HCA Health Services of Kansas, Inc. v. State, Secretary of Kansas Department of Social & Rehabilitation Services

900 P.2d 838, 21 Kan. App. 2d 141, 1994 Kan. App. LEXIS 151
CourtCourt of Appeals of Kansas
DecidedApril 22, 1994
DocketNo. 69,804
StatusPublished
Cited by1 cases

This text of 900 P.2d 838 (HCA Health Services of Kansas, Inc. v. State, Secretary of Kansas Department of Social & Rehabilitation Services) is published on Counsel Stack Legal Research, covering Court of Appeals of Kansas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
HCA Health Services of Kansas, Inc. v. State, Secretary of Kansas Department of Social & Rehabilitation Services, 900 P.2d 838, 21 Kan. App. 2d 141, 1994 Kan. App. LEXIS 151 (kanctapp 1994).

Opinion

Green, J.:

HCA Health Services of Kansas, Inc., d/b/a HCA Wesley Medical Center (Wesley), appeals the trial court’s judgment in favor of the Kansas Department of Social and Rehabilitation Services (SRS) for reimbursement of overpaid Medicaid claims. Wesley claims the methodology used by SRS in determining the recoupment amount was improper. SRS cross-appeals the trial court’s determination of the effective date of its policy change requiring written referrals. We affirm in part, reverse in part, and remand.

The Kansas Primary Care Network (KPCN) operates under a waiver issued by the Health Care Financing Administration (HCFA), which is part of the federal Department of Health and Human Services (HHS). Electronic Data Systems Federal (EDS) serves as fiscal agent for SRS in the Medicaid program. At the request of the KPCN, EDS audited a sample of Wesley’s outpatient Medicaid claims from April 1, 1987, through May 31, 1988.

[143]*143An SRS representative testified that because of the large number of claims, EDS could only audit a sample of the claims paid. After examining the records of the sample, EDS calculated an error rate which was then applied to the total dollar amount of claims paid during the period to determine the amount that SRS had overpaid. The results of the audit showed the sample had an error rate of 45.7%. After applying that percentage figure to the total dollar amount of claims paid, EDS determined SRS had overpaid Wesley by $250,561.15.

Wesley challenged EDS’s findings at an administrative hearing where Wesley provided additional documentation on various claims. Although the overpayment amount was reduced to $140,851.55, Wesley appealed, requesting a statutory fair hearing. As a result of stipulations by the parties, the overpayment amount was reduced to $93,371.03 before the fair hearing. The amount was further reduced to $75,606.96 by the fair hearing officer, whose decision was later affirmed by the State Appeals Committee.

Next, Wesley filed a petition for judicial review of the hearing officer’s decision. Finding that the bulletin sent out in December 1985 furnished adequate notice that telephone referrals would no longer be acceptable, the trial court reversed part of the hearing officer’s decision. Following the trial court’s decision, both parties stipulated that the overpayment amount would be $68,753.54. Both parties appealed.

Because judicial review of agency actions are reviewable by us, we must determine from the record if substantial competent evidence existed to support the findings of the trial court. See K.S.A. 77-621(c)(7). We may not reweigh the facts or substitute our own judgment for that of the trial court or the administrative body. Kaufman v. Kansas Dept. of SRS, 248 Kan. 951, 961-62, 811 P.2d 876 (1991). The party challenging the validity of the agency action bears the burden of proof. 248 Kan. 951, Syl. ¶ 4.

Wesley argues the evidence was insufficient to support the decision of both the hearing officer and the trial court concerning services it provided without a KPCN referral. During the audit, EDS employees reviewed the medical charts of each claim in the sample to check for the type of service and for the proper KPCN [144]*144referral if required. As stated earlier, the KPCN operates under a waiver from the federal agency. This waiver allows Kansas to restrict Medicaid patients to a specific provider; however, this restriction is inapplicable in emergency care situations.

During the period audited, the KPCN required that patients be treated either by their KPCN doctor or by another doctor with a referral from their KPCN doctor. The KPCN required that the referral be in writing. With the exception of emergency cases, failure to have the required referral was grounds for SRS to refuse the claim or to recoup monies previously paid on the claim.

CLASSIFICATION OF CLAIMS AS EMERGENCY OR NONEMERGENCY

Wesley argues it should have been allowed to show that bills submitted as nonemergency services were actually for emergency services. Because the services were emergency, no referral was required, and SRS should not have been allowed to recoup the monies paid for these services. Wesley argues that SRS’s determination of what constitutes emergency services is arbitrary because of its shifting definition of the term “emergency services.” Finally, Wesley claims the testimony in the record shows that most of the claims denied by SRS were for emergency services and, therefore, SRS could not deny payment.

The challenged claims can be broken down into three different categories. The first category consisted of claims originally billed by Wesley as nonemergency claims. These claims were paid by EDS as nonemergency services. Because they were claims for non-emergency services, SRS required a written referral from the KPCN doctor to the emergency room doctor before SRS would pay for the services.

The second category consisted of claims originally billed by Wesley as emergency claims for which, at the time of billing, SRS had denied the emergency status and paid as nonemergency services. Because SRS determined the services were nonemergency, a KPCN referral was required.

The third category consisted of claims originally billed and paid as emergency claims but later, during the post-audit review, de[145]*145termined to be for nonemergency services. SRS sought to recoup overpayment for these claims.

Wesley first argues that it was denied due process because it was prevented from proving that certain claims originally billed as non-emergency were actually emergency services and, therefore, did not need a KPCN referral. Wesley also claims it should be allowed to challenge claims originally billed as emergency but denied by SRS and paid as nonemergency.

The hearing officer ruled that according to K.A.R. 30-7-30 (revoked July 1, 1989) and K.A.R. 30-7-68, Wesley could have requested a fair hearing challenging SRS’s reclassification of Wesley’s claims within 30 days of receiving payment for the claims. Because it failed to challenge either its own billing classification or SRS’s reclassification, Wesley was precluded from trying to challenge SRS’s reclassification of those claims at the administrative proceeding.

In discussing the basic elements of procedural due process, our Supreme Court stated: “The essence of due process is protection against arbitrary government action. The basic elements of procedural due process of law are notice and an opportunity to be heard at a meaningful time in a meaningful manner." Joe Self Chevrolet, Inc. v. Board of Sedgwick County Comm’rs, 247 Kan. 625, 630, 802 P.2d 1231 (1990).

K.S.A. 75-3306 furnishes a fair hearing for any interested party to appeal a final action of SRS. Under K.A.R. 30-7-30, a request for a fair hearing will be dismissed if filed more than 30 days from the date of the agency action. K.A.R. 30-7-30 was replaced by K.A.R. 30-7-68, which states a fair hearing must be requested in writing within 30 days from the date of the order or notice of action.

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Bluebook (online)
900 P.2d 838, 21 Kan. App. 2d 141, 1994 Kan. App. LEXIS 151, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hca-health-services-of-kansas-inc-v-state-secretary-of-kansas-kanctapp-1994.