Ulster Home Care, Inc. v. Vacco

268 A.D.2d 59, 706 N.Y.S.2d 739, 2000 N.Y. App. Div. LEXIS 4204
CourtAppellate Division of the Supreme Court of the State of New York
DecidedApril 13, 2000
StatusPublished
Cited by8 cases

This text of 268 A.D.2d 59 (Ulster Home Care, Inc. v. Vacco) is published on Counsel Stack Legal Research, covering Appellate Division of the Supreme Court of the State of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Ulster Home Care, Inc. v. Vacco, 268 A.D.2d 59, 706 N.Y.S.2d 739, 2000 N.Y. App. Div. LEXIS 4204 (N.Y. Ct. App. 2000).

Opinion

OPINION OF THE COURT

Carpinello, J.

Plaintiff Ulster Home Care, Inc. is the operator of a licensed home care agency enrolled in the Medicaid program and provides personal care services to eligible Medicaid recipients pursuant to a contract, renewed annually, with the Ulster County Department of Social Services, which is responsible for various administrative aspects of the Medicaid program in Ulster County (see, Social Services Law §§ 365, 365-a [2] [d]; §§ 367-j, 367-k, 367-n, 367-p). Although Medicaid clients account for a majority of its revenue, Ulster Home also provides personal care services to non-Medicaid clients. The charges for services to non-Medicaid clients can be paid in a variety of ways, i.e., by third-party payor sources, such as health maintenance organizations, health insurance companies and non-Medicaid State agencies, or directly by the client (this latter category is often referred to as the self-pay clients).

In April 1997, Ulster Home was the subject of an audit and investigation conducted by the Office of the Attorney General through its Medicaid Fraud Control Unit (hereinafter MFCU). According to Ulster Home, its counsel met with members of MFCU’s investigative staff in March 1998 and was advised that the focus of their investigation concerned 18 NYCRR 505.14 (h) (7) (ii) (a), which provides that:

“(1) Medical assistance payments to personal care services providers for any rate year beginning on or after January 1, 1994, are made at the lower of the following rates:
“(i) the rate the provider charges the general public for personal care services; or
[61]*61“(ii) the rate determined by the department in accordance with [a cost-based methodology].”

Specifically, Ulster Home was advised that MFCU’s investigation revealed that it should have been reimbursed pursuant to item (i) of the regulation (hereinafter the public charge portion of the regulation), as opposed to item (ii) of the regulation (the cost-based methodology), because the rate it charged the “general public” was lower than the rate established by the former Department of Social Services (hereinafter DSS).1 At this time, an overpayment of nearly $1.2 million was apparently being sought.2 Thereafter, MFCU limited its finding to the period May 1995 through mid-1997 and the recovery allegedly due the State was reduced to $675,000.

Alleging that Ulster Home’s Medicaid billing practices were undertaken with the express purpose of enriching itself at the expense of the taxpayers and that Ulster Home knowingly lied to the State about its actual charges, MFCU seeks to prosecute it for larceny and offering a false instrument for filing. Faced with the prospect of criminal prosecution because of its alleged violation of the public charge portion of the regulation, Ulster Home commenced this action seeking declaratory and injunctive relief. Plaintiffs James Mahoney and Diane Wiegand, Ulster Home’s Executive Director and Assistant Executive Director, respectively, were granted permission to intervene. On a prior appeal, this Court affirmed an order of Supreme Court issuing a preliminary injunction against defendant enjoining the enforcement of the public charge regulation,, as well as an order finding defendant in contempt of court (255 AD2d 73).

Following this Court’s decision, Ulster Home moved for summary judgment seeking a declaration that defendant’s threatened prosecution violates the contracts between itself and Ulster County, that defendant should be prohibited from enforcing the public charge portion of the regulation on a retroactive basis, that defendant should be prohibited from demanding repayment of funds received by Ulster Home under its [62]*62contracts with Ulster County and, most importantly, that defendant should be enjoined from attempting to impose any criminal or civil liability as a result of enforcement of the public charge portion of the regulation. Supreme Court denied the motion, prompting this appeal by Ulster Home. Various amici curiae briefs have been submitted in support of Ulster Home’s position.

