{ "id": 5810281, "name": "Chang S. Kim, M.D., Dominick S. Renga, M.D., and Michael R. Treister, M.D., for Treister Orthopaedic Services, Ltd., Claimants, v. The State of Illinois, Respondent", "name_abbreviation": "Kim v. State", "decision_date": "1991-05-29", "docket_number": "Nos. 88-CC-2783 through 88-CC-3033 cons.", "first_page": "286", "last_page": "295", "citations": [ { "type": "official", "cite": "43 Ill. Ct. Cl. 286" } ], "court": { "name_abbreviation": "Ill. Ct. Cl.", "id": 8793, "name": "Illinois Court of Claims" }, "jurisdiction": { "id": 29, "name_long": "Illinois", "name": "Ill." }, "cites_to": [ { "cite": "42 C.F.R. \u00a7\u00a7431.17", "category": "laws:admin_compilation", "reporter": "C.F.R.", "opinion_index": 0 }, { "cite": "42 Ill. Ct. Cl. 185", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 3175575 ], "opinion_index": 0, "case_paths": [ "/ill-ct-cl/42/0185-01" ] }, { "cite": "43 Ill. Ct. Cl. 213", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 5809609 ], "opinion_index": 0, "case_paths": [ "/ill-ct-cl/43/0213-01" ] }, { "cite": "38 Ill. Ct. Cl. 208", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 3058065 ], "opinion_index": 0, "case_paths": [ "/ill-ct-cl/38/0208-01" ] }, { "cite": "39 Ill. Ct. Cl. 197", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 5493508 ], "opinion_index": 0, "case_paths": [ "/ill-ct-cl/39/0197-01" ] }, { "cite": "35 Ill. Ct. Cl. 345", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 5317332 ], "year": 1987, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/35/0345-01" ] }, { "cite": "42 Ill. Ct. Cl. 269", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 3175410 ], "year": 1981, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/42/0269-01" ] }, { "cite": "42 Ill. Ct. Cl. 303", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "year": 1990, "opinion_index": 0 }, { "cite": "41 Ill. Ct. Cl. 223", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "year": 1990, "opinion_index": 0 }, { "cite": "41 Ill. Ct. Cl. 176", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 3143013 ], "year": 1989, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/41/0176-01" ] }, { "cite": "40 Ill. Ct. Cl. 73", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 3114044 ], "year": 1988, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/40/0073-01" ] }, { "cite": "40 Ill. Ct. Cl. 233", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 3112892 ], "year": 1988, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/40/0233-01" ] }, { "cite": "40 Ill. Ct. Cl. 246", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 3112205 ], "weight": 2, "year": 1987, "pin_cites": [ { "page": "250-51" } ], "opinion_index": 0, "case_paths": [ "/ill-ct-cl/40/0246-01" ] }, { "cite": "35 Ill. Ct. Cl. 871", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 5316555 ], "year": 1987, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/35/0871-01" ] }, { "cite": "32 Ill. Ct. Cl. 150", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 5324740, 5326063 ], "year": 1982, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/32/0150-02", "/ill-ct-cl/32/0150-01" ] }, { "cite": "31 Ill. Ct. Cl. 548", "category": "reporters:state", "reporter": "Ill. Ct. Cl.", "case_ids": [ 2719006 ], "year": 1978, "opinion_index": 0, "case_paths": [ "/ill-ct-cl/31/0548-01" ] } ], "analysis": { "cardinality": 743, "char_count": 14911, "ocr_confidence": 0.885, "pagerank": { "raw": 1.3266558591939842e-07, "percentile": 0.6280078491062606 }, "sha256": "74e76be6c9eae4393531d4fae0b6d89d51324020742bbcf66d8b4efa1308c80f", "simhash": "1:10ce4a1135a66087", "word_count": 2310 }, "last_updated": "2023-07-14T21:36:42.826417+00:00", "provenance": { "date_added": "2019-08-29", "source": "Harvard", "batch": "2018" }, "casebody": { "judges": [], "parties": [ "Chang S. Kim, M.D., Dominick S. Renga, M.D., and Michael R. Treister, M.D., for Treister Orthopaedic Services, Ltd., Claimants, v. The State of Illinois, Respondent." ], "opinions": [ { "text": "OPINION AND JUDGMENT\nRaucci, J.