Jul 14 2015, 8:37 am
ATTORNEYS FOR APPELLANT ATTORNEYS FOR APPELLEE FSSA
James P. Fenton Gregory F. Zoeller
Kathryn A. Brogan Attorney General of Indiana
Eilbacher Fletcher, LLP
David L. Steiner
Fort Wayne, Indiana
Kyle Hunter
Myra C. Selby Deputy Attorneys General
Ice Miller LLP Indianapolis, Indiana
Indianapolis, Indiana
ATTORNEYS FOR APPELLEE
METHODIST HOSPITALS, INC.
Steven Jackson
Juliana Yanez
Faegre Baker Daniels LLP
Indianapolis, Indiana
IN THE
COURT OF APPEALS OF INDIANA
Parkview Hospital, Inc., July 14, 2015
Appellant-Plaintiff, Court of Appeals Case No. 02A03-
1408-PL-296
v. Appeal from the Allen Superior
Court
John J. Wernert, in his official The Honorable Nancy Eshcoff
capacity as Secretary of the Boyer, Judge
Indiana Family and Social Cause No: 02D01-1212-PL-443
Services Administration,
Appellee-Defendant,
and
The Methodist Hospitals, Inc.,
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Appellee-Intervening Defendant.
Brown, Judge.
[1] Parkview Hospital, Inc. (“Parkview”), appeals the July 25, 2014 judgment of
the trial court in favor of Indiana Family and Social Services Administration
(“FSSA”), and Methodist Hospitals, Inc. (“Methodist,” and FSSA and
Methodist, together, “Appellees”) on Parkview’s petition for judicial review.
Parkview raises two issues, which we revise and restate as whether the court
erred in entering the July 25, 2014 order affirming the decision of the Secretary
of FSSA regarding the denial of disproportionate share hospital payments to
Parkview. We affirm.
Background and Procedural History
[2] FSSA administers the Medicaid program for the State of Indiana. Ind. Code §
12-15-1-1. Certain hospitals receive disproportionate share hospital (“DSH”)
payments, a related part of Medicaid, if the hospitals meet certain criteria and
serve a disproportionate share of Medicaid recipients and other low income
patients in accordance with Ind. Code §§ 12-15-16 through -19 and other state
and federal laws. See Ind. Code § 12-15-17-1; 42 U.S.C.A. § 1396r-4; 42
U.S.C.A. § 1395ww(d)(5)(F). The federal government limits its financial
participation by apportioning a specific DSH allotment for each state. See 42
U.S.C.A. § 1396r-4(f). FSSA may not implement a program until the federal
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Centers for Medicare and Medicaid Services (“CMS”) approves the provisions
regarding the program in an amended state plan for medical assistance. Ind.
Code § 12-15-15-10(d); Ind. Code § 12-15-16-5(a). FSSA may determine not to
continue to implement the provisions relating to DSH payments if federal
financial participation is not available. Ind. Code § 12-15-16-5(b).
[3] Ind. Code §§ 12-15-16 relates to a provider’s eligibility to receive DSH
payments. Ind. Code § 12-15-16-1(a) states that a provider is a disproportionate
share provider if, in part, the “provider’s Medicaid inpatient utilization rate is at
least one (1) standard deviation above the mean Medicaid inpatient utilization
rate for providers receiving Medicaid payments in Indiana.” See also 42
U.S.C.A. § 1396r-4(b)(1)(A). Ind. Code § 12-15-16-2(a) provides:
For purposes of disproportionate share eligibility, a provider’s
Medicaid inpatient utilization rate is a fraction (expressed as a
percentage) where:
(1) the numerator is the provider’s total number of Medicaid
inpatient days in the most recent year for which an audited cost
report is on file with the office; and
(2) the denominator is the total number of the provider’s
inpatient days in the most recent year for which an audited cost
report is on file with the office.
See also 42 U.S.C.A. § 1396r-4(b)(2) (providing in part “the term ‘medicaid
inpatient utilization rate’ means, for a hospital, a fraction (expressed as a
percentage), the numerator of which is the hospital’s number of inpatient days
attributable to patients who (for such days) were eligible for medical assistance
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under a State plan approved under this subchapter . . . , and the denominator of
which is the total number of the hospital’s inpatient days in that period”).
[4] Parkview entered into a provider agreement in 2011 with the State of Indiana
pursuant to which it agreed to provide covered services to Indiana health
coverage program members. The agreement provided in part:
By execution of this Agreement, [Parkview] requests enrollment as a
provider in the Indiana Health Coverage Programs. As an enrolled
provider in the Indiana Health Coverage Programs, [Parkview] agrees
to provide covered services and/or supplies to Indiana Health
Coverage Program members. As a condition of enrollment, this
agreement cannot be altered and [Parkview] agrees to all of the
following:
*****
5. To provide covered services and/or supplies for which
federal financial participation is available for Indiana Health
Coverage Program Members pursuant to all applicable federal
and state statutes and regulations.
*****
12. To abide by the Indiana Health Coverage Programs
Provider Manual, as amended from time to time, as well as all
provider bulletins and notices. Any amendments to the
provider manual, as well as provider bulletins and notices,
communicated to Provider shall be binding upon receipt. . . .
*****
18. To accept payment as payment in full the amounts
determined by [FSSA] or its fiscal agent. . . .
Appellant’s Appendix at 343.
[5] On December 18, 2009, the accounting firm of Myers and Stauffer CL (“Myers
and Stauffer”), on behalf of FSSA, sent a letter to Parkview, and specifically to
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the attention of Director of Reimbursement Eric Nickeson, and enclosed a DSH
eligibility survey form with instructions. The letter stated:
Please find the enclosed survey form that must be completed in order
to determine Indiana Medicaid Disproportionate Share Hospital
(DSH) eligibility for the State Fiscal Years ending June 30, 2010 and
June 30, 2011.
*****
The survey must be completed and postmarked no later than February
26, 2010. Please compare information already entered into the survey
for accuracy and provide support for any changes or additions. Please
note that timely and accurate completion of the enclosed survey will
expedite the completion of DSH eligibility and payment distributions.
Please complete and return the enclosed survey to the address below.
Surveys must be postmarked no later than February 26, 2010. This
will be the only notification sent concerning the deadline. No second
notification will be sent. If the response to the survey is not received
by the deadline, your facility will be deemed ineligible for DSH
payments for SFY 2010 and 2011.
Id. at 184. The instructions accompanying the survey stated in part:
The enclosed survey is designed to collect the information necessary to
administer the Indiana Medicaid Disproportionate Share Hospital
program. This survey will be used to determine DSH eligibility for the
State Fiscal Years (SFY) ending June 30, 2010 and June 30, 2011. . . .
*****
This survey is mandatory and must be completed by each facility in its
entirety. As a condition of participation in the Medicaid program, you
are required, pursuant to your provider agreement, to submit to the
Office of Medicaid Policy and Planning (OMPP) any information it
deems necessary for the program. . . .
*****
Please complete and return the enclosed survey to the address below
postmarked no later than February 26, 2010. This will be the only
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notification sent concerning the deadline. No second notification
will be sent. If the response to the survey is not postmarked by the
deadline, your facility will be deemed ineligible for DSH payment
for SFY 2010 and 2011. Only information submitted by your facility
on a survey postmarked by February 26, 2010 will be included in
your facility’s DSH eligibility calculation. Information received
from your facility that is postmarked after the due date will not
result in increased Medicaid days, payments or charges, etc. being
included in the facility’s Medicaid inpatient utilization rate or low
income utilization rate (the ratios used to determine DSH
eligibility.) In addition, failure to complete the survey may be
considered a breach of the Medicaid provider agreement. If
extenuating circumstances will prevent you from meeting the filing
deadline, please contact Myers and Stauffer immediately at . . . .
