FOR THE DISTRICT OF COLUMBIA
NATIONAL ASSOCIATION FOR
HOME CARE & HOSPICE, INC §
228 7th Street, SE §
Washington, DC 20003 §
§
Plaintiff, §
§
§
KATHLEEN SEBELIUS, in her § Civil Action No. 1:14-cv-00950
official capacity as Secretary, §
U.S. Department of Health and §
Human Services §
200 Independence Ave, SW §
Washington, DC 20201 §
§
and §
§
MARILYN b. TAVENNER, in her official §
capacity as Administrator, §
Centers for Medicare & Medicaid §
Services §
445-G Hubert H. Humphrey Bldg §
200 Independence Ave., SW §
Washington, DC 20201 §
§
Defendants. §
COMPLAINT
I. PRELIMINARY STATEMENT
1. This lawsuit challenges the substantive and procedural validity of Defendants’ rulemaking that implements a requirement under the Patient Protection and Affordable Care Act requiring a Medicare beneficiary receiving home health services to have a face-to-face encounter with a physician in order to qualify for Medicare coverage of those home health services. The Defendants implemented a simple and understandable statutory requirement for a physician/patient encounter by adding complex, unnecessary, and unauthorized physician documentation requirements. Specifically, the PPACA provision requires documentation that a physician encounter occurred while the Defendants have expanded that requirement to also require physicians to provide a detailed narrative explanation as to why the patient is “homebound” and in need of skilled nursing or therapy services.
2. Not only have the Defendants added unauthorized physician documentation, they have also devised and administered these physician documentation requirements in a manner that renders it nearly impossible to achieve compliance as they are wholly confusing to physicians, home health agencies, and patients, leading Medicare administrative contractors to evaluate claims in a manner that is inconsistent, arbitrary, and inaccurate. The Defendants also administer the documentation requirements in a manner that fully disregards the overall health care record of the patient that provides detailed information on the patient’s homebound status and need for care. As a result, Medicare beneficiaries and the home health agencies that serve them face unwarranted barriers to care and Medicare coverage that they cannot understand or resolve.
3. The physician documentation standards established and administered by the Defendants apply to the Medicare claims submitted by home health agencies on behalf of their patients. However, the home health agencies cannot assist the physicians in composing compliant documentation. As such, the home health agencies maintain the documentation responsibility and liabilities while having no control or influence over compliance beyond denying patients access to care.
3. Plaintiff seeks to enjoin and declare invalid the Defendants’ requirements for physician documentation of the required face-to-face encounter and to require the defendants to promulgate and administer reasonable, consistent, and comprehensible documentation requirements in a manner that permits physicians, beneficiaries, and home health agencies that are acting in good faith to comply.
4. Defendants’ rule violates the authorizing Medicare coverage requirement on documenting a physician face-to-face encounter, 42 USC §1395f(a)(C); 1395n(a)(2)(A), in that it requires unauthorized and duplicative physician documentation regarding the patient’s homebound status and need for skilled nursing or therapy services. Further. The documentation requirements violate the Administrative Procedure Act (“APA”), 5 U.S.C. §706, in that the requirements are arbitrary, capricious, and otherwise not in accord with the law both facially and in their manner of administration.
PARTIES
5. Plaintiff National Association for Home Care & Hospice, Inc. (“NAHC”) is a non-profit, IRS 501(c)(6) trade association licensed and operating in the District of Columbia at 228 Seventh Street, SE, Washington, D.C. NAHC represents the interests of home health agencies nationwide with over 6,000 members. Included within its membership are Medicare participating home health agencies that are adversely affected by the challenged rule and its administration. NAHC is acting in this matter as a representative association on behalf of its members’ interests.
6. Defendant Kathleen Sebelius is the Secretary of the United States Department of Health and Human Services (“HHS”) and is responsible for implementing and administering Title XVIII of the Social Security Act 42 U.S.C.§1395 et seq., otherwise known as Medicare. Defendant Sebelius is sued in her official capacity only.
7. Defendant Marilyn Tavenner is the Administrator of the Centers for Medicare and Medicaid Services (“CMS”) and is responsible for the day-to-day administration of Medicare. Defendant Tavenner is sued in her official capacity only.
