United States Ex Rel. Davis v. District of Columbia

34 F. Supp. 3d 30, 2014 WL 1273608, 2014 U.S. Dist. LEXIS 42725
CourtDistrict Court, District of Columbia
DecidedMarch 31, 2014
DocketCivil Action No. 2006-0629
StatusPublished
Cited by6 cases

This text of 34 F. Supp. 3d 30 (United States Ex Rel. Davis v. District of Columbia) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States Ex Rel. Davis v. District of Columbia, 34 F. Supp. 3d 30, 2014 WL 1273608, 2014 U.S. Dist. LEXIS 42725 (D.D.C. 2014).

Opinion

MEMORANDUM OPINION

JOHN D. BATES, United States District Judge

Relator Michael L. Davis (“Davis”), brings this qui tam action on behalf of the United States against defendant the District of Columbia (“the District”), under the False Claims Act (“FCA”), 31 U.S.C. §§ 3729 et seq. Davis alleges that the District knowingly submitted false claims to the federal government for reimbursement of special education costs incurred by the District of Columbia Public Schools (“DCPS”), because the District did not maintain legally required documentation to support its reimbursement requests. The parties have filed [101] [102] cross-motions for summary judgment, and Davis has filed [108] a motion seeking leave to file a (lodged) sur-reply. For the reasons set forth below, the Court will grant in part and deny in part the parties’ cross-motions for summary judgment, and grant Davis leave to file his sur-reply.

BACKGROUND

“It is common knowledge that Medicaid is a joint federal and state program that funds health care services for certain groups.” United States ex rel. Davis v. District of Columbia, 679 F.3d 832, 834 (D.C.Cir.2012). “Less well known is the process by which Medicaid funds are disbursed through local government to agencies to care for those in need and the safeguards in place to make sure that the proper amounts of funds are provided for services properly rendered.” Id. This case raises concerns about the cavalier process by which the District sought reimbursement for tens of millions of dollars in special education costs incurred by DCPS in the late 1990s.

*34 A. Regulatory Background

Medicaid funds medical services for low-income and disabled individuals, and is jointly administered and funded by federal and state government agencies. See 42 U.S.C. §§ 1396a(30)(A) & 1396d(b). The federal government generally bears a larger burden of the cost; its share is known as the “Federal Financial Participation” or “FFP” amount. 42 C.F.R. § 400.203. In the District, the federal share of Medicaid costs is approximately 70%, with the District picking up the remainder. See Def.’s Stmt, of Undisputed Material Facts (“Def.’s Stmt.”) [ECF No. 101-2] ¶2. At the federal level, the United States Department of Health and Human Services (“HHS”) administers Medicaid. Id. ¶ 4. Internally, HHS has delegated its Medicaid administration responsibilities to another federal agency, called the Centers for Medicare and Medicaid Services (“CMS”). Id.

Under federal Medicaid regulations, all states (and the District) must implement a “State Health Plan,” specifying minimum criteria for coverage and payment of Medicaid claims. See 42 U.S.C. § 1396a(a)(30)(A). The District has implemented such a plan. See generally Ex. C to Def.’s Mot. for Summary J. (“Def.’s MSJ”) [ECF No. 101], CMS administers and supervises all state Medicaid programs, including the District’s. Def.’s Stmt. ¶ 4. During the relevant time period, the District of Columbia agency responsible for administering the District’s Medicaid program was called the Medical Assistance Administration (“MAA”), which was a component of the District’s Department of Health. 1 See 42 C.F.R. § 431.10.

Pursuant to the Medicare Catastrophic Coverage Act of 1998 and the Individuals with Disabilities Education Act (“IDEA”), 20 U.S.C. §§ 1400 et seq., health-related services provided to special-education children under the IDEA are generally reimbursable by Medicaid. Def.’s Stmt. ¶ 3. Every Medicaid-eligible child receiving services under this program must have an Individualized Education Plan (“IEP”), which documents the specific services that child requires and certifies that each service is medically necessary. Id.

Under the District’s Medicaid plan, DCPS is a certified clinical provider of IEP medical services for Medicaid-eligible special-education students. Def.’s Stmt. ¶ 6. DCPS provides both medical services (e.g., medication, counseling, speech therapy, etc.) and transportation services (e.g., busing students between school and a medical clinic). DCPS is considered a “public provider” under the District’s Medicaid plan, because it is a local government agency, rather than a private entity. See 42 C.F.R. § 413.10. And DCPS provides what are categorized as “clinic services” to special-education students. See Ex. N to PL’s MSJ [ECF No. 99-17] (“District Med- ■ icaid Plan”) § 9(b)(1). Under the terms of the District’s Medicaid Plan, “public providers” of “clinic services,” like DCPS, are entitled to reimbursement “for 100 percent of their reasonable costs of providing services to Medicaid beneficiaries.” Def.’s Stmt. ¶ 8.

The process by which DCPS obtains reimbursement for providing special-education services to Medicaid-eligible children is also complicated. During the fiscal year, MAA reimburses DCPS on an ongoing basis for the estimated costs of special education services. Id. ¶ 9. MAA reimburses for these costs, using generic “inter *35 im rates” on DCPS’s “interina claims.” Id. ¶¶ 9-10. MAA, in turn, submits quarterly-expense reports to CMS, for which it obtains federal reimbursement of the amount owed to the District. Id. ¶ 11.

These “interim” Medicaid reimbursements are based on estimated, fixed payments for different categories of services (e.g., $40 for a doctor’s visit, $10 for a bus ride), but they often do not reflect the actual cost of such services. See id. ¶ 12. Thus, at the end of each fiscal year, DCPS submits a reimbursement claim to MAA that includes the actual cost of all services provided. Id. “This annual filing of a reimbursement claim is similar to how a tax return reconciles an individual’s with-holdings throughout the year with proof of the actual tax owed at year end.” Davis, 679 F.3d at 834. In other words, the interim payments DCPS has received throughout the year are subtracted from the year’s actual costs, and the result is the amount of additional funds owed to— or owed by — DCPS. See Def.’s Stmt. ¶ 12.

Under the District’s Medicaid plan, MAA must review these annual filings at least once every two years and determine whether DCPS is owed additional funds or, alternatively, must return any overpayment. See

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Bluebook (online)
34 F. Supp. 3d 30, 2014 WL 1273608, 2014 U.S. Dist. LEXIS 42725, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-ex-rel-davis-v-district-of-columbia-dcd-2014.