Robert F. Kennedy Medical Center v. Belshe

919 P.2d 721, 13 Cal. 4th 748, 55 Cal. Rptr. 2d 107, 96 Cal. Daily Op. Serv. 5753, 96 Daily Journal DAR 9345, 1996 Cal. LEXIS 3815
CourtCalifornia Supreme Court
DecidedAugust 1, 1996
DocketS042553
StatusPublished
Cited by45 cases

This text of 919 P.2d 721 (Robert F. Kennedy Medical Center v. Belshe) is published on Counsel Stack Legal Research, covering California Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Robert F. Kennedy Medical Center v. Belshe, 919 P.2d 721, 13 Cal. 4th 748, 55 Cal. Rptr. 2d 107, 96 Cal. Daily Op. Serv. 5753, 96 Daily Journal DAR 9345, 1996 Cal. LEXIS 3815 (Cal. 1996).

Opinions

Opinion

GEORGE, C. J.

Plaintiff Robert F. Kennedy Medical Center, a provider of hospital inpatient services under the California Medical Assistance Program (Medi-Cal), seeks a writ requiring the Director of the California Department of Health Services (Department) to rescind the Department’s final settlement determining the amount of Medi-Cal reimbursement that is due plaintiff, because notice of the final settlement was issued more than three years after plaintiff submitted its cost reports for the years in question. Plaintiff contends that the provision in Welfare and Institutions Code section 14170, subdivision (a)(1),1 specifying that cost report data submitted by Medi-Cal providers “shall be considered true and correct unless audited or reviewed within three years” of submission to the Department, establishes a three-year limitations period within which the Department must determine the amount of reimbursement due a provider.

We granted review to resolve a conflict between the decision reached by the Court of Appeal in the present case and the decision rendered by another division of the same Court of Appeal in Palmdale Hospital Medical Center v. Department of Health Services (1992) 8 Cal.App.4th 1306 [10 Cal.Rptr.2d 926] on this issue. For the reasons that follow, we conclude that section 14170, subdivision (a)(1), requires the Department to raise any challenge to the accuracy of the provider’s cost report data within three years, but does not establish a time limitation governing the Department’s final determination of the amount of reimbursement due a provider.

Accordingly, in the present case the Department complied with section 14170, subdivision (a)(1), when it issued its final audit report within three years of submission of cost reports by plaintiff for each of the years in question, and was not barred from making a final settlement (determining reimbursement liability) after expiration of that three-year period. Therefore, the judgment of the Court of Appeal, directing issuance of the writ relief sought by plaintiff, must be reversed.

[751]*751I

The Medi-Cal program (§ 14000 et seq.) represents California’s implementation of the federal Medicaid program (42 U.S.C. §§ 1396-1396v), through which the federal government provides financial assistance to states so that they may furnish medical care to qualified indigent persons. (See Palmdale Hospital Medical Center v. Department of Health Services, supra, 8 Cal.App.4th 1306, 1312.) The Department is the single state agency designated to administer the Medi-Cal program. (§ 14203.)

When originally enacted in 1965, the Medicaid Act required states to reimburse health care providers for the “reasonable cost” of hospital services rendered; the term “reasonable cost” was defined under federal standards to correspond to the cost of services actually incurred by a hospital provider and otherwise allowable under Medicare. (See Wilder v. Virginia Hospital Assn. (1990) 496 U.S. 498, 505, 507 [110 L.Ed.2d 455, 464, 465-466, 110 S.Ct. 2510]; California Hospital Ass’n v. Obledo (9th Cir. 1979) 602 F.2d 1357, 1358; 42 C.F.R. §§ 413.5, 413.9 (1995).) In accordance with these federal standards, former section 14105 (the predecessor to section 14170), as originally enacted, provided for hospital reimbursement on the basis of “reasonable cost for . . . services.” (Stats. 1966, 2d Ex. Sess. 1965, ch. 4, § 2, p. 115.) The statute, however, did not contain any provision for an audit of a provider’s expenditures under the Medi-Cal program.

