High Country Home Health, Inc. v. Shalala

123 F. Supp. 2d 1275, 1999 U.S. Dist. LEXIS 22689, 1999 WL 33220005
District Court, D. Wyoming·Decided March 25, 1999·No. No. 98-CV-184-J·Published·Cited by 1 cases

Opinion

ORDER ON DISPOSITIVE MOTIONS

ALAN B. JOHNSON, Chief Judge.

The Plaintiffs “Motion for An Order to Declare Unlawful and Set Aside Secretary’s Decision of March 18, 1998” and the “Defendant Secretary’s Motion to Affirm” came before the Court for hearing February 24, 1999. Appearing for plaintiff were Charles MacKelvie of Chicago, Illinois and R. Douglas Dumbrill of Gillette, Wyoming; appearing for the defendant was Thomas Roberts, Assistant United States Attorney. The Court, after hearing arguments of counsel, and after having reviewed the pleadings and administrative record, and the applicable law, FINDS and ORDERS as follows:

Background

This is an appeal of the May 22, 1998 Health Care Financing Administration (“HCFA”) Administrator’s decision denying the plaintiff-provider compensation as an administrator/owner of a home health agency (HHA) health care provider, reversing the Provider Reimbursement Review Board (PRRB) March 18, 1998 unanimous decision holding that the proposed reimbursement adjustment was improper. The Secretary seeks affirmance of the HCFA Administrator’s reversal of the PRRB decision; the plaintiff seeks to have it set aside.

The issue is whether the intermediary of the Secretary properly disallowed a portion of the administrator/owner’s compensation. Plaintiff-provider, High Country Home Health, Inc., is a home health agency owned and administrated by a husband and wife team, Reed and Marilyn Pedrick, in Laramie, Wyoming. The owner, Reed Pedrick, provides physical therapy services in an independent clinic and also provides administrative services for the provider, High Country Health, for the fiscal year at issue in this case, 1993. The field intermediary, Wellmark-Blue Cross Blue Shield of Iowa, audited the provider’s cost report for fiscal year ending June 1993. A significant portion of owner-administrator’s claimed compensation for that fiscal year was disallowed. Pedrick claimed compensation in the amount of $91,498, which was reduced by the intermediary in the amount of $58,040 to $33,458, after finding that the amount claimed by the owner-administrator for High Country was unreasonable compensation for the owner’s dual services. The effect of the finding is that the Provider was overpaid and reimbursement to the program would be required.

A hearing was held before the PRRB, and the intermediary’s adjustment to the owner-administrator’s compensation was reversed as improper. The PRRB’s decision was reversed by the Secretary (acting through the HCFA Administrator) and the Secretary determined the adjustment was appropriate.

The intermediary had disallowed the claimed compensation on the basis that the amount claimed was unreasonable and substantially out of line with comparable providers. The Provider asserts the en[1277] tire amount of the claim ($91,000 +) is the actual reasonable cost of providing Medicare services to beneficiaries which is not substantially out of line with compensation paid by comparable providers in the same geographical region. Pedrick claims he worked 70 hour weeks and should be compensated for his physical therapy visits and the administrative amount requested in entirety. The intermediary determined that of 3,120 hours worked, the owner spent 1,989 hours on physical therapy visits, leaving 1,131 hours of his total time for administrative purposes. The intermediary determined that the 1,131 hours comprised about 35% of the total time spent working by the owner administrator, and thus, determined that only approximately 35% of the total amount claimed should be paid as reasonable compensation for the owner’s administrative services.

High Country, the Provider, argues that hours actually worked by the owner-administrator were greater, as shown by time records kept by the Provider. The Provider argues that he should be entitled to, at the very minimum, the percentage represented by 1,131/2,080 [the number of hours generally used to determine full-time employment], for a greater percentage (approximately 54%) of the amount claimed. However, the Provider further argues that the compensation claimed, in entirety, is reasonable compensation, and that the intermediary’s use of a 1979 Michigan survey in determining comparable compensation for this Provider is invalid and yields incorrect results. The Provider argues that intermediary did not follow administrative regulations and policy in finding that the Michigan survey set out valid, reasonable comparisons of compensation paid to such providers. The Provider asserts that the survey is too old, is not a survey of providers in the High Country universe as Michigan is too remote geographically, the survey does not compare “apples to apples” because it was prepared for OPT’s (outpatient physical therapists) rather than home health agencies, and the survey is inappropriately adjusted to account for inflation. There are two other surveys that were referred to in the reasonable compensation determination, which are similarly criticized by the Provider as inaccurate, an incomplete universe of samples, using inappropriate statistical techniques and invalid geographically.

The Provider argues that under Medicare laws, regulations and instructions, it is entitled to reimbursement for actual reasonable costs in providing services to Medicare beneficiaries unless the governmental agency can demonstrate that those costs are substantially out of line. In determining reasonableness of claimed owner-administrator compensation, comparisons are to be made to comparable individuals and institutions, and the comparison applies to geography, type of services, size, type of personnel, etc. The Provider argues the claimed compensation for fiscal year 1993 was reasonable and well within the range provided as reasonable compensation for comparable services in comparable institutions. The Provider seeks compensation of the entire amount claimed as compensation for full-time services. Provider also argues that necessary non-owner data can be obtained in this case that are of greater validity, citing to a Denver survey as an example. The Provider argues he should receive fair payment under the Medicare regulations for services actually provided and that,the intermediary failed to carry the burden of proving that his costs are substantially out of line in order to justify its denial of reimbursement for actual reasonable costs in' providing services to Medicare beneficiaries.

In opposition, the Secretary argues that it acted appropriately in using the Michigan survey and in reducing the amount of compensation to the Provider, It argues that administrative services were furnished by the owner on a less than full-time basis and that it is also entitled to use “other appropriate means” in determining owner-administrator’s salaries. The concern is that as an owner-administrator setting his/her own salary, the salary will be [1278] out of line with comparable HHA administrators and will not truly reflect the reasonable value of comparable services that have been provided. Reasonableness of compensation for owner-administrators depends upon the facts and circumstances of each case. The Secretary argues High Country failed to show Pedrick actually worked full-time as an owner-administrator and was only able to document working a 60 hour week. Where services are furnished on a less than full-time basis, allowable compensation must reflect an amount proportionate to a full-time basis, citing 42 C.F.R. § 413.102(c)(2).

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High Country Home Health, Inc. v. Shalala, 123 F. Supp. 2d 1275, 1999 U.S. Dist. LEXIS 22689, 1999 WL 33220005 (D. Wyo. 1999).

123 F. Supp. 2d 1275 (High Country Home Health, Inc. v. Shalala) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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