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Tufts Medical Center, Inc. v. Tsai

Superior Court of Massachusetts, Suffolk

February 26, 2018

Daniel TSAI, In his Capacity as Director, Office of Medicaid


          Douglas H. Wilkins, Justice of the Superior Court

         Tufts Medical Center, Inc. ("Tufts") filed this appeal under G.L.c. 30A, § 14 from a final decision ("Decision") of the Director of the Office of Medicaid ("MassHealth"), denying reimbursement for inpatient services that it provided to two MassHealth recipients. The Court held a hearing on January 18, 2018. After MassHealth filed the administrative record pursuant to Superior Court Standing Order 1-96. Tufts filed a Motion for Judgment on the Pleadings ("Motion"), which MassHealth has opposed. Based upon the court’s review of the administrative record, motion and memorandum and upon consideration of oral arguments, the Motion is ALLOWED IN PART AND DENIED IN PART.


         Tufts provided inpatient services to two MassHealth recipients, referred to in the record as patients BC and MW. It alleges that the Decision misrepresents, mischaracterizes, or disregards the facts in evidence. Specifically, Tufts claims that Patient BC’s vital signs and other medical conditions were either inaccurately represented or mischaracterized in the Final Decision. Tufts also claims that the Decision ignored Patient MW’s X-rays and nasopharyngeal scope procedure and their results, as well as not adequately addressed Patient MW’s respiratory conditions.

         MassHealth held a hearing on October 18, 2016 and May 4, 2017. The primary witnesses were the physician experts for Tufts (Dr. Durgham as to BC and Dr. Weingart as to MW) and MassHealth (Dr. Connolly as to BC and Dr. Seigel as to MW). Their testimony, and the medical record support for the Decision, are discussed below.


         The Court "may set aside the decision of an administrative agency if it is not supported by substantial evidence." Cobble v. Commissioner of Social Services, 430 Mass. 385, 390 (1999). See G.L.c. 30A, § 14(7)(e). "[S]ubstantial evidence" is "such evidence as a reasonable mind might accept as adequate to support a conclusion." G.L.c. 30A, § 1(6). When reviewing an agency derision, the Court must give "due weight to the experience, technical competence, and specialized knowledge of the agency, as well as to the discretionary authority conferred upon it." G.L.c. 30A, § 14(7). "[T]o determine whether an agency’s decision is supported by substantial evidence, we examine the entirety of the administrative record and take into account whatever in the record fairly detracts from the supporting evidence’s weight." Cobble, 430 Mass. at 390, citing New Boston Garden Corp. v. Assessors of Boston, 383 Mass. 456, 466 (1981). The appealing party’s burden to demonstrate the invalidity of the agency decision "is heavy." Springfield v. Dep’t of Telecomms. & Cable, 457 Mass. 562, 568 (2010) (citation omitted).

         A misstatement of the record may show a lack of substantial evidence. "While the task of assessing the credibility of witnesses is one uniquely within an agency’s discretion [citation omitted], this court may modify or set aside findings and conclusions that are ... unsupported by substantial evidence." Bettencourt v. Board of Registration in Medicine, 408 Mass. 221, 227 (1990) (faulting the agency’s omissions, i.e. its failure to consider a certain line of evidence). Thus, where the agency has said there is "no evidence" to support a particular proposition, the presence of evidence on that point is enough to negate MassHealth’s substantial evidence argument.

         Patient BC

         a. Critical Vital Signs

         Tufts claims that the correct baseline for patient BC’s pulse oximetry was 97-99% on room air, not 86-91% as stated in the Decision’s second Finding of Fact. Pl.’s Mem. at 9. Appellant’s Opp’n to the Proposed Decision at 2. It also claims that there was evidence of hypoxemia (oxygen deficiency), contrary to the seventh Finding of Fact in the Final Decision. Pl.’s Mem. 9. MassHealth does not specifically address Tufts’ claims regarding either the baseline for pulse oximetry or the existence of hypoxemia. See Def.’s Opp’n 13-14. Instead, MassHealth summarily states that "[t]here was no evidence of hypoxemia." Id. at 3.

         The Decision addresses both the baseline for patient BC’s pulse oximetry and the existence or lack of hypoxemia. In its Summary of Evidence, it acknowledges testimony from Dr. Connolly and Dr. Durgham. Dr. Connolly testified that pulse oximetry of Patient BC was 85% and the baseline was noted to be 86-91%. Final Decision 4. He further testified that "[t]here was no evidence of hypoxemia." Id. Although the Decision does not address Tufts’ specific claims regarding the baseline or existence of hypoxemia, it notes Dr. Durgham’s testimony that there was "a deviation of his vital signs." Id. at 5.

         BC’s pulse oximetry reflected in the medical records varies. The Triage Assessment from the Emergency Department indicates that 86-91% "O2sats" was reported as "normal for him." Ex. 4A at 20. In contrast, the EMS note states that Patient BC’s vital sign was "97-99% on RA." Id. at 16. The PICU Admit Note also states that his "O2 saturations [were] 95% to 98%." Id. at 34. Given the conflicting testimony and records, MassHealth reasonably could conclude that the baseline was 86-91% and that there was no evidence of hypoxemia, that is, there was no deviation in Patient BC’s vital ...

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