential dangers inherent in a transaction between related parties, but then assumes that those dangers cannot be avoided and thus prohibits reimbursement of any capital indebtedness between related parties. The Secretary, in effect, refuses to scrutinize transactions between related parties, assuming that all such transactions would result in excess
The failure to scrutinize a related parties transaction indicates a serious misplacement of priorities on the part of the Secretary. The Act urges reimbursement of incurred expenses necessary for the efficient delivery of needed health services. This is the prime consideration. If a transaction between related parties can help attain that end, the Secretary must not frustrate that transaction. The court is not unmindful of the potential dangers of such a transaction, and would urge the Secretary to closely scrutinize it, but scrutinize it he must. If any of the possible dangers of such a transaction are indeed present then denial of reimbursement for costs incurred as a result of such a transaction would be appropriate.
The court realizes that proper advice prior to the closing of the transaction in question might have enabled petitioner to avoid the confrontation evidenced by this law suit. A financing arrangement through a commercial lender might have been just as satisfactory as the transaction which occurred. Such an arrangement would have avoided consideration of the related parties doctrine by respondents. However, such an argument avoids the issue: Does the related parties doctrine, expressed in the regulations, further the purposes of the Act, or does it erect a roadblock to those who miss a turn and engage in a related parties transaction, albeit in good faith, for a below market value purchase price with entirely reasonable interest rates? The court feels that the roadblock is there; and that it may work, and in this case probably has worked a severe injustice upon petitioner. (See Appendix). The court feels the roadblock must come down.
Elimination of the regulations prohibiting reimbursement of the incurred costs at issue in this case will not result in widespread abuse of the reimbursement provisions of the Act. All claims for reimbursement of costs are reviewed according to standards already set forth in the regulations. The wording of 20 C.F.R. § 405.415(g) is still viable. In order to claim the purchase price of a facility as an ongoing operation, a provider still has to prove a bona fide sale and a purchase price not in excess of the fair market value at the time of sale. This decision only prohibits an arbitrary determination that a related parties transaction cannot be a bona fide sale, regardless of the circumstances. The court does not say that a related parties transaction is automatically a bona fide sale. The elements of proof that any purchaser/provider must make are applicable to a provider purchasing from a related seller. Such a transaction may require closer scrutiny than a non-related parties transaction, but it must be scrutinized.
Similarly, with regard to interest, 20 C.F.R. § 405.419 still retains standards to enable the Secretary to assess whether interest is both "necessary and proper." The standards set forth in sub-section 405.419(b)(2) defining "necessary" are viable in their entirety. The normally accepted definition of "proper" interest set forth in sub-section 405.419(b)(3)(i) retains its vitality and will now apply equally to a provider borrowing from a related party. The potential dangers of related party transactions set forth in sub-section 405.419(c) are important and should continue to be recognized, but the conclusion expressed there, that all such transactions indicate an agreement on higher interest rates or unnecessary loans, must be expunged as without basis in fact, particularly in the case before this court. (See Appendix) It should again be emphasized that a related parties transaction should be closely scrutinized because of its very nature, but
CONSTITUTIONALITY OF 20 C.F.R. §§ 405.415(g) AND 405.419(c)
Since the court has found the above regulations repugnant to purposes for which 42 U.S.C. § 1395x(v)(1)(A) was enacted, it will express no opinion on the constitutional arguments submitted by petitioner, although they are not without merit.
For the reasons discussed above this case is remanded to the Secretary for reconsideration of petitioner's claims for reimbursement without regard to the related parties doctrine as it has been historically applied.
The clerk is directed to send copies of this opinion and judgment to counsel of record.
MEDICARE PROVIDER APPEAL COMMITTEE DECISION
The Committee unanimously decides to uphold the Plan's decision with regard to the reduction of the depreciation expense and the denial of interest associated with the conversion of the provider from a proprietary to not-for-profit institution. The Committee finds these two organizations related as defined in Regulation Section 405.427 and Chapter 10 of HIM-15. The old hospital's administration and staff were carried over to the new hospital, and the management remained the same. Five of the nine board members of the new hospital were members of the five man board of the old hospital.
