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In re Medical Indigency Application of C.H.

Supreme Court of Idaho

February 27, 2019

Re: Medical Indigency Application of C.H. (Gem County Case No. 16-026)
v.
BOARD OF COMMISSIONERS OF GEM COUNTY, IDAHO, Defendant-Respondent. ST. LUKE'S HEALTH SYSTEM, LTD., Plaintiff-Appellant,

          Appeal from the District Court of the Third Judicial District of the State of Idaho, Gem County. Hon. George A. Southworth, District Judge.

         The Board's Amended Determination of Approval for Benefits is vacated, and the case is remanded.

          Hawley Troxell Ennis & Hawley, LLP, Boise, for appellant. Mark C. Peterson argued.

          Erick Thomson, Gem County Prosecuting Attorney, Emmett, for respondent. Tahja Lee Jensen argued.

          BRODY, JUSTICE.

         This appeal arises from a medical indigency application filed by St. Luke's with Gem County. On January 26, 2016, St. Luke's accepted an indigent patient suffering from meningitis, seizures, and brain lesions. The patient was ready for transfer to another medical facility by February 18, 2016, but was refused by multiple care providers because they did not want to admit an indigent patient without a payor source. St. Luke's finally contracted with Life Care, another medical facility, to take the patient on the condition that St. Luke's would guarantee payment for a thirty day period. The patient was transferred to Life Care on March 9, 2016.

         St. Luke's applied for medical indigency benefits covering the period of time from the patient's initial hospitalization until she was transferred to the Life Care facility. Gem County initially approved the application for benefits through February 3, 2016. St. Luke's appealed that determination, and after a hearing, the Board approved medical indigency benefits from January 26, 2016, until February 18, 2016. The Board entered a written determination titled "Amended Determination of Approval for County Assistance" which set forth the various bills that were approved for payment, but did not in any way reflect the denial of benefits or the reasoning of the Board.

         St. Luke's then sought judicial review of the Amended Determination before the district court, which affirmed the Board's decision. St. Luke's appealed. We vacate the Board's Amended Determination because it does not reflect the partial denial of benefits and because there are no findings of fact or conclusions of law setting forth the basis for the Board's denial.

         I. FACTUAL AND PROCEDURAL BACKGROUND

         On January 26, 2016, emergency medical personnel transported a 63 year-old woman to Valor Health because she was unresponsive. She had a tonic-clonic seizure en route. She was then transferred to St. Luke's Meridian Medical Center and began treatment for meningitis and brain lesions. Her health improved over the next several weeks.

         Both St. Luke's and Gem County agree that the patient did not require care from an acute care inpatient hospital after February 18, 2016. However, while St. Luke's made multiple attempts to place her with another, lower care facility, she was consistently denied by providers citing concerns over payment. Ultimately, Life Care agreed to accept the patient on the condition St. Luke's would guarantee payment for daily care for a period of thirty days. St. Luke's agreed and transferred her to Life Care on March 9, 2016. The discharge report explained it was unsafe for the patient to return home at that time. St. Luke's sought reimbursement from Gem County pursuant to Idaho's Medical Indigency Act for care provided from the time the patient was hospitalized through March 9, 2016.

         Following an investigation, the Gem County Clerk of the Board, filed a cursory statement of findings with the Board indicating that the patient was an indigent county resident, the services were medically necessary, the application was complete, and the county was the last resource. The Board approved St. Luke's application five days later for dates of service from January 26, 2016, through February 3, 2016. St. Luke's appealed that decision approximately ten days later.

         The clerk had Dr. Doug Dammrose, a utilization management reviewer retained by counties and the State Catastrophic Health Care Program, examine the patient's medical records at four different times, with each of his successive reports expanding the medical record before the Board as St. Luke's submitted new records. In his medical reviews, Dr. Dammrose changed the recommended cutoff date for medically necessary services from February 3 to February 12, and finally to February 18. He explained his last opinion only in the following summary:

The additional clinical notes indicate the patient was medically stable on 02/19 and it appears she no longer needed the services of an acute care inpatient hospital. Her medical care was at a maintenance level, and her needs were rehabilitative in nature. The inpatient stay from 02/19/2016 to 03/09/2016 is ...

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