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8 N.J.A.R. 561

Morris View Nursing Home v. Medical Assistance and Health Services, Division of
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Citation: 8 N.J.A.R. 561
Decision Date: 1983
Synopsis: Petitioner, a county run long term care facility, contested the reimbursement rates included in respondent's rate setting mechanism in three areas: l) non-legend drugs; 2) pharmaceutical consultant services; and 3) medical supplies. Petitioner based its request for a review on N.J.A.C. 10:63-3.6(a)8, which permits such review when inequities become apparent in rate setting due to unusual circumstances. Petitioner argued that such inequities stemmed from its higher indigent, elderly and handicapped patients as compared to other institutions. In addition petitioner argued that the lack of any private paying patients in its care prevented it from receiving any reimbursements higher than the standard Medicaid rate, unlike other institutions. The petitioner also objected to the failure to include information from government-run homes in the calculation of reimbursement rates and the use of total number of patient days rather than Medicaid patient days in those calculations. The administrative law judge assigned to the case determined that no evidence had been presented to conclude that the practice of using only proprietary nursing homes in arriving at a rate for pharmaceutical consulting, medical supplies and non-legend drugs, had any effort on the rate in these areas. The judge found that petitioner's patient population was sicker than the average population but could not conclude that this need could not be accommodated within the present rate structure. The judge found, however, that private billing of patients could lead to an inequitable calculation of petitioner's rates and ordered respondent to recalculate the median cost with regard to private patient billing. Upon review, the Director of the Division of Medical Assistance and Health Services rejected the initial decision, concluding that the .judge had failed to afford respondent's rate methodology the presumption of reasonableness to which it was entitled and had improperly shifted the burden of proof to the agency to justify its rate scheme. The Director determined that insufficient hearsay evidence had been presented to challenge the existing rate methodology and had not proved any industry-wide practice different from that which is assumed in that methodology. Accordingly petitioner's request for an adjustment to its reimbursement rate screens was denied.
Citation Tracker modified-Div. of Med. Ass't.; affirmed -App. Div., A-973-83, 1/21/85 (unreported) [Updated through 1991]