GAB Decision 547
Docket No. 84-55
June 24, 1984
Wisconsin Department of Health and Social Services;
Ballard, Judith; Garrett, Donald Ford, Cecilia
The Wisconsin Department of Health and Social Services (State)
appealed a decision by the Health Care Financing Administration (Agency)
disallowing $124,630.63 in federal financial participation claimed by
the State under Title XIX of the Social Security Act for the quarter
ending June 30, 1983. The disallowance was based on the Agency's
finding that the State failed to maintain an effective program for
controlling the utilization of long-term care services provided at five
intermediate care facilities (ICFs) in accordance with section 1903(g)
of the Act. The Agency determined that, for the quarter in question,
patients certified as needing skilled nursing care were retained in five
ICFs.
The Board has previously addressed whether it is a violation of the
utilization control requirements to retain SNF patients in ICFs or ICF
patients in skilled nursing facilities (SNFs). Wisconsin Department of
Health and Social Services, Decision No. 482, November 30, 1983, and
Wisconsin Department of Health and Social Services, Decision No. 525,
March 30, 1984. The parties made short simultaneous submissions in this
case and agreed that the Board should proceed to decision based
primarily on the parties' presentations in the previous cases.
The State submitted an appeal file containing documents for SNF
patients in four of the ICFs. The State submitted no documents for one
ICF, Hannah Rutledge Home. /1/ The State noted that it had no record of
any SNF patients in one of the ICFs included in the disallowance,
Trempealeau County Health Care Center. The State provided a death
certificate for an SNF patient who had resided in this facility, but who
died prior to the quarter in question. State Appeal File, p. 121.
Accordingly, the State requested that if we uphold this disallowance, we
direct the Agency to recalculate the amount.
The State gave no reason for distinguishing this appeal from (2)
those decided earlier. Therefore, for the reasons stated in Decision
Nos. 482 and 525, which are incorporated here by reference, we uphold
the disallowance. However, we direct the Agency to reexamine the basis
for including Trempealeau County Health Care Center in this disallowance
after reviewing the documents provided by the State. If the Agency
agrees that there were no SNF patients in this facility during the
quarter in question, then the Agency should reduce the disallowance
accordingly. If the parties cannot agree concerning whether this
facility should be included in the disallowance calculation, the State
may return to the Board on this point. /1/ The Rutledge facility was
State-certified to provide skilled nursing care; it was not
certified to provide skilled nursing services under Medicaid.
NOVEMBER 14, 1984