In Re Greenwald

33 B.R. 607, 1983 Bankr. LEXIS 5344
CourtUnited States Bankruptcy Court, S.D. New York
DecidedSeptember 26, 1983
Docket19-35346
StatusPublished
Cited by3 cases

This text of 33 B.R. 607 (In Re Greenwald) is published on Counsel Stack Legal Research, covering United States Bankruptcy Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
In Re Greenwald, 33 B.R. 607, 1983 Bankr. LEXIS 5344 (N.Y. 1983).

Opinion

DECISION ON SUMMARY JUDGMENT RE: REIMBURSEMENT OF HEALTH CARE BENEFITS

HOWARD SCHWARTZBERG, Bankruptcy Judge.

The motion and cross-motion for summary judgment in this case involve the entitlement of the Chapter 11 debtor, the operator of a residential health care facility, to reimbursement from the New York State Commissioner of the Department of Health under Title XIX of the Federal Social Security Act, 42 U.S.C. §§ 1396a-1396p (Supp. V 1981) (the “Medicaid Act”). The debtor, Sidney Greenwald d/b/a Maple Leaf Nursing Home, commenced an adversary proceeding against the Commissioner seeking two forms of Medicaid reimbursement allegedly owing for the years 1973 and 1975. The Commissioner has asserted an array of defenses consisting of eleventh amendment immunity, expiration of applicable statutes of limitation, failure to exhaust administrative remedies and the right to summary judgment on the merits.

Medicaid Reimbursement in New York State

Under the Medicaid Act, the federal government grants to the states a percentage of the funding required to provide medical care to patients unable to afford it. See Sehweiker v. Gray Panthers, 453 U.S. 34, 36, 101 S.Ct. 2633, 2636, 69 L.Ed.2d 460 (1981). In New York State, the State and local governments furnish the remainder of the funding. Reimbursement rates for residential health care facilities similar to that of the debtor are promulgated by the Department of Health (“DOH”).

The methodology employed in fixing reimbursement rates under the state scheme is generally prospective in nature. Essentially, computation of the rates is based on the actual costs incurred by a facility during an earlier “base” period. To be allowable, these costs must be reasonably related to patient care and within various cost ceilings. The allowed costs are then adjusted by a “trend factor” to reflect inflation because the base period is an attempt to approximate more accurately expenses to be incurred during the rate year. A factor for capital costs is then applied to arrive at a uniform average per diem reimbursement rate for each day of care rendered to a Medicaid eligible patient. 1

Base year cost reports, submitted by a facility seeking Medicaid reimbursement, are subject to subsequent audit by DOH. See N.Y.Pub. Health Law § 2803(l)(b)(ii) (McKinney Supp. 1982-1983); 10 N.Y.C. R.R. § 86-2.7 (1983). A retroactive rate adjustment may be sought if a cost report audit so necessitates, but the audit is final unless the facility requests bureau review within 30 days of receiving an audit report. 10 N.Y.C.R.R. § 86-2.7(e). A second level administrative remedy is provided by appealing from the bureau review within 30 days of written notification of its outcome. 10 N.Y.C.R.R. § 86-2.7(f).

The Salary Cost Appeal

The complaint demands reimbursement for labor' cost increases that the facility incurred in 1975. DOH established 1975 reimbursement rates for the debtor’s facility from which the debtor took a timely administrative appeal pursuant to 10 N.Y.C. R.R. § 86-2.14(b) (authorizing administrative appeal of reimbursement rate within 120 days of rate notification). The appeal was based upon higher labor costs the facility incurred as a result of a collective bargaining agreement it entered into with its employees. This agreement had not been considered by DOH when it initially fixed the reimbursement rate. DOH’s Board of Audit and Investigation later confirmed the *610 escalated labor costs and increased the 1975 reimbursement amount by $265,298. A further audit caused DOH to reduce this figure to $250,934.

The dispute which is the subject of the present litigation arose when DOH refused to pay the additional reimbursement to the debtor pending additional audits of the facility instituted by the Office of the Special Prosecutor for Medicaid Fraud (“OSP”) for 1973-74 and by DOH for 1975-76. The OSP audits were later turned over to DOH and expanded to cover 1977-79. From these audits DOH expected to uncover substantial reimbursement overpayments to the debtor and disclosed its intention to consolidate the salary appeal with the audit proceedings. 2

In light of the denial of the debtor’s demand for the 1975 reimbursement pending the audits, the debtor commenced an action against the Commissioner of the DOH in the United States District Court for the Southern District of New York challenging the consolidation which held in abeyance the salary reimbursement. Greenwald v. Axelrod, 80 Civ. 2396 (S.D. N.Y. May 27, 1981). This action was subsequently dismissed upon the court’s finding that “in the absence of bad faith or dilatoriness ... the procedure of consolidating the salary appeal and the base year audits [is] reasonable under the circumstances of this case and not violative of applicable statutes.” Id., slip op. at 4-5. In June 1981, after the district court action was dismissed, the 1973-74 OSP audit and bureau review of that audit conducted pursuant to 10 N.Y.C.R.R. § 86-2.7(a) were completed. The debtor followed with a second level administrative appeal of the audit in the form of an administrative hearing. See 10 N.Y.C.R.R. § 86-2.7(d). The 1975-79 audit is also final and bureau review of the audit for this period has been timely requested.

More than two years have elapsed since the district court approved consolidation of the salary appeal and audits. A portion of these audit proceedings has now been pending for over five years. Each party blames the other for the delay. The debtor urges the court to find “bad faith and dilatoriness” on the part of DOH so that consolidation of the salary appeal is no longer “reasonable” as within the meaning of the district court’s decision. Moreover, the debtor maintains that withholding of its 1975 reimbursement allowance contravenes the Medicaid Act, the Supremacy and Due Process Clauses of the United States Constitution, gives rise to a cause of action under 42 U.S.C. § 1983, and therefore' excuses exhaustion of administrative remedies under recognized exceptions to the doctrine.

On the other hand, DOH declares it is entitled to summary judgment on the salary cost issue because the debtor has not availed itself of all administrative remedies. DOH accuses the debtor of being uncooperative during the audits and responsible for the delays.

Start-up and Group Average Costs

The debtor also seeks reimbursement for start-up costs and what it labels “group average costs” incurred during 1973, the year in which the debtor’s facility was established. Some time prior to January 22, 1973, DOH licensed and certified the debt- or’s facility as a 120 bed residential health care facility.

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Related

Greenwald v. Axelrod (In Re Greenwald)
48 B.R. 263 (S.D. New York, 1984)
Greenwald v. Axelrod (In Re Greenwald)
34 B.R. 952 (S.D. New York, 1983)

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Bluebook (online)
33 B.R. 607, 1983 Bankr. LEXIS 5344, Counsel Stack Legal Research, https://law.counselstack.com/opinion/in-re-greenwald-nysb-1983.