*****
For survey questions that ask for summary and/or supporting
documentation, attach the required information. This information
must be provided electronically on CD, in the format presented in
Exhibits A, B, C and D. All documentation should be referenced
back to the pertaining survey question. Please maintain all source
documentation used to complete the survey, as additional
information (i.e., remittance advices, patient listings, etc.) may be
requested to verify your numbers. All providers are asked to compare
the information already completed on the survey for accuracy. Please
provide any additional information and submit documentation to
support the additions. If there is any incorrect information included in
the survey, please provide corrected amounts. You may do so in any
format you would like (you may not be able to change the amounts in
locked cells in the workbook). However, please note that any
additional days or payments must be supported by detail reported in
the formats illustrated by Exhibits A, B and C and submitted
electronically. Please be advised that any questions that require
support but do not have the required documentation will not be used
in the calculations for DSH eligibility.
Please note that there is a change in the eligibility survey from past
years as a result of the DSH Audit rule published in the Federal
Register December 19, 2008. Crossover days (days for which a patient
is eligible for both Medicaid and Medicare Part A) should now be
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included in the Medicaid Inpatient Utilization Rate (MIUR). This
information is collected in Section B.
Id. at 186-187. On February 26, 2010, Parkview submitted a response to the
survey.
[6] On June 18, 2010, Myers and Stauffer, on behalf of FSSA, sent a letter to
Parkview and Nickeson which stated in part:
This letter serves as notification from the Office of Medicaid Policy
and Planning (OMPP) regarding your facility’s eligibility to receive
[DSH] payments for the State Fiscal Years (SFY) 2010 and 2011.
Eligibility for DSH payments for this period is based upon information
received from your DSH surveys and your Indiana Medicaid cost
report ended between July 2008 and June 2009 (SFY 2009). . . .
*****
There are three criteria[1] under which a facility can qualify for Indiana
Medicaid DSH payments as follows:
1. Medicaid Inpatient Utilization Rate (MIUR)
The MIUR is a percentage calculated as such:
The hospital’s number of inpatient days attributable to
patients who (for such days) were eligible for Medicaid
The total number of the hospital’s inpatient days in that period
In order to qualify under this criterion, hospital’s MIUR must exceed
one standard deviation above the mean MIUR rate for hospitals
receiving Medicaid payments in Indiana. Therefore, in order to
qualify under this criterion, your MIUR must be at least 32.94%. Your
facility’s MIUR of 30.17% is calculated as follows. . . .
1
This case involves Parkview’s attempt to qualify for DSH payments under the MIUR criterion and not
other criteria.
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*****
Based on the information above, your facility is not qualified to
receive DSH payments for SFY 2010 and SFY 2011. . . .
*****
This notification constitutes an appealable order. . . .
*****
Please note no new information can be accepted at this time. Only
clarification and substantiation of information previously reported
on your DSH eligibility survey is allowed. It is possible that
another provider’s appeal could result in a change in your eligibility
status. In the event this occurs, we will promptly notify you.
Id. at 201-202, 206-207.
[7] On June 22, 2010, Nickeson on behalf of Parkview sent an e-mail message to
Myers and Stauffer. The subject line of the message was “Medicare Crossover
Days Omission,” and the message stated:
As you know, the SFY 2010-2011 Medicaid DSH survey handled
Medicare crossover days differently than past surveys. In reviewing
our information after receipt of the June 18, 2010 eligibility letter from
Myers and Stauffer, we have discovered that a significant number of
Medicare crossover days, both paid and unpaid, were mistakenly
omitted from the Parkview Health facilities’ SFY 2010-2011 Medicaid
DSH surveys. We plan on filing an appeal in the next few days to
properly include these Medicaid-eligible days on line 12 of the surveys
for all of our facilities.
Please let me know if you have questions or would like to discuss this
issue. Thank you very much for your consideration.
Id. at 228.
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[8] In a letter to the Office of Medicaid Policy and Planning (the “OMPP”) at
FSSA dated June 30, 2010, and file-stamped as received on July 7, 2010,
Parkview requested an appeal of the eligibility determination and indicated it
would file a statement of issues. Parkview sent a letter to the OMPP dated
August 5, 2010, stating that it was enclosing Parkview’s statement of issues. In
its statement of issues, Parkview argued in part that it was unable to report its
Medicaid days accurately due to deficiencies in the survey created by Myers
and Stauffer, and that “[t]he number of days underreported by Parkview due to
the deficiencies in the Survey were not insignificant” and “in fact, they totaled
3,166 in-state Medicaid inpatient days.”2 Id. at 212. Parkview further argued
that “[t]he OMPP’s decision to include inpatient days attributable to those
individuals dually eligible for both Medicare and Medicaid [] in the MIUR
calculation was based on a flawed understanding of certain comments made by
the [CMS] in the preamble to the DSH Final Rules published in 2008.” Id. at
215.
[9] Myers and Stauffer sent a letter dated December 10, 2010, to Parkview stating
that it had received and reviewed the statement of issues in Parkview’s appeal
of the DSH eligibility determination. With respect to Parkview’s claim that
deficiencies in the survey caused it to underreport days, the letter stated that “as
noted in the DSH Eligibility Survey instructions, only information submitted on
2
In his subsequent affidavit, Nickeson stated that Parkview omitted 3,134 Medicaid inpatient days from its
survey response.
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the provider’s DSH eligibility survey postmarked by the deadline was included
in the eligibility calculations,” and that “the DSH Eligibility Notification letter
specified that no new information would be accepted.” Id. at 222. In response
to Parkview’s argument that the OMPP’s decision was based on a flawed
understanding made by CMS, the letter stated that “[t]he DSH Audit Rule
(Federal Register, Volume 73, No. 245, December 19, 2008), states on page
77912, ‘The Medicaid Inpatient Utilization Rate (MIUR) is a calculation that
includes all Medicaid eligible days. To the extent that an inpatient hospital day
for a dually-eligible Medicare/Medicaid patient qualifies as a Medicaid day,
that day would be included in the MIUR calculation.’” Id. at 224. The letter
set forth the manner in which the MIUR is calculated and then stated:
In order to qualify under this criterion, a hospital’s MIUR must exceed
one standard deviation above the mean MIUR rate for hospitals
receiving Medicaid payments in Indiana. The original threshold, as
listed in your Eligibility Notification Letter was 32.94%. However,
changes to the MIUR calculations for your hospital and others, as a
result of appeals and subsequent adjustments has resulted in a revised
MIUR threshold. Therefore, in order to qualify under this criterion,
your MIUR must be at least 32.51%. Your facility’s original MIUR
was 30.17%. Based on the adjustments listed above, your facility
MIUR would be 30.34% and calculated as follows. . . .
Revised MIUR 30.34%
Id. at 226. Myers and Stauffer’s letter concluded that, based on this
information, Parkview is not qualified to receive DSH payments for state fiscal
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years 2010 and 2011. In a letter also dated December 10, 2010, Parkview
submitted its statement of issues to an administrative law judge (“ALJ”).3
[10] Parkview filed, with the ALJ, a motion for summary judgment together with
designated evidence and a brief in support of the motion dated January 6, 2012.
Parkview’s designated evidence included, among other evidence, an affidavit of
Nickeson which stated that he was the Director of Reimbursement for
Parkview, that Parkview has qualified for Medicaid DSH payments since state
fiscal year 2004, that since first qualifying for DSH Parkview has received more
than $70.7 million in acute DSH and safety net hospital payments, and that
Parkview has also continuously incurred a shortfall of approximately $198.8
million in revenue since 2004 from serving Medicaid and uninsured patients.
Nickeson stated that the 2010 DSH survey was due on February 26, 2010, and
that the instructions accompanying the survey indicated that any survey
response postmarked after the deadline would result in an ineligible DSH
determination by the OMPP. Nickeson’s affidavit further stated:
7. Based on the clear language of the Survey instructions, I submitted
the completed Survey response on behalf of [Parkview] in strict
compliance with the instructions and deadline. In working with our
contractor in preparing the Survey response, I relied on them to
provide supporting documentation for many days believed to be
includable, while I concentrated my attention on finishing other
aspects of the Survey in order to meet the response deadline.
8. During final preparations of the Survey, the supporting
documentation for the days was not available from our contractor. As
3
The copy of the letter in the appellant’s appendix is not file-stamped.
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soon [as] it was apparent to me that the support would not be
developed in time for submission, I did not consider contacting OMPP
or Myers and Stauffer as I felt such attempts would be fruitless, as
there were no extraordinary circumstances justifying the delay. My
perception of the hard deadline was informed by the strict language of
the Survey instructions.
