Review v. Barnert Memorial Hospital

641 A.2d 1043, 273 N.J. Super. 205, 1994 N.J. Super. LEXIS 146
CourtNew Jersey Superior Court Appellate Division
DecidedApril 7, 1994
StatusPublished

This text of 641 A.2d 1043 (Review v. Barnert Memorial Hospital) is published on Counsel Stack Legal Research, covering New Jersey Superior Court Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Review v. Barnert Memorial Hospital, 641 A.2d 1043, 273 N.J. Super. 205, 1994 N.J. Super. LEXIS 146 (N.J. Ct. App. 1994).

Opinion

The opinion of the court was Delivered by

COLEMAN, P.J.A.D.

Under the Health Care Facilities Planning Act, as amended by L. 1978, c. 83, N.J.S.A 26-.2H-1 et seq., administrative regulations were promulgated to institute and implement a Diagnosis Related Group (DRG) method of payment or reimbursement to hospitals for inpatient care. A second system was established, under the authority of Chapter 83, known as State-qualified utilization review organizations (UROs), “to ensure that the hospital services which are provided are appropriate, necessary, and of high quality.” N.J.AC. 8:31B-3.76(a).

On November 30, 1992, the Health Care Reform Act of 1992, L. 1992, c. 160, codified at N.J.S.A 26:2H-18.51 et seq., was enacted into law. Sections 40 and 41 of Chapter 160 repealed some of the provisions of Chapter 83 which formed the statutory basis for some of the regulations pertinent to this appeal. Significantly, the Health Care Reform Act abolished the DRG payment system effective January 1, 1993, established a “transition year” methodology for 1993, and deregulated the hospital reimbursement system effective January 1, 1994.

These appeals focus on whether the hospitals were required to permit State-qualified UROs to conduct reviews during the 1993 transition year and whether the hospitals were required to pay for those reviews. The period between January 1, 1993, and December 31, 1993, is the transition year. N.J.S.A 26:2H-18.53a. In recognition of the fact that the Health Care Reform Act made major changes in the system for hospital reimbursements, some of which became effective January 1, 1993, counsel for the New [213]*213Jersey Hospital Association (Hospital Association) sought guidance from the Department of Health (DOH). On January 22, 1993, counsel for the Hospital Association sent a letter to the DOH asking for clarification of the DOH’s position regarding the functions of State-qualified URO’s and the method of paying them during 1993. The DOH responded in a memorandum dated April 2, 1993, which forms the basis for the appeals. It informed the hospitals how UROs were to function during 1993 and why the hospitals were expected to collect sufficient funds from payors to pay for the URO services.

The Hospital Association filed an appeal on April 27, 1993, under docket number A-4132-92T3, from the DOH memorandum. We permitted two State-qualified UROs, Axiom Review, Inc. (Axiom), and Peer Review Organization of New Jersey, Inc. (Peer Review), to intervene in that appeal. In addition, Axiom filed a Verified Complaint in the Chancery Division against Barnert Memorial Hospital and twenty other hospitals. The Hospital Association was permitted to intervene. These hospitals and the Hospital Association have appealed, by leave granted, under docket number A-342-93T3, from an order directing the hospitals to permit Axiom to conduct its utilization review functions for 1992 and 1993 and to pay Axiom for services to be rendered. We stayed the payment provisions of the order pending appeal.

On September 28, 1993, another URO, North Jersey Physicians Review, Inc., obtained an order directing Morristown Memorial Hospital to allow that URO access to patient records to perform its utilization reviews pursuant to N.J.AC. 8:31B-3.76. Morris-town Memorial Hospital has filed an appeal from that order, by leave granted, under docket number A-778-93T3F. We now consolidate all three appeals for disposition.

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A. Before Chapter 160

These appeals require some historical understanding of hospital reimbursements for inpatient care and the functions of UROs [214]*214prior to December 31, 1992. The Health Care Facilities Planning Act of 1971, L.1971, c. 136, established a prospective hospital rate setting scheme for Blue Cross and certain federally funded programs such as Medicaid. The Act was amended in 1978 because of spiraling costs of institutional care. Riverside Gen. Hosp. v. New Jersey Hosp. Rate Setting Comm’n, 98 N.J. 458, 460-461, 487 A.2d 714 (1985). These amendments, known as Chapter 83, declared a public policy of cost containment of hospital rates. The cost containment contemplated by Chapter 83 was to be achieved primarily by shortening patients’ hospital stays. In re Schedule of Rates for Barnert Memorial Hosp., 92 N.J. 31, 35-36, 455 A.2d 469 (1983). The system was designed to set a “prospective rate of reimbursement” (that is, in advance of the actual provision of services to patients). In re Amendment of N.J.A.C. 8:31B-3.31, 119 N.J. 531, 536, 575 A.2d 481 (1990). In addition, unlike its predecessors, Chapter 83 extended the State’s supervision and control of hospital rates to all “payors” of hospital services, including the uninsured. N.J.S.A 26:2H-18(b) and (c). The term “payor” has commonly been used in the health care industry to refer to anyone who pays for health care services, such as patients, commercial insurance companies (ie., Prudential), hospital service plans (ie., Blue Cross), and state and federally funded benefits programs (ie., Medicaid and Medicare).

Chapter 83 also created a Hospital Rate Setting Commission (HRSC), with power to approve the rates for all payors. N.J.S.A 26:2H-4.1. More will be said later about the function of the HRSC.

In terms of payment, Chapter 83 employed the DRG method of reimbursement. In re Schedule of Rates for Barnert Memorial Hosp., supra, 92 N.J. at 36, 455 A.2d 469. That is, various medical procedures were divided into DRGs and a rate was assigned to each. United Wire, Metal & Mach. Health and Welfare Fund v. Morristown Memorial Hosp., 995 F.2d 1179, 1189 (3d Cir.), cert. denied, - U.S. -, 114 S.Ct. 382, 126 L.Ed.2d 332 (1993). Under the DRG system, instead of charging [215]*215payors the actual costs incurred for treating an individual patient, a hospital was required to charge the DRG rate which was designated for a particular classification for that hospital. Ibid. Regulations were promulgated to implement Chapter 83 and codified at N.J.AC. 8:31B-1.1 et seq.

A URO is defined as “a group of physicians within a designated geographical area who review the health care provided to patients in area hospitals. Physicians may be assisted by other health care professionals.” N.J.AC. 8.-31B-3.77. As we stated earlier, the regulations created a URO system as well as a system for reimbursements to hospitals under DRG. This dual system was established in N.J.AC. 8:31B-3.76, which provides:

(a) P.L.1978, c.

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641 A.2d 1043, 273 N.J. Super. 205, 1994 N.J. Super. LEXIS 146, Counsel Stack Legal Research, https://law.counselstack.com/opinion/review-v-barnert-memorial-hospital-njsuperctappdiv-1994.