New LifeCare Hospitals of North Carolina LLC v. Becerra, No. 20-5227 (D.C. Cir. 2021)
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In 2008, four long-term care hospitals that treat patients who are dually eligible for the Medicare and Medicaid programs were denied reimbursement by the Secretary of Health and Human Services for “bad debts,” unpaid coinsurances and deductibles owed by patients. The Secretary denied reimbursement on the grounds that the hospitals failed to comply with the “must-bill” policy, 42 C.F.R. 413.89(e)(2), which requires hospitals to bill the state Medicaid program to determine whether Medicaid will cover the bad debts first, and obtain a “remittance advice” indicating whether the state “refuses payment,” before seeking reimbursement under Medicare. uring the relevant time period, the hospitals were not enrolled in Medicaid and were unable to bill their state Medicaid programs; they claim they were previously reimbursed and that there was an abrupt policy change.
The D.C. Circuit affirmed summary judgment for the Secretary, concluding that substantial evidence supported a finding that there was no change in policy. The court rejected arguments that the denial decision impermissibly required them to enroll in Medicaid, despite the fact that Medicaid participation is voluntary, and was arbitrary.
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