JURISDICTION AND VENUE
8. This Court has jurisdiction pursuant to 28 U.S.C.§1361 and 42 U.S.C.§405(g) as incorporated by 42 U.S.C.§1395ff. This matter is a challenge to the validity and administration of a rule promulgated under the authority of the Medicare statute and is not subject or susceptible to timely or effective review in any administrative appeals process.
9. Plaintiff’s claims are collateral to any claim for home health services benefits. This lawsuit does not seek nor would it result in an award of Medicare benefits; it challenges the validity of a documentation rule and its administration that causes harm collateral to any direct determination of benefits. The challenge relates to the Defendants’ unauthorized standards for a physician’s documentation of a patient encounter that are administered in a manner that makes compliance impossible or unreasonable. NAHC members have presented claims to Defendants subject to the challenged rule and its administration and no reasonable and viable administrative remedies are available to address Plaintiff's claims. In addition, Plaintiff NAHC has exhausted all available administrative remedies.
10. Plaintiff seeks declaratory relief pursuant to 28 U.S.C.§§2201 and 2202.
11. Venue is proper in this Court under 28 U.S.C.§§1391(b) and (e) because all parties reside within this judicial district and because the defendants are sued in their official capacity as officers of the government of the United States.
BACKGROUND: MEDICARE HOME HEALTH SERVICES
12. Title XVIII of the Social Security Act, 42 U.S.C.§§1395 et seq., establishes the program of medical insurance generally known as the Medicare program. The beneficiaries of this program are individuals who have become eligible for Social Security insurance benefits under Title II of the Social Security Act. See 42 U.S.C.§§402-433. The Medicare program, administered by the Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS), is a system of health insurance for the aged and disabled. See Social Security Amendment of 1965, Pub. L. No. 89-97, Title I, 79 Stat. 286 (1965) (codified as amended at 42 U.S.C.§1395 et seq.) (Medicare Act).
13. Two basic types of insurance are available to Medicare beneficiaries. Part A of Title XVIII provides basic protection against the cost of hospital, related post-hospital care, home health services, and hospice care. It is available to covered individuals without further cost. 42 U.S.C.§1395c. Part B of Title XVIII covers physicians and other supplemental insurance benefits, including home health care, for those who elect to enroll in the program. Part B is financed both by monthly premiums paid by enrollees supplemented by additional federal funds. 42 U.S.C.§1395j.
14. The eligibility standards for coverage of home health service benefits under both Part A and Part B are not at issue in this case. Part A and Part B of the Medicare program both are designed to provide basic protection against the costs of home health services by providing for payment by the Federal government for those services. See, 42 U.S.C.§1395 et seq..
15. Home health agencies (HHA) provide services in patients’ homes as a more economical and convenient alternative to institutional care. 42 U.S.C.§1395x(u); see also Id., §1395x(m) and (o). In 1980, Congress extended the home care benefits from a maximum of 100 visits per calendar year to an unlimited number of visits. See Omnibus Budget Reconciliation Act of 1980, Pub. L. No. 96-499, 930(g), 94 Stat. 2599, 2631 (1980) (amending 42 U.S.C.§1395k(a)(2)(A). Amendments under the Balanced Budget Act of 1997, P.L. 105-33, continued the availability of unlimited visits through a combination of Part A and Part B.
16. To qualify for home health services through the Medicare program, a person must be “confined to his/her home”; have a physician’s written certification that the person is homebound and under a plan of care established by a physician; and in need of intermittent skilled nursing service, and/or physical therapy or speech-language pathology services. 42 U.S.C.§1395f(a)(2)(C);1395n(a)(2)(A),
17. Section 6407 of the PPACA added the requirement, as an amendment to 42 U.S.C.§1395f(a)(2)(C)[Section 1814(a)(2)(C) of the Social Security Act], that is at issue in this matter; ”in the case of a certification made by a physician after January 1, 2010, prior to making such certification the physician must document that the physician himself or herself, or a nurse practitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5)) who is working in collaboration with the physician in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg) as authorized by State law, or a physician assistant (as defined in section 1861(aa)(5)) under the supervision of a physician, has had a face-to-face encounter (including through use of telehealth, subject to the requirements in section 1834(m), and other than with respect to encounters that are incident to services involved) with the individual within a reasonable timeframe as determined by the Secretary,’’
18. A similar provision is included under 42 U.S.C. 1395n(a)(2)(C) [Section 1835(a)(2)(a) of the Social Security Act]governing home health benefits under Medicare Part B. It provides: “in the case of a certification after January 1, 2010, prior to making such certification the physician must document that the physicain, or a nurse practitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5)) who is working in collaboration with the physician in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg)) as authorized by State law, or a physician assistant (as defined in section 1861(aa)(5)) under the supervision of a physician, has had a face-to-face encounter (including through use of telehealth and other than with respect to encounters that are incident to services involved) with the individual during the 6-month period preceding such certification, or other reasonable timeframe as determined by the Secretary’’.
