Hoag Mem'l Hosp. Presbyterian v. Kent

248 Cal. Rptr. 3d 486, 36 Cal. App. 5th 413
CourtCalifornia Court of Appeal, 5th District
DecidedJune 17, 2019
DocketA153724
StatusPublished
Cited by3 cases

This text of 248 Cal. Rptr. 3d 486 (Hoag Mem'l Hosp. Presbyterian v. Kent) is published on Counsel Stack Legal Research, covering California Court of Appeal, 5th District primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hoag Mem'l Hosp. Presbyterian v. Kent, 248 Cal. Rptr. 3d 486, 36 Cal. App. 5th 413 (Cal. Ct. App. 2019).

Opinion

Petrou, J.

*416The central question before us is whether an administrative appeal challenging the overall legality of a Medi-Cal audit reduction encompasses a later challenge to an alleged calculation error within that same audit for purposes of determining timeliness of the calculation error challenge. We find it does not.

Petitioner Hoag Memorial Hospital Presbyterian (Hoag) is an acute care hospital whose patients include beneficiaries of California's Medi-Cal program. The California Department of Health Care Services (the Department) prepared a Medi-Cal audit reviewing Hoag's cost report for fiscal year 2009, including $ 2,413,623 in audit reimbursement reductions mandated by Assembly Bill (AB) 5 and AB 1183. Hoag filed an administrative appeal that was a blanket challenge to the legality of those assembly bills, and hence the legality of the reimbursement reductions based upon them. Over one and one-half years later, Hoag submitted a second administrative appeal regarding an alleged $ 620,903 calculation error that it requested be "incorporated" into the open administrative appeal. Hoag alleged that if its global challenge failed, the $ 2,413,623 reduction should not include $ 620,903 stemming from an erroneous calculation of Medi-Cal days subject to the reductions required by the assembly bills. The Department's Office of Administrative Hearings and Appeals (OAHA) dismissed the administrative appeal of the alleged calculation error as untimely and Hoag filed a petition for writ of administrative mandate, which was denied. As Hoag's legal challenge to the Medi-Cal audit reduction is a separate issue from its challenge to the alleged calculation error and was therefore untimely, we affirm the dismissal of Hoag's administrative appeal.

BACKGROUND

Hoag is a medical surgical acute care hospital in Newport Beach, California. Along with other services, Hoag provides inpatient hospital services to Medi-Cal beneficiaries.

" 'The Medi-Cal program [citation] represents California's implementation of the federal Medicaid program [citation], through which the federal government provides financial assistance to states so that they may furnish medical care to qualified indigent persons. [Citation.] The Department is the single state agency designated to administer the Medi-Cal program. [Citation].' " ( Santa Ana Hospital Medical Center v. Belshe (1997) 56 Cal.App.4th 819, 822, 65 Cal.Rptr.2d 754.)

*417Hospitals that provide inpatient services to Medi-Cal patients are reimbursed either based upon a contractual payment rate or, for hospitals such as Hoag that have no *489negotiated contracts (non-contract hospitals), based upon costs calculated in accordance with regulatory formulas. ( Mission Hospital Regional Medical Center v. Shewry (2008) 168 Cal.App.4th 460, 474, 85 Cal.Rptr.3d 639.) Non-contract hospitals submit annual cost reports to the Department. The Department then audits the cost reports, makes necessary adjustments in the course of the audit, and prepares a final audit report. ( Welf. & Inst. Code, § 14170.) The audit report may be challenged via an administrative appeal process, further discussed below.

The Medi-Cal reimbursement available to hospitals during the relevant period of time was reduced by the passage of AB 5 and AB 1183. ( Santa Rosa Memorial Hospital, Inc. v. Kent (2018) 25 Cal.App.5th 811, 817-819, 236 Cal.Rptr.3d 199 ( Santa Rosa ).) AB 5, as codified, provided for a 10% reduction in specified Medi-Cal reimbursement rates for inpatient services provided by certain non-contract hospitals beginning July 1, 2008. ( Id. at p. 817, 236 Cal.Rptr.3d 199.) AB 1183 further reduced payments to certain non-contract hospitals for dates of service on or after October 1, 2008 to "to the lesser of 90 percent of audited allowable costs or a rate equal to the regional average contract rate minus 5 percent." ( Id. at p. 818, 236 Cal.Rptr.3d 199.) The rate reductions in AB 5 and AB 1183 were prospectively eliminated in April 2011. ( Ibid. ) In 2009, a number of health care providers and hospitals, including Hoag, initiated litigation challenging the AB 5 and AB 1183 reimbursement reductions on the ground that they violated provisions of the Medicaid Act ( 42 U.S.C. § 1396 et seq. ) governing the substantive and procedural requirements the California Legislature and the Department must follow when establishing reimbursement rates. (See Santa Rosa, supra , 25 Cal.App.5th at p. 814, 236 Cal.Rptr.3d 199.)

The Department's Audit of Hoag's 2009 Cost Report

On April 17, 2012, the Department issued its final audit report of Hoag's cost report for its fiscal year ending September 30, 2009 (FYE 2009). The Department found that AB 5 and AB 1183 required reductions totaling $ 2,413,623 to Hoag's FYE 2009 reimbursement. After factoring in these reductions, interim payments to Hoag, and several other audit adjustments, the Department determined that Hoag had been overpaid $ 149,494 for Medi-Cal services provided during FYE 2009. The final audit report notified Hoag that a party could appeal the audit decision in writing, and that "[t]he written notice of disagreement must be received by the *418Department within 60 calendar days" from receipt of the report, citing Welfare and Institutions Code, Section 14171 and California Code of Regulations, title 22, section 51016, et seq.1

May 2012 Administrative Appeal Challenging the Legality of the AB 5 and AB 1183 Reimbursement Reductions

On May 19, 2012, Hoag began the administrative appeals process by filing a timely Statement of Disputed Issues (SODI) contesting the legality of the AB 5 and AB 1183 reimbursement reductions contained in the April 17, 2012 final audit report.

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Bluebook (online)
248 Cal. Rptr. 3d 486, 36 Cal. App. 5th 413, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hoag-meml-hosp-presbyterian-v-kent-calctapp5d-2019.