Memorial Medical Center v. State

40 Ill. Ct. Cl. 73, 1988 Ill. Ct. Cl. LEXIS 33
CourtCourt of Claims of Illinois
DecidedFebruary 4, 1988
DocketNo. 83-CC-2254
StatusPublished
Cited by9 cases

This text of 40 Ill. Ct. Cl. 73 (Memorial Medical Center v. State) is published on Counsel Stack Legal Research, covering Court of Claims of Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Memorial Medical Center v. State, 40 Ill. Ct. Cl. 73, 1988 Ill. Ct. Cl. LEXIS 33 (Ill. Super. Ct. 1988).

Opinion

POCH, J.

Respondent has moved for summary judgment on this vendor-payment claim, filed under the provisions of section 11 — 13 of the Public Aid Code (Ill. Rev. Stat. 1985, ch. 23, par. 11 — 13), on the ground that the documents submitted by Claimant, in support of its claim, fail to establish its compliance with applicable statutory law and related requirements. The Claimant having received due notice, the Court finds as follows:

Claimant hospital is seeking a vendor payment under the Medical Assistance Program (MAP) administered by the Illinois Department of Public Aid (IDPA). The questions presented for resolution are whether Claimant’s services here related to an abortion performed on its Medicaid-recipient patient, whether Claimant fully and accurately identified its medical services in invoicing them for IDPA’s payment consideration, and whether Claimant had demonstrated its compliance with IDPA’s requirements, as conditions precedent to its entitlement to payment for these services.

IDPA’s report, the contents of which are prima facie evidence under Court Rule 14, advises that Claimant submitted a single invoice, without any attached document, for these March 1982 services. IDPA notes that the information supplied by Claimant is inconsistent, in that its entries on the IDPA invoice-form are contradictory in describing the services which Claimant rendered to its patient. Although one coded entry on the invoice represents that no surgery was performed during the patient’s inpatient stay, Claimant’s ancillary-service entries include charges for operating room, recovery room and anesthesiology; and its “accommodation” entries describe this as a surgical stay. As disclosed in its invoice, Claimant’s services included surgical services, and contrary to IDPA’s invoice-preparation requirements, Claimant failed to identify the surgical procedure which was performed on the patient. Compare IDPA’s requirements for invoice-reporting of services rendered, as discussed in Methodist Medical Center v. State (1986), 38 Ill. Ct. Cl. 208, 209-10.

One of Claimant’s invoice-entries identifies that surgery as an abortion, performed on Claimant’s patient during the stay being invoiced. The invoiced charges were disallowed for payment by IDPA, on a voucher dated April 2,1982. The voucher notified Claimant that the disallowance resulted from Claimant’s failure to submit an abortion certification form with its invoice.

The significance of Claimant’s abortion-code entry is found in certain prohibitions, in State and Federal law, against IDPA’s payment for abortion-related services. Section 5 — 5 of the PAC excludes such services from those types of medical treatment for which IDPA was authorized to pay. As of March 1982, when Claimant rendered the services here at issue, the General Assembly had directed that payment was to be authorized for:

° ° ° any other medical care, ° ° “, but not including abortions, or induced miscarriages or premature births, unless, in the opinion of a physician, such procedures are necessary for the preservation of the life of the woman seeking such treatment, or except an induced premature birth intended to produce a live viable child and such procedure is necessary for the health of the mother or her unborn child. (Ill. Rev. Stat. 1985, ch. 23, par. 5 — 5.)

In assessing the payment-entitlement of an invoice submitted under any exception to the above prohibition, IDPA is to require:

° ° ° that a written statement including the required opinion of a physician shall accompany any claim for reimbursement for abortions, induced miscarriages or premature births. This statement shall indicate what procedures were used in providing such medical services. (Ibid.)

Respondent has no authority to make payment unless the vendor’s invoice for abortion-related services is documented in accordance with the requirements of section 5 — 5.

The U.S. Congress enacted legislation which has a similar prohibitive effect upon Respondent’s payment for abortions for Medicaid recipients. The so-called Hyde amendments deny Federal Medicaid matching funds (“Federal financial participation,” or FFP) for the States’ costs of paying medical vendors for performing abortions, except under specified circumstances. See generally Harris v. McRae (1980), 448 U.S. 297, 100 S. Ct. 2671, 65 L. Ed. 2d 784; and see William v. Zbaraz (1980), 448 U.S. 358, 100 S. Ct. 2694, 65 L. Ed. 2d 831, involving a constitutional challenge of section 5 — 5 of Illinois’ PAC. The Hyde amendment exceptions would require a physician’s written certification as to the patient’s medical condition, similar in content to that required under section 5 — 5.

The Federal physician-certification requirements appear in sections 441.203 and 441.206, of title 42, Code of Federal Regulations; and are further explained in IDPA Rule 140.413 (89 Ill. Admin. Code §140.413). A hospital can comply with these State and Federal requirements by insuring that its invoice, submitted to IDPA, is accompanied by an abortion payment application (DPA form 2390), a form in which the physician certifies in his or her professional judgment that the named recipient’s life would be endangered if her fetus were carried to term.

As noted, Claimant hospital’s invoice listed inconsistent entries, and was deficient in its failure to identify the surgical procedure performed. No explanatory documents accompanied it. If these services were related to abortion surgery, then Claimant could have submitted a correctly prepared, “rebill” invoice, entering the code for the specific abortion procedure which was performed on the patient, and attaching a certification form (DPA 2390) completed by her physician, describing the emergent circumstances which occasioned that particular procedure. If no abortion had been performed — and the initial invoice was incorrect in that respect, then Claimant’s rebill-invoice could have corrected the erroneous entries and accurately identified the procedure which was in fact performed. In this case, however, Claimant failed to submit any rebill-invoice. IDPA reports receiving no rebill of these services, containing internally consistent entries and identifying the procedure which was performed. Claimant does not allege that any such rebill was submitted, within the one-year period following the patient’s stay, as required by subsection (d) of IDPA Rule 140.20, and by 42 CFR §447.45. Good Samaritan Hospital v. State (1982), 35 Ill. Ct. Cl. 379; Rock Island Franciscan Hospital v. State, 39 Ill. Ct. Cl. 100; and Riverside Medical Center v. State (1986), 39 Ill. Ct. Cl. 301.

Respondent has attempted, through discovery, to seek Claimant’s production of its records, including any abortion certification or other documents identifying the surgical procedure and showing whether Claimant had complied with applicable IDPA rule requirements. Claimant answered by admitting each allegation in Respondent’s request for admission of facts, thereby representing that Claimant has no relevant documents to produce, other than those submitted with its complaint.

The Court finds that it can make no vendor-payment award in this matter.

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Cite This Page — Counsel Stack

Bluebook (online)
40 Ill. Ct. Cl. 73, 1988 Ill. Ct. Cl. LEXIS 33, Counsel Stack Legal Research, https://law.counselstack.com/opinion/memorial-medical-center-v-state-ilclaimsct-1988.