Kaiser Foundation Hospitals v. Belshe

54 Cal. App. 4th 1547, 63 Cal. Rptr. 2d 652
CourtCalifornia Court of Appeal
DecidedApril 22, 1997
DocketC023361
StatusPublished
Cited by5 cases

This text of 54 Cal. App. 4th 1547 (Kaiser Foundation Hospitals v. Belshe) is published on Counsel Stack Legal Research, covering California Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kaiser Foundation Hospitals v. Belshe, 54 Cal. App. 4th 1547, 63 Cal. Rptr. 2d 652 (Cal. Ct. App. 1997).

Opinion

Opinion

SPARKS, Acting P. J.

In this appeal from a judgment granting a petition for writ of mandate, we consider the responsibilities of health care providers and the Department of Health Services (Department) for accurate reimbursement of Medi-Cal claims. (See Welf. & Inst. Code, § 14000 et seq. [all subsequent statutory references are to the Welfare and Institutions Code unless otherwise indicated].) We conclude the trial court erred in granting a writ of mandate to compel the Department to audit cost reports filed by *1549 plaintiff Kaiser Foundation Hospitals (Kaiser). We shall therefore reverse the judgment.

Statutory and Regulatory Framework

To place the issues of this appeal in their proper context, we first outline the statutory and regulatory framework of the Medi-Cal program.

As the California Supreme Court recently described in Robert F. Kennedy Medical Center v. Belshé (1996) 13 Cal.4th 748 [55 Cal.Rptr.2d 107, 919 P.2d 721]: “The Medi-Cal program (§ 14000 et seq.) represents California’s implementation of the federal Medicaid program (42 U.S.C. §§ 1396-1396v), 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. (§ 14203.)

“When originally enacted in 1965, the Medicaid Act required states to reimburse health care providers for the ‘reasonable cost’ of hospital services rendered; the term ‘reasonable cost’ was defined under federal standards to correspond to the cost of services actually incurred by a hospital provider and otherwise allowable under Medicare. [Citations.] In accordance with these federal standards, former section 14105 (the predecessor to section 14170), as originally enacted, provided for hospital reimbursement on the basis of ‘reasonable costs for . . . services.’ [Citation.] The statute, however, did not contain any provision for an audit of a provider’s expenditures tinder the Medi-Cal program.

“In 1969, former section 14105 was amended to include, among other provisions, the following language: ‘Cost reports and other data submitted by providers to a state agency for the purpose of determining reasonable costs for services or establishing rates of payment shall be considered true and correct unless audited within eighteen (18) months after July 1, 1969, the close of the period covered by the report, or after the date of submission of the original or amended report by the provider, whichever is later.’ [Citation.] In 1973, section 14105 was amended again to extend the 18-month period governing the auditing process to 3 years. [Citation.] In 1977, the pertinent provisions of section 14105 were recodified as section 14170

”[ 1 ]

“In 1980 and 1981, in an effort to contain spiraling Medicaid costs for hospital services, Congress amended the Medicaid standard for hospital *1550 reimbursement, replacing the ‘reasonable cost’ standard with the current standard requiring states to reimburse hospital providers at rates that are ‘reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities . . . .’ [Citations.] Under this new standard, states were permitted to develop alternate methodologies to limit reimbursement based upon the costs that would have been incurred by an efficient and economically operated facility, even if a provider’s actual costs were greater. [Citation.]

“In response to this change in Medicaid standards, the Department promulgated regulations imposing additional limits on the reimbursement available to a provider. The first, embodied in title 22 of the [California Code of Regulations], section 51536 (enacted July 1, 1980), establishes a maximum reimbursement limit for hospital inpatient services, constituting the lesser of (1) customary charges, (2) allowable costs determined in accordance with applicable Medicare standards and principles of reimbursement, and (3) the ‘all-inclusive rate per discharge.’ The ‘all-inclusive rate per discharge’ established by section 51536 determines the maximum allowable average cost per Medi-Cal patient that is reimbursable [pursuant to specified formulae and allowances]. . . . This rate, when multiplied by the number of Medi-Cal patients treated, establishes an upper limit on the total reimbursement available to the provider. [Citation.]

“The Department also promulgated [California Code of Regulations], title' 22, section 51539 (issued November 1, 1982), which established a ‘pee,/r group’ limit prohibiting reimbursement at a rate per patient greater than the 60th percentile of the rate per discharge of the provider’s ‘peer group,’ established according to factors such as the size of the facility and the types of patients served. [Citation.]

“Under this methodology limiting total reimbursement, the Department retained the existing reasonable cost standard (in the form of the lesser of customary charges and allowable costs), while engrafting onto the existing standard new limitations on reimbursement—the all-inclusive rate per discharge and the peer group limit—restricting reimbursement to those costs that would have been incurred by an efficient and economically operated facility.

*1551 “In order to furnish hospitals with a cash flow sufficient to provide Medi-Cal services during a particular fiscal year, the Department is authorized to make interim payments based upon the hospital provider’s historical rates of Medi-Cal reimbursement for costs. (Cal. Code Regs., tit. 22, § 51536, subd. (c)(2).) At the close of the year, the provider submits its cost reports to the Department, setting forth the provider’s actual costs for covered services that in the provider’s view are allowable under Medi-Cal. [Citations.] Based upon the unaudited cost report data, the Department makes a ‘tentative settlement,’ reconciling the amount of interim payments with the reported unaudited costs. (Cal. Code Regs., tit. 22, § 51536, subd. (b)(9).) Thereafter, following completion of the audit process, the Department issues a final audit report and settlement, determining among other items the provider’s allowable costs as established by the Department, and reconciling the difference, if any, between the tentative settlement and the final audit settlement.

“The Department then undertakes the calculations necessary to determine a final reimbursement settlement of Medi-Cal liabilities based upon the maximum inpatient reimbursement limit, incorporating the all-inclusive rate per discharge and the peer group limit, and utilizing the audited cost data as well as information from other sources. In this final settlement, the Department reconciles the amount of interim payments made, with the maximum amount reimbursable under the regulations.

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Bluebook (online)
54 Cal. App. 4th 1547, 63 Cal. Rptr. 2d 652, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kaiser-foundation-hospitals-v-belshe-calctapp-1997.