19. The Defendants have implemented the section 6407 provisions of PPACA relative to the physician documentation requirement in 42 CFR 424.22(a)(1)(v) as follows: “The physician responsible for performing the initial certification must document that the face-to-face patient encounter, which is related to the primary reason the patient requires home health services, has occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care by including the date of the encounter, and including an explanation of why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services as defined in Sec. 409.42(a) and (c) of this chapter, respectively.”
……
(F) The physician responsible for certifying the patient for home care must document the face-to-face encounter on the certification itself, or as
an addendum to the certification (as described in paragraph (a)(1)(v) of this section), that the condition for which the patient was being treated in the face-to-face patient encounter is related to the primary reason the patient requires home health services, and why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services as defined in Sec. 409.42(a) and (c) respectively. The documentation must be clearly titled and dated and the documentation must be signed by the certifying physician.”
20. Once the person is determined to meet the basic criteria for eligibility, the beneficiary may receive any of the following home health care services, for an unlimited number of visits, provided the services are medically reasonable and necessary
• Part-time or intermittent nursing care provided by or under the supervision of a registered nurse;
• Physical therapy, occupational therapy or speech language pathology services;
• Medical social services that are related to the person’s illness or injury; and
• Part-time or intermittent home health aid services when provided as an adjunct of skilled nursing or therapy care;
• Medical equipment and supplies
21. The Defendants have published a series of guidelines and communications on-line since the promulgation of the face-to-face physician encounter rule. http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html These publications include:
• Home Health Face-to-Face Encounter Question & Answers (03/01/13)
• Chapter 4 Physician Certification and Recertification of Services Manual Changes (4/22/11)
• Update on Physician Signature Requirement and Face-to-Face Encounter Requirements (3/31/11)
• Chapter 7 Home Health Manual Updates with Face-to-Face Revisions - February 16, 2011
• Additional Time to Establish Protocols for newly Required Face-to-Face Encounters for Home Health and Hospice Recertification - December 23, 2010
• Home Health face-to-face Guidance PowerPoint (2/16/11)
• Special Edition MLN Matters article detailing home health face-to-face provision and requirements (12/22/10)
• Listserv home health face-to-face announcement (12/20/10)
20. After stakeholders expressed a need for more information on how what it takes for a physician to compose compliant face-to-face encounter documentation, the Defendants issued another MLN Matters, SE 1405,
FACTUAL ALLEGATIONS
22. The Defendants consider the physician face-to-face encounter rules, including the documentation requirements, under 42 CFR 424.22(a)(1)(v) to be conditions for Medicare payment.
23. In the event that the Defendants determine, directly or through their contractor, that the face-to-face encounter documentation does not include a sufficient “brief narrative statement” that describes how the patient’s clinical condition supports the patient’s homebound status and/or the need for skilled services, the claim will be denied Medicare payment.
24. Defendants prohibit a home health agency and any of its personnel from composing or assisting the physician in composing the requisite face-to-face encounter narratives.
25. The physicians involved in care of home health patients under Medicare are in no way sanctioned, penalized, or held to any adverse consequences within the Medicare program if they fail to comply with the physician documentation requirements regarding the face-to-face encounter.
26. If a home health agency accepts a Medicare patient into care and the patient’s physician fails to provide compliant face-to-face encounter documentation, Medicare payment to the home health agency will be denied by Defendants.
27. Under Defendants’ policy and practice, all control over physician documentation of the face-to-face encounter lies with the physicians or their staffs, while all responsibility for the submission of compliant documentation lies with the home health agency.