\nThe 251 captioned, vendor-payment actions are before the Court on Respondent\u2019s motions for summary judgment as to each of them, pursuant to section 2 \u2014 1005 of the Code of Civil Procedure (Ill. Rev. Stat. 1987, ch. 110, par. 2 \u2014 1005), and for dismissal of 235 of said actions pursuant to section 2 \u2014 619, Id., section 790.90 of the Court of Claims Regulations (74 Ill. Admin. Code \u00a7790.90), section 22(b) of the Court of Claims Act (or \u201cCCA,\u201d Ill. Rev. Stat. 1987, ch. 37, par. 439.22(b)), and section 11 \u2014 13 of the Public Aid Code (or \u201cPAC,\u201d ch. 23, Id.). The Claimant physicians having received notice of said motions, the Court finds as follows:\nStatutory Time Bar. Respondent asserts that Claimants\u2019 causes of action, in 235 of these actions (each presenting charges for a single patient account) and additional, partial accounts in instances involving multiple dates of service, had previously been barred from prosecution as of March 4, 1988, the date on which they were filed with this Court. The State contends that the Court lacks jurisdiction to grant any relief as to such accounts. The actions and related accounts which Respondent challenges on this ground include: those seeking payment for services rendered on and before September 3, 1986, i.e., services rendered more than eighteen months prior to Claimants\u2019 commencement of these actions (see PAC par. 11 \u2014 13, subpar. (2)); as well as those actions and accounts Claimants\u2019 initial DPA-form 2360 invoices for which IDPA had \u201crefus[ed] to pay * * e in whole or in part\u201d (Id., subpar. (1)) in notices (IDPA voucher-responses or remittance advices) issued more than one year prior to March 4, 1988. The related services span the period from March 1982 (in No. 88-CC-2789) through November and December 1986 (Nos. 88-CC-2783 and 88-CC-2969), Claimants\u2019 initial invoices for the latter two accounts having been refused payment by IDPA notices issued on February 4,1987.\nThis Court has consistently taken the position that it lacks jurisdiction to consider the merits of those vendor-payment claims which were not commenced within the time periods prescribed by section 22(b) of the CCA and section 11 \u2014 13 of the PAC. Sitka v. State (1977), 31 Ill. Ct. Cl. 548; Weissman v. State (1978), 32 Ill. Ct. Cl. 150; Midstate Anesthesiologists v. State, No. 82-CC-942 (Order filed Mar. 1, 1982); Northwestern Memorial Hospital v. State (1983), 35 Ill. Ct. Cl. 871; Simon v. State (1987) , 40 Ill. Ct. Cl. 246; Krakora v. State (1987), 40 Ill. Ct. Cl. 233; Memorial Medical Center v. State (1988), 40 Ill. Ct. Cl. 73; Franciscan Medical Center v. State, Nos. 84-CC-0118, et al.; Riverside Medical Center v. State, No. 87-CC-0780; Pinckneyville Medical Group v. State (1988) , 41 Ill. Ct. Cl. 176; Pilapil v. State (1989), 41 Ill. Ct. Cl. 223; Sarah Bush Lincoln Health Center v. State (1990), 42 Ill. Ct. Cl. 303; and Gupta v. State (1990), 42 Ill. Ct. Cl. 269. Neither Respondent nor this Court has authority to .waive the limitation period or other limit on the Court\u2019s jurisdiction, as established by the General Assembly. Illinois Bell Telephone Co. v. State (1981), 35 Ill. Ct. Cl. 345; Potter & Struebin v. State (1987), 39 Ill. Ct. Cl. 197; and St. John's Hospital v. State, No. 86-CC-2055.\nHaving reviewed the facts (dates of Claimants\u2019 services and of IDPA\u2019s payment-refusal notices relative to certain of said services) as outlined in Claimant\u2019s complaints and IDPA\u2019s consolidated report herein, the Court concludes that each of Claimants\u2019 causes as to the claims and portions of claims specified in said report had in fact been barred by statute, prior to Claimants\u2019 filing of the related actions as discussed above. Accordingly, the Court has no authority to award Claimants any relief as to said claims.