Opinion ID: 71592
Heading Depth: 2
Heading Rank: 2

Heading: Defendant AHCA's Case:

Text: 21 AHCA first asserts that there is no case or controversy. Defendant contends it has not recouped any money previously paid to Plaintiffs for in-patient adolescent psychiatric care provided to Medicaid recipients, but later determined by KEPRO to be not medically necessary--in other words, recoupment for administrative or grace days. According to Defendant, it has not yet determined whether to recoup funds from Plaintiff TMRMC. Furthermore, Defendant points out that Plaintiff FHMC has a pending request for a formal administrative hearing to contest Defendant's determination that FHMC was overpaid for rendering services to eight (8) Medicaid recipients 3 . As a result, Defendant concludes that Plaintiffs have not suffered any monetary damage, any prospective damages to or suffered by Plaintiffs are too speculative, and Plaintiffs have not exhausted their administrative remedies pursuant to Florida Statutes Chapter 120. Consequently, Defendant would have the Court hold that there has been no actual dilution in either Plaintiff's Medicaid per diem rates and, therefore, there is no violation of the Boren Amendment. 22 Second, AHCA maintains that HRS, not it, is the proper defendant in this action. Defendant asserts that HRS delays placement of Plaintiffs' adolescent psychiatric patients in outpatient facilities, either because of administrative delays by HRS or the failure of HRS to provide an adequate number of such facilities 4 . Furthermore, Defendant contends that: (1) a substantial number of the adolescent patients in question are in the custody of HRS; or (2) the adolescent patients in question are still a danger to themselves or others fall and within the care of HRS under Florida's Baker Act 5 . Defendant therefore concludes that HRS is responsible for the reimbursement problems at issue in this case, and that Plaintiffs have therefore not proven any Boren Amendment violations. 23 AHCA next asserts the inappropriate level of care reimbursement provision of the Boren Amendment is optional, and that Florida has not elected to provide such coverage 6 . In the absence of inappropriate level of care coverage, Defendant states that medical necessity, or the lack thereof, is the only pertinent criterion for determining the compensability of the grace days. Since Plaintiffs do not dispute that in-patient psychiatric care is not medically necessary for the adolescent patients in question, Defendant argues the hospitals cannot be reimbursed under Florida's Medicaid for the grace days at issue. Accordingly, Defendant would have the Court hold that Plaintiffs have failed to demonstrate a violation of the Boren Amendment. 24 AHCA also argues that the Boren Amendment provides, by definition, that the Plaintiff hospitals are not efficiently operated when they continue to treat patients beyond medical necessity--i.e., when in-patient care is no longer medically necessary for the adolescent psychiatric patients in question. Defendant therefore states that its failure to pay Plaintiffs for such services does not violate the Boren Amendment. 25 Finally, AHCA states that Medicaid per diem rates are established by it only after a hospital provider submits its cost of care (including charity care), which is then divided by the reimbursable Medicaid days to produce a per day/per bed cost for the provider. Defendant reasons that even if this case raises a Boren Amendment issue, the amount of the services not directly paid to Plaintiffs will be recalculated as part of the charity care when any subsequent per diem rates are set. Hence, no Boren Amendment violation has occurred.