9. On February 26, 2010, I submitted the report to the best of my
ability based on the information available to me at the time of
submission. I erred on the side of strict compliance with the deadline.
Further, I acted conservatively in excluding over 3,000 days from the
Survey. Although I believed the days were eligible Medicaid days, the
requisite support was not fully developed by the deadline. According
to the instructions, Medicaid days without full support would “not be
used in the calculations for DSH eligibility.”
10. I had no reason to believe that the OMPP would not strictly
enforce the deadline and instructions in the Survey. Had I known at
the time that the Survey instructions would not be as strictly enforced,
I would have acted differently.
11. My decision resulted in the omission of 3,134 Medicaid inpatient
days from the Survey, comprising of 2,391 in-state cross-over days and
743 out-of-state Medicaid-eligible days.
12. Accounting for the 3,134 omitted days, Parkview’s MIUR would
be 32.63%, which is .09% over the accordingly adjusted state MIUR
eligibility threshold. But for the omission of these days, Parkview
would have met the eligibility threshold for DSH payments. . . .
Id. at 93-94.
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[11] Parkview also designated e-mail messages regarding White County Memorial
Hospital. Melenie Sheehan of Myers and Stauffer4 wrote an e-mail to FSSA
which stated:
White County [Memorial Hospital] reported an additional 43
Medicaid-eligible days. Survey instructions state, “Supporting
information should include the patient name, Medicaid number, and
dates of service. All support must be submitted electronically on CD,
using the format in Exhibits A, B and C. Unsupported days and
payments will not be used.” White County provided an electronic
Excel document with the patient RID, last four of SSN, and name.
They did not include dates of service. We are unsure how you would
like us to proceed in cases such as this, whereas days are reported and
supporting documentation is provided, but incomplete. The handling
of such cases in past eligibility determinations has been somewhat
inconsistent; at times OMPP allowed additional support and other
times, required a strict adherence to instructions and allowing only
under appeal. I believe this has been due to OMPP’s program goals at
the time (timing, aversion to appeals, desire to encourage providers to
submit consistently accurate information, etc.) and also has been
impacted by changes in procedures (elimination of the Reconciliation
letter which was used at one point to allow hospitals to respond to
adjustments before the calculation was finalized).
In order to test the 43 days for duplication and eligibility, we will need
the dates of service, requiring us to contact the provider. The impact
on White’s eligibility is irrelevant . . . . The impact to the MIUR
threshold is estimated to be a hundredth of a percent. We are unable
to determine until the final MIURs are available, whether or not such
a change in the threshold would impact another hospital’s eligibility.
Id. at 115.
4
In her affidavit, Sheehan states she was a certified public accountant for Myers and Stauffer and that, as
part of the firm’s duties as the Medicaid rate setting contractor for FSSA, Myers and Stauffer helped
determine eligibility for funds distribution involving the DSH program.
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[12] Sheehan’s e-mail was forwarded to Pat Nolting5 with FSSA, and Nolting wrote
an e-mail message stating:
Please go ahead and ask [Myers and Stauffer] to contact the provider
for the dates of service, since it should be capped at the 43 additional
reported days.
Also, for the record we need to discuss Melenie’s comment to the
effect that the state has been inconsistent in handling these cases in the
past. That is not true. We have been consistent within the context of
the established procedures. At one time we had a process of write-
backs, reconsideration, etc, which essentially caused the eligibility
determination process to drag on for well in excess of a year. Under
that process the scope of review was much different than is the case
today. The current process establishes a deadline date for submitting
all information (most notably days and income/charges), along with
supporting documentation for additions to the MMIS data supplied by
[Myers and Stauffer] on the survey document. If the provider fails to
supply all substantiating documentation to their reported supplemental
information, we have in the past contacted the provider for
clarification and/or the missing documentation. We are not giving the
provider an opportunity to add more days or payments/changes.
Id. at 114.
[13] In its brief in support of its summary judgment motion, Parkview argued in part
that the exclusion of over 3,000 Medicaid days constituted an obvious error and
that it is entitled to equitable relief. Parkview argued that, “[i]nduced by the
2010 Survey instructions, Nickeson concentrated his attention on ensuring that
the Survey would be submitted by the deadline at all costs” and that, “[w]hile
5
In its brief in support of its summary judgment motion, Parkview states that Nolting was the OMPP’s
Deputy Director.
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he succeeded in submitting the Survey by the deadline, over 3,000 Medicaid
days were excluded from the Survey response.” Id. at 124-125. Parkview
argued that, at the time of the survey, Nickeson was aware of some additional
days that Parkview believed were includable but did not have any of the
underlying support for those days, that as a result a total of 3,134 Medicaid
days were erroneously omitted from Parkview’s Survey, including 2,391
crossover days and 743 out of state Medicaid days, and that “[t]his omission
represented over 7% of the hospital’s total Medicaid days, a significant and
obvious exclusion.” Id. at 125. Parkview asserted that, in order to accomplish
the objectives of the DSH program, it must be given relief to correct the error
based on verifiable data that the hospital has served a disproportionate share of
Medicaid patients during the eligibility determination period and that
“Parkview’s true and accurate MIUR, accounting for the omitted days, is
32.63%, which is .09% over the adjusted 32.54% MIUR DSH qualification
threshold based on the December 31, 2010 calculation.” Id. at 126. Parkview
argued the exclusion of over seven percent of the hospital’s Medicaid days is a
significant omission, and clearly the result of plain error, and that it should be
granted relief because the agency would not suffer prejudice by granting
Parkview leave to amend and “the error affected the substantial rights of
Parkview, as but for the denial to correct the obvious omission, Parkview would
have been found DSH eligible.” Id. at 127.
[14] Parkview further urged that relief is necessary to prevent manifest injustice and
that, “[i]n effect, the erroneous completion of an administrative agency survey
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amounts to an inadvertent regulatory violation, for which a multi-million dollar
consequence is grossly excessive.” Id. at 129. Parkview argued that the
OMPP’s conduct was arbitrary and capricious, and that the OMPP’s
inconsistent enforcement of the deadline and wildly varying interpretation of
the survey instructions is a violation of the Indiana Administrative Orders and
Procedures Act (the “AOPA”), and the OMPP must be estopped from its
arbitrary strict enforcement and interpretation of the survey instructions against
only Parkview. Parkview stated that strict interpretation of the agency policy
against it, but not White County, a similarly situated hospital, is plainly
arbitrary and capricious and that the “distinction between adding days as
opposed to refining data after the deadline is wholly without merit” as “both
actions will change the MIUR threshold in the end,” the distinction “is not
present in the Survey instructions or other agency communication,” and the
decision to allow White County to add omitted data “contradicted the policy
established by the agency for the acceptance of DSH eligibility data.” Id. at
136.
[15] Parkview also argued the OMPP’s decision to include dually eligible
Medicare/Medicaid patient days in the MIUR calculation was in error in part
because state law, namely Ind. Code § 12-15-16-2(b)(3) at the relevant time,
explicitly excludes dually eligible days. Parkview noted that the statute was
amended effective July 1, 2011, but that was over a year after the initial DSH
eligibility determinations were made.
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[16] FSSA filed with the ALJ a response and motion for summary judgment
together with designated evidence and a memorandum. In its memorandum,
FSSA argued that the OMPP uniformly followed all of its own instructions and
made adjustments based on the reported days that were filed with the survey as
required. FSSA further argued that the OMPP properly interpreted the law and
is entitled to summary judgment in its favor. FSSA asserted that federal law is
controlling, that it provides that the MIUR includes a hospital’s number of
inpatient days attributable to patients eligible for Medicaid regardless of
whether that patient was also eligible for Medicare, that Indiana’s state plan as
approved by CMS is consistent with this language, and that every hospital was
subject to the same process and was instructed the same on the dual eligible-
days treatment from the outset of the process. FSSA argued that the provider
agreements are binding and that, under paragraph twelve of the agreement,
providers agree to abide by all bulletins and notices.
