Dr. Frederick Nitta is a board-certified OB/GYN in Hawaii. Despite its tropical climate, the state suffers from a shortage of primary care physicians (PCP) like other locales. Due to this shortage, Dr. Nitta provides PCP services for his patients, is recognized in the community as a PCP, and provides a broad range of services to his patients. As part of the Affordable Care Act (ACA), physicians “with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine” were eligible to temporarily receive increased payments for primary care services provided to Medicaid patients in 2013 and 2014. Prompted by an Alohacare representative, Dr. Nitta’s staff member signed him up through an on-line application with his consent although the Rule prohibited completion by proxy.
In 2015, Dr. Nitta’s seven-year-long saga began when the state’s Department of Human Services (DHS) deemed him ineligible because he allegedly did not meet the specialty requirements. DHS demanded the repayment of over $200,000 in the enhanced payments he had received. The Rule for eligibility required a board certification in family medicine, general internal medicine or pediatric medicine or sixty-percent billing threshold for PCP services. It was not disputed that Dr. Nitta attested to a specialty designation of one of the foregoing areas.
Dr. Nitta requested a hearing and in December 2015 an administrative hearing officer ruled against him finding that he was board certified in in OB/GYN, not in family medicine, general internal medicine, or pediatric medicine, and because Dr. Nitta had not met the sixty percent billing requirement under the Rule. He then sought an administrative appeal but the deputy adopted the hearing officer’s decision. This was despite Alohacare and the Hilo Medical Center identifying him as a PCP with an OB/GYN specialization. Repayment was again ordered.
Not willing to give up, Dr. Natta appealed to the state circuit court. The circuit court also found Dr. Natta ineligible for the reasons given at the agency level. In May 2017, accompanied by amicus briefs from Hawaii Medical Association (“HMA”) and the American Medical Association (“AMA”), Dr. Nitta appealed to the Intermediate Court of Appeals (ICA) for the state. During this appeal, Dr. Nitta got an assist when the Sixth Circuit Court of Appeals of the United States involving a Tennessee physician invalidated the Rule. It ruled that “a physician with a primary specialty designation” for purposes of the Statute meant “a physician who has himself designated, as his primary specialty, one of the specialties recited in those provisions.” This meant that a physician could self-attest to specialty designation of family medicine, general internal medicine or pediatric medicine among others. The ICA vacated the DHS and circuit decisions but remanded the matter to the DHS Administrative Appeals Office “for further proceedings.”
DHS still insisted that Dr. Nitta was ineligible for enhanced payments because he did have a primary specialty designation as an OB/GYN as specified by the Statute. It asked the ICA to review its decision. The ICA found that a physician can have more than one specialty. Although Dr. Nitta designed himself as an OB/GYN on his Medicaid application and NPI specialty designation, he was not precluded from having multiple specialty classifications. Turning to the self-attestation completed by his staff member that he practiced in internal medicine, this too was acceptable because Dr. Nitta ratified his staff’s action. Furthermore, the local medical community, Alohacare, and the Hilo Medical Center all recognized him as a PCP. Dr. Nitta retained the Medicaid payment of $205,000.
Ob-gyn can keep $205,000 in Medicaid pay that state tried to recoup
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