Life Care Centers of America, Inc. v. Department of Social & Health Services

162 Wash. App. 370
CourtCourt of Appeals of Washington
DecidedJune 27, 2011
DocketNo. 66660-6-I
StatusPublished
Cited by12 cases

This text of 162 Wash. App. 370 (Life Care Centers of America, Inc. v. Department of Social & Health Services) is published on Counsel Stack Legal Research, covering Court of Appeals of Washington primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Life Care Centers of America, Inc. v. Department of Social & Health Services, 162 Wash. App. 370 (Wash. Ct. App. 2011).

Opinion

Cox, J.

¶1 Life Care Centers of America Inc. and other nursing facilities (collectively Life Care) appeal the superior court’s order affirming the decision and final order dated January 2009 of the Department of Social and Health Services Board of Appeals (Board). The Board decided that the Department of Social and Health Services (DSHS) correctly calculated the direct care component of the Medicaid payment rate for Life Care. Because Life Care fails to show that the Board erroneously interpreted or applied the law, we affirm.

¶2 DSHS administers the Medicaid program in the state of Washington. As part of this program, DSHS compensates nursing facilities in this state for care they provide to residents who qualify for Medicaid. Chapter 74.46 RCW, the nursing facility Medicaid payment system, states the methodology by which DSHS determines how to allocate payments among the various facilities.

¶3 The dispute in this case is over the methodology DSHS used to allocate Medicaid payment rates effective July 1,2007, for Life Care facilities. Life Care appealed the DSHS determination to the Board. In its decision and final order, the Board entered findings of fact and conclusions of law and determined that DSHS correctly applied the governing statutes in allocating payment rates. The superior court affirmed.

¶4 Life Care appeals.

DIRECT CARE COMPONENT RATE

¶5 Life Care argues that the Board erroneously interpreted and applied the law in determining that DSHS’s calculation of the direct care component rates for Medicaid payment rates to Life Care facilities was proper. We hold that the Board correctly interpreted and applied the law governing direct care component rates: DSHS correctly calculated this rate.

[374]*374¶6 The Administrative Procedure Act governs this court’s review of the Board’s decision.1 We may reverse if the Board’s decision “erroneously interpreted or applied the law.”2 Additionally, we may grant relief only if we decide that Life Care has been substantially prejudiced by the Board’s decision.3 The challenging party, Life Care, bears the burden of demonstrating the invalidity of the Board’s decision.4

¶7 In reviewing the Board’s decision, we sit in the same position as the superior court.5 We apply “ ‘the proper standard of review directly to the record of the administrative proceedings and not to the findings and conclusions of the superior court.’ ”6 Unchallenged factual findings are verities on appeal.7

¶8 Interpretation of the statute governing reimbursement rates is a question of law.8 Therefore, we review de novo the Board’s decision under the error of law standard, which allows us to substitute our interpretation of the law for that of the Board.9 But, we accord “ ‘great weight’ ” to the statutory interpretation of the executive agency [375]*375charged with a statute’s enforcement.10 “But the agency’s interpretation is not conclusive because ‘it is ultimately for the court to determine the purpose and meaning of statutes, even when the court’s interpretation is contrary to that of the agency charged with carrying out the law.’"11

¶9 In determining the Legislature’s intent, we look first to the statute’s plain language.12 We examine the language of the statute, other provisions of the same act, and related statutes to determine the plain meaning.13 We do not “favor repeal by implication, and where potentially conflicting acts can be harmonized, we construe each to maintain the integrity of the other.”14 If the plain language is unambiguous, we enforce the statute in accordance with its plain meaning.15

¶10 DSHS determines a Medicaid payment rate for each nursing facility that is effective July 1 of the applicable year and runs through June 30 of the year specified in the governing statute.16 Medicaid payment rates are facility-specific. For example, DSHS may determine that one facility should receive $156 per Medicaid resident per day, while another facility should receive $161 per Medicaid resident per day.

¶11 A nursing facility’s Medicaid payment rate is based on a combination of seven components, which are [376]*376defined by statute.17 The “direct care component rate” is one of these seven components. It is adjusted annually for economic trends and other factors.18 These annual adjustments are not at issue in this appeal. Accordingly, we do not consider them further in this analysis.

¶12 Generally, the direct care component rate of a facility’s Medicaid payment rate depends on three factors. They are the facility’s allowed costs, the complexity of care required by only the facility’s Medicaid residents, and the complexity of care required by all the facility’s residents.

¶13 The first of these factors, the facility’s allowed costs, consists of those audited costs that DSHS determines are permitted by law.19 The audited costs come from an annual cost report submitted by the facility to DSHS.20 There is no dispute in this appeal over this factor.

¶14 The second of these factors, the complexity of care required by only the facility’s Medicaid residents, is defined as the “Medicaid Average Case Mix Index” (MACMI).21 There is no dispute in this appeal over this index.

¶15 The third and final factor, the complexity of care required by all the facility’s residents, is defined as the “Facility Average Case Mix Index” (FACMI).22 The dispute in this appeal centers on this index.

¶16 One way of expressing the relationship among these three factors is that a facility’s direct care component rate equals the product of the facility’s allowable costs and the [377]*377ratio of its MACMI to its FACMI. This relationship may also be expressed formulaically as follows:

Direct care component rate = Allowed costs x (MACMI -r FACMI).

¶17 Thus, if one assumes that the allowed costs and the MACMI remain constant, an increase in the FACMI will decrease the direct care component rate. Conversely, assuming the allowed costs and the FACMI remain constant, an increase in the MACMI will increase the direct care component rate.

¶18 A brief explanation of the concept of “complexity of care,” found in both the MACMI and FACMI, provides context for this discussion. This concept is specific to each facility’s residents and is a function of first assessing each resident’s nursing care needs. Based on this individual assessment of need, each resident is then classified into one of 44 resource utilization groups.23 A numerical “case mix weight” is assigned to each of these groups. Case mix weights are based on an average number of nursing minutes required to meet each group’s nursing needs by registered nurses, licensed practical nurses, and certified nurse aides and the average wages of these professionals.24

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Cite This Page — Counsel Stack

Bluebook (online)
162 Wash. App. 370, Counsel Stack Legal Research, https://law.counselstack.com/opinion/life-care-centers-of-america-inc-v-department-of-social-health-washctapp-2011.