Department of Medical Assistance Services v. Beverly Healthcare

585 S.E.2d 858, 41 Va. App. 468, 2003 Va. App. LEXIS 474
CourtCourt of Appeals of Virginia
DecidedSeptember 9, 2003
DocketRecord 0802-02-2
StatusPublished
Cited by13 cases

This text of 585 S.E.2d 858 (Department of Medical Assistance Services v. Beverly Healthcare) is published on Counsel Stack Legal Research, covering Court of Appeals of Virginia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Department of Medical Assistance Services v. Beverly Healthcare, 585 S.E.2d 858, 41 Va. App. 468, 2003 Va. App. LEXIS 474 (Va. Ct. App. 2003).

Opinion

CLEMENTS, Judge.

This appeal arises from an order of the Circuit Court of Spotsylvania County (circuit court) reversing the ruling of the Director of the Department of Medical Assistance Services (DMAS) that, pursuant to 12 VAC 30-90-20(C), the appellees, eight nursing home facilities in Virginia that disputed DMAS’s calculation of their Medicaid reimbursement payments, were not entitled, for the years at issue, to reimbursement for their Medicaid-related expenses under the higher cost ceiling applicable to Northern Virginia. In reversing the DMAS Director’s ruling, the circuit court concluded the DMAS Director’s interpretation of 12 VAC 30-90-20(C) was contrary to the plain meaning of the regulation and was, thus, arbitrary and capricious. In that same order, the circuit court also affirmed the DMAS Director’s ruling that four of the appellees were time barred from challenging their Medicaid reimbursement payments for five of the years at issue and further held that the appellees were entitled to recover their attorneys’ fees and costs subject to a statutory cap of $25,000 applicable to the appellees as a group. On appeal, DMAS contends the circuit court erred (1) in concluding the DMAS Director’s interpretation of the relevant Medicaid regulation was arbitrary and capricious and (2) in awarding attorneys’ fees and costs to the appellees. On cross-appeal, the appellees contend the circuit court erred (1) in affirming the DMAS Director’s decision that four of the appellees were time barred from *473 challenging their Medicaid reimbursement payments for certain years and (2) in ruling the fees and costs awarded to the appellees were capped at $25,000 for the appellees as a group. In addition, the appellees seek an award of appellate attorneys’ fees. For the reasons that follow, we affirm the circuit court’s judgment that the DMAS Director’s interpretation of 12 VAC 30-90-20(C) was arbitrary and capricious, that the appellees were entitled to attorneys’ fees and costs, and that certain appellees were time barred from challenging their reimbursement classifications for certain years. We reverse the circuit court’s judgment that the fees and costs awarded to the appellees were statutorily capped at $25,000 for the appellees as a group and remand this matter to the circuit court for determination of the appropriate attorneys’ fees and costs.

I. BACKGROUND

The facts in this case are not in dispute. At all times relevant to this appeal, the appellees, Beverly Healthcare of Fredericksburg, f/k/a Fredericksburg Nursing Home, located in Spotsylvania County; Carriage Hill Nursing Home, located in Spotsylvania County; Heritage Hall-Front Royal, located in Warren County; Heritage Hall-King George, located in King George County; Lynn Care Center, located in Warren County; Oak Springs of Warrenton, located in Fauquier County; Rose Hill Nursing Home, located in Clarke County; and Warrenton Overlook Health & Rehabilitation, f/kja Warrenton Overlook Care Center, located in Fauquier County, were nursing home facilities participating in Virginia’s Medicaid program. 1 As participants in that program, the appellees

*474 were entitled to reimbursement by the Commonwealth for their reasonable and necessary operational and capital costs incurred in providing nursing care and other medical services to Medicaid recipients. DMAS is the state agency responsible for administering Virginia’s Medicaid program.

Under the Virginia Medicaid program, each participating nursing facility must submit an annual cost report to DMAS detailing the actual costs incurred by the facility for the care and services provided to Medicaid patients. DMAS then reviews the nursing facility’s cost report and issues a “Notice of Program Reimbursement” to the facility setting forth the costs that are to be reimbursed to the facility and the costs *475 that are disallowed under the Medicaid program and identifying any adjustments in the reimbursement payment amount to reflect DMAS’s determination that it has underreimbursed or overreimbursed the facility during the cost year under consideration. If the nursing facility disagrees with DMAS’s reimbursement determination, the facility may appeal the matter in accordance with the Administrative Process Act and “the state plan for medical assistance.” Code § 32.1-325.1(B).

To control costs, DMAS has instituted cost ceiling limitations, or caps, on the reimbursement of certain costs incurred by nursing facilities in providing service to Medicaid patients. A nursing facility will not be reimbursed for costs that exceed the facility’s cap. To ensure that nursing facilities operating in different economic environments in Virginia are reimbursed similarly, DMAS has divided the Commonwealth into three distinct geographic regions or “peer groups,” each with its own cap: (1) “the Virginia portion of the Washington DC-MD-VA Metropolitan Statistical Area (MSA),” (2) the “Richmond-Petersburg” MSA, and (3) the “rest of the state.” 12 VAC 30-90-20(C). Because the urban area in which they operate is generally more expensive, nursing facilities in the “Virginia portion of the Washington DC-MD-VA” MSA (Northern Virginia MSA) peer group have a higher reimbursement cap than those in the “rest of the state” peer group.

To determine, for Medicaid reimbursement purposes, whether a nursing facility is in one of the MSA peer groups or in the “rest of the state” peer group, DMAS relies on the list of urban-area jurisdictions published in a final rule by the Health Care Financing Administration (HCFA), the federal agency within the United States Department of Health and Human Services that administers the Medicare program. See id. Generally, a facility located in a city or county included on HCFA’s list of constituent jurisdictions of the Northern Virginia urban area or the Richmond-Petersburg urban area is considered a member of that respective area’s corresponding MSA peer group. See id. Conversely, a facility located in a jurisdiction not included on HCFA’s list of jurisdictions in either the Northern Virginia or Richmond-Petersburg urban *476 area is considered a member of the “rest of the state” peer group. See id.

In compiling and revising its list of urban areas, HCFA relies, in turn, on the latest list of MSAs published by the federal Office of Management and Budget (OMB). Applying decennial census data and federal Census Bureau population estimates to various standards, OMB designates certain geographic areas of the country as MSAs. The boundaries of each MSA reflect OMB’s judgment that, for statistical purposes, the jurisdictions located within those boundaries constitute metropolitan areas. 2 OMB periodically revises its MSA designations to reflect changing populations and economic conditions, adding new jurisdictions that, based on the most current data and standards, qualify as metropolitan areas or removing jurisdictions that no longer qualify. When HCFA updates Medicare payment rates, it adopts OMB’s latest revised MSA designations, which remain in effect until new MSA designations are adopted by HCFA and published in a final rule.

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Cite This Page — Counsel Stack

Bluebook (online)
585 S.E.2d 858, 41 Va. App. 468, 2003 Va. App. LEXIS 474, Counsel Stack Legal Research, https://law.counselstack.com/opinion/department-of-medical-assistance-services-v-beverly-healthcare-vactapp-2003.