\nMultiple Surgical Procedures and Complex Surgery. Claimant Treister submitted charges to IDPA for three separate procedure codes, viz., PCs 29881 (considered by IDPA to be the \u201cmajor procedure\u201d), 29875 and 29879, all relating to arthroscopic knee surgery performed on patient Brito (No. 88-CC-2796), at the same operative session on November 17, 1986. Applicable Department policy is explained in IDPA\u2019s MAP Handbook For Physicians:\n\u201cThe procedure code for the major [surgical] procedure is to be used [reported on the invoice] when multiple procedures are performed e \u00b0 When multiple surgical procedures are performed through the same incision, payment will be based on the major procedure.\u201d (Id., Topic A-262.2; emphasis supplied.)\nFollowing this policy, IDPA paid Claimant for PC 29881, the major procedure; and refused payment for the two related procedures. The Handbook also provides:\n\u201cWhen a charge [invoice to IDPA] for surgery is greater than the physician\u2019s usual and customary fee for the procedure, based upon the operation being seriously complicated by factors not usually present, the physician is to submit [with his or her invoice] clinical data adequate to support [the extraordinary charge for] the claim.\u201d (Id., emphasis supplied.)\nAs Claimant\u2019s invoice was accompanied only by a pathology report (insufficient to support his charges for the two rejected procedure codes). IDPA\u2019s payment-refusal notice advised Claimant that \u201cAdditional Information [was] Required,\u201d e.g., narrative \u201cclinical data\u201d descriptive of the surgery which would be \u201cadequate to support\u201d and justify his separate charges for all three procedures.\nClaimant has not established that IDPA received his rebill-invoice of these charges by November 17, 1987, i.e., within the one year period prescribed by IDPA Rule 140.20 (89 Ill. Admin. Code \u00a7140.20) and by Federal Medicaid regulation (\u00a7447.45(d) of Title 42, Code of Federal Regulations). See this Court\u2019s decisions in Pilapil v. State and Gupta v. State, both cited supra. See also, Methodist Medical Center v. State (1986), 38 Ill. Ct. Cl. 208; Memorial Medical Center v. State; Franciscan Medical Center v. State; Riverside Medical Center v. State; and Sarah Bush Lincoln Health Center v. State, all cited supra.\nThe result of this process is that Claimant Treister was paid for the major procedure performed on patient Brito. He also had the time-limited opportunity to rebill either or both of the other procedures with whatever documented clinical data he might have had available to show that this surgery was \u201cseriously complicated by factors not usually present\u201d and which might thus have justified a vendor-payment in addition to that made for the major procedure. Such \u201cadditional information\u201d necessary to process the rebill (\u00a7447.45(b) of 42 C.F.R.), properly documented, would clearly have been an essential part of a \u201cclean claim\u201d (Id.) rebill-invoice of Claimant\u2019s charges for these two procedures. Given Claimant\u2019s failure to show that a \u201cclean claim\u201d rebill was received by IDPA prior to the regulatory deadline, we conclude, in accordance with subsection (e) of IDPA Rule 140.20, that the Department has no payment liability for the procedures represented by codes 29875 and 29879. Ryan v. State (1990), 43 Ill. Ct. Cl. 213.\nThe claim in No. 88-CC-3002 consists of Claimant Treister\u2019s charge for applying a cast to patient Torres following Claimant\u2019s manipulation surgical treatment of a bone fracture. As IDPA had paid Claimant for the separately-invoiced surgical treatment, we find that such payment covered the entire surgical-service package, including application of the cast. See Treister & Wilcox v. State (1990), 42 Ill. Ct. Cl. 185.