The Committee reaches this decision reluctantly. The circumstances of this case are such that application of the related parties rule has a particularly harsh effect on the provider. The evidence indicates no intention on the part of the owners of the old hospital to make an unconscionable profit as a result of this transaction. In fact the transaction appears to have been motivated by the desire to provide better service to the community. However, on the basis of its understanding of the applicable Law, Regulations and General Instructions, the Committee sees no supportable alternative to upholding the Plan's position.
Provider at the hearing and in its post hearing brief argued that if it is not entitled to interest expense and depreciation, it should be entitled to an amount at least equal to a return on equity capital.
Unfortunately, this alternative is not available to provider because it is a nonprofit institution. The Regulations cited in provider's post hearing brief are meant to apply to proprietary, not to nonprofit providers. In this case, provider was denied interest expense and depreciation on the basis of the related organization principle. By returning to the provider's historical cost when it was proprietary institution the Committee is not converting the provider back into a proprietary institution.
It must be remembered that, although nonprofit corporations are not allowed a return on equity, they enjoy many privileges not afforded proprietary institutions; i. e., an exemption from income taxes and other state and local taxes. In fact, the provider had argued that the
Dear Mr. Lynn:
As the local Medicare intermediary, it was our responsibility to uphold the regulations regarding the disallowance of depreciation and interest expense due to a transaction between related parties at South Boston General Hospital. Consequently, the provider made an appeal to the Blue Cross Medicare Appeals Committee. The committee upheld our decision; however, it was with reluctance. Likewise, we reluctantly upheld the regulations based on the knowledge that the provider had acted in good faith to make the transaction bona fide. This is evident through the following:
1. The sale price of the facility was $650,010 which was above historical cost. This was to be paid over 15 years at an interest rate of 4% per annum. This interest rate appears to be reasonable.
2. The Internal Revenue Service gave the provider 501(c)(3) tax status and deemed the sale to be bona fide.
3. Because of the rural nature of the locale, the only persons with the requisite management experience were the former owners, and they became trustees of the new provider.
4. The provider's conversion from profit to non-profit was undertaken for the benefit of the community. Likewise, the facility became accredited on August 31, 1973 by the Joint Commission on Accreditation of Hospitals.
5. As a result of the sale, the facility's costs have not increased unreasonably. A review of the average cost per Medicare patient
6. In addition, the Internal Revenue Service audited the facility and determined that the facility continued to maintain their tax-exempt status.
During our preliminary negotiations with the provider concerning this appeal, it was our intention to support the provider's position. We did so in our first position paper (Exhibit A). An additional review of this paper was made before it was forwarded to Blue Cross Association, and some modifications were made to adequately reflect the facts and the regulations. (See Exhibit B.) This position paper was forwarded to Blue Cross Association on January 22, 1973. Subsequently we were instructed by Blue Cross Association to further modify the paper to support the regulations. (See Exhibit C.) We revised the final paper showing little, if any, support to the provider's case although we felt that the regulations were inequitable in this case.
We are in full agreement with Mr. Jacoby's letter dated August 3, 1973 requesting an exception be made in order to grant relief to this provider. The effects of the disallowance of depreciation and interest expense are far-reaching in scope as they will effect twelve (12) additional reports not including the ones the provider appealed.
We respectfully request that you reconsider Intermediary Letter No. 72-10's effect on the related organization principle as applied to the facts in this case and grant whatever relief possible to the provider. This is essential to prevent inequities resulting from the Medicare program not reimbursing the facility for their reasonable costs for Medicare beneficiaries and passing on any resulting losses to private pay patients.
Please let me know if you have additional questions. We look forward to receiving a favorable decision in this case from the Bureau of Health Insurance.
The applicable sections of regulations pertaining to this controversy are the following: