Jellico Community Hospital, Inc. v. Tennessee Department of Health

906 S.W.2d 455, 1995 Tenn. App. LEXIS 227
CourtCourt of Appeals of Tennessee
DecidedApril 7, 1995
StatusPublished

This text of 906 S.W.2d 455 (Jellico Community Hospital, Inc. v. Tennessee Department of Health) is published on Counsel Stack Legal Research, covering Court of Appeals of Tennessee primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jellico Community Hospital, Inc. v. Tennessee Department of Health, 906 S.W.2d 455, 1995 Tenn. App. LEXIS 227 (Tenn. Ct. App. 1995).

Opinion

OPINION

TODD, Presiding Judge.

The petitioner, Jellico Community Hospital, Inc., has appealed from the judgment of the Trial Court affirming an administrative decision of the Commissioner of Health which denied the request of petitioner that he recompute its Medicaid Disproportionate Share Adjustment for the fiscal years, 1988 and 1989.

On appeal, petitioner presents the following issues for review:

1.Whether federal law requires the Department to consider out-of-state Medicaid days when calculating Medicaid disproportionate share payments (MDSA).
2. Whether the Department erred by calculating MDSA due Jellico on instate Medicaid days without taking into consideration the Medicaid days provided by Jellico to out-of-state residents.
3. Whether the Department determined the MDSA due Jellico on the “best information available” as required by its rules.
4. Whether the Department erred by failing to request on its cost report form the total number of Medicaid days including out-of-state Medicaid days since this was necessary to accurately calculate MDSA.
5. Whether the Department erred by using a figure from Jellico’s Cost Report for purposes of calculating its MDSA which the Department knew reflected only instate Medicaid days and not the total number of Medicaid days experienced by the hospital.
6. Whether the Department had a duty to attempt to accurately determine by survey or otherwise Jellico’s total number of Medicaid days for purposes of computing MDSA.
7. Whether the Department erred by failing to compute Jellico’s MDSA from its Joint Annual Report which lists Jellico’s total number of Medicaid days.
8. Whether the Department erred by refusing to recompute MDSA due Jellico for fiscal years 1988 and 1989 by taking into account its out-of-state Medicaid days.
9. Whether the Department erred by refusing to pay Jellico the funds owed to it based upon a computation of its MDSA for fiscal years 1988 and 1989 that takes into account its out-of-state Medicaid days.

The Tennessee Department of Health, headed by the Commissioner of Health, has the responsibility of disbursing Medicaid funds to hospitals for health care services provided by them to qualified indigents. The Department (Commissioner) makes payments to each hospital in accordance with a pre-determined “rate per day” based upon cost reports submitted by the hospital for the second fiscal year preceding the fiscal year of rendition of service.

[457]*457For example, the “per diem” payable to a hospital for services rendered in fiscal year 1994/1995 would be based upon the cost report of that hospital for fiscal year 1992/1993.

The “pass through” or standard component of the “rate per day” is based upon ordinary expenses of operation, and is not involved in the present controversy.

A few hospitals have special expense problems not faced by hospitals generally. For these hospitals, in February, 1987, the Department established a “Medicaid Disproportionate Share Adjustment” (MDSA) which is computed and added to the standard or “pass through” rate to determine the per diem compensation of the hospital. One of the criteria for granting MDSA is the percentage of service rendered to Medicaid patients who reside outside the State.

The annual cost report of each hospital is submitted on a form supplied by the Department, which form includes a space for “in patient days,” which is the number of pa-tienVdays regardless of residence of patients. Instructions on the form direct that nonresident patient days are not to be included in the total placed in this space because Tennessee does not pay health care costs of non-resident indigents. No other space is provided on this form for non-resident patient days.

Although other hospitals reported their non-resident days elsewhere on the report form, petitioner did not in any way report to the Department its non-resident patient days in years prior to March, 1990. As a result, petitioner was not granted any MDSA for the fiscal year 1987/1988 because its cost report for 1985/1986 contained no information of non-resident patients. Likewise, no MDSA for non-residents was granted for the year 1988/1989, because no non-resident patients were reported in the year 1986/1987.

On March 29,1990, petitioner reported the number of non-resident Medicaid days during the year 1987/1988, and the Department adjusted the per diem for the year 1989/1990 to include MDSA.

On August 8, 1990, petitioner requested that the Department recompute the per diem for the years 1987/1988 and 1988/1989 based upon a late report of non-resident patient days during the years 1986/1987 and 1985/1986. This request was refused on August 30,1990 in a letter from the office of the State Comptroller reading as follows:

We have received, from the Medicaid Bureau, a response to your request to have disproportionate share payments for two prior years adjusted. Medicaid policy requires filing of an obligation within one year. Therefore, disproportionate share payments for the 1987/1988 and 1988/1989 fiscal years cannot be recomputed. We have already corrected your 1988 cost report which affects disproportionate share payments for fiscal year 1989/1990.

On November 27, 1990, the Bureau of Medicaid of the Department rendered its decision as follows:

Jellico Community Hospital has asked that a revision be made to their Medicaid Disproportionate Share Adjustment (MDSA) for fiscal years 87/88 and 88/89 based on information included in revised cost reports submitted for fiscal years 1986 and 1987. Our position is that an adjustment is not allowable under the current system and support for this position is as follows:
—The State Plan provides that a redeter-mination of the MDSA be made each year at the same time the new pass through component is determined on the basis of the best information available. The Plan further provides that the MDSA will not be changed until the next scheduled rede-termination. (copy attached)
—Rule 1200-13-5-.04 provides that cost reports shall be submitted not later than three months from the end of each provider’s fiscal year, and Jellico Community Hospital did not submit the revised cost reports within this time frame, (copy attached)
—42 CFR 447.45(d)(1) provides that the Medicaid agency must require providers to submit all claims no later than twelve (12) months from the date of service and the requested adjustments in payment are not within the twelve (12) month limitation, (copy attached)
[458]*458—Proposed Rule 1200-13-1-.06 provides that requests to adjust the payment amount of previously adjudicated claims must be submitted within one (1) year of the date of adjudication by Medicaid and the requested adjustments in payment are not within the one (1) year limitation. Although the rule is not yet final, this guideline has been followed for some time, (copy attached)
—There would be no advantage to the state in making the adjustment.

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Bluebook (online)
906 S.W.2d 455, 1995 Tenn. App. LEXIS 227, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jellico-community-hospital-inc-v-tennessee-department-of-health-tennctapp-1995.