Michigan Academy of Family Physicians v. Bowen

Supreme Court of the United States · Administrative Law

Administrative LawJudicial ReviewMedicareAPAjudicial reviewpreclusionMedicare Part Bamount determinations

Facts

Respondents included an association of family physicians and several individual doctors who challenged 42 CFR § 405.504(b) (1985), a regulation authorizing payment of benefits in different amounts for similar physicians' services under Medicare Part B. The District Court held the regulation invalid under the Medicare statute, and the Court of Appeals agreed, describing it as inconsistent with the statute and irrational. The Secretary did not seek review of the merits ruling invalidating the regulation. Instead, he argued that Congress had barred judicial review of all questions affecting the amount of benefits payable under Part B.

Issue

Whether Congress, through 42 U.S.C. § 1395ff or 42 U.S.C. § 1395ii incorporating 42 U.S.C. § 405(h), barred judicial review of regulations promulgated under Medicare Part B. More specifically, the question was whether a challenge to the validity of the Secretary's regulation was unreviewable as a matter affecting Part B benefit amounts.

Rule

There is a strong presumption that Congress intends judicial review of administrative action, and that presumption may be overcome only by clear and convincing evidence, specific statutory language, reliable legislative history, or a fairly discernible intent from the statutory scheme. Under the Medicare scheme, Congress precluded judicial review only of carrier determinations of the amount of Part B benefits, not of challenges to the validity of the Secretary's regulations or instructions that prescribe the method for computing those amounts.

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One of 10 multiple-choice questions for this case. Pick an answer to see why.

In Cleveland, a group of pulmonologists sues in federal district court alleging that a federal health agency instruction unlawfully excludes certain office-based respiratory treatments from a reimbursement formula used across all Part B claims. The physicians do not ask the court to recalculate any single patient claim; they seek only a declaration that the instruction conflicts with the statute.

Is the suit most likely barred from federal court review?

Explanation. The majority drew a method-versus-determination distinction. Congress barred review of carrier determinations of the amount payable on particular Part B claims, but not challenges to the legality of the Secretary's regulations or instructions prescribing the method of computation. Because the physicians seek to invalidate a generally applicable payment instruction rather than revise an individual award, judicial review is available.