Inner Harbour Hospitals, Ltd. on Behalf of Hibberd v. State Dept. of Social Services, S-95-294
| Decision Date | 21 February 1997 |
| Docket Number | No. S-95-294,S-95-294 |
| Citation | 559 N.W.2d 487,251 Neb. 793 |
| Parties | INNER HARBOUR HOSPITALS, LTD., a Georgia nonprofit corporation, on Behalf of Brenda HIBBERD, Appellant, v. STATE of Nebraska DEPARTMENT OF SOCIAL SERVICES, Appellee. |
| Court | Nebraska Supreme Court |
Syllabus by the Court
1. Administrative Law: Judgments: Appeal and Error. On an appeal under the Administrative Procedure Act, Neb.Rev.Stat. § 84-901 et seq. (Reissue 1994), an appellate court reviews the judgment of the district court for errors appearing on the record and will not substitute its factual findings for those of the district court where competent evidence supports those findings.
2. Administrative Law: Statutes: Appeal and Error. The interpretation of statutes and regulations presents questions of law, in connection with which an appellate court has an obligation to reach an independent conclusion irrespective of the decision made by the court below, according deference to an agency's interpretation of its own regulations, unless plainly erroneous or inconsistent.
3. Administrative Law: Final Orders: Appeal and Error. Under the provisions of Neb.Rev.Stat. § 84-917 (Reissue 1994), one aggrieved by a final decision in a contested case before an administrative agency is entitled to judicial review.
4. Appeal and Error. Not only must a claimed prejudicial error be assigned, it must also be discussed in the brief of the asserting party; an appellate court will not consider assignments of error which are not discussed in the brief.
5. Administrative Law: Medical Assistance: Proof. A care facility seeking reimbursement from the Department of Social Services pursuant to state medical assistance program regulations has the burden to prove its entitlement thereto.
6. Administrative Law: Medical Assistance: Federal Acts. Although participation in the medical assistance program is voluntary, a state that chooses to participate must comply with federal statutory and regulatory requirements.
7. Administrative Law: Medical Assistance: Constitutional Law. The Supremacy Clause compels compliance with federal law and regulations by participants in the medical assistance program.
8. Estoppel. The state or one of its political subdivisions may be subject to the doctrine of equitable estoppel under compelling circumstances where right and justice so demand in the interest of preventing a manifest injustice.
9. Estoppel. The doctrine of equitable estoppel applies where, as a result of conduct of a party upon which another person has in good faith relied to one's detriment, the acting party is absolutely precluded, both at law and in equity, from asserting rights which might have otherwise existed.
10. Estoppel. The elements of equitable estoppel are, as to the party estopped: (1) conduct which amounts to a false representation or concealment of material facts, or at least which is calculated to convey the impression that the facts are otherwise than, and inconsistent with, those which the party subsequently attempts to assert; (2) the intention, or at least the expectation, that such conduct shall be acted upon by, or influence, the other party or other persons; and (3) knowledge, actual or constructive, of the real facts. As to the other party, the elements are: (1) lack of knowledge and of the means of knowledge of the truth as to the facts in question; (2) reliance, in good faith, upon the conduct or statements of the party to be estopped; and (3) action or inaction based thereon of such a character as to change the position or status of the party claiming the estoppel, to one's injury, detriment, or prejudice.
11. Administrative Law: Final Orders: Appeal and Error. When reviewing an order of a district court under the Administrative Procedure Act, Neb.Rev.Stat. § 84-901 et seq. (Reissue 1994), for errors appearing on the record, the inquiry is whether the decision conforms to the law, is supported by competent evidence, and is neither arbitrary, capricious, nor unreasonable.
Richard P. Nelson and Abbie J. Widger, of Nelson Morris & Titus, and R. Scott Stevenson, of Harry Trauffer & Associates, Lincoln, for Appellant.
Don Stenberg, Attorney General, and Royce N. Harper, Lincoln, for Appellee.
