IN RE: NEW YORK CITY HEALTH AND HOSPITALS CORPORATION (2019)

Determination of respondent New York State Department of Health, dated February 23, 2017, which, after a hearing, affirmed the findings of an audit conducted by respondent Office of the Medicaid Inspector General (OMIG) disallowing approximately $ 1.44 million in Medicaid payments claimed by petitioner for medical care rendered to five undocumented aliens, unanimously confirmed, the petition denied, and the proceeding brought pursuant to CPLR article 78 (transferred to this Court by order of Supreme Court, New York County [John J. Kelley, J.], entered June 14, 2018), dismissed, without costs.

Respondents rationally construed the governing Medicaid statutory and regulatory framework as limiting reimbursable treatment for care for undocumented aliens' “emergency medical conditions” to treatment for acute symptoms, not extending to treatment for chronic conditions not manifesting in acute symptoms (see 42 USC § 1396b[v][3];  42 CFR 440.255[b][1];  Social Services Law § 122[1][e];  18 NYCRR 360–3.2[j][1][iii];  Greenery Rehabilitation Group, Inc. v. Hammon, 150 F.3d 226, 232–233 [2d Cir. 1998] ).

Substantial evidence supports respondents' determination that petitioner failed to meet its burden of presenting documentation showing that its care for “emergency medical conditions” on the dates at issue was reimbursable (18 NYCRR 519.18[d][1];  see generally 300 Gramatan Ave. Assoc. v. State Div. of Human Rights, 45 N.Y.2d 176, 180, 408 N.Y.S.2d 54, 379 N.E.2d 1183 [1978] ).  Petitioner's contentions are largely premised on a misconstruction of the Medicaid framework as permitting reimbursement for treatment of emergency medical conditions—such as a course of antibiotics for an infection initially manifesting with a fever—even after the emergent condition—the fever—has subsided.  In any event, during days of hearing testimony, OMIG's peer reviewer explained his decisions whether to allow or disallow the hundreds of claims at issue, citing documentary evidence that he had examined.  To the extent petitioner points to other evidence that might have supported different outcomes, it is unavailing, as we “may not weigh the evidence or reject the choice made by [OMIG] where the evidence is conflicting and room for choice exists” (see Matter of Collins v. Codd, 38 N.Y.2d 269, 270–271, 379 N.Y.S.2d 733, 342 N.E.2d 524 [1976] [internal quotation marks omitted] ).