Commonwealth, Cabinet for Health & Family Services v. Rivervalley Behavioral Health

465 S.W.3d 460, 2014 Ky. App. LEXIS 148, 2014 WL 4258277
CourtCourt of Appeals of Kentucky
DecidedAugust 29, 2014
DocketNo. 2013-CA-001226-MR
StatusPublished
Cited by5 cases

This text of 465 S.W.3d 460 (Commonwealth, Cabinet for Health & Family Services v. Rivervalley Behavioral Health) is published on Counsel Stack Legal Research, covering Court of Appeals of Kentucky primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Commonwealth, Cabinet for Health & Family Services v. Rivervalley Behavioral Health, 465 S.W.3d 460, 2014 Ky. App. LEXIS 148, 2014 WL 4258277 (Ky. Ct. App. 2014).

Opinion

[462]*462 OPINION

MAZE, Judge:

The Commonwealth of Kentucky, Cabinet for Health and Family Services (the Cabinet), and the Cabinet Secretary appeal from a May 30, 2012 opinion and order by the Franklin Circuit Court which granted the statutory appeal by RiverVal-ley Behavioral Health and set aside the Final Order entered by the Cabinet Secretary. The Cabinet primarily argues that the circuit court failed to give proper deference to its interpretation of the controlling statutes and regulations regarding the setting of Medicaid reimbursement rates. However, we agree with the circuit court that the Cabinet acted in excess of its statutory authority by freezing RiverVal-ley’s reimbursement rates for seven years without reference to its actual costs. We further agree with the circuit court that the Secretary’s Final Order failed to set forth sufficient findings to explain the deviation from the hearing officer’s recommended findings concerning the amount which RiverValley is owed. Consequently, the circuit court properly adopted the recommended order, and we affirm.

The circuit court set out the undisputed factual and procedural history of this case as follows:

The procedural history of this case is unconventional and protracted. River-Valley Behavioral Health (hereinafter “RiverValley”) is a not-for-profit mental health provider offering inpatient services for juveniles in and around Da-viess County, Kentucky. The Cabinet’s Department for Medicaid Services (hereinafter “DMS”) regularly reimburses mental health providers, including RiverValley, for inpatient psychiatric services for Medicaid patients. At issue in this appeal are reimbursements for the period of July 1, 2000 through October 14, 2007. Petitioner claims that the rate of reimbursement set by DMS for services provided was not reasonable or adequate, and was not related to the actual cost of providing care, as required by the applicable statute. DMS issued its final July 1, 2000 rate notice on May 13, 2004, which RiverValley then challenged. An initial review of this issue occurred at the administrative level. On July 22, 2004 a Dispute Resolution Meeting (hereinafter “DRM”) was held pursuant to 907 [Kentucky Administrative Regulations (KAR) ] 1:671, Section 8. No Dispute Resolution Decision was ever issued, as provided for in 907 KAR 1:671, Section 8(1), and no administrative hearing was ever held. On March 24 2009 DMS did give RiverVal-ley notice that the final rates for the July 1, 2001 through October 14, 2007 rate periods were all set at $374.85 per diem. RiverValley again filed a timely request on this rate in accord with the regulations. Because the Cabinet essentially refused to process its administrative appeal of this decision, RiverVal-ley sought relief by filing the present action in Franklin Circuit Court.
The Franklin Circuit Court action was filed May 13, 2009. The Court noted the Cabinet’s argument that RiverValley failed to complete administrative processes for seeking internal review of its decision, but recognized that RiverVal-ley attempted to exhaust its administrative remedies to no avail. The Court was convinced that it was in the public interest to seek resolution of Petitioner’s claims through mediation. The Court recognized that RiverValley had already waited more than five years for an administrative decision, and that no progress had been made toward resolving the dispute. It appeared from the record that the failure to resolve the dispute was largely due to the Cabinet’s [463]*463unwillingness to process the administrative appeal, and that RiverValley was being unfairly penalized through this delay caused primarily, if not exclusively, by the Cabinet.

This Court, ■ after consultation with and agreement by the parties, referred the matter to mediation per Local Rule 14. The parties further agreed, and the Court ordered, that the mediation, if unsuccessful, would be followed by a summary administrative proceeding that would be conducted in lieu of a remand for exhaustion of administrative remedies. Both parties agreed to this procedure, and the Court appointed Hon. Roger Crittenden as mediator. The parties agreed that Judge Crittenden would also serve as hearing officer and would make a recommended order to the Cabinet Secretary in the event mediation was unsuccessful.

Mediation did prove unproductive. Judge Crittenden held a further hearing and allowed a full opportunity for both parties to present all documentary evidence, legal argument, factual presentation, and testimony. Thereafter, Judge Crittenden made a recommendation to the Cabinet Secretary in the same manner as a hearing officer’s report and recommendation per Chapter 18B. A two-day summary hearing was held in June, 2011 and both parties presented testimony. Following the hearing, Judge Crittenden issued his formal Findings of Fact, Conclusions of Law, and Recommended Decision.
The Recommended Decision thoroughly details the process by which DMS pays free-standing psychiatric hospitals such as RiverValley a per diem rate for inpatient psychiatric hospital services to Medicaid patients. These per diem rates are typically established by DMS at the beginning of the July 1 rate year, and the rates are based on the previous year’s Medicaid allowable costs, with some adjustments made for inflation. (Recommended Decision, p. 3-4). The total allowable costs are then divided by a facility’s total Medicaid days to arrive at a per diem rate. (Id) The parties agreed that RiverValley was actually paid $374.85 per diem for the July 1, 2000 rate year through October 14, 2007, as calculated by DMS. (Id at 5). The 2001 rate was established based on the lesser July 1, 2000 rate.
This July 1, 2000 rate was calculated based on RiverValley’s FYE June 30, 1999 cost report, adjusted for inflation. However[,] fixed costs were spread out over an unusually large number of patient days in that year, resulting in costs per day that when calculated were unusually low. (Id) RiverValley argues, and the uncontested record supports, that these and other changes in circumstances resulted in the inadequate per diem rate of $374.85, and that RiverVal-ley’s actual costs were in fact $456.36 per diem. (Id. at 6). Mr. Cooper, a DMS Budget Reimbursement Officer who testified at the hearing conceded in his testimony, “[RiverValley] and I probably have a different definition of adequate, but mine would be we are covering your [marginal] costs and we are covering a [proportional] amount of your fixed costs. And we were not.” (Id at 6; Cooper Tr. Vol I, pp. 111-12). Further he stated, “RiverValley, to my recollection, caught the worst in terms of a prospective rate, being that their census was high and then .it was low. And I can’t recall of another hospital being in that dilemma.” (Id at 7; Cooper Tr. At [119]).
Judge Crittenden’s Recommended Decision also details changes made to DMS regulations. Prior to June 29, 2001, any changes in the hospital’s cir[464]*464cumstances which might cause the rate to be inadequate for one year would have been taken into consideration and the rate year adjusted accordingly. However, DMS filed an emergency regulation on June 29, 2001, which provided that psychiatric hospitals would receive either the rate established for the previous July 1, 2000 rate year, or its costs as determined by the traditional rate setting method based on a calculation of the hospital’s costs, whichever amount was less. 907 KAR 1:013E, Section 15.

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

Related

Cite This Page — Counsel Stack

Bluebook (online)
465 S.W.3d 460, 2014 Ky. App. LEXIS 148, 2014 WL 4258277, Counsel Stack Legal Research, https://law.counselstack.com/opinion/commonwealth-cabinet-for-health-family-services-v-rivervalley-kyctapp-2014.