Rocky Mountain Health Maintenance Organization, Inc. v. Colorado Department of Health Care Policy & Financing Ex Rel. Rizzuto

54 P.3d 913, 2001 Colo. J. C.A.R. 4595, 2001 Colo. App. LEXIS 1520, 2001 WL 1045537
CourtColorado Court of Appeals
DecidedSeptember 13, 2001
Docket00CA1517
StatusPublished
Cited by12 cases

This text of 54 P.3d 913 (Rocky Mountain Health Maintenance Organization, Inc. v. Colorado Department of Health Care Policy & Financing Ex Rel. Rizzuto) is published on Counsel Stack Legal Research, covering Colorado Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Rocky Mountain Health Maintenance Organization, Inc. v. Colorado Department of Health Care Policy & Financing Ex Rel. Rizzuto, 54 P.3d 913, 2001 Colo. J. C.A.R. 4595, 2001 Colo. App. LEXIS 1520, 2001 WL 1045537 (Colo. Ct. App. 2001).

Opinion

Opinion by

Judge ROTHENBERG.

In this dispute concerning the calculation of Medicaid capitation rates, defendant, Colorado Department of Health Care Policy and Financing, appeals the trial court's judgment following a bench trial finding it liable to plaintiff, Rocky Mountain Health Mainte-nanee Organization, Inc. (RMHMO). We affirm.

I. Background

The department is the state agency responsible for administering the State of Colorado's Medicaid program, a cooperative federal and state program that provides medical services to individuals otherwise unable to meet the costs of such services. The department contracts with private parties to provide the medical services to its Medicaid recipients.

RMHMO is a nonprofit managed care corporation that entered into three contracts with the department to provide medical services to certain Medicaid recipients for the fiscal years 1997-1999. Those three contracts are the subject of this dispute.

A. Statutes and Regulations

Federal law requires those that choose to participate in the Medicaid program, such as the department, to set rates on an actuarially sound basis. See § 42 U.S.C. 1396b(m) (2000).

Certain state regulations also restrict rate settings. Under $ 8.211.08, 10 Code Colo. Regs. 2505-10 (1997), capitation rates, the premiums per recipient, must be established in accordance with actuarial principles after considering the medical and administrative costs of covered services. Colorado has also established restrictions governing the upper and lower limits for health maintenance organization's capitation rates. See § 26-4-119(1)(a), (b), C.R.S8.2000.

*916 B. Contracts

The parties used one basic form for the three contracts in issue here. The effective date of each contract was July 1 of the relevant fiscal year. The contracts require that the department pay a capitation rate that is a fixed monthly payment.

Exhibit B of each contract provides the rates. The contracts state that the rates set forth in Exhibit B are calculated based on a seven-step process which provides for:

(1) calculating fee-for-service expenditures under a prior fiscal year;
(2) adjusting for inflation by applying a trend to project rates to the rating period; (3) adjusting for any significant prospective financial events;
(4) counting the number of fee-for-service eligibles and adjusting them for projected case mix;
(5) dividing projected costs by projected eligibles;
(6) multiplying the result by 95 percent; and
(7) possibly adding administrative costs.

In addition, the contracts expressly incorporate applicable federal and state laws and provide that:

[this contract shall be governed and construed in accordance with the laws established in Article 16, Title 10, Colorado Revised Statutes, as amended, hereinafter referred to as the Colorado Health Coverage Act, and as defined in 42 United States Code 8006, hereinafter referred to as the Health Maintenance Organization Act of 1978, as amended, Article 4, Title 26, Colorado Revised Statutes, Title XIX of the Social Security Act, and all pertinent Department regulations of the Colorado Department of Health Care Policy and Financing Staff Manual Volume VIII, as amended. The laws of the United States of America shall be governing in the event of a conflict or any inconsistency with the laws of the State of Colorado.
C. Current Litigation

At the bench trial, RMHMO asserted that the department had miscalculated the capitation rates for each year of the contracts and that these miscaleulations had resulted in a breach of contract, causing damages to RMHMO.

The facts were largely undisputed and the department presented little evidence at trial. It was undisputed that: (1) the department had a duty to calculate annually the specific dollar amounts of the capitation rates based on data from previous fiscal years; (2) these calculations involved the analysis of massive amounts of data and took months to complete; (8) as a result, the capitation rates were not finalized by the July 1 effective date of the contracts; (4) these parties had contracted with each other since the 1970s; and (5) they had an understanding that the department would voluntarily correct any rate errors that were later discovered.

The testimony also showed that the parties had customarily and routinely corrected rate errors prior to 1996. However, in 1996, the department hired a new director, and at his directive, it had ended the practice of correcting any rate errors discovered later by RMHMO. ‘

The department asserted some defenses to RMHMO's action, but its primary contention at trial and on appeal is that, even assuming the department miscalculated the capitation rates, RMHMO lacks a remedy at law. According to the department, there were extensive negotiations between RMHMO and the department as part of the ratesetting process; the department could have cancelled the contract if it was not satisfied by the rates; and the seven-step process was not intended as an exact calculation.

However, a department employee testified at trial that the department unilaterally had set the rates, and an RMHMO representative also testified that RMHMO lacked any meaningful input into the rate-setting process. The director, who testified as the department's representative, conceded that state and federal laws and the seven-step process apply to the department when it sets rates under the contracts.

*917 The department had hired an actuarial firm to conduct a review of the department's rates, and one actuary testified that he had discovered at least fifteen errors in the department's rate calculations, RMHMO presented other actuarial reports and evidence that the Colorado General Assembly had ordered an audit of the department's rate calculations.

The evidence also included an e-mail from a department employee to his co-workers admitting that he had miscaleulated a portion of the rates. The same employee testified that he was certain the department had both underpaid and overpaid the rates in the past.

As to damages, RMHMO presented evidence from an actuarial firm that had reconstructed and analyzed the rates for the three years at issue. The firm reported that RMHMO had suffered $21,820,841 in damages from the miscaleulations.

D. Trial Court's Findings and Conclusions

After hearing the evidence, the trial court made oral findings of facts and conclusions of law from the bench and directed RMHMO's counsel to submit a written order and judgment, which the court later executed.

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54 P.3d 913, 2001 Colo. J. C.A.R. 4595, 2001 Colo. App. LEXIS 1520, 2001 WL 1045537, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rocky-mountain-health-maintenance-organization-inc-v-colorado-department-coloctapp-2001.