28. Since the home health agency has no control over the physician’s documentation, the only control that a home health agency has is whether to admit the patient for care. The Defendants rules, 42 CFR 424.22(a)(1)(v), permit a physician to provide the requisite encounter and compose documentation within 30 days of the patient’s admission to home health care. As such, a home health agency may provide at least 30 days of care without reimbursement in the event that the physician does not provide compliant documentation.
29. Since the promulgation of the face-to-face encounter rule, 42 CFR 424.22(a)(1)(v), Plaintiff and its members have made repeated requests to Defendants to explain and clarify the documentation requirements. In particular, Plaintiff and its members have explained that the requirements for the physician narratives on homebound status and skilled care need are outside the statutory authorization and continue to be unclear, leading to nationwide confusion among all parties involved, including physicians, home health agencies, and Medicare contractors. As recently as May 22, 2014, the Defendant has held to a final position and final decision that she will maintain the enforcement of the unauthorized physician narrative documentation requirement. Plaintiff has fully pursued all reasonable and available administrative remedies prior to this litigation, including efforts in recent weeks to avoid litigation all together.
30. Numerous members of Congress have also expressed to Defendants that the policies of physician face-to-face encounter needed to be revised, clarified, and comprehensively explained in order to avoid the rules creating unnecessary paperwork burdens and roadblocks top care for bona fide Medicare home health patients.
31. While Defendants have attempted to supply the requested clarifications and explanations, those efforts have failed to provide sufficient guidance such that home health agencies, along with physicians and Medicare beneficiaries, can adequately understand what it takes to provide compliant documentation. At this point, home health agencies and other stakeholders consider the Defendants’ documentation requirements and compliance standards a mystery shrouded in a deep fog with little chance for any security or consistency in claim determinations.
32. Defendants’ attempts at clarification and explanation of the documentation requirements have fallen far short of that necessary to inform stakeholders as to the standards for compliance. The Defendants have relied on the use of extreme examples that present either documentation that is blatantly noncompliant or documentation with such a high degree of detail that it is far beyond the “brief narrative” that the Defendants’ policies express as compliant.
33. The level of confusion among stakeholders is such that Plaintiff presented 11 claims that had been denied for failure to meet the face-to-face encounter physician narrative documentation requirements to the Medical Directors of the Medicare contractors had denied them. The Medical Directors of these contractors concluded that 9 of the 11 presented compliant narratives. Two of the three Medical Directors agreed that one of the remaining two were compliant. A different two of three Medical Directors agreed that the last claim had compliant documentation. Among those 11 claims rejected for insufficient physician narratives without a full record review beyond the narratives are the following:
-- a patient with a fractured left femur and liposarcoma with a physician narrative on home bound status stating "recent need for O2 due to liposarcoma. WB status due to recent L femur fx."
-- A patient with a total knee replacement with a narrative stating, "Con't PT as stated above for gait, strength, endurance. Taxing effort to leave home due to weakness & surgery."
-- a patient with COPD, respiratory failure, and HTN with a physician narrative stating, " Patient is home bound due to unsteady gait and poor balance. Inability to manage medical condition."
34. Recent statistics on claim determinations depict a home health industry and physician community that is deep in confusion as to what is compliant physician documentation. One Medicare contractor has denied nearly 85% of all home health claims subject to post-payment review on the basis that the physician face-to-face encounter documentation was not compliant. Another Medicare contractor reports that 79% of claim denials issued relate to face-to-face encounter documentation deficiencies.
The claims involved patients who all had a compliant physician encounter on a timely basis. Only the documentation was considered noncompliant.
35. In a recent decision of a Medicare contractor, the consequences of an unauthorized documentation requirement and inadequate guidance on the standards for compliance with that requirement are highlighted. The patient was a 95 year old male with a principal diagnosis of pressure ulcers on the buttocks. In addition, he had another pressure ulcer on his back, hypertensive chronic kidney disease, and Alzheimer’s disease. His physician ordered skilled nursing services for wound care, observation and assessment of body systems, pain management, vital sign assessment, instruction in disease processes, medication management and education, and monitoring signs and symptoms of infection. The patient was bedfast, in need of a wheelchair for transportation, transferred using a Hoyer lift, incontinent of bowel and bladder, and limitations in endurance with complete bedrest.
