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Clifton Care Center v. Ohio Department of Job and Family Services

Court of Appeals of Ohio, Tenth District

June 27, 2013

Clifton Care Center et al., Appellants-Appellants,
v.
Ohio Department of Job and Family Services, Appellee-Appellee.

APPEAL from the Franklin County Court of Common Pleas (C.P.C. No. 12CVF04-4732).

Benesch, Friedlander, Coplan & Aronoff LLP, Roger L. Schantz and Harry M. Brown, for appellants.

Michael DeWine, Attorney General, and Rebecca L. Thomas, for appellee.

DECISION

KLATT, P.J.

{¶ 1} Appellants, Clifton Care Center, City View Nursing & Rehabilitation Center, Falling Water Healthcare Center, Candlewood Park Healthcare Center, Aristocrat Berea Nursing Home, Greenbrier Health Center, Lake Point Health Care, Grande Pointe Healthcare Community, Pine Valley Care Center, Pebble Creek, Wyant Woods Care Center, Pine Grove Healthcare Center, Communicare at Waterford Commons, Crestwood Care Center, Riverside Nursing & Rehabilitation Center, Wood Glen Alzheimer's Community, Burlington House Nursing Home, and Regency Manor Rehab & Subacute Center, appeal from a judgment of the Franklin County Court of Common Pleas dismissing their appeal against appellee, the Ohio Department of Job and Family Services ("ODJFS"). For the following reasons, we affirm.

{¶ 2} ODJFS administers the Medicaid program in Ohio. Each appellant is a nursing facility that has entered into a provider agreement with ODJFS pursuant to R.C. 5111.22. A nursing facility must enter into a provider agreement to be eligible for the receipt of Medicaid funds in payment for services that a facility provides to a resident who is a Medicaid recipient. R.C. 5111.21.

{¶ 3} ODJFS conducted Medicaid compliance audits of appellants and determined that appellants owed ODFJS for Medicaid overpayments. ODJFS' Combined Proposed Adjudication Order Unit issued notices of opportunity for hearings to appellants that proposed to collect the overpayments from appellants. If appellants wished to dispute the proposed action, they had to request hearings pursuant to R.C. Chapter 119. As an alternative to the hearings, appellants could settle with ODFJS, pay an agreed-upon amount to reimburse ODJFS, and waive their rights to the hearings. Appellants indicated that they would enter into a settlement and sign waivers if ODJFS would review 539 fee-for-service claims that appellants had for Medicaid payment. ODJFS had not considered these 539 fee-for-service claims as part of the audit.

{¶ 4} The claims at issue arose from medical services that appellants provided to Medicaid recipients from 2002 to 2007. The claims included both crossover and therapy claims. Crossover claims are claims for payment for services provided to residents who are eligible for both Medicaid and Medicare benefits. Ohio Adm.Code 5101:3-1-05. Generally, after Medicare adjudicates and pays the claim, Medicaid pays any remaining amount due. Id. Therapy claims are claims for physical, occupational, and speech therapy services provided to Medicaid recipients.

{¶ 5} The Long Term Care Payment Unit of ODJFS reviewed the 539 claims. Based on that review, ODJFS paid some of the claims and denied others. Appellants asked ODJFS to reconsider its denial of 58 claims. ODJFS did so. In a letter dated March 30, 2012, Carolyn Thurman, chief of the Claims Reconciliation Section of ODJFS, informed appellants that ODJFS would not pay the 58 disputed claims because they were not timely submitted and/or the recipient of the medical service had not been deemed eligible for Medicaid. At the conclusion of the letter, Thurman represented that "[t]his is the final review and no further action(s) will be taken for these claims."

{¶ 6} On April 13, 2012, appellants filed a notice of appeal in the trial court. In their notice of appeal, appellants contended that the March 30, 2012 letter was a final adjudication order that they could appeal under R.C. 5111.06 and 119.12. ODJFS moved to dismiss, arguing that the trial court lacked jurisdiction over the appeal and that appellants had failed to exhaust their administrative remedies. In a July 26, 2012 decision and entry, the trial court granted ODJFS' motion and dismissed the appeal.

{¶ 7} Appellants now appeal the July 26, 2012 judgment, and they assign the following errors:

1. The trial court erred in sustaining Appellee's Motion to Dismiss.
2. The trial court erred by considering the additional evidence submitted by Appellee.

{¶ 8} By their first assignment of error, appellants argue that the trial court had jurisdiction under R.C. 5111.06 and 119.12 to hear ...


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