[17] An affidavit of Melenie Sheehan of Myers and Stauffer designated by FSSA
stated that, with respect to the Medicaid inpatient days Parkview did not timely
report, to her knowledge the OMPP made no exceptions to the instructions that
were sent to the hospitals and treated all of the hospitals in the same manner,
that hospitals were allowed to provide explanatory or supporting information
on days that had been reported, but they were not allowed to report new days
that had not previously been reported. Sheehan’s affidavit further stated that,
unlike the case with Parkview, White County had already reported the
additional days on their original survey submission, but their supporting detail
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was missing some information required to verify the additional days, that the
OMPP merely allowed White County to provide additional data elements to
support the days they had already reported on the survey, and that the OMPP
distinguishes between allowing a provider to submit additional elements of data
for days already reported on the survey as in the case of White County as
opposed to allowing new days to be submitted that were not included in the
original survey response as in the case of Parkview. The affidavit also stated
that Indiana’s State Plan includes a definition of the MIUR that requires
including dually-eligible or crossover days. Sheehan’s affidavit also stated: “It
is my understanding that if the ‘dually-eligible’ days were excluded from the
calculation, Parkview would still not be eligible for DSH participation.” Id. at
182.
[18] On September 20, 2012, the ALJ issued an order and recommendation. The
ALJ’s order found in part that Parkview notified Myers and Stauffer “[o]n June
26, 2012” that it had discovered a significant number of crossover days and that
“Parkview cannot submit newly discovered [evidence] two years after the initial
survey was due and after being notified that it did not qualify for DSH funds.” 6
Id. at 349. The ALJ further concluded that “[t]he undisputed facts show White
County Hospital was asked to clarify information regarding days that it had
6
The ALJ’s order cited to an exhibit in support of this finding. The exhibit contains the June 22, 2010 e-mail
message by Nickeson on behalf of Parkview to Myers and Stauffer stating that Parkview had discovered that
a significant number of Medicare crossover days were mistakenly omitted from the Parkview Health
facilities’ SFY 2010-2011 Medicaid DSH surveys.
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already submitted; it was not given the opportunity to submit more days,” that
“White County Hospital was not treated any differently than Parkview
Hospital,” and that “[n]either hospital was permitted (or allowed) to submit
additional days after the February 26, 2010 deadline.” Id. at 349-350. The
order provided in part:
5. . . . . At the time Parkview’s DSH eligibility was established[,] I.C.
12-15-16-2(b) (2010) required that days attributable to dually eligible
individuals (individuals eligible for both Medicaid and Medicare) were
to be excluded from the MIUR calculation when calculating the
denominator of the DSH fraction.[7]
*****
7. I.C. 12-15-16-2(b)(3) (2010) was not consistent with federal law. In
2010 Federal Medicaid law provided that dually eligible patients were
to be excluded when calculating the denominator of the DSH fraction.
*****
11. On December 19, 2008, [CMS] published in the Federal Register
an amended version of 42 CFR § 447. The commentary to the
amended rule in two different places speaks to the calculation of the
MIUR and whether or not dually eligible individuals should be
included in the MIUR calculation. Medicaid Program;
Disproportionate Share Hospital Payments, 73 Fed. Reg. 77904(December 19, 200[8]) (amending 42 CFR § 447).
7
A footnote here stated:
P.L. 53-2011, effective on July 1, 2012, [sic] removed the following language regarding
dual eligible patients: “However, a day is not a Medicaid inpatient day for purposes of
this section if the patient was entitled to both Medicare Part A (as defined in 42 U.S.C.
1395c) and Medicaid on that day.” Effective July 1, 2012 [sic] state law became
consistent with federal law (as set out below).
Appellant’s Appendix at 351 n.1. We note P.L. 53-2011 was effective on July 1, 2011, and not on July 1,
2012.
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12. In § “4. Dual Eligible” in response to comments that days
attributable to dual eligible should be included in the MIUR
calculation CMS stated:
The Medicaid Inpatient Utilization Rate (MIUR) is a
calculation that includes all Medicaid eligible days. To the
extent that an inpatient hospital day for a dually-eligible
Medicare/Medicaid patient qualifies as a Medicaid day, that
day would be included in the MIUR calculation.
Id. at 77912. In response to the next comment questioning whether
the costs attributable to dual eligible patients should be included in the
MIUR calculation,[8] CMS responded:
We disagree; since Section 1923(g)(1) does not contain an
exclusion for dually eligible individuals, we believe the costs
attributable to dual eligibles should be included in the
calculation of the uncompensated costs of serving Medicaid
eligible individuals.
Id.
13. Only in the context of discussing methodologies used by states
that use an alternate DSH eligibility criteria did CMS indicate that it
was permissible for states not to include dually eligible individuals. Id.
at 77919 (middle column). The comment was referring to a question
regarding states that use alternative qualifying. The commentary
further indicated: “With respect to the statutory MIUR [as opposed to
an alternative methodology], it is a calculation that includes all
Medicaid eligible days.” Id.
*****
15. . . . . 42 U.S.C. §1396r-4(b)(2), as interpreted by CMS to exclude
dually eligible patients when calculating DSH eligibility for federal
Medicaid funds, pre-empts language in the 2010 version of I.C. § 12-
15-16-1 that provided otherwise. . . .
8
Specifically, the comment provided in part: “The commenter indicated that, since Medicare is the primary
payer for the duals, it seems appropriate to exclude the costs of those patients from this calculation, since the
payments are also excluded.”
Court of Appeals of Indiana | Opinion 02A03-1408-PL-296 | July 14, 2015 Page 20 of 45
Id. at 351-353. The ALJ ordered that there were no material issues of fact in
dispute and that FSSA is entitled to summary judgment in its favor.
[19] On October 5, 2012, Parkview filed a petition for review of the ALJ’s order and
requested review by the Secretary of FSSA. In the petition, Parkview argued
that it had filed reports with the State of Indiana in 2008 and 2009 which
contained information about all inpatient admissions and third party payor
sources and, consequently, that the State had in its possession the relevant data
pertaining to Parkview’s erroneously omitted Medicaid days. Parkview argued
that the ALJ drew an incorrect conclusion as to the inclusion or exclusion of
inpatient hospital days attributable to dually eligible individuals by the OMPP
in its calculation of the MIUR. Parkview also argued it notified Myers and
Stauffer of its discovery of the omitted dually eligible days within four months
of the due date of the initial survey and not after two years as found by the ALJ.
Parkview asserted that the ALJ did not address the issue that the OMPP should
account for the Medicaid days that were erroneously excluded from Parkview’s
survey in the MIUR calculation and that, but for this obvious omission,
Parkview would have qualified as a DSH provider for fiscal years 2010/2011,
and that it is entitled to equitable relief.
[20] On November 20, 2012, the Secretary of FSSA, as the ultimate authority for
FSSA/OMPP, entered a Decision of the Ultimate Authority Designee which
affirmed the decision of the ALJ. The decision of the Secretary of FSSA
adopted the conclusions of law of the ALJ’s order with several corrections. The
decision found that paragraph 5 of the ALJ’s order should read: “At the time
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Parkview’s DSH eligibility was established[,] I.C. 12-15-16-2(b) (2010) required
that days attributable to dually eligible individuals (individuals eligible for both
Medicaid and Medicare) were to be excluded from the MIUR calculation when
calculating the numerator of the DSH fraction.” Id. at 38 (emphasis added and
emphasized word reflecting correction). The decision also found that
paragraph 7 of the ALJ’s order should read: “I.C. 12-15-16-2(b)(3) (2010) was
not consistent with federal law. In 2010 Federal Medicaid law provided that
dually eligible patients were to be included when calculating the numerator of the
DSH fraction.” Id. (emphases added and emphasized words reflecting
corrections). The decision concluded that the ALJ was correct to grant the
motion for summary judgment submitted by FSSA/OMPP based on the
evidence that the requirements of the survey clearly stated that all responses had
to be submitted no later than February 26, 2010, and the survey responses
timely submitted by that date did not justify granting DSH status to Parkview.
