Al-Shaikh v. State Dep't of Health Care Servs.

230 Cal. Rptr. 3d 832, 21 Cal. App. 5th 918
CourtCalifornia Court of Appeal, 5th District
DecidedMarch 27, 2018
DocketA147939
StatusPublished
Cited by3 cases

This text of 230 Cal. Rptr. 3d 832 (Al-Shaikh v. State Dep't of Health Care Servs.) is published on Counsel Stack Legal Research, covering California Court of Appeal, 5th District primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Al-Shaikh v. State Dep't of Health Care Servs., 230 Cal. Rptr. 3d 832, 21 Cal. App. 5th 918 (Cal. Ct. App. 2018).

Opinion

Banke, J.

*920INTRODUCTION

When Dr. Raad Al-Shaikh, an orthopedic surgeon, moved his Fremont practice a couple of miles from its original location, he applied to the Department of Health Care Services (DHCS), pursuant to Medi-Cal regulations, for approval of his new office as an "established place of business." He had been an approved Medi-Cal provider at his prior location for six years. Much to Dr. Al-Shaikh's surprise, the DHCS denied his application on two grounds, only one of which is at issue here. The DHCS claimed Dr. Al-Shaikh's fee arrangement with the medical billing service he used was unlawful. When Dr. Al-Shaikh filed an administrative appeal, the DHCS agreed the regulatory provisions it had cited in asserting his fee arrangement was unlawful, were inapplicable. It then cited to a different state statutory provision, which incorporates a federal Medicaid regulation. Although Dr. Al-Shaikh pointed out this federal regulation also was inapplicable, the DHCS was unmoved, and the administrative law judge (ALJ) denied his *833appeal.1 Dr. Al-Shaikh sought writ relief in the superior court.

In the meantime, Dr. Al-Shaikh also relocated his Auburn practice, for which he used the same billing service as he did for his Fremont practice. His application for Medi-Cal approval for his new Auburn office was granted (by a different regional office of DHCS).

The superior court thereafter heard the merits of Dr. Al-Shaikh's challenge to the denial of his application for his Fremont office. At the hearing, Dr. Al-Shaikh directed the court's and DHCS's attention to an official publication of the Office of the Inspector General (OIG), the principal law enforcement agency for federally funded health care programs, that expressly states his fee arrangement with the billing service does not violate federal law. The court took the matter under submission. The DHCS, in turn, promptly approved Dr. Al-Shaikh's application for his Fremont office and then urged the superior court to deny Dr. Al-Shaikh's writ petition as moot. The court did not deny the petition, but instead dismissed it as moot and without prejudice to Dr. Al-Shaikh seeking costs and statutory attorney fees.

Dr. Al-Shaikh then moved for fees under Code of Civil Procedure section 1028.5, which allows a small business or a licensee that prevails in an action *921against a state regulatory agency to recover a maximum of $7,500 in fees if the agency acted (or refused to act) without substantial justification. The DHCS's position on fees, in a nutshell, was that federally funded health care, implemented through Medi-Cal, is a complicated business and the copy of the excerpt from the OIG publication that Dr. Al-Shaikh presented at the hearing was but a single page of the multitudinous Federal Register. The DHCS emphasized that once Dr. Al-Shaikh directed its attention to the OIG publication, it promptly approved his application. Dr. Al-Shaikh, in turn, emphasized it had taken three years to obtain approval of his relocated Fremont office and, during that time, his Fremont practice had been decimated. The trial court denied Dr. Al-Shaikh's fee request.

We reverse and remand with directions to award Dr. Al-Shaikh the full amount of fees recoverable under Code of Civil Procedure section 1028.5. As the state agency responsible for implementing Medicaid and Medi-Cal, the DHCS has an obligation to be knowledgeable about the law it is charged with implementing. Moreover, this is not a case where the applicable regulatory law was unclear or in dispute. On the contrary, the OIG's publication has been on the books for more than a decade, and it has never been questioned by any regulatory body or court. Nor was this publication hidden within the Federal Register. On the contrary, the pertinent OIG publication is one of a series of publications the OIG has prepared to enhance compliance with federal law, and it continues to be cited in reference materials on federally funded health care programs. Furthermore, in its Medicare Claims Processing Manual, the Centers for Medicare and Medicaid has taken the same view on third-party billing as the OIG. Accordingly, it is no surprise that throughout these proceedings the DHCS has been unable to cite a single case or regulatory decision supporting its position that Dr. Al-Shaikh's fee arrangement with the billing service is unlawful.

*834We conclude the DHCS acted without substantial justification in refusing Dr. Al-Shaikh's application to continue as a Medi-Cal provider in his new Fremont location, and reverse with directions to award statutory attorney fees.

BACKGROUND

Dr. Al-Shaikh is an orthopaedic surgeon, and at the time of the events in question, had been an approved Medi-Cal provider at his Fremont location for six years. In May 2012, he relocated his practice to an office several miles from his prior location. As required by the DHCS, Dr. Al-Shaikh applied for approval as a Medi-Cal provider at his new Fremont location.

In the course of evaluating Dr. Al-Shaikh's application, the DHCS sent a representative from its Audits and Investigation Division to review compliance *922with Medi-Cal laws and regulations to determine whether the Fremont practice was an "established place of business." More than a year and a half later, in December 2013, the DHCS denied Dr. Al-Shaikh's application on the basis of two asserted regulatory violations: (1) that the third-party billing service he used was paid on a percentage of billings basis (citing Cal. Code Regs., tit. 22, § 51502.1, subd. (e) ), and (2) that his office business hours were not permanently posted (citing Cal. Code Regs., tit. 22, § 51000.60, subd. (c)(9)(B) ).2

Dr. Al-Shaikh filed an administrative appeal. During the appeal, the DHCS acknowledged the cited authority for denial based on the billing fee arrangement, was inapplicable. It then cited to other statutory and regulatory provisions, specifically Welfare and Institutions Code section 14040.5, subd. (b)3 and 42 Code of Federal Regulations section 447.10.4 However, the DHCS's fundamental position remained unchanged-that any percentage-based fee arrangement with a billing service violates statutory and regulatory law. Dr. Al-Shaikh responded that these statutory and *835regulatory provisions were directed at a different problem, and his fee arrangement with the billing service was not unlawful under either provision.

The DHCS issued its ruling on Dr. Al-Shaikh's appeal in May 2014. It sustained his appeal as to permanently posted business hours. It denied his appeal as to the fee arrangement with the billing service, stating, the service *923"is compensated on a percentage basis ... [t]herefore, the [a]pplicant is not in compliance with Welfare and Institutions Code, section 14040.5(b), which prohibits compensation for biller services based on a percentage of the amount collected."

Dr.

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Cite This Page — Counsel Stack

Bluebook (online)
230 Cal. Rptr. 3d 832, 21 Cal. App. 5th 918, Counsel Stack Legal Research, https://law.counselstack.com/opinion/al-shaikh-v-state-dept-of-health-care-servs-calctapp5d-2018.