Anthony L. Jordan Health Corp. v. Axelrod

140 Misc. 2d 1044, 532 N.Y.S.2d 480, 1988 N.Y. Misc. LEXIS 570
CourtNew York Supreme Court
DecidedAugust 25, 1988
StatusPublished

This text of 140 Misc. 2d 1044 (Anthony L. Jordan Health Corp. v. Axelrod) is published on Counsel Stack Legal Research, covering New York Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Anthony L. Jordan Health Corp. v. Axelrod, 140 Misc. 2d 1044, 532 N.Y.S.2d 480, 1988 N.Y. Misc. LEXIS 570 (N.Y. Super. Ct. 1988).

Opinion

OPINION OF THE COURT

Andrew V. Siracuse, J.

Petitioner, a not-for-profit corporation, operates the Anthony L. Jordan Health Center, a licensed nonresidential diagnostics and treatment center located in Rochester, New York. It provides health care services to persons eligible to receive medical assistance under title XIX of the Social Security Act (42 USC § 301 et seq.) and New York State Plan for Medical Assistance (Social Services Law §§ 363-369), collectively known as Medicaid. Petitioner is compensated for medical services rendered to Medicaid patients at a rate which is periodically established by the New York State Department of Health (hereinafter the Department) and approved by the Director of the Budget pursuant to section 2807 of the Public Health Law and subpart 86-1 of the Commissioner’s Administrative Rules and Regulations (10 NYCRR 86-1.1 et seq.).

In issue is the Department’s calculation or, more specifically, recalculation of petitioner’s Medicaid reimbursement rate for two periods: April 1, 1983 through March 31, 1984 (hereinafter the 1983/1984 period) and April 1, 1984 through March 31, 1985 (hereinafter the 1984/1985 period). On December 1, 1983, Jordan received from the Department the rate notification for the 1983/1984 period. Jordan timely appealed the Department’s determination on several grounds. In its initial administrative decision issued April 23, 1986, the Department’s Bureau of Ambulatory Care Reimbursement (hereinafter the Bureau) allowed certain of the items raised in Jordan’s appeal and recalculated the rate from $51.69 to $56.43 effective beginning April 1, 1983. On May 22, 1986, Jordan submitted a formal request for a hearing from the Bureau’s April 23, 1986 decision. The hearing request did not challenge the determination of the rate revision and thereby acknowledged that Jordan accepted the $56.43 revised rate. Jordan actually received retroactive reimbursement for the full rate period of April 1, 1983-March 31,1984.

The only items which were challenged in the hearing request were: (1) the grouping methodology, specifically Jordan’s grouping with the upstate urban multiservice category; (2) the inclusion of 1980 cost data for facilities who did not file 1981 cost reports in the calculation of group ceilings; (3) calculation [1046]*1046of an administrative cost center ceiling for Jordan but not for other cost centers; (4) applicability date of new rate; and (5) disallowance of outreach workers and patient relations supervisor costs. The grouping issue was determined to be one of law, having been the subject of previous appeals, and was resolved by stipulation of the parties. The second, third, and fourth issues were also resolved or determined not to be proper subjects for a hearing prior to the hearing. Thus, the only issue left for the hearing on the 1983/1984 appeal was the exclusion of the outreach workers and patient relations supervisor costs from the rate calculation.

With regard to the 1984/1985 reimbursement rate, the Department notified Jordan on September 10, 1984 that the rate for that year would be $59.64. Jordan timely appealed the determination, objecting to the disallowance of expenses for the patient relations supervisor, outreach workers, and referred laboratory work. The Bureau totally rejected Jordan’s appeal on these grounds on December 2, 1985. A timely request for a hearing on these issues was submitted by Jordan on December 20, 1985. Significantly, the group composition was not an issue of the appeal.