The decision also stated that the “[s]o called newly discovered evidence,
submitted almost two years later, was untimely and not appropriate to
consider.” Id. The decision further found that “[t]hose portions of the decision
of the ALJ and the parties’ arguments on the subject of the appropriate method
for determination of the [MIUR], while fascinating, is irrelevant,” that “[t]he
information timely provided by Parkview on the survey submitted on or before
February 26, 2010 did not demonstrate a MIUR sufficient to merit DSH
status,” and “[a]ll other evidence tendered was untimely and not relevant.” Id.
Court of Appeals of Indiana | Opinion 02A03-1408-PL-296 | July 14, 2015 Page 22 of 45
[21] On December 20, 2012, Parkview filed a verified petition for judicial review of
FSSA’s decision with the Allen County Superior Court. Parkview alleged that
the decision of the Secretary of FSSA was arbitrary, capricious, not supported
by substantial evidence, and not in accordance with law because of inconsistent
enforcement of the DSH eligibility survey deadline and instructions, and
inconsistent application of the OMPP’s policies and procedures for DSH
determinations; that the OMPP failed and refused to consider material evidence
pertaining to the inclusion of days; and that FSSA’s decision is contrary to
public policy establishing that hospitals such as Parkview, which serve a
disproportionate number of low-income patients, are entitled to adjustment
payments. Parkview also alleged the decision was in excess of the authority of
the OMPP and short of Parkview’s statutory rights because the OMPP’s
decision to include inpatient days for those patients dually eligible for Medicare
and Medicaid in the MIUR calculation contradicted state law and the state plan
in effect at that time. Methodist sought to intervene, and the court granted the
request on November 19, 2013. The parties submitted briefs to the trial court in
support of their positions.
[22] In its brief, Parkview argued among other things that FSSA’s decision has
imposed an inequitable forfeiture. In support of this assertion, Parkview argued
in part that it has substantially performed its contractual obligations of serving
Medicaid patients in a sufficient number of patient days to be entitled to the
compensation provided by the DSH funds and that, even if its failure to submit
the proper documentation by a deadline date imposed unilaterally by the State
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does constitute a breach of contract, the millions of dollars of which the State
would deprive Parkview are entirely out of proportion to the harm, if any, that
flowed from Parkview’s breach. Parkview argued that the consideration for
Parkview’s promise to abide by the provider agreement was the State’s
obligation to compensate Parkview for its Medicaid services. Parkview noted
that, within one or two business days after receipt of the June 18, 2010 letter
from Myers and Stauffer, on June 22, 2010, it informed the State of the
undercount of Medicaid patient days.
[23] In its brief, Methodist argued that Parkview cannot forfeit what it never
possessed, that it did not qualify for DSH payments, and that it failed to comply
with the provider agreement. In its brief, FSSA argued that equitable relief is
inappropriate, that there was no forfeiture, that Parkview had no existing
interest in DSH funds, that a hospital has no automatic right or freestanding
entitlement to the grant, and that Parkview did not forfeit any interest in its
Medicaid provider agreement. FSSA also contended that, even if equitable
principles should be applied, a party may lose its right to relief through its own
negligence, that Nickeson’s June 22, 2010 e-mail message stated that Parkview
discovered a significant number of days were mistakenly omitted from the
surveys, that Nickeson’s later affidavit indicates he knew about the missing days
when Parkview submitted its survey, and that regardless of the post hoc
explanations, it is evident that any negligence is attributable to Parkview.
[24] On May 27, 2014, the court held a hearing on Parkview’s petition for judicial
review at which the parties presented arguments. When asked how Parkview
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could forfeit something it never had, Parkview asserted that the law of forfeiture
is not limited to property in possession but also applies to money earned, that it
had an interest in the money it had earned as a disproportionate share hospital,
and that it earned the DSH payments it was denied. Parkview contended that
hospitals that obeyed the instructions, like itself, were penalized.
[25] FSSA argued that Parkview did not have a vested interest and that Parkview’s
assertion is that as a matter of law anyone who should qualify should be able to
go back and reopen proceedings after ineligibility is determined. FSSA noted
that White County Hospital did submit supporting data, there were a few fields
that were missing, and that for the sake of completeness Myers and Stauffer
obtained the missing information to confirm them. FSSA argued that it wished
to limit the universe of appeals and that, if it permitted Parkview to submit
more days after the deadline, it would open up cascading appeals with everyone
else if they were right on the line and that this could be a never-ending process.
[26] Methodist argued that granting the relief Parkview seeks would be inequitable
to Methodist, that Parkview waited four months and hoped its submission was
good enough to receive a payment, that it then used words like “mistake” and
“omission,” that it was not a mistake for Parkview to fail to submit the
additional days but a deliberate considered act of a veteran of the process, and
that Parkview did not take the step of contacting Myers and Stauffer if it had
concerns or extenuating circumstances. Id. at 47. Methodist asserted that
Parkview never explained what was going on, whether its consultant was
negligent, or whether Parkview was waylaid, and that a party asking for equity
Court of Appeals of Indiana | Opinion 02A03-1408-PL-296 | July 14, 2015 Page 25 of 45
needs to provide all of the facts so the court can determine where the equities
might lie. With respect to Parkview’s argument about an entitlement or vested
interest, Methodist further contended that Parkview was fully compensated for
all of the care it rendered to Medicaid patients, that Parkview received
$44,900,770 and did not provide care for free, that Parkview suffered no
equitable forfeiture, that more than seventy-five percent of the hospitals in
Indiana do not receive DSH funds, and that there was no reasonable
expectation or entitlement to DSH funds. It argued that the fact that a hospital
provided the same amount of Medicaid days as the previous year is
meaningless and only relevant in relation to the other hospitals, and there is no
possible expectation because the hospital would have to know the care provided
by the other hospitals.
[27] On July 25, 2014, the trial court entered an order affirming the decision of
FSSA’s ultimate authority, including that FSSA properly followed its own rules
and procedures when it declined to consider the patient days Parkview
submitted after the DSH survey deadline. The court concluded that Parkview
did not show that it was treated differently than any other hospital in the
calculation and that, specifically, the record showed that White County
Hospital was permitted to submit certain documentation after the deadline, but
that information did not affect either White County Hospital’s DSH eligibility
or the amount of DSH funds paid to it. The court also concluded that for a
number of reasons, Parkview has not established a valid claim for equitable
forfeiture. Further, the court noted that Parkview’s failure to submit the
Court of Appeals of Indiana | Opinion 02A03-1408-PL-296 | July 14, 2015 Page 26 of 45
inpatient days by the deadline was not an inadvertent error but rather a willful
act that bars Parkview from having the attributes of a party claiming equitable
relief; that Parkview was paid all of its 2010-2011 Medicaid funds of nearly
forty-five million dollars for provision of care to the Medicaid population and
therefore Parkview suffered no forfeiture or loss in its provision of services to
the Medicaid population; and that Parkview did not possess a right to DSH
payments because, among other reasons, timely completion of the survey was a
prerequisite to eligibility and Parkview cannot forfeit what it never possessed.
The court concluded that it would not be equitable for Parkview to recover
DSH payments at the expense of several other hospitals that timely and
correctly completed their surveys, and that Parkview willingly refused to avail
itself of a request for additional time to submit additional information, and its
delay in exercising this option precludes equitable relief.
[28] The court also concluded that, “[t]o the extent there is a proper contract claim
here, Parkview did not use the available method of contacting FSSA’s
contractor about obtaining relief for ‘extenuating circumstances’” and that
“Parkview having not used this ‘safety valve’ provision of the ‘contract,’ the
Court will not engraft an additional ‘safety valve’ that is not already written in
the contract.” Id. at 17. The court denied Parkview’s petition for judicial
review and affirmed the decision of the Secretary of FSSA.
Court of Appeals of Indiana | Opinion 02A03-1408-PL-296 | July 14, 2015 Page 27 of 45
Issue and Standard of Review
[29] The issue is whether the trial court erred in entering its July 25, 2014 order
affirming the Decision of the Ultimate Authority Designee regarding FSSA’s
denial of DSH payments to Parkview.
