McAllen Hospitals, L.P. v. Suehs

426 S.W.3d 304, 2014 WL 794806, 2014 Tex. App. LEXIS 2325
CourtCourt of Appeals of Texas
DecidedFebruary 24, 2014
DocketNo. 07-12-00291-CV
StatusPublished
Cited by15 cases

This text of 426 S.W.3d 304 (McAllen Hospitals, L.P. v. Suehs) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
McAllen Hospitals, L.P. v. Suehs, 426 S.W.3d 304, 2014 WL 794806, 2014 Tex. App. LEXIS 2325 (Tex. Ct. App. 2014).

Opinion

OPINION

MACKEY K. HANCOCK, Justice.

McAllen Hospitals, L.P. and Fort Duncan Medical Center, L.P. (the Hospitals)1 appeal the trial court’s order granting the Texas Health and Human Services Commission’s plea to the jurisdiction and dismissing the Hospitals’ claims. We will affirm the trial court’s order in part, reverse it in part, and remand the cause for further proceedings.

Factual and Procedural History

The Agency, Its Departments, and Its Duties

The Texas Health and Human Services Commission (THHSC) oversees the Texas Medicaid Program. Having entered into Medicaid provider agreements with the THHSC, the Hospitals are Medicaid providers. As such, the Hospitals provide medically necessary treatment to Texas Medicaid beneficiaries and submit claims to the THHSC for reimbursement.

The THHSC’s Office of Inspector General (OIG) bears the responsibility for reviewing and determining the payment or denial of claims submitted by enrolled healthcare providers. Among its other duties, the OIG is legislatively charged with the specific duties of “prevention, detection, audit, inspection, review, and investigation of fraud, waste, and abuse in the provision and delivery of all health and human services in the state ... and the enforcement of state law relating to the provision of those services.” See Tex. Gov’t Code Ann. § 581.102(a) (West Supp. 2013).2 “[U]pon a finding by the Inspector General of fraud and abuse in Medicaid,” the OIG is authorized to impose sanctions against the offending provider. 1 Tex. Admin. Code § 871.11(a) (2013) (Tex. Health [308]*308& Human Servs. Comm’n, Purpose and Scope). In response to “[p]rima facie cases of misuse, waste, abuse or fraud,” the OIG can determine the “appropriate administrative enforcement, including re-coupment and other necessary administrative action, sanction or penalty.” Id. § 371.1701 (2011) (Tex. Health & Human Servs. Comm’n, Inspector General Investigation of Overpayments) repealed 37 Tex. Reg. 7998 (2012) (proposed Aug. 10, 2012).

Within the OIG is the Utilization Review (UR) Department, which is governed by Title 1, Chapter 371, Subchapter C of the Texas Administrative Code. The UR Department of the THHSC is charged with implementing the Texas Medical Review Program (TMRP). More specifically, the TMRP “is the inpatient hospital utilization review process used by the [THHSC] for hospitals reimbursed under the [THHSCJs prospective payment system.” Id. § 371.200(a) (2013) (Tex. Health & Human Servs. Comm’n, Inpatient Hospital Utilization Review Program). The Texas Administrative Code thoroughly outlines the TMRP review process and provides that “[t]he TMRP review process includes, but is not limited to ... [a]dmission review to evaluate the medical necessity of the admission.” Id. § 371.203(a)(1) (2013) (Tex. Health & Human Servs. Comm’n, Texas Medical Review Program (TMRP) Review Process). “For purposes of the TMRP reviews, medical necessity means the patient has a condition requiring treatment that can be safely provided only in the inpatient setting.” Id.

In the event that a reviewed claim is deemed medically unnecessary or provided in an inappropriate setting, the THHSC will notify the enrolled provider of the denial decision and instruct the claims administrator to recoup payment on that claim. Id. § 371.206(a) (2013) (Tex. Health & Human Servs. Comm’n, Denials and Recoupments for Texas Medical Review Program (TMRP), Tax Equity and Fiscal Responsibility Act (TEFRA), and LoneSTAR Select II Contracted Hospitals) amended 38 Tex. Reg. 9479 (2013) (effective Jan. 1, 2014).3 It is worth noting that this denial is retroactive in nature, occurring two to three years after the date services were rendered.

With respect to a provider’s remedies upon receiving a denial of payment under Section 371.206, the Texas Administrative Code provides the following:

If a hospital receives notification from the [THHSC] Utilization Review Unit of an adverse decision regarding medical necessity of admission, days of stay, diagnosis related group (DRG) validation, or a final technical denial, the hospital may appeal to [the THHSC]. The written notification of adverse decision will set out the responsible area and time frame within which the appeal must be received by [the THHSC]. The Texas Medicaid Policy and Procedure Manual provides additional information on the appeal process.

Id. § 371.208 (2013) (Tex. Health & Human Servs. Comm’n, Appeals Related to Utilization Review Department Review Decisions).

Payments and Actions at Issue

Between June 26, 2004, and January 7, 2008, the Hospitals rendered medical treatment on an inpatient basis to the patients whose medical treatment forms the underlying basis of this suit. At the time of medical treatment, these patients were recipients of Texas Medicaid medical bene[309]*309fits, and the Hospitals timely filed claims with the THHSC. The THHSC reimbursed the Hospitals for services rendered.

Two to three years after the medical services in question were rendered, the THHSC conducted a sample study of patients who were admitted to the Hospitals. See id. § 371.201 (2013) (Tex. Health & Human Servs. Comm’n, Case Selection Process). The OIG, through its UR Unit and under the authority provided by the TMRP, reviewed the medical records of each of the patients at issue to determine if the inpatient setting was medically necessary and the appropriate treatment setting or whether the treatment could have been rendered on an outpatient basis. In each case at issue, the UR Unit determined that it was not medically necessary for the treatment to be rendered in an inpatient setting and sent to the Hospitals a Notice of Admission Denial, informing the Hospitals that admissions on an inpatient basis were not medically necessary for these patients and directing that the payments be recouped.

The Hospitals appealed the OIG UR Unit’s decision to the THHSC’s UR/Medical Appeals Unit,4 as provided for in Section 371.208 and as directed by the UR Unit’s denial letter. The appeal the Hospitals submitted to the UR Appeals Unit consisted of a written appeal supported by a written explanation of the reasons the Hospitals believed the inpatient service to be medically necessary.

Subsequently, the UR/Medical Appeals Unit denied the Hospitals’ appeal, upholding the OIG UR Unit’s decision that the inpatient setting was not medically necessary.5 The THHSC further advised that the UR/Medical Appeals Unit’s determination was “the final administrative decision on your appealed case. Therefore, in accordance with Medicaid program policies and procedures, this determination is now considered final and the case is closed.”

The Hospitals maintain that, to preserve their rights to additional administrative review, they sent requests to the OIG Manager of Sanctions that their appeals be forwarded to the Office of General Counsel (OGC) to be docketed, pursuant to 1 Tex. Admin. Code § 371.1667 (2011) (Tex. Health & Human Servs. Comm’n, Due Process for Administrative Sanctions) repealed 37 Tex. Reg. 7998 (2012) (proposed Aug. 10, 2012), and 1 Tex. Admin. Code § 371.1669 (2011) (Tex. Health & Human Servs. Comm’n, Notice of Appeal) repealed 37 Tex. Reg. 7998 (2012) (proposed Aug.

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Cite This Page — Counsel Stack

Bluebook (online)
426 S.W.3d 304, 2014 WL 794806, 2014 Tex. App. LEXIS 2325, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mcallen-hospitals-lp-v-suehs-texapp-2014.