The defendant-appellee, Nebraska Department of Social Services, denied the claim of the plaintiff-appellant, Inner Harbour Hospitals, Ltd., for payment under the terms of the "Medical Assistance Provider Agreement" entered into by Inner Harbour and the department for care Inner Harbour provided Brenda Hibberd, a minor adopted by Patrick and Barbara Hibberd under a "Subsidized Adoption Agreement" with the department. Inner Harbour appealed to the district court pursuant to the Administrative Procedure Act, Neb.Rev.Stat. § 84-901 et seq. (Reissue 1994). The district court affirmed the department's decision, but remanded the matter in order that the department might determine whether it had an obligation under the adoption agreement to pay Inner Harbour for the care it provided the minor. In its appeal to the Nebraska Court of Appeals, Inner Harbour asserted, in summary, that the district court erred in (1) determining the type of care Inner Harbour provided the minor, (2) determining the type of care qualifying for medicaid payments, and (3) failing to rule that the department was estopped from denying liability for medicaid reimbursement. Under our authority to regulate the caseloads of the two courts, we, on our own motion, removed the matter to this court. We now affirm as modified.
On an appeal under the Administrative Procedure Act, an appellate court reviews the judgment of the district court for errors appearing on the record and will not substitute its factual findings for those of the district court where competent evidence supports those findings. Rainbolt v. State, 250 Neb. 567, 550 N.W.2d 341 (1996). However, to the extent the interpretation of statutes and regulations is involved, questions of law are presented, in connection with which an appellate court has an obligation to reach an independent conclusion irrespective of the decision made by the court below, according deference to an agency's interpretation of its own regulations, unless plainly erroneous or inconsistent. See Slack Nsg. Home v. Department of Soc. Servs., 247 Neb. 452, 528 N.W.2d 285 (1995).
Although the pertinent copy of the provider agreement in the record is not as readable as it should be, we can discern that in addition to agreeing to participate as a medical assistance program hospital provider, Inner Harbour undertook to follow the department's policies and procedures in the administration of the program and to accept the payments made under the program as full and complete payment for the services rendered.
Inner Harbour provides care in both a locked unit and an unlocked "wilderness setting" unit. Its locked unit is similar to an acute care hospital. Its unlocked unit consists of cabins in a wilderness setting which house two to three patients each. Inner Harbour does not place supervisors in every cabin, but does have supervisors on the "campsite" 24 hours a day. Thus, the patients in the unlocked unit have access to 24-hour medical treatment. Although the cabins in the unlocked unit are less restrictive than the locked facilities, the frequency, intensity, and type of treatment are the same in both.
Inner Harbour admits its children patients into the locked unit in 99.6 percent of its cases, and when the children reach a "level of stability," they are transferred into the unlocked unit. Before a patient is transferred permanently to the unlocked unit, the patient goes through a transition phase wherein the patient is allowed to spend the day in the wilderness setting and the evenings in the locked unit.
The Sunderbruch Corporation-Nebraska is the physician peer review organization authorized under the terms of a contract with the department for services financed through the program to conduct on behalf of the department reviews of inpatient hospital services and to perform inpatient utilization reviews. Pursuant to program regulations, Sunderbruch performs preadmission reviews and regular "continued stay" reviews to determine if inpatient stay is required. A continued stay review is performed after admission during a patient's hospitalization to determine the medical necessity and appropriateness of continuing the patient's stay in a hospital level of care. According to Bonnie Brown, a department employee, when nonstate wards, such as the minor, go to inpatient hospitalization, Sunderbruch handles the preauthorization and continued stay reviews; in contrast, the department conducts continued stay reviews for state wards.
On March 24, 1992, pursuant to a telephone review, Sunderbruch approved the minor's admission into an acute care program. Inner Harbour admitted the minor on March 25 and placed her in the locked unit. Sunderbruch's records indicate that on February 9, 1993, the minor was transferred to "residential care" and that the "acute psychiatric review was terminated." On May 4, Inner Harbour staff discovered that the minor was carrying a knife, and after being confronted, the minor threatened staff. As a result, the minor was readmitted into the locked unit. Sunderbruch's records further indicate that the minor was returned to the unlocked unit on May 6. However, Dr. James Claytor, who is board certified in psychiatry, has worked with Inner Harbour since October 1988, and is one of its clinical directors and the minor's attending physician since her admittance, is of the view that the minor was transferred back to the unlocked unit on May 25, 1993.
Claytor testified that the minor was returned to the locked unit on June 3 or 4, 1993, for a brief period of time after threatening staff...
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