[30] When we review the decision of an administrative agency, we are bound by the
same standard as the trial court. Parker v. Ind. State Fair Bd., 992 N.E.2d 969,
976 (Ind. Ct. App. 2013) (citing Musgrave v. Squaw Creek Coal Co., 964 N.E.2d
891, 899 (Ind. Ct. App. 2012), trans. denied). We do not try the case de novo and
do not substitute our judgment for that of the agency. Musgrave, 964 N.E.2d at
899. We will reverse the administrative decision only if it is (1) arbitrary,
capricious, an abuse of discretion, or otherwise not in accordance with law; (2)
contrary to a constitutional right, power, privilege, or immunity; (3) in excess of
statutory jurisdiction, authority, or limitations, or short of statutory right; (4)
without observance of procedure required by law; or (5) unsupported by
substantial evidence. Ind. Code § 4-21.5-5-14(d); see also Musgrave, 964 N.E.2d
at 899. While an appellate court grants deference to an administrative agency’s
findings of fact, no such deference is accorded to its conclusions of law.
Musgrave, 964 N.E.2d at 899-900 (citing LTV Steel Co. v. Griffin, 730 N.E.2d
1251, 1257 (Ind. 2000)). The burden of demonstrating the invalidity of the
agency action is on the party who asserts the invalidity. Ind. Code § 4-21.5-5-
14(a); see also Musgrave, 964 N.E.2d at 900.
Court of Appeals of Indiana | Opinion 02A03-1408-PL-296 | July 14, 2015 Page 28 of 45
[31] The order of the ALJ was entered on cross motions for summary judgment. In
an administrative proceeding, a party may, at any time after the matter has been
assigned to an administrative law judge, move for a summary judgment in the
party’s favor as to all or any part of the issues in the proceeding. Ind. Code § 4-
21.5-3-23(a); Musgrave, 964 N.E.2d at 900. When a party files a summary
judgment motion, the administrative law judge considers the motion as a court
would if considering a motion for summary judgment filed under Trial Rule 56.
Ind. Code § 4-21.5-3-23(b); Musgrave, 964 N.E.2d at 900.
[32] Pursuant to Indiana Trial Rule 56(C), summary judgment is appropriate when
there are no genuine issues of material fact and when the moving party is
entitled to judgment as a matter of law. Musgrave, 964 N.E.2d at 900. A
genuine issue of material fact exists where facts concerning an issue which
would dispose of the litigation are in dispute or where the undisputed facts are
capable of supporting conflicting inferences on such an issue. Id. The party
moving for summary judgment bears the burden of making a prima facie
showing that there is no genuine issue of material fact and that he or she is
entitled to a judgment as a matter of law. Id. Once the moving party meets
these two requirements, the burden shifts to the non-moving party to show the
existence of a genuine issue of material fact by setting forth specifically
designated facts. Id. The fact that the parties made cross motions for summary
judgment does not alter our standard of review. Id. Instead, we consider each
motion separately to determine whether the moving party is entitled to
judgment as a matter of law. Id.Court of Appeals of Indiana | Opinion 02A03-1408-PL-296 | July 14, 2015 Page 29 of 45
Arguments of the Parties
[33] Parkview contends that it is entitled to relief since FSSA’s final decision on
Parkview’s DSH’s eligibility was arbitrary and capricious, an abuse of
discretion, not in accordance with law, and unsupported by substantial
evidence. It argues that the trial court’s findings ignored the evidence and that:
“Perhaps the most egregious omission in the trial court’s findings is its failure
even to mention the fact that Parkview’s claim was based on specific provisions
of its binding contract with the State, the very same contract which the State
claimed gave it the right to enforce its DSH instructions and procedures against
Parkview in the first place.” Appellant’s Brief at 21. It also argues that the
court found that Parkview “intentionally omitted” more than 3,000 Medicaid
patient days from its survey but “ignor[ed] the fact that the survey instructions
stated that days such as these should not be submitted if a provider lacked the
required documentation.” Id. at 22.
[34] Parkview further contends that, “[u]nder contract law, the State could not
arbitrarily enforce its ‘procedures’ where those procedures were not material to
the contract and resulted in forfeiture.” Id. at 23. It points to paragraphs 5 and
12 of the Medicaid provider agreement9 and argues in part that it is undisputed
9
The provider agreement stated in part:
As a condition of enrollment, this agreement cannot be altered and [Parkview] agrees to
all of the following:
*****
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that, had Parkview’s Medicaid days been considered by FSSA, Parkview would
have received DSH funds, that “Parkview was prima facie entitled to receive
payment of those DSH funds from the State,” that there are forty-five
paragraphs in the provider agreement imposing voluminous obligations on
Parkview, that during the trial court proceedings FSSA never once claimed that
Parkview violated any of those specific provisions, and that Parkview has never
denied that paragraph 12 is binding or that the DSH instructions are
enforceable, but that “the question presented here is whether under the law of
contracts the DSH instructions are enforceable where to do so results in a
substantial forfeiture, and where those instructions ultimately were not material
to the vitality of the contract as a whole.” Id. at 24-25.
[35] Parkview maintains that it is entitled to relief under Sections 229 and 241 of the
Restatement (Second) of Contracts,10 and that, under Section 229, it is entitled
5. To provide covered services and/or supplies for which federal financial
participation is available for Indiana Health Coverage Program Members
pursuant to all applicable federal and state statutes and regulations.
*****
12. To abide by the Indiana Health Coverage Programs Provider Manual, as
amended from time to time, as well as all provider bulletins and notices. Any
amendments to the provider manual, as well as provider bulletins and notices,
communicated to Provider shall be binding upon receipt. . . .
Appellant’s Appendix at 343.
10
Section 229 of the Restatement (Second) of Contracts provides:
Excuse of a Condition to Avoid Forfeiture. To the extent that the non-occurrence of a
condition would cause disproportionate forfeiture, a court may excuse the non-occurrence of
that condition unless its occurrence was a material part of the agreed exchange.
Section 241 provides five factors to consider in determining whether a breach of contract is material:
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to relief once it establishes that depriving it of DSH monies constitutes a
“disproportionate forfeiture,” and that the burden then shifts to FSSA to
establish that compliance with the instructions was a “material part of the
agreed exchange.” Id. at 27. Parkview asserts that it has established its right to
relief under Section 229 and Indiana law as a matter of law, or, at the very least,
has established disputed material issues of fact. With respect to the trial court’s
finding that Parkview cannot forfeit what it never possessed, it argues that the
court misunderstood the law of forfeiture and that forfeiture may occur if a
party is deprived of compensation, even if it was never in possession of that
which has been forfeited, and points to Restatement § 229 cmt. b.11 Parkview
further argues that the forfeiture constitutes a disproportionate forfeiture, that
there is no evidence establishing that harm to the State could justify depriving
Parkview of twenty-seven million dollars or more in DSH funds, and that the
State does not even assert that it suffered any loss whatsoever as a result of
(a) the extent to which the injured party will be deprived of the benefit which he reasonably
expected;
(b) the extent to which the injured party can be adequately compensated for the part of that
benefit of which he will be deprived;
(c) the extent to which the party failing to perform or to offer to perform will suffer forfeiture;
(d) the likelihood that the party failing to perform or to offer to perform will cure his failure,
taking account of all the circumstances including any reasonable assurances; and
(e) the extent to which the behavior of the party failing to perform or to offer to perform
comports with standards of good faith and fair dealing.
11
Restatement §229 cmt. b provides that “the denial of compensation that results when the obligee loses [its]
right to the agreed exchange after [it] has relied substantially, as by preparation or performance on the
expectation of that exchange.”
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Parkview’s conduct, let alone a loss even remotely comparable to the loss
suffered by Parkview.
[36] Parkview also notes that the court failed to engage in any analysis of whether
Parkview had committed a material breach. Parkview asserts that, by any
measure, the State has not been deprived of any benefit for which it bargained
when it entered into the provider agreement with Parkview as all of its
Medicaid patients were properly cared for, that the State has never even
asserted that it has suffered any monetary loss as a result of Parkview’s conduct,
that the State seeks to deny Parkview the supplemental DSH monies in the
millions of dollars that it had fully earned, and that this presents a forfeiture
entirely disproportionate to whatever harm the State may ever assert. Parkview
states it not only promptly offered to cure, but by August 5, 2010, it had
actually cured any defect in its performance. It posits that, “[u]nder these
circumstances and under Indiana law, Parkview’s failure to report its additional
3,134 Medicaid days by the February 26, 2010 deadline cannot be regarded as a
material breach of a condition of the Medicaid Provider Agreement,
discharging the State’s obligation to pay DSH monies to Parkview.” Id. at 36.
