Court of Appeal Denied CAMPS Writ on Upper Billing Limit

 

On September 16th the California Court of Appeal for the First Appellate District issued its ruling in CAMPS vs. David Maxwell-Jolly ( then Director of Department of Health Care Services). This was our appeal of the denial of our writ of mandate to challenge the adoption of the Medi-Cal Upper Billing Limit issued in Alameda Superior Court in 2009.

 

The Appellate Court denied our appeal after oral argument was held last month. In the decision the Court deferred to the judgment and latitude of DHCS  in adopting regulation to address fraud and abuse. Though the record and evidence of information used by DHCS to adopt this regulation was woefully limited the Court concluded that the conclusions or assumptions they made were not capable of being second guessed. In several portions of the 37 page decision  the Court would refer to the other Medi-Cal reimbursement methodology for medical supplies ( cost plus 23%) or incontinence supplies ( cost plus 38%) as demonstrating that a UBL limit of net purchase price plus 100% was more than reasonable. Any provider charge about that amount would clearly be an "abusive billing practice" and within the jurisdiction of DHCS to address to limit taxpayer exposure.

 

The Court also did not agree with our challenges to the DHCS compliance with the Administrative Procedure Act in the adoption of the UBL. Our concerns about the impact on the provider community, the difficulty in compliance, and the lack of "one size fits all approach" for mark-up on different supplies or equipment fell on deaf ears.

 

The CAMPS Board will review options for appeal but that is both expensive and a very small chance of success. In both of these Court decisions it was clear that the Judges could never ignore the percentage of mark-up and the confusion with other Medi-Cal policies using cost plus a much lesser mark-up, i.e. how could it be unreasonable. We appreciate the support of those of you  that contributed to our legal effort to mount this challenge. Win or lose it was a fight and stand we had to take.

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