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Another chapter in the never-ending stop-loss saga came to a close on June 24, 2019 when the State Office of Administrative Hearings (SOAH) finally issued its long-awaited decision in the stop-loss cases.
The stop-loss cases involve the “stop-loss exception” to the Division’s former Inpatient Hospital Fee Guideline which was in effect from August 1, 1997 through March 1, 2008.  This rule stated that the hospital is entitled to reimbursement of 75% of its charges if the services provided by the hospital are both “unusually extensive” and “unusually costly.”  The issue in these cases is how to interpret and apply the terms “unusually extensive” and “unusually costly” services. 
To give you an idea how long it’s taken SOAH to issue a decision, the hearing in the Vista stop-loss cases ended February 24, 2016 and the briefing finished October 7, 2016 when the parties filed their proposed findings of fact and conclusions of law.  Most of the non-Vista stop-loss cases were tried in 2014.  The record has been kept open in those cases while the Vista cases were tried.
SOAH’s Decision and Order consists of two parts.  The first part contains the legal conclusions common to all of the cases.  The second part consists of attachments listing all of the stop-loss cases with the case-specific decision for each case. 
SOAH’s decision addressed a total of 532 stop-loss cases.  The stop-loss exception was held to apply in only 14 cases; it was determined that no additional reimbursement was owed to the provider in 461 cases; and, it was determined that, under the per diem methodology, additional reimbursement was owed to the provider in 57 cases. 
To view a copy of the Decision and Order, click here.
Copyright 2019, James M. Loughlin, Stone Loughlin & Swanson, LLP