Opinion ID: 2766677
Heading Depth: 2
Heading Rank: 2

Heading: Maine's Process

Text: The Centers for Medicaid and Medicare Services (CMS), acting on behalf of the Secretary, processes crossover claims from Maine pursuant to a trading partner agreement with MaineCare. See -7- Grossmont Hosp. Corp. v. Sebelius, 903 F. Supp. 2d 39, 43-45 (D.D.C. 2012) (citing 42 U.S.C. §§ 1395h, 1395u). Under the agreement, medical providers like Maine Medical submit crossover claims to an Intermediary, a private-sector contractor that processes the claims for CMS. The Intermediary (1) pays the Medicare portion as primary payer, and (2) identifies and aggregates crossover claims, which (3) it submits -- i.e., bills -- to MaineCare on a weekly basis. Ordinarily, MaineCare then processes these billed claims, issuing RAs that confirm receipt of the billed claims and identify MaineCare's obligations for each claim. Providers use these RAs to substantiate their bad debt reimbursement claims for amounts exceeding MaineCare's obligations. For FY 2002 and FY 2003, the cost years at issue, Maine Medical submitted its crossover claims to the Intermediary. The Intermediary then submitted these claims to MaineCare, pursuant to the trading partner agreement.7 But from November 15, 2001 to August 21, 2003, MaineCare failed to process these crossover claims and to issue RAs for them due to an anomaly of unknown origin in MaineCare's claim management system (MMIS). Maine Med. Ctr., 2014 WL 1234173 at . Maine Medical does not appear to have 7 The parties do not meaningfully dispute that Maine Medical submitted these crossover claims to the Intermediary, or that the Intermediary submitted these claims to MaineCare, pursuant to the trading partner agreement. We would reach the same outcome in any event: if Maine Medical failed to submit its claims to the Intermediary, then there would be absolutely no evidence that it made reasonable collection efforts. -8- sought the missing RAs from MaineCare or taken other steps to rectify the problem during this period of over twenty months. The MMIS program continued to encounter technical difficulties, and by the end of 2004 was unable to process any claims for anyone. In November 2004, the Maine Hospital Association, of which Maine Medical is a member, urged the Maine Department of Health and Human Services (Maine DHHS) to adopt regulations requiring the issuance of RAs within sixty days after the close of the hospital fiscal year. But Maine DHHS denied the request as outside the scope of the rulemaking because it concerned reports that d[id] not affect Medicaid reimbursement. MMIS was taken offline in January 2005, and replaced by a new system, MeCMS. The new system still encountered difficulties, which Maine is working to resolve.8 Despite these problems, Maine Medical does not appear to have taken any individual action to acquire the missing RAs until early 2005, three years after the problem began in November 2001 8 Evidence in the record suggests that Maine is working both to resolve the technological glitch and to arrive at settlements with providers. For example, MaineCare has again authorized Maine Medical's CPA in this case, Roland Mercier, on behalf of other clients, to work with MaineCare Eligibility files and to perform claim level detail to MaineCare eligibility verification for Maine Providers who cannot verify MaineCare eligibility prior to September 1, 2010. Maine DHHS granted the authorization because Maine DHHS had recently received data requests from Maine Providers regarding verification of MaineCare Eligibility but did not have the time or resources to dedicate to respond to these individual claim level detail data requests. -9- and over a year after the relevant cost years concluded in September 2003. At that time, Maine Medical's CPA, Roland Mercier, request[ed] assistance [from MaineCare] . . . for th[e] discrepancy in crossover processing for [Maine Medical]. According to Mercier, MaineCare's response suggested that between the uncertainty of the cause and ongoing difficulties with the MeCMS, it was apparent that this older problem could not be remediated [sic] with the new environment. Instead, Mercier sought and received permission from MaineCare officials to work with the Muskie Institute, a quasi-state agency that assists MaineCare with certain functions and has MaineCare eligibility data, to develop alternative documentation. Mercier submitted the bad debt logs and alternative documentation to the Intermediary in July 2005. But the CMS Central Office rejected Mercier's alternative methodology for compiling crossover bad debts, citing the Congressional moratorium on CMS's bad debt policy. When informing Mercier of this decision, the Intermediary lamented that [i]t is unfortunate that [Mercier] did not present his methodology to our office prior to us being in the field for [Maine Medical's] audit, so that an earlier decision could have been obtained from CMS and communicated to [Maine Medical]. Mercier again pressed the Intermediary in early 2006, and the Intermediary again iterated its position that RAs would be -10- required and that bad debt reimbursement claims for FY 2002 and FY 2003 would be rejected without them. It added that Mercier's claim that the State cannot produce these [RAs] contradicts what state representatives had told them. The Intermediary then denied Maine Medical's reimbursement claims for crossover bad debt from FY 2002 and FY 2003, totaling $2,859,083, because the bad debt reimbursement claims were not substantiated by the requisite RAs denying payment. A week later, on March 22, 2006, Mercier finally contacted MaineCare to request the missing RAs for FY 2002 and FY 2003. But MaineCare declined to issue them. The claims had never been processed in MaineCare's system, and so MaineCare could not at this point verify that [the claims] were ever received as claimed by the Medicare intermediary. Similarly, because the claims were never processed, an RA was never issued and in addition, obviously cannot now be generated two to four years after the fact. [I]n an effort to resolve [the] issue between Maine Medical and Medicare auditors, the Director of Maine DHHS emphasized that he was completely confident in the analysis of [the Muskie Institute] . . . and believe[d] it to be the best available solution to this problem. In suggesting this solution, Maine DHHS did not deny or otherwise specify MaineCare's liability for the claims, or confirm that, had they been processed, MaineCare would have denied them completely. -11- The Muskie Institute had used MaineCare's eligibility data to verify MaineCare eligibility for patients on crossover listings from FY 2002 and FY 2003. But the alternative documentation produced omitted two important types of information ordinarily present on RAs. First, the alternative documentation failed to distinguish between crossover claims for Qualified Medicare Beneficiaries (QMB) and crossover claims for nonQualified Medicare Beneficiaries (non-QMB).9 Second, the documentation did not include a claim-by-claim analysis of MaineCare's obligations because the Muskie Institute assumed that MaineCare's payment would have been $0 under a MaineCare regulation eliminating payment for all crossover claims that had been in effect during the relevant period.10 But the parties vigorously dispute whether MaineCare would have, or lawfully could have, denied all reimbursement for Maine Medical's FY 2002 and FY 2003 crossover claims. In particular, the Secretary argues that states cannot escape at least some liability for QMB crossover claims. 9 To the best of our understanding, the verification of Medicaid eligibility for all crossover claims, QMB and non-QMB alike, is important to providers because dual-eligible patients are presumed indigent under PRM § 312, relieving the provider of the need to bill the patient for the outstanding debt. The distinction between QMB and non-QMB patients is important, however, because while the state could eliminate payment for non-QMB crossover claims, it cannot escape at least some liability for QMB crossover claims. 10 MaineCare adopted this regulation on July 1, 1999, and it continued through 2006. According to Maine Medical, MaineCare consistently applied this policy to crossover claims. -12- See 42 U.S.C. § 1396a(a)(10)(E)(i) (requiring state plans to provide for Medicare cost-sharing for QMBs); see also PRM § 322 (stating that amounts the state is statutorily obligated to pay are not allowable as bad debts). Yet the alternative documentation did not identify any of these QMB crossover claims, or calculate the extent of the resulting obligation.