Grier v. Kizer

219 Cal. App. 3d 422, 268 Cal. Rptr. 244, 1990 Cal. App. LEXIS 323
CourtCalifornia Court of Appeal
DecidedApril 2, 1990
DocketB036081
StatusPublished
Cited by32 cases

This text of 219 Cal. App. 3d 422 (Grier v. Kizer) is published on Counsel Stack Legal Research, covering California Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Grier v. Kizer, 219 Cal. App. 3d 422, 268 Cal. Rptr. 244, 1990 Cal. App. LEXIS 323 (Cal. Ct. App. 1990).

Opinion

Opinion

KLEIN, P. J.

Defendants and appellants Kenneth Kizer, Director of the Department of Health Services, State of California (Director), and the Department of Health Services, State of California (Department) (sometimes collectively referred to as Department), appeal a judgment granting plaintiff and respondent Dr. Raymond E. Grier’s (Grier) petition for writ of administrative mandamus (Code Civ. Proc., § 1094.5). Grier’s petition successfully challenged an administrative determination that he overcharged the Department. We affirm the judgment.

Summary Statement

The Department used an in-house random sampling and extrapolation method to audit the claims for payment of physicians who were Medi-Cal providers. The Department viewed this method of auditing as consistent with accepted auditing principles and as a rule of internal management; as such, the auditing procedure was exempt from the necessity of promulgating a regulation pursuant to the Administrative Procedure Act (APA). (Gov. Code, §§ 11340 et seq., 11370). 1

After losing at the administrative level, Grier, one of the physicians, filed a petition for writ of administrative mandamus to challenge the Department’s audit of his claims on the grounds, inter alia, the method utilized was in violation of the APA and thus void and unenforceable.

While the petition for writ was pending, the Office of Administrative Law (OAL), the state agency charged with reviewing proposed administrative *428 regulations, determined the Department’s audit procedure to be the subject of a regulation within the contemplation of section 11342, subdivision (b). Therefore, because the audit technique had not been duly adopted as a regulation pursuant to the APA, the OAL deemed it to be an invalid and unenforceable “underground” regulation. 2

The OAL’s determination in this regard is entitled to due deference. Further, case law holds that where an agency’s rule is of general application, as contrasted with dealing with matters relating solely to the management of an agency’s internal affairs, the rule becomes the subject of a regulation, which regulation must be adopted pursuant to APA standards.

We find the Department’s random sampling audit method was a standard of general application to all Medi-Cal providers and should have been promulgated as a regulation in accordance with the APA. We affirm the judgment.

Factual & Procedural Background

Grier was a provider under the Medi-Cal program. In August or September of 1982, the Department audited claims for payment filed by Grier during the period between December 1980 and March 1982. The total amount paid to Grier for the period was $932,642.

Fan Yee (Yee), an operations research specialist for the Department, developed a random sampling plan to audit physician claims. As to Grier, Yee selected a sample size of 200 pages from a 9,711-page record of all claims for services rendered to Medi-Cal beneficiaries by Grier during the period in question and submitted for payment.

After the selected samples were audited, the audit results were extrapolated, which process disclosed an estimated overpayment to Grier of $654,592, with a 95 percent confidence at a projection of plus or minus $16,344.

Grier filed an audit appeal with the Department. A hearing was held before the Department’s administrative law judge (ALJ) on December 4, 1985. Grier, his expert, Dr. Michael Intriligator, and Yee testified. Grier testified as to the wide variety of patients seen in his practice. In his testimony, Intriligator attacked Yee’s methodology, opining that in view of the *429 heterogeneity of Grier’s practice, a stratified sampling method would have yielded a more accurate result than simple random sampling. 3

In an interlocutory decision adopted April 15, 1986, the Department held: “The appeal with respect to [the] Department’s ability to offer as proof the sampling and extrapolation methods employed by the Department in this case is denied. However, the determination of the ultimate trustworthiness of the sample and extrapolation methodology in terms of the weight to be given the evidence is reserved until there has been a full hearing on the audit adjustments (possible sources of nonrandom error) and a recalculation of both the estimated overpayment and precision has been made.”

On September 29, 1986, Grier filed a petition for writ of mandate, alleging, inter alia, the sampling methods utilized by the Department were arbitrary and capricious, there was no evidence to support the findings of the ALJ, and the ALJ employed by the Department was biased. Grier subsequently filed an amended petition, alleging the sampling methods adopted by the Department were in violation of the APA and thus void and unenforceable.

The Department’s answer urged, inter alia, that Grier’s challenge to its authority to use the subject sampling method was untimely. The Department also invoked Welfare and Institutions Code section 14170, requiring the Department to audit Medi-Cal providers in a manner consistent with accepted auditing practices, as sufficient authority for the method in issue.

During this time frame, the Union of American Physicians and Dentists requested the OAL to determine whether the Department’s policy of using a statistical sampling and extrapolation method for determining overpayment when auditing physicians’ claims constituted a regulation as defined in section 11342, subdivision (b).

After considering the Department’s arguments, the OAL filed an opinion concluding: the challenged audit method was a regulation, none of the recognized exceptions to the APA rules was applicable, and because the method had not been duly adopted as a regulation and filed with the Secretary of State in accordance with the APA, it was invalid and unenforceable. (1987 OAL Determination No. 10 [Docket No. 86-016] Aug. 6, 1987.)

*430 The hearing on the petition for writ of mandate was held on April 6, 1988. The record of the administrative proceedings was received into evidence, arguments were presented and the matter was submitted.

The trial court ruled “the statistical methods utilized by [the Department] in this case are invalid and unenforceable for failure to comply with the requirements of the Administrative Procedure Act, Gov. Code Sections 11342 et seq., [sic] and as a separate and independent basis for judgment, having also determined that there is not substantial evidence to support the findings of fact of the Director . . . that the statistical methods utilized by the Department in this case were valid or adequate[.]”

The trial court granted Grier’s petition to set aside the Department’s decision and ordered the Department to refrain from making any claim against Grier based upon the sampling and extrapolation methods utilized herein.

Following entry of judgment, the Department appealed. 4

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Bluebook (online)
219 Cal. App. 3d 422, 268 Cal. Rptr. 244, 1990 Cal. App. LEXIS 323, Counsel Stack Legal Research, https://law.counselstack.com/opinion/grier-v-kizer-calctapp-1990.