Administrative: Court affirms ALJ’s resolution of dispute over Medicare hospice benefits

Where an administrative law judge’s decision resolving a hospice’s claims for Medicare benefits was supported by substantial evidence and applied the correct legal standards, it was affirmed.

Background

Capital Hospice sued the Secretary of the U.S. Department of Health and Human Services over the denial of Medicare hospice benefits. The parties have filed cross motions for summary judgment.

Plaintiff moves this court to reverse the coverage denial of the remaining 151 claims at issue and awarding plaintiff payment for the services it provided to the patients. Defendant opposes plaintiff’s motion and seeks summary judgment in his favor.

Substantial evidence

The primary issue before the administrative law judge, or ALJ, was whether the criteria for Medicare coverage was satisfied for each patient during the relevant hospice service periods. In a comprehensive decision, the ALJ set out the applicable law and policy, his general findings of fact and analysis, his findings of fact and analysis for each individual patient and his conclusions of law as to each patient.

The ALJ engaged in a thorough analysis and ultimately concluded: (1) that beneficiary P.E.’s claims were fully covered; (2) that beneficiaries W.B., R.C., and T.T.’s claims were not covered and (3) that certain periods of service for beneficiaries H.N. and R.R. were covered, while other periods of service were not. The ALJ’s conclusions as to each patient were supported by substantial evidence; that is, “more than a mere scintilla of evidence but . . . less than a preponderance.”

Plaintiff argues that the ALJ improperly discredited the medical opinion testimony from the hearing and acted as a medical expert by substituting his opinion for those of hospice physicians. Specifically, plaintiff contends that 10 different physicians signed certifications of terminal illness for the patients in question, and argues that physician certifications have great weight if there is no conflicting evidence.

Defendant counters that, while certifications are a necessary condition for Medicare coverage, certifications are not sufficient and must be corroborated by objective medical evidence. Defendant thus argues that the ALJ correctly analyzed whether the certifications were supported by objective documentation. This court agrees.

The ALJ properly analyzed whether the certifications were supported by the patients’ medical records because “[c]linical information and other documentation that support the medical prognosis must accompany [a] certification.” The ALJ observed deficiencies and inconsistencies in the medical records of the patients whose claims were denied for the service dates in question and concluded that the objective medical records did not support the certifications of terminal prognosis because they painted pictures of patients with stabilized conditions for long periods of time.

Legal standards

Plaintiff first contends that the ALJ failed to afford the local coverage determination, or LCD, guidelines substantial deference because the ALJ cited the incorrect LCD guideline and because the ALJ did not explicitly discuss the LCD guidelines in his analysis of the individual patients. These arguments are without merit.

First, while the ALJ does incorrectly cite to LCD L33393 instead of LCD L34538 in the “Applicable Law and Policy” section of the decision, the citation appears to be a mere typographical error. The subsequent block quotes, as well as the title of the LCD, are directly from the applicable LCD. And the ALJ set forth the relevant guidelines from LCD 34538 in the “Applicable Law and Policy” section of the decision and applied the guidelines to each patient.

Plaintiff next argues that, even if it did not demonstrate the propriety of each appealed claim, it is still entitled to payment pursuant to the Medicare limitation of liability provision. Plaintiff argues that the ALJ improperly applied this provision to deny plaintiff’s claims.

The ALJ essentially concluded that given the noted deficiencies in the objective medical documentation that was submitted in support of certification for each patient, plaintiff should have known that the hospice services provided during the relevant time periods were not covered due to the patients’ stabilized conditions. This is “such evidence as a reasonable mind might accept as adequate to support a conclusion” that the Medicare limitation of liability provision does not apply to limit plaintiff’s liability in this case, especially given the availability of the LCD guidelines as “administrative and educational tools to assist providers in submitting correct claims for payment.”

Plaintiff’s motion for summary judgment denied. Defendant’s motion for summary judgment granted.

Capital Hospice v. Kennedy, Case No. 1:23-cv-1741, March 31, 2025. EDVA at Alexandria (Alston). VLW 025-3-146. 27 pp.