Encompass Health Rehabilitation Hospital of Sarasota, LLC v. Becerra

CourtDistrict Court, M.D. Florida
DecidedSeptember 11, 2024
Docket8:22-cv-02573
StatusUnknown

This text of Encompass Health Rehabilitation Hospital of Sarasota, LLC v. Becerra (Encompass Health Rehabilitation Hospital of Sarasota, LLC v. Becerra) is published on Counsel Stack Legal Research, covering District Court, M.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Encompass Health Rehabilitation Hospital of Sarasota, LLC v. Becerra, (M.D. Fla. 2024).

Opinion

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF FLORIDA TAMPA DIVISION

ENCOMPASS HEALTH REHABILITATION HOSPITAL OF SARASOTA, LLC, et al.,

Plaintiffs,

v. Case No: 8:22-cv-2573-KKM-UAM

XAVIER BECERRA,

Defendant. ___________________________________ ORDER Medicare denied coverage to Encompass Health Rehabilitation Hospital of Sarasota, LLC, and Encompass Health Rehabilitation Hospital of Largo, LLC, (“Encompass”) for the medical services that Encompass provided to sixty-three patients. In each case, an administrative law judge (ALJ) determined that the patient’s medical condition did not justify the type of care offered by Encompass. Encompass requested review of the ALJs’ decisions, but the Medicare Appeals Council affirmed after finding that Encompass’s requests did not adequately explain its reasons for appealing. 42 C.F.R. § 405.1112(b) (requiring appellants to explain their disagreement with an ALJ’s decision). Encompass now asks this Court to remand the cases to the agency. Pl. MSJ

(Doc. 53) at 97. For the reasons given below, the Court instead affirms. I. BACKGROUND From 2012 to 2017, Encompass provided various inpatient rehabilitation facility

(IRF) services to the sixty-three patients at issue in this case. Pl. MSJ at 8; Def. MSJ (Doc. 61) at 5. “Compared to other rehabilitation settings, IRFs maintain a high level of physician supervision in order to provide intensive rehabilitation therapy services.”

, No. 8:14-cv-778, 2021 WL 149265, at *1 (M.D. Fla. Jan. 15, 2021) (quotation omitted), , No. 21-10421, 2021 WL 6102260 (11th Cir. Dec. 23, 2021). erefore, the Centers for Medicare and Medicaid Services (CMS) takes care to discern

whether IRF services are “reasonable and necessary” and thus reimbursable. 42 U.S.C. § 1395y(a)(1)(A). During the relevant time period, CMS regulations specified that IRF services are

only reasonable and necessary when there is a reasonable expectation that the patient’s condition: (i) Requires the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy), one of which must be physical or occupational therapy. (ii) Generally requires and can reasonably be expected to actively participate in, and benefit from, an intensive rehabilitation therapy program. Under current industry standards, this intensive rehabilitation therapy program generally consists of at least 3 hours of therapy (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy) per day at least 5 days per week. . . . Benefit from this intensive rehabilitation therapy program is demonstrated by measurable improvement that will be of practical value to the patient in improving the patient's functional capacity or adaptation to impairments. e required therapy treatments must begin within 36 hours from midnight of the day of admission to the IRF. (iii) Is sufficiently stable at the time of admission to the IRF to be able to actively participate in the intensive rehabilitation therapy program that is described in [the previous] paragraph . . . (iv) Requires physician supervision by a rehabilitation physician, defined as a licensed physician with specialized training and experience in inpatient rehabilitation. e requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient's stay in the IRF to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient's capacity to benefit from the rehabilitation process. 42 C.F.R. § 412.622(a)(3) (2010). Collectively, these four requirements are known as the beneficiary eligibility criteria. CMS regulations also imposed other limitations on IRF coverage. ese included technical documentation criteria, which oblige the party seeking reimbursement to include several types of medical records in the patient’s file. § 412.622(a)(4). Further, “the patient must require an interdisciplinary team approach to care” consisting of weekly team meetings between a rehabilitation physician, a registered nurse, a social worker or case

manager, and a therapist from each therapy discipline involved in treating the patient. § 412.622(a)(5). If coverage is denied, either the hospital or the patient is liable for the expense. 42 U.S.C. § 1395pp (identifying who is liable under what circumstances).

Medicare claims are initially adjudicated by a private contractor, 42 U.S.C. § 1395ff(a)(1), and objections to the contractor’s decision are subject to a multi-step appeal process. To start, parties who are denied reimbursement may ask the contractor to

reevaluate its decision. . § 1395ff(a)(3). If the contractor still denies coverage, parties may seek review from a new, independent contractor. . § 1395ff(b)(1), (c). If the second contractor agrees with the first, parties may ask an ALJ to adjudicate the coverage

decision. . § 1395ff(d)(1). If the ALJ also denies coverage, parties may appeal to the Medicare Appeals Council. . § 1395ff(d)(2). e agency denied the claims at issue here at each level of review, culminating in

the Council’s affirmation of the denial of coverage. AR Vols. 1–63 at 3–4. Encompass then sought judicial review by suing the Secretary of the United States Department of Health and Human Services in this Court. Compl. (Doc. 1). Both parties now move

for summary judgment. II. LEGAL STANDARDS

In an action for judicial review of a Medicare claim denial, the district court sits as an appellate tribunal. 42 U.S.C. § 405(g) (providing for judicial review of final decisions of the Commissioner of Social Security); 42 U.S.C. § 1395ff(b)(1)(A)

(incorporating § 405(g) for Medicare). “[J]udicial review of the Secretary’s decision regarding a claim for Medicare benefits is limited to whether there is substantial evidence to support the findings of the Secretary, and whether the correct legal standards were

applied.” , 468 F.3d 1347, 1350 (11th Cir. 2006) (cleaned up). “Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a

conclusion.” , 614 F.3d 1276, 1280 (11th Cir. 2010). Summary judgment motions are the correct mechanism to resolve Medicare appeals in the district court, but the appropriate legal standard is supplied by 42 U.S.C. § 405(g),

not Federal Rule of Civil Procedure 56. , 175 F. Supp. 3d 1338, 1349 (M.D. Fla. 2016), ., 702 F. App’x 856 (11th Cir. 2017). III. DISCUSSION

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