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UCP-Bayview Nursing Home v. Novello12/15/2003
This opinion is uncorrected and subject to revision before publication in the Official Reports.
HOWARD MILLER and WILLIAM F. MASTRO, JJ.
DECISION & ORDER
(Index No. 13205/01)
In a hybrid proceeding pursuant to CPLR article 78, inter alia, to review a determination of Antonia C. Novello and Richard Pellegrini dated June 14, 2001, which reduced a component of the petitioner's Medicaid reimbursement rate following an audit, and an action for a judgment declaring that the guideline of the New York State Department of Health for designating a diagnosis of "quadriplegia" on a Patient Review Instrument is invalid, the petitioner appeals from so much of a judgment of the Supreme Court, Nassau County (Franco, J.), entered July 10, 2002, as failed to annul that portion of the determination which found that the petitioner had misclassified two of its residents in the RUG-II special care group, failed to direct that the New York State Department of Health permit the petitioner to submit revised February 2001 Patient Review Instruments for certain of its residents, and declared that the challenged guideline does not constitute a rule or regulation subject to the provisions of the State Administrative Procedure Act, and Antonia C. Novello and Richard Pellegrini cross-appeal from so much of the same judgment as annulled that portion of the determination which reclassified the two residents in the reduced physical functioning group and remitted the matter to the New York State Department of Health to reclassify the two residents in the clinically complex group and to calculate the petitioner's Medicaid reimbursement rate for the period covered by its August 2000 Patient Review Instruments accordingly.
ORDERED that the judgment is affirmed, without costs or disbursements.
The petitioner is a not-for-profit corporation owned by the United Cerebral Palsy Association of Nassau County, Inc., which operates a 185-bed nursing home in Nassau County. The petitioner commenced this hybrid proceeding and action seeking, inter alia, to review the determination of Antonia C. Novello, as Commissioner of the New York State Department of Health and Richard Pellegrini, as Director of the Bureau of Financial Management and Information Support of the New York State Department of Health (hereinafter collectively the Commissioner) dated June 14, 2001, which reduced a component of the petitioner's Medicaid reimbursement rate following an audit. The reduction of the reimbursement was based on the adjustment by the Commissioner of the petitioner's case mix index (hereinafter CMI). The adjustment of the CMI was based on misclassifications revealed in an audit by the New York State Department of Health (hereinafter the DOH) of patient review instrument (hereinafter PRI) data used in computing the direct cost component of the petitioner's Medicaid reimbursement rate (see 10 NYCRR 86-2.10 ). The petitioner challenges the finding of the DOH that it misclassified two residents as having a diagnosis of quadriplegia.
As part of the Medicaid reimbursement rate calculation, PRIs are completed semiannually for each patient in the nursing home (see 10 NYCRR 86-2.11 ). PRIs require detailed information assessing patients' conditions, treatment, and dependencies and required care, needs, and services. These PRIs place patients into 16 patient classification categories or "resource utilization groups" (hereinafter RUG-II categories; see 10 NYCRR Appendix 13-A), corresponding roughly to the severity of the patients' medical conditions and the intensity of the required care. The RUG-II categories are further divided into five hierarchical groups which, in descending order
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