United States v. Huron Consulting Group, Inc.

929 F. Supp. 2d 245, 2013 WL 856370, 2013 U.S. Dist. LEXIS 32477
CourtDistrict Court, S.D. New York
DecidedMarch 5, 2013
DocketNo. 09 Civ. 1800(JSR)
StatusPublished
Cited by5 cases

This text of 929 F. Supp. 2d 245 (United States v. Huron Consulting Group, Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States v. Huron Consulting Group, Inc., 929 F. Supp. 2d 245, 2013 WL 856370, 2013 U.S. Dist. LEXIS 32477 (S.D.N.Y. 2013).

Opinion

MEMORANDUM ORDER

JED S. RAKOFF, District Judge.

In this long-running qui tarn action, plaintiff-relator Associates Against Outlier Fraud alleges that defendants Huron Consulting Group, Inc., Huron Consulting Group, LLC, and Huron Consulting Services, LLC (collectively, “Huron”), and defendants Empire Health Choice Assurance, Inc., and Empire Medicare Services (collectively, “Empire”) violated the False Claims Act, 31 U.S.C. § 3729 (“FCA”) and the analogous New York False Claims Act, N.Y. State Fin. Law § 187 et seq., in connection with the submission of certain Medicare and Medicaid reimbursement forms to the Centers for Medicare and Medicaid Services (“CMS”), a Government agency that oversees the programs.1

By way of brief procedural background, the Court notes that the relator filed its First Amended Complaint on December 9, 2010. On August 25, 2010, 2010 WL 3467054, the Court issued a Memorandum Order dismissing with prejudice the state law claim against Empire and dismissing without prejudice the remaining claims in the First Amended Complaint. See 08/25/10 Memorandum Order at 6-7. On October 6, 2010, the relator filed a Second Amended Complaint and reasserted all of the claims that the Court previously dismissed without prejudice except for a conspiracy charge. The defendants filed new motions to dismiss on October 19, 2010, and, on December 30, 2010, the Court denied the motions. Relator further amended the Complaint on March 21, 2011, to correct which “Huron” entities it wished to name as defendants. See Third Amended Complaint (“TAC”).

After the parties completed discovery, the defendants separately moved for summary judgment on relator’s surviving claims. For the reasons set forth below, the Court hereby grants defendants’ motions for summary judgment.

The pertinent facts, either undisputed or, where disputed, taken most favorably to relator, are as follows.2 Under the Medicare payments system, providers are reimbursed for inpatient procedures based on billing categories known as diagnosis-related groups, for which Medicare usually reimburses providers a certain fixed amount. These payments are based on a predetermined schedule, and for most claims, providers receive a fixed payment regardless of what the hospital listed as its actual charges for a given service. Empire’s Rule 56.1 Statement of Undisputed Facts (“Empire 56.1”) 7.

However, while reimbursement at a fixed rate is the usual outcome of the Medicare reimbursement process, occasionally providers are reimbursed additional add-on payments, id., which include amounts called “outlier payments” in the parlance of the Medicare system. See 42 U.S.C. § 1395ww(d)(5)(A)(ii). Most relevant to this case, these outlier payments can arise in the following circumstances:

When a provider submits its bill to Medicare (usually through an intermediary, as discussed below), even though the reimbursement from Medicare for the procedure is usually predetermined by the procedure’s diagnostic-related-group, the provider nevertheless includes its own stated charge for the service. An automated computer system created by CMS [248]*248takes these submitted charges and calculates its own estimate of the provider’s costs using a provider-specific “cost-to-charge ratio.” Empire 56.1 ¶ 14. As the name suggests, the cost-to-charge ratio is calculated based on a provider’s overall report of its total costs for services and its overall report of its charges. Before 2003, only “settled” cost reports were used for this purpose but after 2003, either “settled” or “tentative” cost reports could be used to calculate a facility’s cost-to-charge ratio. Id. ¶¶ 19-20. When the automated payments system determines that a provider’s submitted charge, adjusted for cost, is higher than the usually applicable fixed price and loss amounts, the provider will automatically receive an outlier payment. Id. ¶ 14. Thus, outlier payments are made automatically whenever a provider’s stated charge, adjusted by the provider’s historical cost-to-charge ratio, exceeds the price and loss amounts assumed by Medicare’s ordinary diagnosis-related-group model. Id. ¶¶ 11-13.

The cost-to-charge ratio is always a retrospective calculation: it represents the quotient of the hospital’s costs during a reported cost period divided by the hospital’s charges in effect during the same period. Because the calculation of an outlier payment is based upon a current charge adjusted by a historical cost-to-charge ratio, a program of across-the-board increases in the amounts a provider charges Medicare can immediately increase the “charge” component of the outlier calculation before the provider’s retrospective cost-to-charge ratio has a chance to catch up. Thus, when a facility increases its charges across the board, the formula for calculating outlier payments will apply a cost-to-charge ratio that is stale to a charge that is freshly marked up. In short, there will be a time lag between the new increase in charges and the moment “when the increased charges impact the hospital-specific [cost-to-charge ratio] contained in the [processing] system.” Id. ¶23.3

A simplified hypothetical may help explain the otherwise opaque logic of the cost-to-charge ratio in Medicare’s “outlier” reimbursement system. Suppose in year 1, a provider were, on average, to charge Medicare $1000 for procedure A, which, on average, costs it $500. This would yield a cost-to-charge ratio of 0.5. Suppose further that the next year the provider raised its charges to average $2000 for procedure A while its costs remained constant at an average of $500. Year 2 would yield a cost-to-charge ratio of .25. In both year 1 and year 2, it is possible to come to a judgment about whether a particular instance of procedure A was aberrantly costly — that is, an “outlier” from the norm — by multiplying the singular charge for an instance of a procedure by the year’s overall cost-to-charge ratio.4 So, an instance of procedure A for which the provider charged $2000 would yield an estimated cost of $1000 in year 1 (during which the procedure was relatively expensive to perform) but only $500 in year 2 (during [249]*249which the cost for the procedure was par for the course).

Because this hypothetical assumes an up-to-date calculation of the cost-to-charge ratio, therefore, in a Utopian world of efficient administration of medicare reimbursement, a provider’s decision to double its charges even though its costs remained constant would not allow it to collect new “outlier payments” from the government because the increase in the average charge would likewise affect the cost-to-charge ratio. But if, more realistically, government cost accounting proceeded at a slower pace, the hypothetical provider who submitted new claims for reimbursement at uniformly higher prices would, in effect, be able to apply the ratio from year 1 to its charges for year 2, so that every $2000 instance of the procedure A could now appear an “outlier.” Medicare enables this to occur by paying individual outlier claims as they are submitted, even though cost reports for that year — and thus the cost-to-charge ratio — may take up to five months beyond the close of a calendar year to be submitted and several years to be settled. Id.

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929 F. Supp. 2d 245, 2013 WL 856370, 2013 U.S. Dist. LEXIS 32477, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-v-huron-consulting-group-inc-nysd-2013.