[37] Parkview also argues it gained nothing by failing to submit its additional
Medicaid days by the deadline and therefore it had no motive for any behavior
that did not comport with good faith and fair dealing, and that it simply
attempted to abide by FSSA’s own written instructions. Parkview asserts that it
did not have the documentation supporting its additional days by the February
2010 deadline, that the DSH instructions stated that a count of days could not
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be submitted without the support, that many of the days for which Parkview
lacked documentation were crossover days and this was the first year that these
dual-eligible days were included in the DSH calculation, that “[a] reasonable
inference from Eric Nickeson’s affidavit testimony is that, although he knew
these cross-over days existed, he was not aware of their significance,” and that
in prior years Parkview had always met the MIUR threshold for DSH and the
effect of including the crossover days was unknown. Id. at 41. Parkview
contends the survey instructions were very clear that Parkview could not submit
a count of its additional days without simultaneously providing this supporting
data, that Nickeson testified that was his interpretation of the instructions, that
perhaps Nickeson committed an error of judgment in not asking for relief from
the DSH survey deadline but such an error does not establish willful
misconduct, and that the trial court’s reference to a “safety valve” provision in
the contract did not absolve the court of its duty to analyze any of the contract
issues in the case. Id. at 45.
[38] Parkview also contends FSSA did not adhere to the written instructions, that
instead it permitted hospitals to submit a count of days by the deadline and then
submit supporting data after the deadline, and that the actual undisclosed policy
of the OMPP was that, after the deadline, hospitals were allowed to provide
explanatory or supporting information on days that had been reported, but were
not allowed to report new days that had not previously been reported.
Parkview argues that, had it been aware of the actual unwritten rule, it would
have been able to comply with that instruction by the February 26, 2010
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deadline, and that it follows that failing to comply with the written DSH
instructions could not have been a breach material to the agreed bargain under
Sections 229 or 241 of the Restatement. Parkview asserts that FSSA’s issuance
of inaccurate and misleading instructions was arbitrary and capricious. It
argues that the agency’s decision should be reversed because the ALJ and FSSA
misstated the undisputed facts and denied Parkview’s appeal of its eligibility
determination based on a gross exaggeration of Parkview’s delay in submitting
its Medicaid days information to FSSA as it is undisputed that no more than
two business days after receiving the June 18, 2010 letter Parkview sent an
email on June 22, 2010 informing Myers and Stauffer that Parkview had
determined that a number of Medicaid crossover days had been mistakenly
omitted from its Survey. Parkview requests this matter be remanded with
instructions to accept its additional Medicaid patient days or remanded for an
evidentiary hearing to address any disputed issues of material fact.
[39] Among many other assertions, FSSA argues that all hospitals in Indiana were
notified of and subject to the same deadline and standards, and that it is
reasonable to assume that FSSA may need to reach out to hospitals after the
February 26, 2010 deadline to clarify information they provided or resolve
issues or discrepancies that arise. It maintains that what Parkview suggests is
not reasonable and would lead to an unmanageable debacle which would allow
for an inundation of new, post-deadline information from the providers who
did not qualify attempting again to qualify, effectively creating a second wave of
submission for all hospitals without a set deadline, and that the standards
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established by FSSA are reasonable and adherence to those standards is not
arbitrary and capricious.
[40] FSSA argues that it uniformly applied and adhered to its established standards,
that Parkview’s comparison between White County and itself is misplaced, that
White County submitted days without some supporting documentation before
the deadline, that Parkview submitted additional days long after the deadline,
and that the survey instructions, in form and practice, prohibit the use of days
not submitted before the deadline.
[41] In addition, FSSA maintains that Parkview waived its contract claims and in
any event this case may not be analyzed under contract principles because
nothing in the existing provider agreement gave Parkview any right to receive
DSH payments. FSSA asserts that a review of the record indicates that
Parkview did not advance claims based on contract principles before the
agency, and such claims should now be disregarded because they were not
initially raised.
[42] FSSA argues that there was no disproportionate forfeiture in any event, and
that the trial court aptly noted there was no equitable forfeiture for a number of
reasons, including Parkview’s willful actions in the submission of what it later
contended was an incomplete survey, its receipt of full payment for Medicaid
services it actually rendered, the need for timely completion of surveys, the
inequity to other hospitals if DSH funding was now extended to Parkview
because the other hospitals’ share would diminish, and Parkview’s failure to
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request more time to submit its survey if it needed the time for extenuating
circumstances. It notes that DSH payments can be significant, Parkview was
no novice in requesting such payments, and that if something changed in the
way the survey was to be prepared this was all the more reason to request an
extension if an extension was warranted.
[43] Among its many arguments, Methodist asserts that, if this court reaches
Parkview’s equitable arguments, it should find they are insufficient for reversal,
that DSH payments are not an entitlement, and that DSH funds are not earned
compensation but are akin to a bonus for treating a disproportionate share of
Medicaid patients. Methodist argues that, because Parkview’s original
submission fell short of establishing it qualified for DSH payments, Parkview
demands special treatment. Methodist contends that contractual principles
such as forfeiture do not apply as Medicaid is not governed by a private
agreement between two parties but by numerous state and federal regulations,
that Parkview cannot show clean hands to obtain equitable relief as it knew at
the time of its DSH survey that it was excluding 3,134 days, and that Parkview
has pointed its finger to a contractor who did not have documentation for dual-
eligible claims by the deadline but does not explain why this occurred.
Methodist also states that allowing Parkview to qualify for DSH payments
would create a cascade of appeals.
[44] In its reply brief, Parkview argues in part that Appellees’ briefs repeatedly
construe the facts and inferences in favor of the ALJ’s ruling granting summary
judgment to FSSA rather than correctly construing all facts and reasonable
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inferences in favor of Parkview as the non-movant. It contends that FSSA’s
position ignores and undermines the entire purpose of the DSH statute which is
intended to provide financial assistance to hospitals that serve a
disproportionate number of Medicaid and low income patients, and that this
court should reject the position that Parkview’s administrative error, one which
was entirely capable of being rectified, should produce the a harsh result of
depriving Parkview of twenty-seven million dollars.
Discussion
[45] The December 18, 2009 letter and instructions accompanying the DSH
eligibility survey form to Parkview stated that the survey must be completed
and postmarked no later than February 26, 2010, and the survey instructions
stated that only information submitted in a response postmarked by February
26, 2010, would be included in the facility’s DSH eligibility calculation. The
survey instructions also expressly stated that “there is a change in the eligibility
survey from past years as a result of the DSH Audit rule published in the
Federal Register December 19, 2008,” and that “Crossover days (days for
which a patient is eligible for both Medicaid and Medicare Part A) should now
be included in the Medicaid Inpatient Utilization Rate (MIUR).” Appellant’s
Appendix at 187.
[46] Parkview submitted its response to the survey on February 26, 2010, and Myers
and Stauffer, on behalf of FSSA, sent a letter dated June 18, 2010, to Parkview
which stated that Parkview was not qualified to receive DSH payments for
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fiscal years 2010 and 2011, that “no new information can be accepted at this
time,” and that “[o]nly clarification and substantiation of information
previously reported on your DSH eligibility survey is allowed.” Id. at 207.
