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Can a Healthcare Provider Bring Action Under Medicaid Act


The petitioners in this case are L. Douglas Wilder and the Governor of Virginia et all. The respondent in the case is the Virginia Hospital Association.

Background Information

In order for a medical services provider such as a hospital to qualify for federal assistance in paying for medical care provided to the needy, the State must submit a plan to the Secretary of Health and Human Services. Once approved, this plan will establish a scheme for the reimbursement of health care providers. The Boren Amendment was passed by Congress in 1980 and this requires the reimbursements to the provider at rates that are set by the state. These rates must be adequate and meet the cost to provide efficient care at the facilities.

A New York Criminal Lawyer said that the plan that is in place in Virginia was originally approved by the Secretary in 1982 and was approved again in 1986. The 1986 approval included an amendment. A non profit corporation filed a suit against the state in 1986 stating that the plan was in violation of the Boren Amendment as the reimbursement rates provided by the state were not adequate or reasonable.

The Case

This particular case requires the court to determine whether or not a health care provider can bring an action against the State regarding the Medicaid Act. The case is questioning whether or not the Boren Amendment to the Medicaid Act that requires the states to reimburse health care providers at a reasonable and adequate rate can be questioned.

Medicaid is a program that involves cooperation from the state with the federal government. This is not a required program and participation requires the state to follow regulations in order to receive the federal money to help provide medical care to those in need. A Queens Family Lawyer said these regulations include that the state plan for assistance must provide for the payment of hospital services, services in intermediate care facilities, and nursing care facilities. The rate for this payment is determined by methods outlined by the state.

The issue in this particular matter is whether or not the reimbursement rates that are set forth by the state of Virginia are indeed adequate to ensure the hospitals and medical care facilities can be ran efficiently.

Case Conclusion

In this case the court must consider the fact of determining reasonable and adequate rates for reimbursement. A Nassau County Lawyer said that if the motion by the respondent is denied then the state cannot be held accountable for the rates that it imposes and would therefore be able to determine rates that were in fact not fair or reasonable. The current way that rates are determined in the state of Virginia is based on the median cost of care from the year 1982. These costs have not remained fair through the years and are required to be updated.

It is our conclusion that there can legally be an action brought against the state in regards to the amounts of the reimbursements determined by the plan. This is the only way to determine that the rates that the medical care facilities are being provided remain fair and just.

In this particular case the ruling is in favor of the respondents and they are allowed to bring forth a case against the state in regard to the amounts of reimbursements that are provided for the care they provide patients.

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