Maryland Court of Appeals Hears Hopkins Request for Medicaid Liver Transplant Reimbursement

An attorney for Johns Hopkins Hospital argued before the Maryland Court of Appeals Dec. 4 that the state's Medicaid program should reimburse the hospital for two liver transplants performed in 1996, even though preauthorization was denied at the time of the operations, the Baltimore Sun reports. In 1998, the hospital filed suit in Howard County Circuit Court, charging that the state violated federal Medicaid law when it refused to preauthorize more than $250,000 in payments for the surgeries. The state, however, successfully argued to have the suit dismissed in March 1999, and the state Court of Special Appeals affirmed the dismissal one month later. Hopkins administrators had filed the suit on behalf of the two teenagers, Taurus Jackson and Jessica Nettles, who received the unauthorized transplants. In the first case, Hopkins administrators requested authorization for a third liver transplant for Jackson in November 1995, despite the fact that the patient had a life-long history of liver problems and had already had two unsuccessful liver transplants. Doctors at Johns Hopkins contended that without the third procedure, Jackson would die. Saying the patient had "behavioral problems" and an "unstable psychiatric evaluation," state Medicaid officials denied the request three times. But in June 1996, Hopkins physicians found a matching liver and completed Jackson's third transplant without the state's approval. Nettles, the second patient involved in the suit, had been diagnosed with liver failure, chronic hepatitis and "other medical problems," prompting her doctors to request a liver transplant in 1995. State Medicaid officials, however, said that a "definitive causative diagnosis" had not been established and denied the request. After sending additional information about Nettles' condition and receiving a second denial from the state, Hopkins doctors performed the transplant in 1996. Nettles, however, died in 1997 at the age of 15. After performing operations for both teens, Hopkins administrators sought reimbursement from Medicaid -- a request that was denied. The hospital did not attempt to collect payment from the patients' families.

Hopkins' Appeal
In the latest move in the Maryland Court of Appeals, the hospital charges that the state "illegally used a cost-benefit analysis" to decide whether to grant preauthorization payments, rather than "looking at the medical necessity of the operations." Marta Harting, an attorney for Hopkins, said in the Dec. 4 oral arguments, "It's indisputable [Jackson and Nettles] were going to die without the operation. ... Hopkins decided to treat first and worry about (the) payment source later." But Maryland's Assistant Attorney General Andrew Baida "disputed" the notion that the state used cost-benefit analysis and noted that if Hopkins officials "wanted to litigate the case," they should have filed suit immediately to seek a "preliminary injunction to require the state to fund the procedure." Baida called the case "extremely unusual," saying he knew of no other case that "has been brought involving this preauthorization issue" (Cadiz, Baltimore Sun, 12/5).