Several days later, on June 22, 2010, Nickeson, on behalf of Parkview, sent an
e-mail message to Myers and Stauffer stating in part that, “[i]n reviewing our
information after receipt of the June 18, 2010 eligibility letter from Myers and
Stauffer, we have discovered that a significant number of Medicare crossover
days, both paid and unpaid, were mistakenly omitted from the Parkview Health
facilities’ SFY 2010-2011 Medicaid DSH surveys” and that Parkview planned
to file an appeal to include those days in its survey response. Id. at 228. In his
affidavit, included in Parkview’s designated evidence in support of its summary
judgment motion, Nickeson stated in part that, “[b]ased on the clear language
of the Survey instructions,” he submitted Parkview’s survey response “in strict
compliance with the instructions and deadline,” that “[i]n working with our
contractor in preparing the Survey response, I relied on them to provide
supporting documentation for many days believed to be includable,” that “[a]s
soon [as] it was apparent to me that the support would not be developed in time
for submission, I did not consider contacting OMPP or Myers and Stauffer as I
felt such attempts would be fruitless, as there were no extraordinary
circumstances justifying the delay,” and that his “perception of the hard
deadline was informed by the strict language of the Survey instructions.” Id. at
93-94.
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[47] These facts are not disputed, and there is no dispute that, based on the
information Parkview submitted by the February 26, 2010 deadline, it was
determined that Parkview was not eligible for DSH payments. As revealed by
the procedural history set forth above, while it challenged the issue at the
agency level and in its petition for judicial review, Parkview does not present
arguments on appeal regarding whether crossover or dually-eligible inpatient
days were properly considered in making the MIUR calculations or regarding
the impact of any state law in effect at the time of the initial DSH eligibility
determinations which required the exclusion of such days in calculating the
MIUR, and thus we do not disturb the conclusions of the ALJ and Secretary of
FSSA on this issue.
[48] We turn to Parkview’s arguments regarding FSSA’s decision not to consider
any Medicaid inpatient days Parkview submitted or wished to submit
subsequent to the February 26, 2010 deadline.
Arbitrary, Capricious, or Unsupported by Substantial Evidence
[49] With respect to Parkview’s argument that the decisions of the ALJ and
Secretary of FSSA were arbitrary and capricious as it was treated differently
than White County Memorial Hospital, we note that the instructions
accompanying the survey stated that the survey was mandatory and requested
the facilities to complete and return the survey postmarked no later than
February 26, 2010. Significantly, the survey instructions specifically stated
“[o]nly information submitted by your facility on a survey postmarked by
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February 26, 2010 will be included in your facility’s DSH eligibility calculation”
and “[p]lease be advised that any questions that require support but do not have
the required documentation will not be used in the calculations for DSH
eligibility.” Appellant’s Appendix at 186-187 (emphases added). These
instructions make it clear that any inpatient days Parkview wished to be
considered in making an eligibility determination were required to be submitted
as a part of its responsive survey postmarked no later than February 26, 2010,
and that no information received after that date would be considered in making
an eligibility determination.
[50] White County submitted forty-three inpatient days for which it had not
provided dates of service. Following the scheduled deadline, Myers and
Stauffer, at FSSA’s direction, asked White County for this information.
However, as acknowledged at oral argument and found by the trial court,
White County was eligible for DSH payments without taking into consideration
the inpatient days for which it had not provided dates of service. Sheehan’s
email message to FSSA stated in part that White County reported an additional
forty-three days without dates of service and that “[t]he impact on White’s
eligibility is irrelevant . . . .” Id. at 115. Once White County was determined to
be eligible for DSH payments based upon its inpatient days submitted with all
required information by the scheduled deadline, White County was permitted
to supplement its documentation upon request by providing dates of service,
which could have impacted its share of the available DSH funds, and this was
not in contravention of the survey instructions. See id. at 186-187 (the survey
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instructions provided “Please maintain all source documentation used to
complete the survey, as additional information (i.e., remittance advices, patient
listings, etc.) may be requested to verify your numbers”). Parkview, on the
other hand, failed to submit over 3,000 inpatient days which it desired for FSSA
to consider in making an eligibility determination by the scheduled deadline
and, as a result, was found to be ineligible for DSH payments. We cannot say
that the decision of the Secretary of FSSA was arbitrary or capricious on the
grounds Parkview was treated differently than White County.
[51] Also, Parkview states that exhibits containing supporting documentation
necessary to verify its additionally-requested inpatient days were attached to its
August 5, 2010 statement of issues, and FSSA states that the record only
conclusively shows that Parkview submitted the additional days on December
10, 2010. Thus, to the extent the findings of the ALJ and Secretary of FSSA
suggest Parkview did not submit documentation for the inpatient days it wished
for FSSA to consider until two years after the initial survey deadline, those
findings are not correct. Nevertheless, we cannot say that these findings render
the decision of the Secretary of FSSA unsupported by substantial evidence.
Parkview did not submit supporting documentation for the additional inpatient
days it wished for FSSA to consider in calculating its MIUR until at least
August 5, 2010, several months after the February 26, 2010 deadline set forth in
the instructions, and Parkview did not notify FSSA or Myers and Stauffer of the
possible crossover days until four days after it had received FSSA’s June 18,
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2010 letter notifying it that it was not eligible for DSH payments for the
applicable period.
[52] Based upon the designated evidence before the ALJ and Secretary of FSSA, we
cannot say that the decision of the Secretary of FSSA as the ultimate authority
designee was arbitrary, capricious, or unsupported by substantial evidence.
Excuse of a Condition to Avoid Forfeiture
[53] We next turn to Parkview’s argument that it had a contract with FSSA and that
it suffered a disproportionate forfeiture, as contemplated by the Restatement
(Second) of Contracts, when it failed to submit all of its inpatient days by the
deadline established by FSSA.
[54] The designated evidence does not support the conclusion that a contract or
agreement existed between FSSA and Parkview which governed DSH
payments or eligibility for DSH payments, and Parkview is not entitled to relief
on the basis of a forfeiture of a reasonably-expected contract benefit. The
Medicaid program in general, and the DSH payment program in particular, is
not governed principally by one or more agreements by or between hospitals
and states or the federal government, but instead is administered in accordance
with a number of federal and state laws and regulations. While Parkview
agreed to certain terms in the Medicaid provider agreement and there may have
been other existing agreements related to health coverage programs and
hospital reimbursements, the designated evidence does not show there was an
agreement, contained within the Medicaid provider agreement or elsewhere,
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between FSSA and Parkview pursuant to which FSSA agreed that, in exchange
for Parkview providing services to Medicaid-eligible patients, Parkview would
receive DSH payments for the state fiscal years 2010 and 2011, or which
otherwise contained material terms and conditions regarding DSH payments or
eligibility for DSH payments to providers and the amount of those payments.
[55] Under the regulations referenced above, whether a particular provider is or will
be eligible for DSH payments and the amount of those payments in any
particular year turns on the provider’s MIUR relative to the mean MIUR for
providers receiving Medicaid payments in Indiana, and the MIUR calculations
are made using the information provided to FSSA by the providers. Thus, the
eligibility determination for any provider was dependent upon the provider’s
compliance with the administrative processes established by FSSA as the
agency administering the Medicaid program for the State of Indiana. DSH
eligibility and payment determinations were not governed by any contract or
agreement between FSSA and providers. Accordingly, Parkview does not have
a contract claim against FSSA or any claim related to excuse of a condition to
avoid forfeiture under the Restatement (Second) of Contracts § 229.
[56] In addition, a Medicaid provider does not know whether it will be eligible for
DSH payments until the MIUR calculations for all providers receiving
Medicaid payments in Indiana are completed and the mean MIUR and
standard deviation calculations are completed. Based upon the designated
evidence, a Medicaid provider could not have reasonably expected to become
eligible for DSH payments unless it submitted all of its inpatient days, including
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crossover or dually-eligible inpatient days, prior to the February 26, 2010
deadline.
[57] The designated evidence shows there was no contract or agreement of material
terms and conditions between FSSA and Parkview regarding DSH payments or
eligibility for DSH payments and thus Parkview does not have a contract claim
against FSSA and is not entitled to relief on the basis of a forfeiture of a
reasonably-expected contract benefit.
Conclusion
[58] Based upon the record, the decision of the Secretary of FSSA was not arbitrary,
capricious, or unsupported by substantial evidence. In addition, there was no
contract or agreement of material terms and conditions regarding DSH
payments supporting a forfeiture claim.
[59] For the foregoing reasons, we affirm the July 25, 2014 judgment of the trial
court affirming the decision of the Secretary of FSSA.
[60] Affirmed.
Riley, J., and Robb, J., concur.
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