ARSENIO L. CANLAS, M.D., Claimant, u. THE STATE OF ILLINOIS, Respondent.
Case summary
Claimant, a physician, sought vendor payment for medical services provided to an IDPA recipient, arguing that payment was refused only due to lapse of appropriated funds. The court dismissed the claim because claimant failed to meet regulatory requirements, including enrollment as a MAP vendor, verification of patient eligibility, and proper invoicing.
Statutes cited: Ill. Rev. Stat., ch. 23, par. 11-13; Ill. Rev. Stat., ch. 127, par. 151; Ill. Rev. Stat., ch. 23, par. 2-5; Ill. Rev. Stat., ch. 23, par. 2-9
Cases cited: Weissman v. State (1978), 32 Ill. Ct. Cl. 150; Rush Anesthesiology Group v. State (1983), No. 82-CC-1580; Barnes Hospital v. State, No. 82-CC-708 et seq.; St. John's Hospital v. State (1977), 32 Ill. Ct. Cl. 115; Rock Island Franciscan Hospital v. State, No. 79-CC-91, filed November 23, 1981; Columbus, Cuneo, Cabrini Medical Center v. State, Nos. 84-CC-401 and 84-CC-734, filed March 7, 1985
AI-generated summary from the opinion text — may contain errors. The opinion text and PDF above are the official record.
Headnotes
- NEIL F. HARTICAN, Attorney General (SUZANNE SCHMITZ, Assistant Attorney General, of counsel), for Respondent.
- PnAcrrcE AND PRocEounE-department reports-prima facie evidence. Under the rules of the Court of Claims, department reports are prima facie evidence as to the contents.
- CoNTnAcrs-claim for medical services provided public aid recipientcause of action not stated. No cause of action was stated by the Claimant’s contention that his claim for medical services rendered to a public aid recipient was denied by reason of a lapsed appropriation, since the controlling statute clearly contradicted the contention by providing that such claims be paid and not be denied by reason of lapsed appropriation.
- SAME-ckirn for medical services to public aid recipient-claimant not enrolled uendor-claim dismissed. A claim for medical services rendered to a public aid recipient was dismissed, because the Claimant was not an enrolled participant in the State program providing for services to public aid recipients, and enrollment in the program as a “vendor” is an essential prerequisite to being entitled to receive payment for rendering such services.
- SAME-medical services to public aid recipient-recipient not eligible on dates of service-claim dkmksed. A claim for medical services rendered to a public aid recipient was dismissed, since the records of the Department of Public Aid showed that the recipient of the services was not eligible for such services on the date they were rendered, therefore the Department of Public Aid was not liable for payment of the claim.
- SAME-medical services for public aid recipient-invoicing requirements not satisfied-claim dismissed. Claimant’s failure to comply with the invoicing requirements applicable to rendering medical services to public aid recipients negated his right to payment of his claim for medical services, since timely completion of the prescribed invoice forms is a condition of being entitled to payment for rendering such medical services.
- SAME-Department of Public Aid may regulate “vendor payments.” Regulations may be adopted by the Department of Public Aid requiring vendors who provide services to public aid recipients to file certain forms within certain times, and those regulations must be satisfied before a vendor will be entitled to receive payment for specified services rendered.
This cause is before the Court on Respondent’s motion to dismiss the captioned claim. Claimant having been given due notice, and the Court being fully advised in the premises, finds as follows: Claimant Canlas, a St. Louis, Missouri, physician, is here seeking a vendor payment, as provided in section 11-13 of the Illinois Public Aid Code (PAC) (Ill. Rev.
Stat., ch. 23, par. 11-13), from funds appropriated to the Illinois Department of Public Aid (IDPA) for medical services provided to IDPA’s “recipients,” as defined in section 2-9 of the PAC. The subject of Dr.
Canlas’ claim is services provided to his patient, Lana McReynolds, during August 1980. His Court action was filed in March 1984.
In its Department report, the contents of which are prima facie evidence under rule 14 of the rules of this Court, IDPA advises that there are certain requirements which all medical vendors must meet, in order to be eligible to receive a vendor payment (defined in section 2-5 of the PAC) for their services. These requirements include the following: (a) The vendor must have been enrolled as a participant in IDPA’s Medical Assistance Program (MAP) at the time when the subject services were rendered. (IDPA Rules 140.11 through 140.19, 89 111. Admin. Code §§140.11through 140.19) [*152] (b) The vendor’s patient must have been a “recipient”, and eligible to receive such services at the Respondent State’s expense as determined by IDPA in accordance with applicable statutory requirements, as of the dates on which the services were rendered. See prior decisions of this Court, cited below in this Opinion. (c) The services must have been “covered services”, eligible for payment in accordance with the requirements of IDPA’s MAP program. (See, e.g., IDPA Rules 140.3, 140.5, 140.6, 140.7 and 140.9; 89 Ill. Admin. Code ff140.3, 140.5, 140.6, 140.7 and 140.9) (d) In certain situations, IDPA staff‘s “prior approval” must have been obtained, for particular services, before the services are provided to the patient by the vendor. (See, e.g., subsec. c of IDPA Rule 140.2; and IDPA Rules 140.40 thru 140.42,Id.) (e) The vendor must have invoiced his services to the department, on IDPA invoice-forms which have been properly prepared by the vendor and timely submitted to IDPA, in accordance with department Handbook instructions and regulatory requirements (IDPA Rule 140.20, Id.)
