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Arnold Memorial Medical Center v. State, Department of Health and Human Services

Superior Court of Maine, Kennebec

August 7, 2018

ARNOLD MEMORIAL MEDICAL CENTER, Petitioner,
v.
STATE OF MAINE, DEPARTMENT OF HEALTH AND HUMAN SERVICES Respondent.

          Plaintiff's Attorney Charles Dingman, Esq.

          Defendant's Attorney Thomas Bradley, MG

          ORDER ON PETITIONER'S M.R. CIV. P. 80C APPEAL

          Michaela Murphy, Justice Superior Court

         Before the Court is Petitioner's M.R. Civ. P. 80C appeal of agency action seeking reversal of the Respondent Department of Health and Human Services ("DHHS") decision to recoup $970, 315.55 in payments to Petitioner for care relating to opioid addiction and other substance abuse issues that it rendered to MaineCare patients between January 1, 2011 and September 17, 2012 (the "Review Period").

         I. Background

         A. Arnold Memorial Medical Center

         Arnold Memorial is a community medical center in Washington County which was founded in 1985. Effective February 3, 2010, Arnold Memorial entered into a Medicaid/Maine Health Program Provider/Supplier Agreement" with the Department of Health and Human Services (the "Department") in order to become a MaineCare provider. In 2003, Arnold Memorial became one of the first providers in Maine to become certified to prescribe Suboxone. Since then, it has consistently met its patient regulatory cap for its Suboxone program. A cornerstone of Arnold Memorial's addiction treatment program is urine drug screening tests to monitor the presence of drugs in the patient's system. Treatment consists of monitoring a patient multiple times a week at the beginning of their treatment, in order to ensure that there is not time between screenings for drug use to become indiscernible.

         Arnold Memorial, in its capacity as a Rural Health Clinic, also administers the core diagnostic laboratory tests in order to care for their population's typical medical needs. These tests include urinalysis to screen for kidney disease, liver disease, blood in urine, and certain cancers; hemoglobin test; blood sugar screening for diabetes; stool sample; pregnancy test; and a strep test.

         B. MaineCare Reimbursement and Billing Codes

         The MaineCare Benefits Manual sets out the guidelines for MaineCare coverage and payment of Rural Health Clinics services. Chapter II, § 103 provides for coverage of "core services" delivered by a Rural Health Clinic, including "basic laboratory services essential for the immediate diagnosis and treatment of illness or injury." One example provided of such services is "chemical examination of urine by stick or tablet method." Chapter II, § 103.04(1)(C)(1). The regulations note that "[t]o qualify for reimbursement, laboratory services must be in compliance with the rules implementing the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88') and any related amendments."

         According to the MaineCare Benefits Manual, when billing as a Rural Health Clinic, providers must bill all core services using the billing code T1015. However, Rural Health Clinics "have the option of obtaining a separate MaineCare provider billing number for the limited purpose of fee-for-service billing and reimbursement for such services as X-ray, EKG, inpatient hospital visits and other Medicare defined non-RHC Services that are billable under Medicare Part B." Chapter II, § 103.09.

         In this case, Arnold Memorial used a separate MaineCare provider billing number specific to Arnold Memorial, 80101, when billing for urine drug screening tests. Arnold Memorial added "QW" to the code to indicate that it was a "CLIA-waived" test.[1] By billing in this manner, Arnold Memorial billed for each substance that the test screened for individually. The Department found that this was incorrect billing for two reasons. First, the Department determined that urine drug screening tests were core services and therefore should have been billed for using the billing code T1015. Second, even if the Department had found that urine drug screening tests were not core services, Arnold Memorial should have used the billing code G0434 rather than 80101. Billing code G0434 was created November 29, 2010 and was made to be used for high complexity lab tests.[2] Therefore, the Department found, Arnold Memorial should have submitted a single UB claim form including both billing code T1015 and billing code G0434 for a low-complexity, "CLIA waived" test, with a single unit of service identified for each multi-drug screen performed.[3]

         C. Core Services and "CLIA-waived" Tests

         The Department determined that a urine drug screening test was a "basic laboratory service" and therefore should have been billed as a core service according to Chapter II, § 103.04(1)(C)(1). The categorization as a "basic laboratory service" was based upon the CLIA standards as set by the Centers for Medicare and Medicaid Services and the Food and Drug Administration which assign relative complexity levels to laboratory tests based upon the training and experience required to administer the test, the operational steps, and the materials required, among other factors. See 42 C.F.R. § 493.17. The urine drug screening test at issue in this appeal was considered CLIA-waived, or a low complexity test.[4] The Department found that because the test is CLIA-waived, it is a "basic laboratory service" ...


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