36. In reviewing the patient records, the contractor concluded that:
“The skilled nursing visits were warranted based on the submitted documentation. The patient met homebound criteria and the skilled nursing visits were reasonable and necessary.”
37. Despite that the contractor found the documentation clearly showed the patient met Medicare coverage criteria, it ultimately denied the claim stating, “However, the provided documentation does not support that a complete Face-to-Face evaluation was performed as the homebound eligibility was an insufficient description of how the patient’s clinical condition warranted homebound status.”
38. The Face-to-Face encounter documentation submitted by the patient’s physician stated,
“The veteran never leaves his home or his bed. He is a total care patient who is dependent in all ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living).”
39. Home health agencies nationwide have made ongoing and bona fide efforts to understand the Defendants’ requirements for documentation of the physician’s face-to-face encounter with the home health patients. They desperately want to achieve compliance, but the continuing inadequate standards make that nearly impossible as demonstrated by the statistics set out in paragraph 34 and the experiences set out in paragraph 33.
40. At this point, the options available to home health agencies to address their concerns are limited and harmful to their patients, their business security, and the Medicare program. A home health agency that is uncertain about the sufficiency of the physician’s documentation can:
• Reject the patient for admission to care. This can lead to serious health consequences for the patient, increased costs to Medicare, and the closure of the home health agency business.
• Admit the patient to care. The evidence to date indicates that such action presents a high risk of a retroactive claim denial, leaving the provider with uncompensated care. The ultimate consequence in such circumstance is business bankruptcy.
• Pursue appeals of claim denials. This is no better an option as appellate decision-makers have nor better guidance on compliant documentation that do the home health agencies. In addition, the current wait time for a hearing before an Administrative law Judge is in excess of 3 years. With Medicare taking back any payments made on claim denials, bankruptcy is the inevitable result for the business.
41. The defendants’ have done very little to educate physicians regarding the documentation requirements even though all the documentation responsibility rests with the physicians and outside the input and control of the home health provider. To the extent that the Defendants’ have provided physician education it is limited to the same vague and ambiguous guidance to home health agencies that has been proven to be as inadequate and uninformative.
42. The Defendants’ failure to provide adequate guidance on compliant documentation is compounded by their failure to examine and evaluate the entire patient record before denying a claim based on an allegation of noncompliant documentation. On information and belief, Defendants’ contractors limit their review to the documentation labeled, as required by the Defendants, as “face-to-face encounter” documentation. This process ignores the extensive documentation including the patient plan of care, physician assessment, physician certification of homebound status and need for skilled care, a comprehensive patient assessment (“OASIS’), and detailed clinical records of patient care and condition. Accordingly, while the Defendants expect physicians to know the magic words that meet the ill-defined standard of a “brief narrative, they refuse to evaluate a very extensive record on the patient that could very likely resolve any questions or doubts regarding qualification for Medicare benefits.
43. The Plaintiff does not seek the payment of Medicare benefits through this action. Instead, Plaintiff’s claims are collateral to benefit payment and are limited to the validity of a documentation rule and the quest for adequate guidance on the standards for documentation compliance.
44. There is no other adequate remedy. Plaintiffs have exhausted all possible administrative remedies. Claims appeals provide no avenue for redress are the necessary systemic change sought in this action.
FIRST CAUSE OF ACTION
Violation of 42 USC 1395f(a)(2)(C) and 42 USC 1395n(a)(2)(C)
45. Plaintiff restates ad incorporates by reference herein paragraphs 1-44.
46. Section 6407 of PPACA, as codified at 42 USC 1395f(a)(2)(C) and 42 USC 1395n(a)(2)(C), provides that a physician must document that he/she had a face to face encounter with the home health care patient.
47. The Defendants have added extensive physician documentation requirements beyond that required in the statute, including a requirement under 42 CFR
424.22(a)(1)(v) that the physician include a narrative or other pre-existing documents that explain why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services.
48. Defendants’ promulgation and effectuation of the final rule provision requiring extensive and burdensome documentation from the patient’s physician is inconsistent with, contrary to, and in violation of Section 6407 of PPACA, as codified at 42 USC 1395f(a)(2)(C) and 42 USC 1395n(a)(2)(C).
