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Case Law Database

Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. MISSING
Regular Panel Decision

Claim of Perrin v. Builders Resource, Inc.

The case concerns an appeal from a Workers' Compensation Board decision regarding the reimbursement rate for home health aide services provided to a claimant by their sister. Initially, the carrier denied payment but was later directed to pay. The Workers’ Compensation Law Judge set the reimbursement rate at $12 per hour for services starting in 2011, which the Board affirmed. The claimant appealed, solely challenging this rate. The court dismissed the appeal, ruling that the claimant was not an aggrieved party concerning the reimbursement rate, as the dispute was between the care provider (the sister) and the carrier. The court affirmed that the claimant received the care sought and could not raise issues on behalf of the care provider.

Workers' CompensationHome Health Aide ServicesReimbursement RateAppeal DismissalAggrieved PartyCare ProviderWorkers' Compensation BoardAppellate ProcedureNew York LawCarrier Liability
References
4
Case No. MISSING
Regular Panel Decision

Anthony L. Jordan Health Corp. v. Axelrod

The Anthony L. Jordan Health Center, a not-for-profit corporation, challenged the New York State Department of Health's recalculation of its Medicaid reimbursement rates for the 1983-1984 and 1984-1985 periods. Following an appeal, the parties entered into a stipulation agreement. However, the Department, while recalculating the rates in accordance with the stipulation, unilaterally changed the group composition, resulting in a significant negative adjustment and recoupment from Jordan. The court determined that this regrouping constituted an 'error of judgment,' not a permissible correction for mathematical error or an audit finding. Consequently, the court found that the Department did not have the right to retroactively adjust the rates based on this discretionary change. The petition was granted.

Medicaid ReimbursementRate RecalculationAdministrative ReviewStipulation AgreementError of JudgmentGroup CompositionRetroactive AdjustmentHealth Care LawJudicial ReviewDepartment of Health
References
5
Case No. MISSING
Regular Panel Decision

Frances Schervier Home & Hospital Inc. v. Axelrod

This case concerns an appeal regarding Medicaid reimbursement rates for a residential health care facility. The Department of Health (DOH) disallowed certain costs from the petitioner's 1981 cost report, affecting 1983-1985 rates. Petitioner appealed, arguing it was a data error, not an alternative cost allocation method requiring prior approval. After DOH denied the appeal, the Supreme Court annulled DOH's determination, ruling in favor of the petitioner. The Appellate Division affirmed the Supreme Court's decision, finding DOH's interpretation of its regulations regarding data error corrections to be irrational.

Medicaid reimbursement ratescost reportDepartment of Healthresidential health care facilityCPLR article 78administrative lawdata errorcost allocationagency interpretationirrational interpretation
References
2
Case No. MISSING
Regular Panel Decision
Jul 05, 2008

New Franklin Center for Rehabilitation & Nursing v. Novello

Six private residential health care facilities, including New Franklin Center for Rehabilitation & Nursing and the Bayview petitioners, appealed determinations by the Commissioner of Health. They challenged the removal of Medicaid reimbursement rate adjustments for recruitment and retention of nonsupervisory health care workers, which occurred after they reclassified nursing personnel expenses as 'fees' following a leasing arrangement with Budget Services, Inc. The Supreme Court dismissed one proceeding as untimely and affirmed the Commissioner's decision for the other, finding it consistent with Public Health Law § 2808 (18). The appellate court affirmed the Supreme Court's judgment, upholding the Commissioner's interpretation and emphasizing the statute's intent to ensure proper use of funds.

Medicaid ReimbursementHealth Care FacilitiesCPLR Article 78Recruitment and Retention FundsPublic Health LawStatutory InterpretationAdministrative AppealsTimeliness DoctrineStatute of LimitationsJudicial Deference
References
13
Case No. MISSING
Regular Panel Decision

People v. Young

An attorney representing an indigent defendant in Monroe County filed an application seeking reimbursement for legal services at a rate of $200 per hour, mirroring the rate charged by the Special Prosecutor, rather than the statutory rates under County Law § 722-b. The attorney argued that the significant disparity in hourly compensation violated the defendant's right to equal protection and that his qualifications justified the requested rate. The New York State Association of Criminal Defense Lawyers supported the application as amicus curiae, while Monroe County opposed it, arguing the request was untimely and lacked extraordinary circumstances. Presiding Judge Donald J. Mark, J., acknowledged the court's authority to grant compensation in excess of statutory limits under extraordinary circumstances but ultimately denied the application. The denial was based on the court's reasoning that an analogous argument was previously rejected, that linking assigned counsel rates to prosecutor rates would render County Law § 722-b ineffective, and that extraordinary circumstances could not be demonstrated prior to the conclusion of the criminal action. The court, however, reserved the right to reconsider an increased hourly fee upon the case's termination if such circumstances are then proven.

