Clark Regional Medical Center v. Shalala

136 F. Supp. 2d 667, 2001 U.S. Dist. LEXIS 4658, 2001 WL 332064
CourtDistrict Court, E.D. Kentucky
DecidedMarch 30, 2001
Docket2:03-misc-00007
StatusPublished
Cited by2 cases

This text of 136 F. Supp. 2d 667 (Clark Regional Medical Center v. Shalala) is published on Counsel Stack Legal Research, covering District Court, E.D. Kentucky primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Clark Regional Medical Center v. Shalala, 136 F. Supp. 2d 667, 2001 U.S. Dist. LEXIS 4658, 2001 WL 332064 (E.D. Ky. 2001).

Opinion

*669 OPINION AND ORDER

FORESTER, Chief Judge.

This matter is before the Court on the plaintiffs’ motion for judgment [DE# 11] and the plaintiffs’ motion for leave to file a supplemental brief [DE# 19].

I. FACTUAL AND PROCEDURAL BACKGROUND

This case involves the defendant’s interpretation and application of the complex Medicare payment system to the plaintiff hospitals, and specifically the defendant’s determination of the plaintiffs’ eligibility for an adjustment for “disproportionate share hospitals” or “DSH” under 42 U.S.C. § 1395ww(d)(5)(F)(v).

The plaintiffs are licensed by the Commonwealth of Kentucky for 100 and 105 acute care beds and both operate and staff their facilities for all of these licensed beds. Both facilities are also certified by the defendant as “swing-bed” facilities, which means that they may, as necessary, use a designated number of their acute care beds to provide post-hospital skilled' nursing care on a temporary basis. 1 Both facilities also occasionally use their beds for patient observation to determine whether a particular patient should be admitted — some patients are ultimately admitted, while others are not.

Medicare uses different payment methods for different services. Inpatient hospital services are reimbursed under Part A on a “Prospective Payment System” (“PPS”). In general, under this method a hospital is paid a predetermined rate based upon the patient’s diagnosis, regardless of the hospital’s actual costs. Observation beds, on the other hand, are paid under Part B on a “reasonable cost” basis because observation is considered an outpatient service. Likewise, SNF beds are not paid under the PPS, but on a separate basis. In determining its “reasonable costs,” a hospital must apportion costs between Medicare and non-Medicare patients in the cost reports that it submits to the defendant. According to the defendant, this requires hospitals to make a calculation of “total inpatient routine service costs,” which excludes observation days and SNF days in swing-bed hospitals. In other words, observation and SNF days are carved out of the “reasonable cost” calculation.

When Congress established PPS, it recognized that hospitals that serve a significantly disproportionate number of low-income patients incur additional costs that may not be fully compensated by the PPS. Therefore, it established an adjustment for these disproportionate share hospitals, commonly referred to as the “DSH adjustment.” 42 U.S.C. § 1395ww(d)(5)(F)(v). Under the statute, a hospital that is located in an urban area 2 and has “100 or more beds” qualifies for the DSH adjustment if 15% of its patients are low-income patients. However, if the hospital has less than 100 beds, the low-income patient threshold is a substantially higher 40%. Id.

For the years at issue here, 1992-1996, both of the plaintiffs qualified for and received the DSH adjustment. However, according to the plaintiffs, in June of 1997 the defendant changed the method it used *670 to count beds in determining eligibility for the DSH adjustment and then retroactively applied this new counting method to previous years. As a result, the plaintiffs were no longer eligible for the adjustment and were required to return approximately $5,092,243 in adjustments previously paid, but for which the plaintiff hospitals were retroactively determined to have been ineligible.

The plaintiffs appealed this decision to the Provider Reimbursement Review Board (“PRRB”), which found in favor of the hospitals. The defendant 3 then appealed this decision to the Health Care Financing Administration (“HCFA”), which reversed the PRRB’s ruling and reinstated the earlier finding that the plaintiffs were ineligible for the DSH adjustment for the years at issue. This suit followed.

II. THE REGULATIONS AND ADMINISTRATIVE RULINGS

A. Applicable Regulations and Guideline

Pursuant to regulations promulgated by the defendant, the number of beds in a hospital for purposes of determining DSH adjustment eligibility “is determined in accordance with § 412.105(b).” 42 C.F.R. § 412.106(a)(1)(I). Section 412.105(b) is used to determine a hospital’s eligibility for a separate PPS adjustment for indirect costs associated with graduate medical education programs, referred to as the “IME” adjustment. Thus, the defendant determined that in counting beds for either adjustment, the same method would apply. 4 The applicable regulation states as follows:

Determination of number of beds. Fox-purposes of this section, the number of beds in a hospital is determined by counting the number of available bed days during the cost reporting period, not including beds or bassinets in the healthy newborn nursex-y, custodial care beds, or beds in excluded distinct part hospital units, and dividing that number by the number of days in the cost reporting pei-iod.

Id. § 412.105(b). The defendant also provided further guidance on the methodology of counting beds under 42 C.F.R. § 412.105 in its “Provider Reimbursement Manual” (“PRM”) as follows:

G. Bed Size. — A bed is defined for this purpose as an adult or pediatric bed (exclusive' of beds assigned to newborns which are not in intensive care areas, custodial beds, and beds in excluded units) maintained for lodging inpatients, including beds in intensive care units, coronary care units, neonatal intensive care units, and other special care inpatient hospital units. Beds in the following locations are excluded from the definition: hospital-based skilled nursing facilities or in any inpatient area(s) of the facility not cei-tified as an acute care hospital, labor rooms, PPS excluded units such as psychiatric or rehabilitation units, postanesthesia or postoperative l-ecovery rooms, outpatient areas, emergency rooms, ancillary departments, nui-ses’ and other staff residences, and other such areas as are regularly maintained and utilized for only a portion of the stay of patients or for pui-poses other than inpatient lodging.
*671 To be considered an available bed, a bed must be permanently maintained for lodging inpatients. It must be available for use and housed in patient rooms or wards (i.e., not in corridors or temporary beds). Thus, beds in a completely or partially closed wing of the facility are considered available only if the hospital put the beds into use when they are needed. The term “available beds” as used for the purpose of counting beds is not intended to capture the day-to-day fluctuations in patient rooms and wards being used.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
136 F. Supp. 2d 667, 2001 U.S. Dist. LEXIS 4658, 2001 WL 332064, Counsel Stack Legal Research, https://law.counselstack.com/opinion/clark-regional-medical-center-v-shalala-kyed-2001.