{
  "id": 3058065,
  "name": "Methodist Medical Center (Peoria, Illinois), Claimant, v. The State of Illinois, Respondent",
  "name_abbreviation": "Methodist Medical Center v. State",
  "decision_date": "1986-01-31",
  "docket_number": "No. 83-CC-1572",
  "first_page": "208",
  "last_page": "212",
  "citations": [
    {
      "type": "official",
      "cite": "38 Ill. Ct. Cl. 208"
    }
  ],
  "court": {
    "name_abbreviation": "Ill. Ct. Cl.",
    "id": 8793,
    "name": "Illinois Court of Claims"
  },
  "jurisdiction": {
    "id": 29,
    "name_long": "Illinois",
    "name": "Ill."
  },
  "cites_to": [
    {
      "cite": "35 Ill. Ct. Cl. 379",
      "category": "reporters:state",
      "reporter": "Ill. Ct. Cl.",
      "case_ids": [
        5317186
      ],
      "opinion_index": 0,
      "case_paths": [
        "/ill-ct-cl/35/0379-01"
      ]
    }
  ],
  "analysis": {
    "cardinality": 404,
    "char_count": 7211,
    "ocr_confidence": 0.878,
    "pagerank": {
      "raw": 2.74399120338182e-07,
      "percentile": 0.8321714895347181
    },
    "sha256": "0156922a7cfd5ff5cb01636b488aaa3cb14bd8c00edb7ae6fe4a9a7c5df011fe",
    "simhash": "1:d1efe440b8f7929f",
    "word_count": 1112
  },
  "last_updated": "2023-07-14T19:09:05.193768+00:00",
  "provenance": {
    "date_added": "2019-08-29",
    "source": "Harvard",
    "batch": "2018"
  },
  "casebody": {
    "judges": [],
    "parties": [
      "Methodist Medical Center (Peoria, Illinois), Claimant, v. The State of Illinois, Respondent."
    ],
    "opinions": [
      {
        "text": "Patchett, J.\nThis cause coming on to be heard on the joint stipulation of the parties and due notice having been given and the Court being fully advised finds as follows:\nClaimant hospital, a participant in the Medical Assistance Program (MAP) administered by the Illinois Department of Public Aid (IDPA), here seeks vendor payments, as provided in section 11 \u2014 13 of the Illinois Public Aid Code, on six patient accounts. (Ill. Rev. Stat., ch. 23, par. 11 \u2014 13.) IDPA\u2019s report, as filed herein, advises that it has paid, or accepts payment liability in appropriate amounts in respect to four of the six accounts. This opinion addresses the issue of whether Claimant is entitled to payment of the two remaining accounts for which IDPA denies liability.\nThe first account, that of patient Barnes, concerns inpatient services directly relating to hysterectomy surgery, rendered in November and December 1980, in Claimant\u2019s facility. By Federal regulation (42 C.F.R. 441.250 through 441.259) and State regulation (IDPA Rule 4.15), the State\u2019s MAP payment obligation for sterilization surgery \u2014 including hysterectomies \u2014 is contingent upon the medical vendor\u2019s compliance with certain conditions. One of these conditions is that the patient acknowledge, in writing, her understanding that the planned surgery will render her permanently incapable of bearing children; and, in the case of hysterectomy, that the physician certify, also in writing, the medical necessity of the planned surgery. Presurgery completion of the relevant document (an IDPA form designed for this purpose), required in order to comply with these conditions, is the joint responsibility of the physician and the hospital. This Court has previously so held; see Good Samaritan Hospital v. State (1982), 35 Ill. Ct. Cl. 379.\nThe Claimant\u2019s invoice of these services was disallowed by IDPA as being incomplete. The invoice failed to report the patient\u2019s diagnosis, the fact that surgery had been performed, or the surgical procedure which was in fact performed. Each such item of information is required to be reported by the hospital in the invoice. Claimant had also failed to supply, with its invoice, the completed IDPA form to establish compliance with the above-referenced regulations. Claimant has offered no evidence that it submitted a corrected rebill-invoice to IDPA, properly documented with a completed hysterectomy acknowledgement form (DPA form 1977), within the one-year period prescribed by IDPA Rule 140.20 and by Federal regulation (42 C.F.R. 447.45(d)).\nFrom IDPA\u2019s report, we note that the Federal government\u2019s continuing participation in the funding of Illinois\u2019 MAP program is dependent upon IDPA\u2019s regular enforcement of these regulatory requirements. Applicable here are the requirements that medical vendors must fully and correctly complete their invoice forms being submitted for IDPA\u2019s payment consideration, so as properly to identify the services being invoiced; in the case of hysterectomy surgeries, that they must document both the patient\u2019s awareness of the consequences of the planned surgery and the physician\u2019s certification of its necessity; and that correctly-prepared invoices be timely received by IDPA.