Feds not accepting judge's decision on Medicaid recovery

By John O'Brien | Apr 27, 2011


ATLANTA (Legal Newsline) - The federal government is appealing a ruling that prevents it from taking certain funds from state-filed Medicaid lawsuits.

Earlier this month, the federal government appealed U.S. District Judge Mark Fuller's decision that a letter sent to state health officials sidestepped formal rulemaking procedures. The appeal is before the U.S. Court of Appeals for the 11th Circuit.

The lawsuit was brought by former Alabama Attorney General Troy King, who has since been succeeded by Luther Strange. King alleged in 2008 that a letter sent to state health officials outlining new procedures amounted to a final agency action by the federal Centers for Medicare and Medicare Services. The problem, King said, is that the rule was finalized without the formal notice-and-comments period.

The letter, sent in October 2008, said CMS would begin claiming a percentage of civil penalties from settlements and verdicts. The federal government funds the majority of each state's Medicaid program and already asks for the corresponding percentage from funds designated as recovery for state Medicaid programs. In 2008, CMS provided 68 cents of every dollar Alabama spent on Medicaid.

The decision can have multimillion-dollar consequences. King was trying to protect millions of dollars from lawsuits filed against 79 pharmaceutical companies in 2005. The State has taken in at least $89 million in settlements.

But the largest amounts he was defending came from jury awards. Three cases earned the State more than $270 million, but the state Supreme Court overturned all three.

And recently, CMS finalized its decision to take more than $18 million from a $49 million settlement reached in 2006 by Michigan Attorney General Mike Cox and Omnicare.

Had U.S. District Judge Mark Fuller ruled that the letter was not a final agency action, then the federal government would have had sovereign immunity against the claim.

"The 'guidance' that the SHO letter conveys to states is much more like an implementation of the Medicaid Act than an interpretation," Fuller's ruling says. "As pointed out by the Court's thorough analysis of the substance of the SHO letter, there is hardly any linguistic connection between the legal duties created by the letter and the text of the statute.

"The defendants contend that even in the portions of the letter that do not quote or cite statutory language, 'it is clear from context that the agency is interpreting such a provision.' The Court disagrees with this contention.

"Additionally, the SHO letter creates new law. Contrary to the letter's assertion that 'the Act's broad mandate demands' the rules set out in the SHO letter, nothing in the text of the statute requires the rules that CMS chose."

Fuller vacated the letter, ruling that it will cause minimal disruption to CMS's administration of the Medicaid program.

"The narrow set of circumstances to which the SHO letter applies - suits filed by states to recover from fraud-and-abuse defendants - represents a very small part of the entire Medicaid scheme," he wrote.

"In the absence of the SHO letter, states will continue reporting predicted expenditures to (the Department of Health and Human Services) and HHS will continue to pay each state the federal share of Medicaid expenses."

From Legal Newsline: Reach John O'Brien by e-mail at jobrienwv@gmail.com.

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