Assigned CounselLegal Aid CompensationCounty Law Section 722-bHourly Rate DisputeSpecial Prosecutor FeesIndigent RightsJudicial DiscretionExtraordinary CircumstancesMonroe County LawEqual Protection Challenge
References
16
Case No. MISSING
Regular Panel Decision
Sep 08, 1987

Richmond Memorial Hospital & Health Center v. Axelrod

The petitioner, a hospital not a member of the League of Voluntary Hospitals, sought to increase its 1983 third-party reimbursement rates from the Commissioner of the New York State Department of Health. This application was based on a 'trend factor' applicable to League members, stemming from a collective bargaining agreement which the petitioner also adopted. The Commissioner denied the request, citing the petitioner's non-membership in the League. The Supreme Court annulled this determination, directing the use of the League trend factor. On appeal, the judgment was modified: the annulment of the Commissioner's arbitrary determination was affirmed, but the direction to use the specific trend factor was deleted, and the case was remitted for recalculation based on permissible factors.

CPLR Article 78Third-Party Reimbursement RatesTrend FactorMedicaid RatesBlue Cross RatesWorkers' Compensation RatesNo-Fault RatesPublic Health LawArbitrary and CapriciousJudicial Review
References
5
Case No. MISSING
Regular Panel Decision

Matter of Greenwood v. Inland Fisher Guide

The claimant suffered a chest strain injury in 1994, leading to a permanent partial disability and a weekly compensation rate. In 2000, the Workers’ Compensation Board affirmed that the claimant had not voluntarily withdrawn from the labor market and continued compensation awards, including a period with reimbursement to the employer. A dispute arose in 2010 regarding unsubstantiated reimbursement payments, leading the WCLJ to set a tentative reduced earnings rate. The Board later modified this by increasing the claimant's weekly award rate, finding the employer no longer entitled to reimbursement. The Appellate Division reversed this decision, finding it unsupported by substantial evidence, as there was no indication that the employer's disability benefits plan necessitated reimbursement. The matter was remitted for further proceedings to determine the claimant's entitlement to disability payments and a reduced earnings award.

Workers' CompensationPermanent Partial DisabilityReduced EarningsReimbursementSubstantial EvidenceAppellate ReviewRemittalLabor MarketAward RateDisability Benefits Plan
References
2
Case No. ADJ4258585 (OXN 0130492) ADJ220258 (OXN 0130487)
Regular
Apr 17, 2018

ENRIQUE HERRERA vs. MAPLE LEAF FOODS, U.S. FIRE INSURANCE COMPANY, ALEA NORTH AMERICAN INSURANCE COMPANY

This notice informs parties that the Workers' Compensation Appeals Board (WCAB) intends to admit its rating instructions and a disability rater's recommended permanent disability rating into evidence. The WCAB previously granted reconsideration for further study. Parties have seven days to object to the rating instructions or the recommended rating, with specific procedures for addressing objections. If no timely objection is filed, the matters will be submitted for decision thirty days after service.

WORKERS' COMPENSATION APPEALS BOARDPermanent Disability RatingDisability Evaluation UnitRating InstructionsRecommended Permanent Disability RatingJoint RatingReconsiderationObjectionRater Cross-ExaminationRebuttal Evidence
References
0
Case No. MISSING
Regular Panel Decision

Texas Workers' Compensation Commission v. Patient Advocates of Texas

Justice Smith concurs with the Court's conclusion that a private insurance carrier's act of reviewing medical bills and determining a reimbursement amount without an established Medical and Reimbursement guideline (MAR) does not constitute a legal delegation. Justice Smith further clarifies that such a reimbursement determination by the carrier is not considered an administrative rule. Importantly, any subsequent determination of a 'fair and reasonable' reimbursement rate in a Texas Workers’ Compensation Commission medical service review or a State Office of Administrative Hearings contested-case hearing will be made de novo, meaning without any deference to the carrier's initial reimbursement decision. This ensures an independent evaluation of the reimbursement rate.

Medical Bill ReviewReimbursement RatesWorkers' CompensationDe Novo ReviewInsurance CarrierAdministrative LawContested Case HearingFair and Reasonable RatesDelegation of AuthorityMedical Service Review
References
3
Case No. 03-09-00318-CV
Regular Panel Decision
Aug 04, 2011

Texas Health and Human Services Commission and Thomas Suehs, Commissioner v. El Paso County Hospital District D/B/A R. E. Thomason General Hospital Conroe Hospital Corporation D/B/A Conroe Regional Medical Center Bay Area Healthcare Group, Ltd. D/B/A Corpus Christi Medical Center Sunbelt Regional Medical Center, Inc.

This appeal concerns a long-standing dispute over Medicaid reimbursement rates. The Texas Health and Human Services Commission (HHSC) challenged a district court's injunction requiring it to recalculate reimbursement rates for hospitals dating back to state fiscal year 2002, after the Texas Supreme Court previously deemed HHSC's rate-setting methodology (the 'February 28 cutoff' rule) invalid. The Court of Appeals found that while the Supreme Court's judgment applied to rates from fiscal year 2008 forward, extending the injunction to recalculate rates for fiscal years 2002 through 2007 constituted additional, retroactive relief barred by sovereign immunity and inconsistent with HHSC's own rules. Therefore, the court reversed and vacated the injunction for 2002-2007 while affirming it for 2008 and 2009.

Medicaid ReimbursementAdministrative LawAPA ViolationsRate-Setting MethodologySovereign ImmunityInjunctive ReliefJudicial ReviewRetroactive ApplicationProspective ApplicationHealthcare Law
References
42
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