Select Specialty Hospital - Denver, Inc. v. Sebelius

District Court, District of Columbia·Decided November 4, 2019·No. Civil Action No. 2010-1356·Published

Opinion

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA

SELECT SPECIALTY HOSPITAL- DENVER, INC., et al., Civil Action No. 10-1356 (BAH)

Plaintiffs,

Chief Judge Beryl A. Howell v.

ALEX M. AZAR II, Secretary, U.S. Department of Health and Human Services,

Defendant.

MEMORANDUM OPINION

The plaintiffs, seventy-five long-term care hospitals (“LTCHs”) located in twenty-six states, sought reimbursement from the Department of Health and Human Services (“HHS”) for unpaid co-insurance and deductible obligations (“bad debts”) of patients eligible for both Medicare and Medicaid (“dual-eligible patients”). The plaintiffs’ Motion for Summary Judgment, ECF No. 66, was granted and HHS’s Cross-Motion for Summary Judgment, ECF No. 67, was denied. See Select Specialty Hosp.-Denver, Inc. v. Azar, 391 F. Supp. 3d 53, 70 (D.D.C. 2019). Now, HHS seeks reconsideration of that decision under Federal Rules of Civil Procedure 59(e) and 60(b). See Def.’s Mot. for Reconsid. of the Court’s Aug. 22, 2019 Mem. Op. (“Def.’s Mot.”), ECF No. 78. Plaintiffs ask for an order amending the judgment to include an award of prejudgment interest under 42 U.S.C. § 1395oo(f)(2). See Pls.’ Mot. for Prej. Interest (“Pls.’ Mot.”), ECF No. 77. For the reasons set forth below, the defendant’s motion is denied and the plaintiffs’ motion is granted.

I. BACKGROUND The statutory, regulatory, procedural, and factual background for this case were provided in the earlier opinion. See Select Specialty, 391 F. Supp. 3d at 56–66. Still, some background bears repeating here.

A. Statutory and Regulatory Background “Bad debts” are defined in the Medicare context as “amounts considered to be uncollectible from accounts and notes receivable that were created or acquired in providing services.” 42 C.F.R. § 413.89(b)(1). Medicare providers may be reimbursed by the Centers for Medicare and Medicaid Services (“CMS”), which administers the Medicare program, for “allowable” bad debts. Id. § 413.89(d). A bad debt cannot be “allowable” unless “[t]he provider [is]. . . able to establish that reasonable collection efforts were made.” Id. § 413.89(e) (outlining four criteria that determine whether a debt is allowable). For dual-eligible patients’ bad debts, providers can satisfy this reasonable collection requirement by showing (1) that the patient has “been determined eligible for Medicaid” and (2) that “no source other than the patient,” including Medicaid, “would be legally responsible for the patient’s medical bill.” Provider Reimbursement Manual, Part I (“PRM-I”) § 312. The second obligation is at issue here.

To fulfill this obligation, CMS currently requires that all providers “bill the patient or entity legally responsible for the patient’s bill.” H-AR at 584 (Joint Signature Memorandum 370 (“JSM 370”) (Aug. 10, 2004)).1 “[W]ith respect to ‘dual-eligibles,’” current CMS guidance

1 Four Administrative Records have been filed in this consolidated case. The AR from the first-filed case, Select Specialty Hosp.- Denver, Inc. v. Azar (“Select I”), Civ. No. 10-1356, is referred to as the Select I Administrative Record (“S1-AR”). See Joint Appendix (“JA”), Appendix from Select I AR (1 of 2), ECF No. 73-1; JA, Appendix from Select I AR (2 of 2), ECF No. 73-2. The first-filed case also includes a Supplemental AR (“S1S- AR”) with documents from after the case was remanded to CMS. See JA, Appendix from Select I AR Supplement, ECF No. 73-3. The AR from the second-filed case, Select Specialty Hosp.-Birmingham v. Azar (“Select II”), Civ. No. 17-235, is referred to as the Select II Administrative Record (“S2-AR”). See JA, Appendix from Select II AR (1 of 3), ECF No. 73-4; JA, Appendix from Select II AR (2 of 3), ECF No. 73-5; JA from Select II AR (3 of 3), ECF No. 73-6. Finally, the AR from the third-filed case, Select Specialty Hosp.-Tulsa/Midtown, LLC v. Azar

further states that “in those instances where the state owes none or only a portion of the dual- eligible patient’s deductible or co-pay, the unpaid liability for the bad debt is not reimbursable to the provider by Medicare until the provider bills the State, and the State refuses payment (with a State Remittance advice).” Id.