\nThe second patient account relates to newborn-nursery care provided in June 1981, to patient Isaac Harris, a newborn child. Claimant had submitted one invoice to IDPA for the mother\u2019s obstetrical services, and, much later, tendered a second invoice, pertaining to the same dates of service, for the newborn care. IDPA reports that it had previously made full payment to Claimant for both the mother\u2019s and the newborn\u2019s care, by paying the invoice which Claimant had submitted in the mother\u2019s name for the same dates of service.\nThe Department\u2019s conclusion is grounded in IDPA Rule 140.100(d), which provides:\n\u201cIn obstetrical cases payment for services to both the mother and the newborn child shall be made at one per diem rate. Only in instances in which the medical condition of the newborn, as certified by the utilization review authority, necessitates care in other than the newborn nursery, shall payment be made in the child\u2019s name.\u201d\nAs explained in IDPA\u2019s MAP Handbook for Hospitals, all charges for the inpatient (per diem) services of both mother and newborn are considered to be incurred by the mother, for so long as both remain inpatients; and only one per diem charge is payable upon IDPA\u2019s receipt of the hospital\u2019s charges for such services involved in the mother\u2019s name.\nThe hospital may invoice newborn services separately, and expect them to be paid for by IDPA, only when the newborn\u2019s condition, properly certified, necessitates care provided in other than the newborn nursery (such as in a perinatal center) or when the newborn continues to require inpatient nursery care following the mother\u2019s discharge from the hospital. See IDPA\u2019s MAP Handbook for Hospital, II-H-17.\nHere, Claimant\u2019s invoice establishes that the newborn received nursery care only, that no perinatal or other intensive care services were provided, and that the patient and his mother were discharged on the same day. IDPA was therefore correct in considering Claimant\u2019s invoice, naming the mother as patient, to represent all of Claimant\u2019s charges for both the mother and her newborn child. We find that, having paid that invoice, the State has fully discharged its MAP-payment obligation for both mother\u2019s and newborn\u2019s services.\nSection 11 \u2014 13 of the Public Aid Code (111. Rev. Stat., ch. 23, par. 11 \u2014 13), provides that a vendor\u2019s right to a vendor payment may be \u201climited by regulations of the Illinois Department.\u201d The IDPA rules relevant here are such limiting regulations, as are the above-referenced Federal Medicaid regulations. Moreover, as IDPA notes in its report, Claimant and other participating hospitals have each signed provider agreements upon enrolling in the Department\u2019s MAP, in which they agree \u201cto abide by the Department\u2019s properly promulgated Rules and Hospital Handbook\u201d requirements, necessarily including IDPA Rules 4.15, 140.20 and 140.100, as well as the Handbook\u2019s conditions, service-coverage limitations and invoice-preparation requirements. In summary, Claimant has contracted to abide by each of the regulatory and Handbook requirements as discussed above.\nWe conclude, as to the Rarnes account, that Claimant failed to submit a properly prepared and documented invoice for its services within the time prescribed for IDPA\u2019s receipt thereof. The absence of required data on the invoice and the lack of a completed DP A form 1977 warranted IDPA\u2019s denial of payment on this account. We further conclude that Claimant had previously been paid in full on the Harris newborn\u2019s account.\nIt is therefore ordered that:\n1. The Claimant be awarded the sum of $15,246.96, the liability for which IDPA has admitted;\n2. The balance of this claim be, and hereby is, dismissed.",
        "type": "majority",
        "author": "Patchett, J."
      }
    ],
    "attorneys": [
      "Westervelt, Johnson, Nicoll & Keller, for Claimant.",
      "Nett. F. Hartigan, Attorney General (Suzanne Schmitz, Assistant Attorney General, of counsel), for Respondent."
    ],
    "corrections": "",
    "head_matter": "(No. 83-CC-1572\nMethodist Medical Center (Peoria, Illinois), Claimant, v. The State of Illinois, Respondent.\nOpinion filed January 31, 1986.\nWestervelt, Johnson, Nicoll & Keller, for Claimant.\nNett. F. Hartigan, Attorney General (Suzanne Schmitz, Assistant Attorney General, of counsel), for Respondent."
  },
  "file_name": "0208-01",
  "first_page_order": 294,
  "last_page_order": 298
}