\nPrepaid Health Service-Plan Coverage and Access-Restrictions To Health Care. Several of Claimants\u2019 invoices (e.g., in Nos. 88-CC-2969, 88-CC-2970 and 88-CC-3007) were refused payment by IDPA because the services invoiced were covered by prepaid health care plans (contracted with HMOs, or health maintenance organizations), which coverage IDPA had purchased for the patient-recipients served and was in force when Claimants\u2019 services were rendered. Section 5 \u2014 11 of the PAC authorizes the Department\u2019s State-financed provision of such coverage. The medical-eligibility card (MEC), issued by IDPA to the HMO-enrolled recipient, identifies the HMO in which the recipient is enrolled, so that the medical vendor who treats that recipient may bill his or her services directly to the HMO for payment. Handbook Topics 131 and 133.\n\u201cIn no instance will [IDPA] reimburse a [vendor] when the service provided a recipient is one which the HMO has contracted to pay.\u201d (Id., Topic 133)\nThus, Claimants\u2019 recourse in these matters was to bill his services to the HMO for payment, rather than to IDPA.\nThe treatment involved in No. 88-CC-3007 also required the prior, written authorization of the recipient\u2019s designated primary care physician (PCP), before being rendered; and Claimant Renga was obliged to submit the PCP\u2019s authorization for such treatment (on a DPA form 1662), when billing his treatment charges for payment. These access-restriction requirements had been imposed as a result of the recipient-patient\u2019s history of utilizing medical services \u201cat a frequency or amount not medically necessary\u201d as gauged by established standards. (\u00a71396n(a)(2) of 42 U.S.C.), in accordance with applicable regulations (\u00a7431.54(e) of 42 C.F.R.; and \u00a7120.80 of 89 111. Admin. Code). The PCP\u2019s name was listed on the MECs which IDPA had issued to the recipient; and vendors were advised (Handbook Topics 131.18 and 134) that the PCP\u2019s written (DPA 1662) authorization must be obtained before rendering non-emergency care to the recipient. Claimant\u2019s compliance, by submitting the PCP\u2019s authorization with his bill or invoice, was essential to the Department\u2019s efforts to prevent overutilization of services under its Recipient Restriction Program, or RRP (Id., Topic 134).\nTardy Invoice Submittal. In the remaining fifteen actions, Claimants Renga and Treister are seeking vendor-payments for the following accounts:\nPatient Account\n88-CC-2786 \u2014 Amador\n88-CC-2796 \u2014 Brito 88-CC-2808 \u2014 Williams 88-CC-2825 \u2014 Colon 88-CC-2844 \u2014 Dominowski 88-CC-2873 \u2014 Granada 88-CC-2886 \u2014 Howard 88-CC-2910 \u2014 Lozada 88-CC-2933 \u2014 Olivo 88-CC-2944 \u2014 Perez 88-CC-2956 \u2014 Rasho 88-CC-2963 \u2014 Rivera 88-CC-2978 \u2014 Ruiz 88-CC-3006 \u2014 Vazquez 88-CC-3016 \u2014 Velez\nDate(s) Of Service_\nSeptember 10 & 25,1986\nNovember 11,1986 September 16,1986 September 16(26?), 1986 October 24 & 28,1986 September 13,1986 September 23,1986 January 12,1987 October 11,1986 December 16,1986 November 20,1986 November 15,1986 November 18,1986 November 20,1986 March 17,1987\nDate Of Initial DPA-form 2360 Invoice(s), Alleged by Claimants\n3 invoices, all dtd.\n\u201c09/17/86\u201d \u201c01/09/87\u201d \u201c09/16/86\u201d \u201c09/17/86\u201d \u201c01/09/87\u201d \u201c09/17/86\u201d \u201c11/17/86\u201d \u201c03/18/87\u201d \u201c11/17/86\" \u201c02/18/87\u201d \u201c01/01/86\u201d \u201c01/08/87\u201d \u201c01/08/87\u201d \u201c02/18/87\" \u201c03/19/85\u201d\nClaimants\u2019 pleadings fail to establish that any of these 17 invoices was received by IDPA within the time prescribed by IDPA Rule 140.20 and 42 C.F.R. section 447.45(d). Yet, with only one exception (patient Velez\u2019s services in No. 88-CC-3016), all of said services had been rendered more than one year prior to March 4, 1988, when these Court actions were filed.