Northern Metropolitan Residential Healthcare Facility v. Novello

4 Misc. 3d 394, 777 N.Y.S.2d 277, 2004 N.Y. Misc. LEXIS 538
CourtNew York Supreme Court
DecidedMay 14, 2004
StatusPublished
Cited by2 cases

This text of 4 Misc. 3d 394 (Northern Metropolitan Residential Healthcare Facility v. Novello) is published on Counsel Stack Legal Research, covering New York Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Northern Metropolitan Residential Healthcare Facility v. Novello, 4 Misc. 3d 394, 777 N.Y.S.2d 277, 2004 N.Y. Misc. LEXIS 538 (N.Y. Super. Ct. 2004).

Opinion

OPINION OF THE COURT

Dan Lamont, J.

Petitioner brings this proceeding pursuant to CPLR article 78 seeking a judgment reversing, annulling and/or modifying the respondents’ administrative determination to recover $366,816 from petitioner in alleged Medicaid overpayments as set forth in a decision after hearing dated February 28, 2003. Respondents have filed an answer in opposition, and petitioner has filed a reply thereto.

Background

Petitioner is a residential health care facility. In October of 1988, respondent Department of Health (DOH) approved petitioner to operate an adult day health care (ADHC) program for 33 nonoccupant registrants. Petitioner began to operate the program with seven registrants with a total of 69 visits in 1988. Initially, petitioner transported the participants with its own handicap van. The costs of using its own van for transportation were reimbursed in petitioner’s nursing home Medicaid rate. On January 1, 1989, petitioner was authorized to seek Medicaid reimbursement for services rendered to Medicaid eligible ADHC program registrants.

Petitioner’s application for a Medicaid reimbursement rate for its ADHC program was based upon a budget of estimated [396]*396costs. Petitioner included estimated costs of $55,000 for transportation of its registrants in the ADHC program in its budgeted costs to be included in the Medicaid reimbursement rate. The estimate was based upon taxicab fares for registrants of $10 per trip with an estimate of 5,260 visits ($52,600) rounded up to $55,000. Through percentage increases, the budgeted amount went from $10 per trip in 1989 to $14 per trip in 1995.

Following its authorization to seek Medicaid reimbursement for services rendered to eligible ADHC program registrants on January 1, 1989, petitioner entered into contracts with outside ambulette transportation providers for transportation of the ADHC program registrants. The transportation providers were to bill the Medicaid program directly on a fee-for-service basis for providing these transportation services. Notwithstanding petitioner’s contracts with five outside ambulette services, petitioner still continued to utilize its own van from time to time during the audit period to transport ADHC registrants. The extent of the use of petitioner’s van is disputed by the parties. However, the costs of the vehicle and the driver were included in the nursing home’s books, and therefore, were included in petitioner’s inpatient Medicaid reimbursement rates.

At some point in time, the State Department of Social Services (DSS) became aware of the possibility that DSS may have been paying twice for the transportation of ADHC registrants— once through the facilities’ ADHC rate, and once on a fee-for-service basis from the ambulette transportation providers. By letter dated March 22, 1996, DSS informed petitioner that an audit would be conducted regarding its transportation costs for the ADHC program for the rate period January 1, 1992 to December 31, 1995, and that petitioner should make particular records available. Petitioner immediately raised an issue contending that DSS does not have the authority to conduct an audit of these costs since petitioner’s rate is based upon a budget — rather than upon actual costs. Petitioner has preserved said contention throughout the administrative process and this proceeding.

On September 26, 1996, an initial conference between DSS employees and petitioner’s employees was conducted. During the conference, DSS employee Anit Maitra informed petitioner that if the audit discovered that the transportation costs were only incidental, DSS would ask for transportation costs for 1989 through 1991 also. Petitioner’s representative immediately asserted that DSS had no authority to expand the period of the [397]*397audit without a written notification to that effect. DSS’ employee responded that a letter would be sent, but DSS did not send such letter.

On February 19, 1997, following the audit, an exit conference was held. Immediately prior to the exit conference, petitioner submitted a rate appeal to the DOH requesting that petitioner be provided with a cost-based rate. On March 31, 1997, DOH denied petitioner’s rate appeal and stated that the ADHC rate would continue to be based upon the approved budget.

On June 18, 1997, DSS issued a draft audit report advising petitioner that it had been overpaid $412,613 from the Medicaid rate years 1989 through 1995. DSS (1) removed the yearly $55,000 budgeted by petitioner for ADHC transportation costs based upon most of the transportation services being provided by outside contractors and billed to Medicaid on a fee-for-service basis by those providers; (2) acknowledged that petitioner did incur some transportation expenses through the use of its own vehicle transporting ADHC registrants; (3) determined that the transportation costs incurred by petitioner were reimbursed through its inpatient Medicaid rates; and (4) determined that petitioner had deleted transportation services from its ADHC program.

On September 8, 1998, a final audit was issued by DOH, which had taken over the audit functions from DSS, for the alleged overpayments associated with the 1989 through 1995 Medicaid rate years. The final audit basically confirmed the findings from the draft audit. DOH cited the following regulatory authority for its determination: (1) 10 NYCRR 86-2.27— the department was not notified that petitioner deleted its service for transporting the ADHC registrants by contracting out the services to outside companies, and (2) 10 NYCRR 86-2.17 (d) — the transportation costs were not reasonably related to the efficient production of services. The final audit report stated in writing that the purpose of the audit was to identify Medicaid overpayments associated with years 1989 through 1995. By letter dated October 29, 1998, petitioner requested an administrative hearing.

An administrative hearing was conducted on January 27, 2000, March 14, 2000, May 22, 2000, October 24, 2000, April 5, 2001, and February 7, 2002. The administrative record was closed June 28, 2002. On February 28, 2003, the Administrative Law Judge (ALJ) issued the decision after hearing.

The ALJ determined: (1) that DSS did have the requisite regulatory authority to conduct the audit and to adjust [398]*398petitioner’s ADHC program Medicaid reimbursement rate which was based upon budgeted costs; (2) that the statute of limitations prohibited the State from auditing the 1989 and 1990 rate years, but the State could audit the 1991 and later rate years based upon its notification contained within the June 18, 1997 draft audit report; and (3) that petitioner had deleted transportation services from its ADHC program. The ALJ established the Medicaid overpayment at $366,816.

Discussion

A) Auditing Authority of the Department of Social Services:

Petitioner contends that DSS had no regulatory authority to conduct an audit of its Medicaid rate because such rate was based upon budgeted costs rather than actual costs. Respondents contend that DSS has the authority to audit rates, pursuant to 18 NYCRR 517.3 and 10 NYCRR 86-2.7, set both by actual costs and budgeted costs — a contention which the ALJ adopted.

18 NYCRR part 517 applies to “Provider Audits.” 18 NYCRR 517.3 is labeled “Audit and record retention.” 18 NYCRR 517.3 (a) and (b) are labeled “Cost-based provider” and “Fee-for-service providers,” respectively.

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Related

General Medicine, P.C. v. Alex Azar
963 F.3d 516 (Sixth Circuit, 2020)
Matter of N. Metro. Residential Healthcare Facility v. Novello
2004 NY Slip Op 24152 (New York Supreme Court, Albany County, 2004)

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Bluebook (online)
4 Misc. 3d 394, 777 N.Y.S.2d 277, 2004 N.Y. Misc. LEXIS 538, Counsel Stack Legal Research, https://law.counselstack.com/opinion/northern-metropolitan-residential-healthcare-facility-v-novello-nysupct-2004.