Defendant insists that the must-bill policy and the more specific remittance advice (“RA”) requirement are both longstanding. See Def.’s Mot. at 2. Prior to 2007, however, the LTCH plaintiffs had been reimbursed for their dual-eligible patients’ bad debts without first billing state Medicaid programs and obtaining an RA. See Select Specialty, 391 F. Supp. 3d at 55, 60–62. These steps were viewed as unnecessary because states were not liable for inpatient care of dual-eligible patients by LTCHs. Id. at 55. Indeed, none of the plaintiffs were enrolled in their state Medicaid programs as providers prior to 2007, id. at 60, and some states would not allow these LTCHs to enroll, id. at 61.

In 2007, Medicare administrative contractors suddenly began denying plaintiffs’ requests for reimbursement for dual-eligible bad debts, citing plaintiffs’ failure to present RAs.2 In July and August 2007, one set of plaintiffs, the Select I plaintiffs, had their reimbursement requests for dual-eligible patients’ bad debts in fiscal year 2005, totaling $438,693, denied by their contractor, Wisconsin Physicians Service Corporation (“WPS”) (formerly known as “Mutual of Omaha”). See Select Specialty, 391 F. Supp. 3d at 61 (citing S1-AR at 674). A second set of plaintiffs, the Select II plaintiffs, had various such requests for fiscal years 2006–2010, totaling $19,317,678, denied by contractors WPS and Novitas Solutions, Inc. (“Novitas”), beginning in

(“Hillcrest”), Civ. No. 18-584, is referred to as the Hillcrest Administrative Record (“H-AR”). See JA, Appendix from Hillcrest AR, ECF No. 73-7. 2 The Secretary of HHS is required by statute to delegate most of “[t]he administration of [Medicare Part A]

. . . through contracts with [M]edicare administrative contractors.” 42 U.S.C. § 1395h(a). These contractors are responsible for “[d]etermining . . . the amount of the payments required . . . to be made to providers of services, suppliers and individuals” and for making those payments. Id. § 1395kk-1(a)(4).

June 2007. Id. (citing S2-AR at 457 (Stipulations ¶ 9)). The third plaintiff, the Hillcrest plaintiff, had dual-eligible bad debts reimbursement requests denied for the first time by WPS in December 2008; this plaintiff was ultimately denied $568,803 in reimbursements for dual- eligible bad debts for fiscal years 2007 and 2008. Id. (citing H-AR at 555–57, 565–67; H- Answer ¶¶ 6).

The three sets of plaintiffs appealed the contractors’ denials to the Provider Reimbursement Review Board (“PRRB”), which reversed those denials in part. See id. at 64–65 (citing Select Specialty ’05 Medicare Dual Eligible Bad Debts Grp. v. Wisc. Physicians Serv., PRRB 2010-D25 (Apr. 13, 2010); Select Specialty Medicare Dual Eligible Bad Debts CIRP Grps. v. Novitas Solutions, Inc., PRRB 2016-D22 (Sept. 27, 2016); Hillcrest Specialty Hosp. v. Novitas Solutions, Inc., PRRB 2018-D3 (Nov. 6, 2017)). The CMS Administrator, whom the Secretary has given authority to hear appeals from the PRRB, reinstated the contractors’ decisions to deny the plaintiffs’ dual-eligible bad debt reimbursements for failure to submit RAs. Id. at 65 (citing S1-AR at 2–19; S2-AR at 1–22; H-AR at 2–29).

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