The two appeals were joined and a hearing was commenced. The hearing was adjourned shortly after it commenced to allow the parties to pursue settlement negotiations. The parties thereafter entered into a stipulation which was fully executed on March 19, 1987. The stipulation, which was drafted by the Department, provided that the Department was to advise Jordan of the new rate figures calculated in accordance with the stipulation within 30 days. Some six months later, on November 17, 1987, the Department advised Jordan that the rate had been recalculated to reduce the 1983/1984 rate from $56.43 to $54.75 and the 1984/1985 rate from $59.64 to $51.17. This notice came four years after the initial rate calculation in the case of the 1983/1984 period and 38 months after the initial calculation in the case of the 1984/1985 period. Had all other factors used in calculating the rate remained the same, the inclusion of the previously disallowed expenses would have resulted in an increase in the rate upon recalculation. In performing the recalculation, however, the Bureau unilaterally changed the group composition. This resulted in a negative adjustment of approximately $466,500 which the Department is recouping.

Before addressing the substantive issues, the Department’s allegation that petitioner has failed to exhaust admin[1047]*1047istrative remedies must be examined. Administrative remedies are to be pursued to resolve factual issues and only if there is some utility in so doing. (10 NYCRR 86-1.17 [c]; Hurlbut v Whalen, 58 AD2d 311 [4th Dept 1977].) After receiving the Department’s recalculation in November 1987, counsel for the petitioner wrote to the Administrative Law Judge who had handled this matter to request his assistance. The Administrative Law Judge replied that the appeals were moot once the stipulation had been entered. It is clear that there are no issues of fact herein which would be appropriate for resolution in an administrative proceeding. Since the issue presented is one of law, that being the application of the stipulation to the rate recalculation, petitioner appropriately commenced this CPLR article 78 proceeding and was not required to exhaust administrative remedies as a prerequisite to this proceeding.

It is quite clear from the record that the negotiations and Jordan’s entry into the stipulation were based upon the premises that the base data was to remain unchanged and that the only adjustments to be made to the rate calculation was the inclusion of the previously disallowed expenses in the group ceiling calculation. Significantly, paragraph 4 of the stipulation states that the group ceiling was to be recomputed in accordance with two previous appeals and the stipulation. The stipulation makes no mention of regrouping or changing any of the other factors in the rate calculation.

It is the Department’s position that the initial grouping was in error and that they are entitled to correct errors when discovered. (See, Matter of Westledge Nursing Home v Axelrod, 68 NY2d 862 [1986]; Matter of Daleview Nursing Home v Axelrod, 91 AD2d 1161 [3d Dept 1983], affd 62 NY2d 30 [1984]; Matter of University of Rochester Strong Mem. Hosp. v Whalen, 61 AD2d 867 [3d Dept 1978].) There are two circumstances in which Medicaid reimbursement rates may be retroactively reduced: (1) after an audit (10 NYCRR 86-1.8) or (2) after discovery of an error in the mathematical calculation (10 NYCRR 86-2.13).

The stipulation did provide that the rates to be revised were subject to audit pursuant to applicable statutes and regulations. A reading of 10 NYCRR 86-1.8 indicates that the purpose of an audit is to verify the records maintained by the medical facility which form the basis for the fiscal and statistical reports. In other words, an audit is intended to check the veracity and accuracy of the records which the medical fácil-, ity supplies to the Department and which the Department [1048]*1048uses as the basis for its calculation of the rate.

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Related

Daleview Nursing Home v. Axelrod
464 N.E.2d 130 (New York Court of Appeals, 1984)
Westledge Nursing Home v. Axelrod
501 N.E.2d 22 (New York Court of Appeals, 1986)
Hurlbut v. Whalen
58 A.D.2d 311 (Appellate Division of the Supreme Court of New York, 1977)
University of Rochester Strong Memorial Hospital v. Whalen
61 A.D.2d 867 (Appellate Division of the Supreme Court of New York, 1978)
Daleview Nursing Home v. Axelrod
91 A.D.2d 1161 (Appellate Division of the Supreme Court of New York, 1983)

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Bluebook (online)
140 Misc. 2d 1044, 532 N.Y.S.2d 480, 1988 N.Y. Misc. LEXIS 570, Counsel Stack Legal Research, https://law.counselstack.com/opinion/anthony-l-jordan-health-corp-v-axelrod-nysupct-1988.