49. Plaintiff has no adequate remedy at law.
SECOND CAUSE OF ACTION
Violation of the Due Process Clause of the Fifth Amendment to the United States Constitution, 42 USC 1395hh, and the Administrative Procedures Act, 5 USC 553.
50. Paragraphs 1-44 are incorporated by reference herein.
51. The Defendants’ implementation of 42 CFR 424.22(a)(1)(v) through various guidelines, FAQs, MLN Matters publications, and web-based information is ambiguous and wholly unclear as to the appropriate standards for compliant documentation. As a result, home health agencies, acting in good faith and with sincere intent to submit compliant claims documentation regarding the physician face to face encounter with the patient, are unable to understand what the defendants require for compliant documentation.
52. As a result of the unclear and ambiguous implementing guidance on physician documentation issued by the Defendants, home health agencies face a serious risk of a retroactive claim rejection even though the patient has had a timely physician encounter that has been documented by the physician.
53. Defendants’ failure to issue and apply clear and unambiguous standards regarding physician documentation of the face-to-face encounter while holding home health agencies responsible for submitting compliant documentation violates the home health agencies’ rights to Due Process under the Fifth Amendment to the US Constitution and their rights to adequate rules and guidelines of general applicability under 42 USC 1395hh.
54. Plaintiff has no adequate remedy at law.
THIRD CAUSE OF ACTION
Violation of the Fifth Amendment to the US Constitution and 42 U.S.C.§1395gg
55. Paragraphs 1-44 are incorporated by reference herein.
56. Defendants’ policy and practice is to deny Medicare claims for payment of home health services without reviewing the entire documentation of record when the review of the physician face-to-face documentation results in a finding that the physician narrative on skilled care or homebound status exists, but is noncompliant with the documentation requirements. The additional documentation of record provides more extensive and comprehensive information regarding the patient’s need for care and homebound status than any face-to-face encounter narrative.
57. The Defendants’ refusal to evaluate the whole record of clinical documentation when evaluating the documentation compliance of a home health services claim violates the Fifth Amendment to the US Constitution and 42 U.S.C.§1395gg.
58. Plaintiff has no adequate remedy at law.
.
PRAYER FOR RELIEF
WHEREFORE, Plaintiff respectfully prays for the following relief:
A. A declaration, pursuant to 28 U.S.C.§2201, that Defendants requirements regarding physician documentation of the face-to-face encounter under 42 CFR 424.22(a)(1)(v) violate the Medicare statute, 42 U.S.C §1395f(a)(2)(C) and 1395n(a)(2)(C).
B. A declaration that the Defendants’ failure to provide clear, adequate, and unambiguous guidance on the standards for compliance regarding physician documentation of the face-to-face encounter under 42 CFR 424.22(a)(1)(v) violate the Due Process Clause of the Fifth Amendment to the United States Constitution, 42 USC 1395hh, and the Administrative Procedures Act, 5 USC 553.
C. A declaration that the Defendants’ failure to consider the entire documentation record when issuing a claim determination elative to the physician face-to-face documentation requirements violates the Fifth Amendment to the US Constitution and 42 U.S.C.§1395gg.
D. A permanent injunction prohibiting Defendants from requiring a physician narrative on homebound and skilled care need to comply with 42 U.S.C §1395f(a)(2)(C) and 1395n(a)(2)(C).
E. A permanent injunction enforcing the physician documentation of the face-to-face encounter under 42 CFR 424.22(a)(1)(v) until such time as clear, adequate, and unambiguous guidance is issued on the standards for compliance.
F. A permanent injunction requiring the Defendants to review the entire patient record to determine compliance with the physician documentation requirements of the face-to-face encounter under 42 CFR 424.22(a)(1)(v).
G. An order awarding plaintiff’s cost and attorney’s fee pursuant to the Equal Access to Justice Act, 28 U.S.C.§2412.
H. Such other and further relief as the Court deems appropriate.
Respectfully submitted,
William A. Dombi
D.C. Bar No. 445832
Center for Health Care Law
228 Seventh Street, SE
Washington, D.C. 20003
Telephone: (202) 547-5262
Facsimile: (202) 547-7126
wad@nahc.org
Attorney for Plaintiff
National Association for Home Care & Hospice, Inc.