To fully understand the nature of this action, a brief overview of the Medicaid reimbursement program with respect to personal care services is necessary. From the inception of the personal care services program through 1994, providers such as Ulster Home had been reimbursed at rates they negotiated with social service districts around the State. This methodology resulted in negotiated payment rates which did not necessarily reflect a provider’s actual costs, lacked uniformity from district to district and placed an additional administrative burden upon social service districts (i.e., negotiating payment rates) (see, NY Reg, Oct. 13, 1993, at 43). Pursuant to the Laws of 1990 (ch 53), DSS was directed to submit to the Legislature and the Governor a plan containing criteria for the establishment of a rate-setting methodology for personal care services (see also, L 1993, ch 59, § 61; L 1992, ch 41, § 3). The goal of the Legislature at this time “was to require [DSS] to develop a rate setting methodology for personal care services that considers personal care services providers’ actual costs of providing services to [Medicaid assistance] recipients” (NY Reg, Oct. 13, 1993, at 44 [emphasis supplied]). Pursuant to this legislative authority, DSS promulgated regulations establishing a new methodology by which payment rates for personal care services provided on or after January 1, 1994 would be calculated. The regulation changed not only the method by which these rates would be established but also changed the entity responsible for establishing such rates (see, 18 NYCRR 505.14 [h] [7]).

Consequently, under the revised regulatory scheme, payment rates were no longer based on district negotiated rates; rather, they were determined by DSS based upon the methodology defined in 18 NYCRR 505.14 (h) (7) (ii) and approved by the Division of Budget (see, NY Reg, Oct. 13, 1993, at 45). Under the regulations, a provider with cost experience, like Ulster Home, reported its operating costs to DSS on a cost report, which, in turn, is used by DSS to establish that provider’s rate (see, NY Reg, Oct. 13, 1993, at 43). As previously noted, since 1994, DSS has calculated Ulster Home’s rate during the relevant time period using this cost-based methodology.

[63]*63In turning to our legal analysis, we reiterate, as strenuously emphasized by Ulster Home and the amici curiae, that a provider’s approved Medicaid reimbursement rate is calculated by DSS, not the provider, and that the provider merely submits the required costs report to DSS (see, 18 NYCRR 505.14 [h] [7] [i]). Once its rate is set, the provider submits bills to Medicaid for payment at the approved rate (see, 18 NYCRR 505.14 [h] [1]; 540.7). Thus, these parties argue that a gross injustice would result by criminalizing the conduct of a provider who bills Medicaid at a DSS promulgated and approved cost-based rate instead of “the rate” it charges the “general public.” This concern is indeed compelling. Equally compelling, however, is the need on behalf of the public fisc to prosecute any provider who, although lacking the authority to set its reimbursement rates, submits false information to the State on, for example, a cost report in order to wrongfully obtain State funds.

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

Related

Rubin v. Garvin
Second Circuit, 2008
Ulster Home Care, Inc. v. Vacco
296 A.D.2d 671 (Appellate Division of the Supreme Court of New York, 2002)
People v. Rubin
757 N.E.2d 762 (New York Court of Appeals, 2001)
Ulster Home Care, Inc. v. Vacco
757 N.E.2d 764 (New York Court of Appeals, 2001)
Frohlinger v. DeBuono
278 A.D.2d 323 (Appellate Division of the Supreme Court of New York, 2000)
People v. Doe
271 A.D.2d 29 (Appellate Division of the Supreme Court of New York, 2000)
People v. Rubin
271 A.D.2d 759 (Appellate Division of the Supreme Court of New York, 2000)

Cite This Page — Counsel Stack

Bluebook (online)
268 A.D.2d 59, 706 N.Y.S.2d 739, 2000 N.Y. App. Div. LEXIS 4204, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ulster-home-care-inc-v-vacco-nyappdiv-2000.