The department advises that each of these requirements is explained in its provider (vendor) Handbooks, which are furnished, upon enrollment, to each participating vendor.
According to the Department’s investigation, this claim is deficient in several respects, as compared with the above requirements. First, Respondent’s initial challenge concerns the complaint’s alleged failure to state a cause of action. The complaint alleges that Claimant’s payment demand for patient McReynolds’ services was refused solely due to lapse of appropriated funds. Its exhibits clearly indicate that the subject of this lawsuit is medical services, and that Claimant is “ presenting a vendor payment” claim, as defined in Sections 2-5 and 11-13 of the PAC. Section 25 of “AN ACT in relation to State finance (Ill. Rev. Stat., ch. 127, par. l S l ) , authorizes IDPA’s payment of such claims “without regard to the fact that the medical services being compensated for by such payment may have been rendered in a prior fiscal year,” i.e., payments from the [*153] Department’s medical payment fund are not denied by reason of lapsed appropriation. The complaint here is thus contradicted by section 25. As a result, Claimant’s allegations misstate Illinois statutory law and, for that reason, fail to state a cause of action. See this Court’s decisions in Midstate Anesthesiologists v . State, No. 82- CC-942, filed March 1, 1982; Barnes Hospital v . State, No. 82-CC-708 et seq., filed March 1, 1982; and Rock Zsland Franciscan Hospital v . State, No. 82-CC-899, filed May 5, 1982; Henrotin Hospital v. State, No. 84-CC3315, filed August 29, 1984 (representing 67 Henrotin Hospital claims dismissed on that date); St. Anne’s Hospital v . State, No. 84-CC-3063, filed August 29, 1984 (representing 118 St. Anne’s Hospital claims dismissed on that date); Franciscan Medical Center v . State, No. 84-CC-2655, filed August 29, 1984 (representing 4 Franciscan claims dismissed on that date); and St.
Elizabeth Hospital v. State, No. 86-CC-1802, filed June 20, 1986.
Second, IDPA reports it finds no record that Dr.
Canlas was an enrolled participant in its Medical Assistance Program (MAP),in 1980. In this regard, IDPA advises that many physicians, hospitals and other vendors, located in neighboring states, are enrolled participants; however, Claimant was not among them.
To be authorized to receive payment for services to IDPA recipients, a person must first apply to IDPA for enrollment in the Department’s MAP program. Until he or she is enrolled, the person cannot be a “vendor”, and thus is not entitled to such payment. See subsection d of IDPA Rule 140.13.
Third, Claimant has supplied no evidence that IDPA had determined his patient, Mrs. McReynolds, to be an eligible MAP recipient, with respect to the dates [*154] on which the subject services were rendered. As the Department’s records indicate that she was not MAPeligible on these dates of service, Respondent has no liability for payment of this claim for such services. See this Court’s decisions in Illini Hospital v . State (1977),32 111. Ct. C1. 115; Rock Island Franciscan Hospital v . State, No. 79-CC-91, filed November 23,1981; and Columbus, Cuneo, Cabrini Medical Center v. State, Nos. 84-CC-401 and 84-CC-734, filed March 7,1985.
Fourth, Claimant offers no exhibit suggesting that he had ever invoiced his services to IDPA, on the forms prescribed by IDPA regulation (89 Ill. Admin. Code, §140.20), or within the time prescribed by that regulation. Appropriate invoice-forms for billing such services, and IDPA medical vendor Handbook provisions explaining the MAPS requirements and providing invoice preparation instructions, would have been available to Dr. Canlas, if he had been a MAP enrolled vendor. Completion of the prescribed invoice forms, and their submission to IDPA prior to the prescribed deadline, are conditions which the enrolled vendor must meet in order to comply with the regulation, and thus to be eligible for vendor payment consideration. Weissman 2). State (1978), 32 Ill. Ct. C1. 150; Rush Anesthesiology Group 0. State (1983), No. 82-CC-1580; and see this Court’s March 1, 1982, order in Barnes Hospital v. State, No. 82-CC-708 et se9.
A vendor’s entitlement to a “vendor payment,” enforceable under section 11-13 of the Illinois Public Aid Code and under sections 439.8 and 439.22 of the Court of Claims Act, may be “limited by regulations of the Illinois Department” (Ill. Rev. Stat., ch. 23, par. 11- 13). Each of the regulatory requirements discussed above imposes a condition which the vendor must meet, if he is to receive a vendor payment for specified [*155] services to a named patient. In this instance, Claimant has failed to demonstrate that he has met such conditions.
It is therefore hereby ordered that the subject claim be, and it is hereby dismissed.