Southeast Missouri Hospital Ass'n v. Missouri Department of Social Services, Division of Medical Services

886 S.W.2d 94, 1994 Mo. App. LEXIS 1414, 1994 WL 463700
CourtMissouri Court of Appeals
DecidedAugust 30, 1994
DocketNo. WD 48677
StatusPublished
Cited by4 cases

This text of 886 S.W.2d 94 (Southeast Missouri Hospital Ass'n v. Missouri Department of Social Services, Division of Medical Services) is published on Counsel Stack Legal Research, covering Missouri Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Southeast Missouri Hospital Ass'n v. Missouri Department of Social Services, Division of Medical Services, 886 S.W.2d 94, 1994 Mo. App. LEXIS 1414, 1994 WL 463700 (Mo. Ct. App. 1994).

Opinion

ELLIS, Judge.

Southeast Missouri Hospital Association (“Southeast”) appeals from an order and judgment of the Circuit Court of Cole County affirming a decision of the Administrative Hearing Commission (“AHC”).

Southeast is a licensed hospital located in Cape Girardeau, Missouri. The Missouri Department of Social Services1 has authorized Southeast to provide Title XIX Medicaid services for which § 208.152, RSMo 1986,2 provides benefit payments. Pursuant to § 197.300 et seq., a health care provider wishing to expand or renovate its facility must obtain a Certificate of Need (“CON”). If a [96]*96CON is issued, the provider may apply for a Medicaid per diem rate (“Medicaid rate”) increase based upon the amount approved in the CON.

Before January 1, 1984, the Department granted Southeast an increase in its Medicaid rate for its pediatric special care unit, and included that increase in Southeast’s 1983 rate. On February 21, 1984, Southeast requested an increase in its 1984 Medicaid rate for new and expanded services due to an extensive modernization program and purchase of a CT scanner. Southeast had a CON for both projects. The Department decided that the projects merited an increase in Southeast’s Medicaid rate as of January 1, 1984. At that time, the Department’s regulations required that, in determining the Medicaid rate to which an increase for a CON project must be added, the Medicaid rate must be the lowest yielded by one of three methods of calculation. The first method used Southeast’s December 15, 1983 rate, increased by a certain percentage to allow for some degree of inflation. Increasing a rate in such manner is referred to as “trending forward.” The third method used the third prior fiscal year’s cost report trended forward.

The.second method used the Title XVIII “Medicare rate” most recently filed with the Missouri Medical Services Section. The Department’s regulation specified that the “Medicare rate” was an amount “determined by the servicing fiscal intermediary based on yearly Hospital Cost Reports.” 13 CSR 70-15.010(2)(C). The “servicing fiscal intermediary” in this case was Blue Cross/Blue Shield. The manner in which Southeast’s Medicare reimbursement was calculated had been changed some time before 1984, and therefore, Blue Cross/Blue Shield no longer determined a Medicare rate and no longer filed such a rate with the Department. As a result, there was no Medicare rate on file. Since there was no rate' on file, the Department adopted a method of calculating such a rate itself. It used estimated Medicare payment computations, which were apparently based on Medicare cost reports, to come up with the rate. This calculation yielded the lowest Medicaid rate of the three methods required to be used, $322.68. The Depart ment then added $22.91 to that amount for the incremental costs of the CON project increase to arrive at a Medicaid rate for Southeast as of January 1, 1984 of $345.59.

On June 11, 1984, the Department sent Southeast a notice advising that its request for an increase in Medicaid rate had been reviewed and was granted at a new rate of $345.59. The notice stated that the Pediatric Special Care Unit costs had been previously granted and carried forward, and therefore resulted -in no additional increase for that area. An attachment identified three alternative rates as calculated by the three methods required by the regulations in effect at that time. The one reflecting the approved rate was captioned “Most Current Medicare Per Diem On File (PRE DRG).” The notice farther indicated that Southeast had 30 days in which to appeal the decision to the AHC. Southeast did not appeal.

The methodology employed by the Department to calculate the Medicare rate actually excluded Southeast’s labor, delivery, pediatric and neonatal costs, and therefore, the portion of the notice indicating that those costs were carried forward and there was no entitlement to an additional increase for them was incorrect. Furthermore, on June 4, 1984, a week before the notice was sent, a Department employee, Kevin Syberg sent a memo to the Department’s director, Jane Kruse. In that memo, under the heading “Analysis,” Syberg stated:

This is a rather complex issue. Not only must we decide if and how much of an increase is due for renovated services but also how to determine a Medicare rate under the DRG payment system (base year 1982).

The memo also acknowledged that Southeast’s proposed rate of $408.03 and the method used in establishing it “may stand up to Federal assessment.” The rate proposed by Southeast included labor, delivery and neonatal costs. Southeast was unaware of this memo until shortly before this ease was heard before the AHC, when it obtained a copy by virtue of discovery procedures.

In addition, the Department did not inform Southeast that the rate captioned “Most Cur[97]*97rent Medicare Per Diem on File (PRE DRG)” was not the amount “determined by the servicing fiscal intermediary based on yearly Hospital Cost Reports” as required by the Department’s regulations, but rather was an amount calculated by the Department based on estimated Medicare payment computations. Southeast first learned of this in 1990 when it hired a new accountant with extensive experience in providing accounting services for Missouri Medicaid providers. The CPA concluded something was wrong with the rate and requested further information from the Department, which led to discovery of the manner in which the rate was calculated. As a result of the improperly computed rate, Southeast was denied a cumulative total of $1,049,870 in Medicaid payments between 1984 and 1990.

This background leads us to the origin of the instant appeal. In December, 1989, Southeast requested increases in its Medicaid rate for a change in case mix and for new and expanded services (CON projects). As a result of differences in calculating the proposed increases, much of the information regarding the 1984 rate calculation came to light. Thus, the case mix and CON increases of 1989 became relatively minor, and essentially uncontested, parts of the litigation. The primary focus of the case before the AHC, the trial court, and in this appeal is whether the Department correctly limited Southeast’s 1984 Medicaid rate to which it added Southeast’s 1984 requested CON project increase.

The AHC granted Southeast a CON project increase effective January 1, 1990 and a case mix increase as of May 1, 1990. However, it refused to increase Southeast’s January 1, 1990 Medicaid rate (a prospective increase based on recalculation of the 1984 rate) before adding the CON and case mix increases. The AHC also ruled that it lacked subject matter jurisdiction under § 208.156.2 over Southeast’s claim for lost Medicaid reimbursement between 1984 and 1990.

Southeast presents three points on appeal. First, it contends the trial court erred in affirming the AHC’s denial of Southeast’s request for a prospective rate increase from January 1,1990 based on recalculation of the 1984 rate because such increase was authorized by the extraordinary circumstances adjustment provisions of 13 CSR 70-15.010(5)(E)2. Second, it asserts the trial court erred in affirming the AHC’s determination that it lacked subject matter jurisdiction over Southeast’s claim for retroactive Medicaid reimbursement for the period from 1984 through 1989.

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Bluebook (online)
886 S.W.2d 94, 1994 Mo. App. LEXIS 1414, 1994 WL 463700, Counsel Stack Legal Research, https://law.counselstack.com/opinion/southeast-missouri-hospital-assn-v-missouri-department-of-social-moctapp-1994.