Contested Case of Brown v. Minnesota Department of Public Welfare

354 N.W.2d 115, 1984 Minn. App. LEXIS 3497
CourtCourt of Appeals of Minnesota
DecidedSeptember 4, 1984
DocketNo. C9-84-295
StatusPublished
Cited by1 cases

This text of 354 N.W.2d 115 (Contested Case of Brown v. Minnesota Department of Public Welfare) is published on Counsel Stack Legal Research, covering Court of Appeals of Minnesota primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Contested Case of Brown v. Minnesota Department of Public Welfare, 354 N.W.2d 115, 1984 Minn. App. LEXIS 3497 (Mich. Ct. App. 1984).

Opinion

OPINION

LESLIE, Judge.

On February 17, 1982, the Department of Public Welfare notified Dr. Brown that an audit disclosed he had received payments [116]*116for services not authorized by the department. The notice demanded reimbursement. Brown appealed the notice of the proposed agency action and a contested case hearing was held before a hearing examiner on November 10, 1982. On January 7, 1983, the hearing examiner issued his findings of fact and conclusions, recommending that the department receive reimbursement. On March 3, 1983, the Department of Public Welfare Medical Advisory Committee reviewed the matter and agreed with the hearing examiner’s recommendation. The department’s Deputy Commissioner issued his order on January 12, 1984, adopting the hearing examiner’s recommendation. Brown filed a petition for a writ of certiorari for review by this court.

We reverse.

FACTS

Dr. Brown was enrolled as a provider in the Medical Assistance Program administered by the Minnesota Public Welfare Department from January 1, 1981 to February 14, 1982. As a part of his medical practice, Dr. Brown provided weight reduction services to his patients.

In early 1981, the Department of Public Welfare sent the Physician’s Handbook to Brown’s office. The Physician’s Handbook contains rules for participation in the medical assistance program. It includes a rule requiring prior authorization from the department before weight reduction services can be administered under the program. Brown’s office manager, Sheila Trumble, reviewed the handbook and telephoned Thomas JoliCoeur, the department’s supervisor of professional services, to learn the procedures for gaining compensation for weight reduction services. Trumble testified that following the conversation, she had the “impression” prior authorization was not required for Brown’s medical assistance patients. The hearing examiner accepted Trumble’s testimony but found JoliCoeur did not specifically tell Trumble that Brown need not comply with the prior authorization requirement.

Following the conversation, Brown provided weight reduction services to many patients whose primary diagnosis was obesity. Brown and his patients expected that his services would be compensated by the medical assistance program. In January 1981 Brown’s office submitted its first claims for those services which the department processed and paid. Those claims did not indicate prior authorization had been obtained. During the ensuing 12 months Brown submitted over 900 claims for weight reduction 'services and received $13,624.74 in payments from the department. No claims submitted indicated prior authorization had been obtained.

In February 1982, the department conducted an audit and discovered Brown had been paid for weight reduction services without prior authorization. The department demanded reimbursement of $13,-624.74 in payments made, and withheld an additional $1,048.37 in payments for claims submitted by Brown.

Testimony at the hearing indicated that 70% to 80% of weight reduction requests are granted by the department and that 50% to 60% of surgical intervention requests are granted. The hearing examiner, although concluding the department was entitled to reimbursement, recognized that his decision would create a substantial windfall for the department and cause a hardship to Brown.

ISSUE

Is the department estopped from demanding reimbursement of medical assistance payments made to a treating physician whose patients did not receive prior authorization for that treatment?

ANALYSIS

The Minnesota Department of Public Welfare administers the Minnesota Medical Assistance Program under the authority of Minn.Stat. ch. 256B (1982). The legislature authorized the Department of Public Welfare to

[m]ake uniform rules and regulations, not inconsistent with law, for carrying [117]*117out and enforcing the provisions hereof in an efficient, economical, and impartial manner, and to the end that the medical assistance system may be administered uniformly throughout the state, having regard for varying costs of medical care in different parts of the state and the conditions in each case, and in all things to carry out the spirit and purpose of this program * * *

Minn.Stat. § 256B.04 subd. 2. The statute, as in effect when this proceeding was initiated by the department, also authorized the department to

[establish by rule general criteria and procedures for the identification and prompt investigation of suspected medical assistance fraud, theft, abuse, presentment of false or duplicate claims, presentment of claims for services not medically necessary, or false statement or representation of material facts by a vendor of medical care, and for the imposition of sanctions against a vendor of medical care * * *

Minn.Stat. § 256B.04 subd. 10 (1982) (emphasis supplied).

Under the authority delegated to it, the department promulgated a rule requiring physicians enrolled in the medical assistance plan to gain “prior authorization” from the department for weight reduction services. Minnesota Rules 9500.1070 sub-part 4(A)(1). The department also promulgated a rule defining “abuse” for purposes of its “surveillance and utilization review program”:

“Abuse” means a pattern of practice by a provider, or a pattern of health care utilization by a recipient which is inconsistent with sound fiscal, business, or medical practices, and results in unnecessary costs to the programs, or in reimbursements for services that are not medically necessary or that fail to meet professionally recognized standards for health care. Abuse is characterized by, but not limited to, the presence of one of the following conditions:
C. The repeated submission of claims by a provider for health care which is not reimbursable under the programs, or the repeated submission of duplicate claims.

Minnesota Rules 9505.1750 subpart 2(C). These rules form the basis for the department’s claim against Brown.

On appeal we are bound by the hearing examiner’s findings of fact when there is substantial evidence to support them. Our scope of review is limited by Minn.Stat. § 14.69 (1982) (formerly Minn. Stat. § 15.0425), Brunner v. Minnesota Department of Public Welfare, 285 N.W.2d 74, 75 (Minn.1979). The department is entitled to deference from courts when it acts within its area of expertise. Red Lion Broadcasting Co., Inc. v. F. C. C., 395 U.S. 367, 381, 89 S.Ct. 1794, 1802, 23 L.Ed.2d 371 (1969). Yet, where an agency decision is affected by harmful error of law it will be reversed.

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Related

Brown v. Minnesota Department of Public Welfare
368 N.W.2d 906 (Supreme Court of Minnesota, 1985)

Cite This Page — Counsel Stack

Bluebook (online)
354 N.W.2d 115, 1984 Minn. App. LEXIS 3497, Counsel Stack Legal Research, https://law.counselstack.com/opinion/contested-case-of-brown-v-minnesota-department-of-public-welfare-minnctapp-1984.