Saint Anthony Hospital - Chicago Files Federal Court Lawsuit Against State Of Illinois
CHICAGO, April 28, 2020 /PRNewswire/ -- Saint Anthony Hospital has filed suit against the state of Illinois in the U.S. District Court for the Northern District of Illinois, seeking overdue reform of the State's Medicaid reimbursement system.
Saint Anthony was forced to take the state to court yesterday to continue providing essential services to patients on Chicago's West and Southwest Sides who otherwise would lack access to healthcare, including children, low-income uninsured and other vulnerable populations.
"We believe that, regrettably, the Pritzker Administration inherited a broken Medicaid reimbursement system from the Rauner Administration. Saint Anthony Hospital was left with no alternative except to sue the state after negotiations with the Illinois Department of Healthcare and Family Services (HFS) hit what appears to be a dead end," said Saint Anthony President and CEO Guy A. Medaglia.
"Saint Anthony needs disclosure by the state to open to public view the opaque systems used to pay safety net hospitals like Saint Anthony for Medicaid Services and uncompensated care. It needs to be paid the approximately $42 million it is owed as a result of the lack of transparency and accountability from the state and its Managed Care intermediaries. It needs emergency reimbursement to help keep the doors open," he said
"Gov. J.B. Pritzker did not create this broken system, but hopefully he can fix it. Saint Anthony Hospital had no choice other than to sue the state in federal court to protect the vulnerable, largely Hispanic and African American patients for whom we provide essential care to on the West and Southwest Sides of Chicago. We continue to hope for an amicable resolution," Medaglia said.
"The COVID-19 pandemic makes our situation more urgent because the community we serve is a hotspot within a hotspot. That has put even greater demands on the hospital. We credit Gov. Pritzker with proactively managing the state's pandemic response, but the state's recruiting away of some of our nursing staff to the temporary McCormick Place field hospital with much higher salaries has been an unintended double hit for Saint Anthony and our patients," he said.
Saint Anthony's lawsuit, which names Theresa Eagleson in her capacity as HFS director, includes the following:
-- A request of the Court to order the State and the managed care
organizations with which the State contracts (MCOs) to provide
transparency in their programs and payments so Saint Anthony can ensure
it is receiving all applicable amounts due to safety net hospitals like
Saint Anthony, which take all patients without ability to pay for care.
-- A request of the Court to require the state to cause MCOs to pay
Medicaid claims as required by Federal law. Federal and state laws
require the State to ensure that the MCOs timely and properly make these
payments to providers like Saint Anthony. Neither the MCOs, which are
agents of the State, nor the State are meeting their obligations.
-- The complaint states that the MCOs have systematically delayed and
denied claims without justification, failed to pay undisputed claims,
and when payments are made, they refuse to provide the detail necessary
for Saint Anthony to determine if it is receiving proper payment or, if
not, why not. Other safety net hospitals face the same problems. When
asked by the Department to provide this detail to the providers, several
large MCOs have admitted that they cannot do so. The MCOs appear to
operate on a "squeaky-wheel" principle: whichever hospital raises the
loudest outcry gets paid something, but not necessarily what it was
owed.
-- To ensure timely payment of claims, the Medicaid law requires that the
states ensure payment on 90% of all clean claims submitted by certain
providers within 30 days and 99% of all clean claims submitted by such
providers within 90 days. A clean claim is generally one that can be
processed without the need to obtain additional information from the
provider or a third party.
-- When Saint Anthony asks for explanations from MCOs and from the State
about payment delays and amount of reimbursement, it often gets the
run-around. Transparency is woefully lacking. The MCOs often do not even
tell it which claims were not paid in full or the reasons for such
underpayments.
-- The complaint states that from 2015 (when the shift to the MCOs
accelerated) to 2019, Saint Anthony's cash on hand has fallen
approximately 98%: from over $20 million (enough to fund 72 days of
operation) to less than $500,000 (less than 2 days). Much of this
decrease is due to the unnecessary and often unexplained delays in
payments, and lack of consistency and rationale, on the part of the
MCOs, and the State's failure to ensure that the MCOs comply with
express Medicaid obligations regarding payment of claims.
The Complaint also alleges:
-- " . . . the State, through HFS, has failed to comply with its
obligations under the federal Social Security Act and implementing
regulations with regard to the operation of the State's Medicaid program
that are meant to protect the finances of safety-net health care
providers like Saint Anthony, and thus assure their ability to provide
necessary medical services to their patient cohort."
-- "Under former Governor Rauner's administration, the State aggressively
shifted its Medicaid reimbursement process by contracting with private
healthcare insurance companies--generally referred to as managed care
organizations or MCOs -- rather than administering Medicaid
reimbursement itself. "
-- "The State pays MCOs billions of federal and State Medicaid dollars and
entrusts them with ensuring that the most vulnerable patient populations
are provided necessary medical care, and that health care providers are
compensated for their services on a fair and timely basis."
-- ". . . before the Rauner administration instituted the expanded and
overhauled managed care regime, Saint Anthony achieved a high and
predicable level of Medicaid reimbursement from the State when the State
administered a direct payment system. Saint Anthony has not materially
changed its billing practices or provision of care. It follows the same
procedures for reimbursement from MCOs but is not getting paid either as
promptly or as fully as it was under the prior system."
-- As a result, "Saint Anthony has to wait anywhere from 90 days to 2 years
to be paid for services provided to these patients, all while still
timely making payroll and struggling to pay its vendors. The guesswork
and lack of transparency makes it impossible to know if Saint Anthony
has been paid properly. What is known, however, is the bottom line:
Saint Anthony is being paid much less than before the Medicaid managed
care expansion under the prior administration."
Prior to filing the suit, Saint Anthony had made a number of good-faith attempts to work with the MCOs, HFS and the state to resolve these issues.
The Center for Medicaid and Medicaid Services (CMS) scores Saint Anthony Hospital in the top 10(th) percentile in the state and first in Chicago for "Patient Safety" and first in Chicago for "Total Performance," based on quality of care, patient safety, cost and patient experience measures. These scores, considered excellent for any community hospital, are almost unheard of for a safety net hospital. In addition, Saint Anthony is the only hospital in Chicago to be awarded the Perinatal Certification by The Joint Commission, received the Partners in Progress Award in 2018 and 2019 as part of the Illinois Health and Hospital Association's Innovation Challenge and is a CMS five-star-rated dialysis center.
Links to Filings: https://ecf.ilnd.uscourts.gov/cgi-bin/login.pl. Login via Pacer and access Docket Number 20-cv-02561.
About Saint Anthony Hospital
For more than a century, Saint Anthony Hospital has been a community?centered organization, serving more than 400,000 residents on Chicago's West and Southwest Sides. Saint Anthony Hospital, its affiliated clinics and community wellness centers provide quality health and wellness services, as well as a wide variety of free bilingual community health education and outreach programs.
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SOURCE Saint Anthony Hospital