\nIn each instance, the Claimant\u2019s allegations suggest that he had timely prepared his form 2360 invoices for submittal to IDPA. IDPA policy provides that, except for vendor-payment claims submitted on unapproved forms or otherwise facially unacceptable for automated processing,\n\u201call claims [vendor invoices] received are assigned a Document Control Number, microfilmed and computer processed [for assessment of payment entitlement]. The action taken on each [invoice] so processed is reported to the provider [vendor] on Form DPA 194-M-l, Remittance Advice [or voucher-response](MAP Handbooks, Topic 144.)\nThus, if IDPA had received any of these 17 invoices, then the Claimant should be able to produce or identify IDPA\u2019s voucher-response to that invoice for the purpose of pleading IDPA\u2019s \u201caction taken\u201d in respect to it, as required by Rule 5(A)(3)(b) of the Court of Claims Regulations (74 111. Admin. Code \u00a7790.50(a)(3) (B)). See Treister & Wilcox v. State; and Franciscan Medical Center v. State, both cited supra. The Claimant should be able to produce any such voucher, because State and Federal Medicaid regulations obligate vendors to maintain and retain all of their business and professional records relating to their services rendered to IDPA recipients. 89 111. Admin. Code \u00a7140.28; 42 C.F.R. \u00a7\u00a7431.17 and 431.107(b); and see the MAP Handbook For Physicians, Topics 112, A-205, A-230 and A-240.\nIf any invoice was transmitted but not received by IDPA, the Claimant would have been alerted to that fact when, after 60 days, he had not received IDPA\u2019s voucher acknowledging such invoice. In such instances, he is urged (Handbook topic 144) promptly to submit either a written inquiry or a replacement invoice. Simon v. State (1987), 40 Ill. Ct. Cl. 246, 250-51; and Franciscan Medical Center v. State, cited supra. Here, neither Claimant alleges that he had taken such action as to any of these 15 accounts.\nAlso noted is the fact that, were Respondent now to pay Claimant for any of said recipients\u2019 care, the payment would not qualify for Federal Medicaid matching funds, given Claimants\u2019 failures to invoice their related charges to IDPA within the time prescribed by 42 C.F.R., section 447.45. This Court has previously reviewed the likely implications for the funding of IDPA\u2019s MAP expenses, if we were to disregard Federal regulatory requirements in such matters; see, as examples, Memorial Medical Center, Riverside Medical Center and Pinckneyville Medical Group, all cited supra.\nIt is therefore hereby ordered and adjudged that Respondent\u2019s Motion For Summary Judgment is granted as to each of these 251 claims, Claimants Kim\u2019s, Renga\u2019s and Treister\u2019s causes as to the accounts presented in 235 of such claims (and portions of additional claims) having previously been barred by statute; Claimant Treister having been paid in full for patient Brito\u2019s November 17, 1986 services (No. 88-CC-2796) and patient Torres\u2019 November 7, 1986 services (No. 88-CC-3002) to the extent they had been timely and properly invoiced; and Claimant Renga\u2019s and Treister\u2019s pleadings having failed to establish that their charges in the 15 remaining actions had been invoiced to IDPA in the manner and within the time prescribed by State and Federal regulatory requirements. Judgment on all issues presented is entered against Claimants and in favor of Respondent; and each of said claims is dismissed.", "type": "majority", "author": "Raucci, J." } ], "attorneys": [ "William L. Silverman, for Claimants.", "Roland W. Burris, Attorney General (Steven Schmall, Assistant Attorney General, of counsel), for Respondent." ], "corrections": "", "head_matter": "(Nos. 88-CC-2783 through 88-CC-3033 cons.\nChang S. Kim, M.D., Dominick S. Renga, M.D., and Michael R. Treister, M.D., for Treister Orthopaedic Services, Ltd., Claimants, v. The State of Illinois, Respondent.\nOpinion filed May 29, 1991.\nWilliam L. Silverman, for Claimants.\nRoland W. Burris, Attorney General (Steven Schmall, Assistant Attorney General, of counsel), for Respondent." }, "file_name": "0286-01", "first_page_order": 398, "last_page_order": 407 }