Northwest Covenant Medical Center v. Fishman

770 A.2d 233, 167 N.J. 123, 2001 N.J. LEXIS 500
CourtSupreme Court of New Jersey
DecidedApril 23, 2001
StatusPublished
Cited by58 cases

This text of 770 A.2d 233 (Northwest Covenant Medical Center v. Fishman) is published on Counsel Stack Legal Research, covering Supreme Court of New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Northwest Covenant Medical Center v. Fishman, 770 A.2d 233, 167 N.J. 123, 2001 N.J. LEXIS 500 (N.J. 2001).

Opinions

The opinion of the Court was delivered by

COLEMAN, J.

The primary issue in this case is whether the Department of Health and Senior Services’ (DHSS) refusal to reallocate Northwest Covenant Medical Center’s (Northwest) 1997 charity care subsidy was a quasi-legislative decision. If so, then the forty-five day time limit for appealing an agency action does not apply and Northwest may maintain its appeal if not barred by laches.

The Appellate Division concluded that the DHSS’s charity care subsidy decision was a quasi-judicial determination; thus, the court ruled that the forty-five day time limit applied and was not satisfied. Alternatively, the court ruled that even if the forty-five day time limit was inapplicable, Northwest’s appeal should nonetheless be barred based on the doctrine of laches. We disagree and reverse. We hold that the DHSS decision was more quasi-legislative than quasi-judicial in nature. Hence, the forty-five day time limit does not apply and the equitable doctrine of laches does not bar Northwest’s appeal.

I.

In 1992, New Jersey enacted the Health Care Act (Act), which, in relevant part, subsidizes hospitals that serve a disproportionate number of low-income patients who are unable to pay their hospital bills. N.J.S.A. 26:2H-18.51 to -18.70. Charity care subsidies are distributed from the Health Care Subsidy Fund, N.J.S.A. 26:2H-18.58, and are calculated based on a statutory formula. N.J.S.A. 26:2H-18.58e (announcing total amount of charity care subsidy funds collectively available for eligible hospitals in a given year); N.J.S.A. 26:2H-18.59e (explaining statutory formula for allocating total subsidy amount among eligible hospitals). But even if a hospital qualifies for a subsidy, it does not necessarily receive a full “reimbursement” covering all of its actual charity [129]*129care expenses; rather, a hospital receives only its proportionate share of the total subsidy funded by the Legislature for that year. Ibid. For 1997, the year involved in this case, the Legislature appropriated $300 million for charity care subsidy payments. N.J.S.A 26:2H-18.59e. Northwest was one of sixty-seven hospitals that sought a share of the 1997 charity subsidy.

Hospitals seeking charity care subsidies are “required to submit all claims for charity care cost reimbursement ... to the department in a manner and time frame specified by the Commissioner of Health and Senior Services.” N.J.S.A. 26:2H-18.59b(3). Pursuant to the Act, the DHSS contracted with the UNISYS corporation (UNISYS) to process charity care claims and price them at the appropriate Medicaid rate, as required under the Act. UNI-SYS developed the Essential Health Services Claims Pricing System Manual (ECPS Manual), which sets forth the manner and time frame for hospitals submitting subsidy claims.

The ECPS Manual encourages hospitals to submit claims for charity care on a monthly basis according to a schedule published by the DHSS. If a claim is submitted in a timely manner and accepted, UNISYS then issues a “remittance advice” to the hospital “by the 5th working day after the monthly adjudication cycle date.” The ECPS Manual also provides that, “[i]f a submitter fails to receive the requested remittance tape(s) or if there are problems with the remittance tape(s), it is the responsibility of the submitter to notify UNISYS in writing within fourteen days from the remittance date.” Furthermore, “[t]he individual provider is ultimately responsible for the accuracy and validity of every ECPS claim submitted for payment.”

Northwest is a non-profit, acute care medical center comprised of three member hospitals: (1) St. Clare/Riverside (St.Clare), (2) Dover General, and (3) Walkill Valley General Hospital. A large percentage of St. Clare’s patient population is indigent and it historically has received a substantial charity care subsidy. In 1995, St. Clare began submitting its charity care claims electronically and identified an Elmer Bean as its contact person.

[130]*130On February 2, 1996, the DHSS issued a schedule of monthly submission and remittance statement dates for the processing of subsidy claims. The memorandum specifically noted that “[cjlaims submitted after the Submission CuWDff Date through the Adjudication Cycle Date will most likely process, but are not guaranteed to process for the upcoming adjudication cycle.” On September 27, 1996, DHSS issued a letter stating that the claims submission deadline for 1997 charity care subsidies was October 18,1996.

For reasons unexplained, Northwest did not submit monthly claims for St. Clare as directed, but instead submitted claims for the entire year’s cycle on October 18, 1996. Several other hospitals also submitted their claims based on the entire year’s cycle. Moreover, St. Clare’s charity care claims data contained numerous errors that prevented UNISYS from processing the claims; hence, a remittance advice was not issued. A dispute exists over whether UNISYS attempted to contact Elmer Bean, Northwest’s designated contact person regarding charity claims, concerning the erroneous charity data that Northwest submitted for St. Clare. Despite that dispute, the DHSS, in an attempt to avoid a total loss by St. Clare, calculated the hospital’s charity care subsidy by using Northwest’s “aggregate pricing ratio.” In other words, the DHSS used data from Northwest’s other member hospitals to calculate a charity care subsidy amount for St. Clare. That subsidy was substantially less than the amount Northwest anticipated receiving for St. Clare.

On February 18, 1997, Northwest contacted UNISYS and was informed that St. Clare’s request that its subsidy be determined using its hospital-specific data was rejected. On February 24, 1997, Northwest responded that it had not previously been told of any errors and requested that the Director of the Health Care Financing System recalculate the subsidy with the proper data. Despite Northwest’s protest, three days later on February 27, 1997, the DHSS issued a memorandum to all sixty-seven participating hospitals detailing the charity care subsidies for 1997. St. [131]*131Clare was awarded a subsidy of $5.7 million, a shortfall of about two million dollars from that which it would have received had its claims been properly submitted. That same day, Northwest made a direct appeal to Leonard Fishman, the DHSS Commissioner, to increase St. Clare’s subsidy.

At the same time, Northwest began pursuing a legislative solution. Northwest arranged a March 3, 1997, meeting with New Jersey State Senator Robert Littell and the DHSS. The DHSS staff explained to Senator Littell that recalculating St. Clare’s subsidy would not be possible because it would take money from hospitals less able to self-subsidize their charity care. Charity care under the Act is a zero sum system, such that an increase for one hospital causes all other hospitals to realize a decrease. Because only $300 million was allotted for 1997, the DHSS observed that any increase to St. Clare would require recoupment from the other sixty-six hospitals that received subsidies. Senator Littell then requested that the DHSS calculate the figure that St. Clare would have been entitled to had it submitted a correct claim.

With corrected data from St. Clare, Commissioner Fishman responded to Senator Littell on May 29,1997, by informing him of the amount that St. Clare would have received. The Commissioner also indicated that he

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Bluebook (online)
770 A.2d 233, 167 N.J. 123, 2001 N.J. LEXIS 500, Counsel Stack Legal Research, https://law.counselstack.com/opinion/northwest-covenant-medical-center-v-fishman-nj-2001.