In 1969, former section 14105 was amended to include, among other provisions, the following language: “Cost reports and other data submitted by providers to a state agency for the purpose of determining reasonable costs for services or establishing rates of payment shall be considered true and correct unless audited within eighteen (18) months after July 1, 1969, the close of the period covered by the report, or after the date of submission of the original or amended report by the provider, whichever is later.” (Stats. 1969, ch. 1274, § 1, pp. 2486-2487.)2 In 1973, section 14105 was amended again to extend the 18-month period governing the auditing process to 3 years. (Stats. 1973, ch. 856, § 1, p. 1548.) In 1977, the pertinent provisions of section 14105 were recodified as section 14170 (Stats. 1977, ch. 1046, § 6, pp. 3172-3173), discussed in detail, post.

In 1980 and 1981, in an effort to contain spiraling Medicaid costs for hospital services, Congress amended the Medicaid standard for hospital [752]*752reimbursement, replacing the “reasonable cost” standard with the current standard requiring states to reimburse hospital providers at rates that are “reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities . . . (42 U.S.C. § 1396(a)(13)(A); Wilder v. Virginia Hospital Assn., supra, 496 U.S. at pp. 506-507 [110 L.Ed.2d at pp. 464-466].) Under this new standard, states were permitted to develop alternate methodologies to limit reimbursement based upon the costs that would have been incurred by an efficient and economically operated facility, even if a provider’s actual costs were greater. (Wilder v. Virginia Hospital. Assn., supra, 496 U.S. at pp. 506-507 [110 L.Ed.2d at pp, 464-466].)

In response to this change in Medicaid standards, the Department promulgated regulations imposing additional limits on the reimbursement available to a provider. The first, embodied in title 22 of the former California Administrative Code (now California Code of Regulations), section 51536 (enacted July 1, 1980), establishes a maximum reimbursement limit for hospital inpatient services, constituting the lesser of (1) customary charges, (2) allowable costs determined in accordance with applicable Medicare standards and principles of reimbursement, and (3) the “all-inclusive rate per discharge.” The “all-inclusive rate per discharge” established by section 51536 determines the maximum allowable average cost per Medi-Cal patient that is reimbursable. In calculating this maximum rate per patient treated, the provider is given full credit for certain costs, such as rents and property taxes (§ 51536, subd. (b)(7)), but not for other costs (such as costs of services that have increased significantly over those incurred in prior years). The regulation also controls the amount that the all-inclusive rate per discharge may increase above the rate allowed in prior years. (§ 51536, subds. (c)-(i).) The rate must be updated annually and must incorporate data based upon a series of price indicators that may be derived from a variety of sources, including the consumer price index. (§ 51536, subd. (g).) This rate, when multiplied by the number of Medi-Cal patients treated, establishes an upper limit on the total reimbursement available to the provider. (§ 51536, subd. (b)(6).)

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Crestwood Behavioral Health, Inc. v. Baass
California Court of Appeal, 2023
Riverside County Public Guardian v. Snukst
California Court of Appeal, 2022
(HC) Rivas v. Koenig
E.D. California, 2021
Lent v. California Coastal Commission
California Court of Appeal, 2021
Lent v. Cal. Coastal Commission
California Court of Appeal, 2021
Gonzalez v. City National Bank
California Court of Appeal, 2019
Gonzalez v. City Nat'l Bank
248 Cal. Rptr. 3d 770 (California Court of Appeals, 5th District, 2019)
Santa Rosa Memorial Hospital v. Kent
California Court of Appeal, 2018
Santa Rosa Mem'l Hosp., Inc. v. Kent
236 Cal. Rptr. 3d 199 (California Court of Appeals, 5th District, 2018)
American Indian Health etc. v. Kent
California Court of Appeal, 2018
Am. Indian Health & Servs. Corp. v. Kent
234 Cal. Rptr. 3d 583 (California Court of Appeals, 5th District, 2018)

Cite This Page — Counsel Stack

Bluebook (online)
919 P.2d 721, 13 Cal. 4th 748, 55 Cal. Rptr. 2d 107, 96 Cal. Daily Op. Serv. 5753, 96 Daily Journal DAR 9345, 1996 Cal. LEXIS 3815, Counsel Stack Legal Research, https://law.counselstack.com/opinion/robert-f-kennedy-medical-center-v-belshe-cal-1996.