McLean Hospital Corp. v. United States

26 Cl. Ct. 1144, 1992 U.S. Claims LEXIS 416, 1992 WL 224640
CourtUnited States Court of Claims
DecidedSeptember 14, 1992
DocketNo. 175-88C
StatusPublished
Cited by1 cases

This text of 26 Cl. Ct. 1144 (McLean Hospital Corp. v. United States) is published on Counsel Stack Legal Research, covering United States Court of Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
McLean Hospital Corp. v. United States, 26 Cl. Ct. 1144, 1992 U.S. Claims LEXIS 416, 1992 WL 224640 (cc 1992).

Opinion

OPINION

SMITH, Chief Judge.

This case comes before the court on an appeal from the final decision of the Director of the Office of the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS) denying cost sharing of inpatient psychiatric care provided to Amy W., a thirteen-year-old CHAMPUS beneficiary, for the time period September 1, 1984 to November 9, 1984. Plaintiff McLean Hospital Corporation (McLean) seeks recovery of $37,433.06, which, plaintiff contends, represents OCHAMPUS’ portion of reimbursable expenses under the cost-sharing statute. Pending before the court are cross-motions for summary judgment which raise two questions: 1) whether the regulations implementing the waiver standard can be applied retroactively; and 2) whether the OCHAMPUS Final Decision, which denied cost sharing, is supported by substantial evidence.

After careful consideration of the briefs and hearing oral argument, the court concludes that although the regulation may be retroactively applied, the OCHAMPUS Final Decision is not supported by substantial evidence and thus must be reversed. Therefore, for the reasons set forth below, plaintiff’s motion for summary judgment is granted.

FACTS AND STATUTORY HISTORY

Amy W., the CHAMPUS beneficiary in this case, was admitted to McLean for psy[1146]*1146chiatric treatment. Amy was thirteen years of age. Amy had exhibited violent tendencies since the age of eight, and her admission to McLean was her third inpatient psychiatric hospitalization in her lifetime. Amy’s violent behavior included hitting her mother and others, throwing furniture, and at least one occasion of knife-wielding. In April 1983, Amy attempted suicide. The State of Massachusetts, acting on a petition filed by Amy’s mother, attempted to place Amy in a residential school. At the admissions interview, Amy physically attacked the interviewer, attempted to light the interviewer’s clothes on fire, and ran away from the building. This incident prompted Amy’s admission to McLean on October 24, 1983.

Amy remained hospitalized at McLean for over one year. Her treatment included passes home to visit her family. While the ultimate goal of Amy’s doctors was to allow her to return to her home and school, the intermediate treatment goal was to move her to a Residential Treatment Center (RTC). On July 20, 1984, the McLean staff began to plan for Amy’s eventual transfer to an RTC. Amy remained hospitalized at McLean during this preliminary planning stage, although she was released on weekend passes. In August, Amy’s application to an RTC was rejected after she became threatening during an admissions interview. Two other RTC applications were rejected. Amy was accepted into one RTC, but that option was rejected by Amy’s physicians- because it was located too far from Amy’s home to allow for the involvement of Amy’s family in her treatment. Family involvement in Amy’s treatment was considered essential since most of her acting out was directed toward her mother. Amy was accepted into an appropriate RTC on October 31, and Amy was released from McLean on November 9. Amy began school at the RTC a few days later.

McLean provided Amy with inpatient psychiatric care from October 24, 1983 to November 9, 1984, for a total of 381 days. The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) provides for cost sharing for acute inpatient psychiatric hospital care, 10 U.S.C. § 1079(a), although cost sharing is limited to 60 days per calendar year, 10 U.S.C,. § 1079(a)(6). A waiver from the 60-day limit may be permitted where “extraordinary medical or psychological circumstances” exist. 10 U.S.C. § 1079(i)(4).

In 1983,. when Amy was first hospitalized, reimbursement for inpatient mental health services was limited to 60 days per patient per year. However, this 60-day limitation did not apply to, among other things:

inpatient mental health services ... provided as residential treatment care; ... or provided pursuant to a waiver for medical or psychological necessities, granted in accordance with the findings of current peer review, as prescribed in the guidelines established and promulgated by the Director [of OCHAMPUS].

Department of Defense Appropriation Act of 1983, Public Law 97-377, 96 Stat. 1830, § 785. The guidelines, issued by OCHAMPUS on December 29, 1982, provided that waivers of the 60-day limitation could be granted if:

the patient is suffering from an acute mental disorder or acute exacerbation of a chronic mental disorder which results in the patient being a significant risk to self or of becoming a danger to others; and the patient requires a type, level, and intensity of services that can only be provided in an in-patient setting.

CHAMPUS Policy Manual, Vol. I, Chp. I, § 11 (emphasis in original).1

In 1984, the statutory language was changed to require the Secretary of Defense to promulgate regulations pertaining to the requirements for “extraordinary ... psychological circumstances.” The 1984 statute provided that a waiver may be authorized:

[1147]*1147by the Secretary of Defense because of extraordinary medical or psychological circumstances that are confirmed by a review by a non-federal health professional pursuant to regulations prescribed by the Secretary of Defense.

10 U.S.C. § 1079(i)(4). Regulations were promulgated in January 1986, and were purportedly made retroactive to December 29, 1982. The regulations are virtually identical to the guidelines in effect in 1983, and provide that a waiver may be granted when:

[t]he patient is suffering from an acute mental disorder or an acute exacerbation of a chronic mental disorder that results in the patient being put at significant risk to self or of becoming a danger to others; and the patient requires a type, level, and intensity of otherwise authorized service that can only be provided in an acute care inpatient setting.

32 C.F.R. § 199.4(b)(5)(ix)(B)(l) (1987) (emphasis in original).

OCHAMPUS agreed to cost-share Amy’s care provided by McLean for the period of October 24, 1983 through September 1, 1984.2 McLean’s fourth waiver request— for the period between October 1, 1984 and December 31,1984—was denied. OCHAMPUS refused to cost-share McLean’s care of Amy for the period of September 1, 1984 to November 9, 1984. OCHAMPUS’ refusal to cost-share for this period is the subject of this litigation.

DISCUSSION

1. Standard of Review

OCHAMPUS decisions are to be reviewed under the standard of review applicable to final administrative actions under the Administrative Procedure Act, 5 U.S.C. § 706.

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36 Fed. Cl. 91 (Federal Claims, 1996)

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Bluebook (online)
26 Cl. Ct. 1144, 1992 U.S. Claims LEXIS 416, 1992 WL 224640, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mclean-hospital-corp-v-united-states-cc-1992.