Dch v. Fulton-Dekalb Hosp.

669 S.E.2d 233
CourtCourt of Appeals of Georgia
DecidedNovember 7, 2008
DocketA08A0948
StatusPublished

This text of 669 S.E.2d 233 (Dch v. Fulton-Dekalb Hosp.) is published on Counsel Stack Legal Research, covering Court of Appeals of Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dch v. Fulton-Dekalb Hosp., 669 S.E.2d 233 (Ga. Ct. App. 2008).

Opinion

669 S.E.2d 233 (2008)

GEORGIA DEPARTMENT OF COMMUNITY HEALTH et al.
v.
FULTON-DeKALB HOSPITAL AUTHORITY et al.

No. A08A0948.

Court of Appeals of Georgia.

November 7, 2008.

Thurbert E. Baker, Atty. Gen., Shalen S. Nelson, Senior Asst. Atty. Gen., Michelle Townes, Asst. Atty. Gen., for Appellants.

Holland & Knight, Charles S. Johnson III, Sarah Catherine Leopold, Joshua I. Bosin, Atlanta, for Appellees.

PHIPPS, Judge.

We granted an application for discretionary appeal by the Georgia Department of Community Health (the DCH) from an order of the Superior Court of Fulton County reversing a decision rendered by the DCH in an administrative proceeding.

Two questions present themselves. The first is whether the petitioners for judicial review—Fulton-DeKalb Hospital Authority, d/b/a Grady Health System, and its division Hughes Spaulding Children's Hospital (referred to collectively as "Grady")—can challenge the constitutionality of the DCH's retroactive application of a revision to its hospital services manual when in the administrative *234 proceeding Grady complained of the retroactive application of the manual but did not challenge it on constitutional grounds. The second is whether the DCH was indeed applying the manual retroactively.

For reasons that follow, we answer both questions in the affirmative and, therefore, affirm the order of the superior court invalidating the DCH's application of the manual.

"Pursuant to [OCGA § 50-13-19], courts review agency findings of fact to determine whether they are supported by any evidence. And in considering agency conclusions of law, courts conduct a de novo review."[1]

Grady renders outpatient medical services to participants in Georgia's Medicaid and Peachcare programs. The DCH is the state agency responsible for administering Georgia's Medicaid program.[2] The record here shows that DCH reimburses Georgia hospitals for outpatient services on an interim payment basis subject to later settlement. The DCH determines allowable and reimbursable charges through settlement calculations contained in the Hospital Statistical and Reimbursement Report (HS & R report).

In 2004, the DCH provided Grady with notices, in response to cost reports submitted by Grady to the DCH for fiscal years 1999 through 2002, that the DCH had overpaid Grady in the approximate amount of $2,076,700. Pursuant to requirements outlined in the DCH's Medicaid Provider Reimbursement Manual, Grady immediately paid that sum to the DCH. Grady then sought administrative review of the notices. In the administrative proceeding, Grady asserted a claim against the DCH to recover most of the money that the DCH had assessed against it. At the administrative hearing, the DCH sought to show that the DCH's overpayment claim was consistent with a revision to its "policies and procedures for hospital services" manual providing that effective with settlements completed on or after July 1, 2003, no other methodology will be used to determine allowable and reimbursable costs other than the HS & R report. The manual further states that the determination of allowable and reimbursable costs is made retrospectively based on cost reports submitted by the hospital. A statement of participation entered into between Hughes Spaulding and the Georgia Department of Medical Assistance (DMA) provides, however, that the participant shall be reimbursed for services rendered in accordance with terms and conditions of the policies and procedures manual "in effect on the date the service is rendered."

Although Grady and the DCH had entered into a settlement agreement in 2002 providing a methodology different than that contained in the HS & R report for determination of allowable Medicaid charges for Grady, the administrative law judge (ALJ) and the Commissioner of the DCH concluded that, even though Hughes Spaulding Children's Hospital is a division of Grady, the settlement agreement does not apply to the children's hospital because the children's hospital and Grady are separate and distinct Medicaid providers with their own Medicaid provider numbers.

At the hearing before the ALJ, Grady argued that it was error for the DCH to apply a July 2003 revision to its hospital services manual retroactively to its review of the children's hospital's cost reports for fiscal years 1999 through 2002. The ALJ rejected this argument and denied Grady's claim that the DCH had erred in its calculation of overpayments.

After the Commissioner affirmed the ALJ's decision, Grady filed a petition for judicial review in the Fulton County Superior Court. On judicial review, the superior court concluded that the DCH's use of the July 2003 manual revision in reviewing the children's hospital's cost reports for prior fiscal years constituted an unconstitutional retroactive application of it. Accordingly, the superior court reversed the DCH's decision and ordered it to remit payment to Grady in the amount of $1,826,333.

*235 1. In this appeal, the DCH charges the superior court with error in allowing Grady to advance arguments not urged in the administrative proceeding.

As authority, the DCH relies on our Supreme Court's decisions in Cerulean Cos. v. Tiller[3] and Dept. of Public Safety v. MacLafferty,[4] and this court's decision in Perkins v. Dept. of Med. Assistance.[5]

In Cerulean, the state insurance commissioner approved a plan for conversion of a health insurance company from a nonprofit company to a new for-profit company. Subscribers of the nonprofit company who had not been issued shares in the for-profit company later brought a lawsuit claiming that the conversion plan should have required the health insurance company to issue such shares to them. We held that those subscribers' failure to raise that issue before the state insurance commissioner and thereby exhaust their administrative remedies barred them from bringing suit. The longstanding Georgia rule, cited by Cerulean, requires that "a party aggrieved by a state agency's decision must raise all issues before that agency and exhaust available administrative remedies before seeking any judicial review of the agency's decision."[6] As pointed out by Cerulean, part of the rationale for requiring exhaustion of administrative remedies is that resort to the administrative process will permit the agency to apply its expertise to matters within the agency's jurisdiction.[7]

In Perkins, two companies that provided transportation services to certain indigent medical patients under contract with the Department of Medical Assistance (DMA) brought suit against the DMA over the method used by the DMA to calculate amounts owed for such transportation. One of the companies, Executive, had not previously sued the DMA or used the administrative appeal process. The other company, Royal Lion, had previously brought suit to adjudicate DMA's methodology and received an award of damages. DMA answered the new suit and moved for either summary judgment or dismissal. In reliance on Cerulean, we held that the trial court should have dismissed Executive's suit without prejudice due to its failure to exhaust administrative remedies.[8]

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Related

United States v. Rapone, Anthony
131 F.3d 188 (D.C. Circuit, 1997)
Perkins v. Department of Medical Assistance
555 S.E.2d 500 (Court of Appeals of Georgia, 2001)
Department of Public Safety v. MacLafferty
195 S.E.2d 748 (Supreme Court of Georgia, 1973)
Cerulean Companies, Inc. v. Tiller
516 S.E.2d 522 (Supreme Court of Georgia, 1999)
Howell v. Harden
203 S.E.2d 206 (Supreme Court of Georgia, 1974)
Infinite Energy, Inc. v. Georgia Public Service Commission
572 S.E.2d 91 (Court of Appeals of Georgia, 2002)
Georgia Department of Community Health v. Fulton-DeKalb Hospital Authority
669 S.E.2d 233 (Court of Appeals of Georgia, 2008)

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Bluebook (online)
669 S.E.2d 233, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dch-v-fulton-dekalb-hosp-gactapp-2008.