Beverly Enterprises v. Miss. Div. of Medicaid

808 So. 2d 939, 2002 WL 307828
CourtMississippi Supreme Court
DecidedFebruary 28, 2002
Docket2000-CC-01090-SCT
StatusPublished
Cited by9 cases

This text of 808 So. 2d 939 (Beverly Enterprises v. Miss. Div. of Medicaid) is published on Counsel Stack Legal Research, covering Mississippi Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Beverly Enterprises v. Miss. Div. of Medicaid, 808 So. 2d 939, 2002 WL 307828 (Mich. 2002).

Opinion

808 So.2d 939 (2002)

BEVERLY ENTERPRISES,
v.
MISSISSIPPI DIVISION OF MEDICAID.

No. 2000-CC-01090-SCT.

Supreme Court of Mississippi.

February 28, 2002.

*940 John L. Maxey, Christina Carroll, Jackson, attorneys for appellant.

Barbara A. Bluntson, Jackson, attorney for appellee.

EN BANC.

ON MOTION FOR REHEARING

EASLEY, J., for the Court.

¶ 1. The motion for rehearing is granted. The original opinions are withdrawn, and these opinions are substituted therefor.

¶ 2. After being denied reimbursement by the Mississippi Division of Medicaid (Medicaid) for medical services rendered to Medicaid beneficiaries, Beverly Enterprises (Beverly) appeared before the Division of Medicaid Review Panel (Panel) at a hearing on April 18, 1999. The Panel recommended denying Beverly's appeal, and the Executive Director of Medicaid adopted the recommendation in its order of July 15, 1999. Beverly appealed to the Hinds County Chancery Court, First Judicial District, which affirmed the order on June 5, 2000.

¶ 3. Beverly appeals the chancellor's order affirming the decision of the Panel, which denied reimbursements for nursing services that were undervalued due to a computer programming "glitch."

FACTS

¶ 4. Beverly operates a number of nursing facilities in Mississippi, and a majority of its patients are insured by Medicaid. Pursuant to Miss.Code Ann. § 43-13-117(4)(b) (1999) and federal regulations promulgated by the federal Health Care Financing Administration (HCFA), Medicaid operates on a case mix system, which is designed to pay nursing facilities according to the amount of care devoted to particular patients. This requires the facility to prepare a medical assessment of each patient, called a Minimum Data Set (MDS), and the date that it is performed becomes the reference date. This assessment is performed on each resident at least once a quarter, and Medicaid reimburses the facility quarterly for those patients who are covered by Medicaid. The facilities are reimbursed according to the treatment provided to individual patients.

¶ 5. In mid-December, 1998, Beverly installed a new computer program system. Due to programming errors, Beverly's system was incompatible with Medicaid's system, causing the MDSs of several hundred patients to be mischaracterized as "BC-1" from that time until Beverly reset its reference dates on January 14, 1999, by making its significant corrections of prior assessments. As a result, Beverly was reimbursed for all of its Medicaid patients at a rate of BC-1 for a period of a few months to a few days, depending on the date of the last assessment for individual patients. BC-1 represents the lowest pay rate possible, and usually applies to residents who are mostly self-sufficient, but require some supervision.

*941 ¶ 6. The HCFA provides that errors in a MDS may be corrected by making significant corrections to prior assessments. This resets the reference date, and essentially begins a new quarter for that particular patient. On January 8, 1999, Medicaid alerted Beverly of a possible problem in its billing. Upon investigation Beverly realized that approximately 700 patients were mischaracterized by the defective programming. Beverly made corrections to all but twelve on January 14, 1999. Once the corrections were made, Medicaid adjusted the pay rate prospectively from that day. Beverly estimates that it lost $734,633.45 in reimbursements for nursing care that it provided between mid-December, 1998, and January 14, 1999.

STANDARD OF REVIEW

¶ 7. When this Court reviews a decision by a chancery or circuit court concerning an agency action, it applies the same standard of review that the lower courts are bound to follow. Miss. Comm'n on Envtl. Quality v. Chickasaw County Bd. of Supervisors, 621 So.2d 1211, 1216 (Miss.1993). We will entertain the appeal to determine whether the order of the administrative agency 1) was unsupported by substantial evidence, 2) was arbitrary or capricious, 3) was beyond the power of the administrative agency to make, or 4) violated some statutory or constitutional right of the complaining party. Id. at 1215. The Court must reverse an agency decision if the decision "violated some statutory or constitutional right of the complaining party." Molden v. Miss. State Dep't of Health, 730 So.2d 29, 33 (Miss. 1998).

LEGAL ANALYSIS

I. Whether the Mississippi Division of Medicaid's refusal to grant Beverly Enterprises's request for reimbursement without substantial evidence, or, in the alternative, arbitrarily and capriciously violated Beverly's statutory and constitutional rights.

¶ 8. The Health Care Financing Administration of the United States Department of Health and Human Services manual provides as follows:

[If] the erroneous data in the prior MDS is major enough to warrant correction, then the facility may optionally choose to perform a new comprehensive "significant correction of prior assessment" if both of the following conditions are satisfied:
(1) The assessment in error is the most recent assessment; and
(2) The resident did not experience an actual change "significant change in status" between the time of the original assessment and the new comprehensive assessment. However, the resident's clinical condition is different from that depicted in the assessment in error and it would otherwise appear that there had been a significant change in status.
If the facility chooses to perform a "significant correction" assessment, then a new MDS and RAPs are required, with the new MDS performed using a new observation period (i.e., a new Assessment Reference Date (A3a)).

HCFA RAI Version 2.0 Guidelines (1995).

¶ 9. The above-quoted passage provides for the correction of errors in the most recent MDS reports, and requires "a new observation period." "The Division of Medicaid, Case Mix, does not allow assessments with the same assessment reference date to be replaced by new assessments with that same assessment reference date once they have been received and accepted into the Medicaid system." Division of *942 Medicaid Case Mix Update CMX-1 (April 1, 1998) (emphasis added).

¶ 10. Medicaid interprets this updated regulation to mean that the corrected MDSs submitted by Beverly cannot relate back to the date of the original, mischaracterized MDSs. Therefore, it contends, the corrected MDSs may only be applied prospectively for the purposes of Medicaid reimbursements, and it may not retroactively pay Beverly additional reimbursements for the services it rendered prior to January 14, 1999.

¶ 11. Beverly has presented evidence that it is possible for Medicaid to delete erroneous information from the system and replace it. It cites the State Medicaid Plan, 1-7(A), which allows Medicaid to make adjustments to the MDSs that change the classification of the resident. These changes may result in a lower or a greater payment to the provider. However, this provision of the State Plan only applies when Medicaid performs an audit pursuant to the State Plan, 3-1(c). The errors of which Beverly complains were not discovered by an internal audit of Medicaid, and this remedy is therefore not available to Beverly.[1]

¶ 12.

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