In the Matter of the Surveillance and Integrity Review (SIRS) Appeals by Trinity Home Health Care Services and Etyane ...

Supreme Court of Minnesota·Decided October 11, 2023·No. A220183·Published

Opinion

STATE OF MINNESOTA

IN SUPREME COURT

A22-0183

Court of Appeals Thissen, J.

Dissenting, Chutich, J.

Took no part, Procaccini, J.

In the Matter of the Surveillance and Integrity Review (SIRS) Appeals by Trinity Home Health Care Services and Etyane Ayana.

Filed: October 11, 2023

Office of Appellate Courts

Matthew J. Schaap, Cassandra C. Wolfgram, Dougherty, Molenda, Solfest, Hills & Bauer P.A., Apple Valley, Minnesota, for appellants.

Keith Ellison, Attorney General, Leonard J. Schweich, Assistant Attorney General, Saint Paul, Minnesota, for respondent.

Keith Ellison, Attorney General, Rachel Bell-Munger, Assistant Attorney General, Saint Paul, Minnesota, for amici curiae Commissioners of the Minnesota Departments of Health, Labor and Industry, and Veterans Affairs.

Brianna Boone, Russell Squire, Southern Minnesota Regional Legal Services, Saint Paul, Minnesota, for amicus curiae Southern Minnesota Regional Legal Services.

SYLLABUS

The Department of Human Services does not have the authority to remand a case to an administrative law judge under Minn. Stat. § 14.62 (2022), or under any other source of implied authority, after the administrative law judge issues a final recommendation.

Reversed.

OPINION

THISSEN, Justice.

The question in this case is whether the Department of Human Services (DHS)

appropriately remanded a case to an administrative law judge (ALJ) under the Minnesota Administrative Procedure Act, Minn. Stat. § 14.62 (2022). We conclude that DHS did not have the authority to remand the case to the ALJ. Accordingly, the ALJ’s September 21, 2019, Findings of Fact, Conclusions of Law, and Recommendation—the ALJ’s first report—is the binding decision in this matter. Based on this resolution of the case, we do not reach the questions of whether the DHS Commissioner’s final order issued after the remand to the ALJ was arbitrary and capricious or whether the final order was supported by substantial evidence.

FACTS

Appellant Etyane Ayana is the sole owner of appellant Trinity Home Health Care Services (collectively, “Trinity”). Trinity provides nursing services, personal care assistant (PCA) services, and homemaking services. It receives reimbursement from respondent DHS for services that it provides to Medicaid-eligible persons with disabilities. Minnesota’s Medicaid program is known as Medical Assistance. As part of its oversight

of the program, DHS has a Surveillance and Integrity Review Section (SIRS), which conducts audits and investigations into suspected noncompliance with program requirements.

Medicaid is a joint federal-state program. Federal law requires DHS to make sure that providers comply with federal program requirements as a condition of receiving federal funding. 42 U.S.C. § 1396c. SIRS’s responsibility includes “identifying and investigating fraud, theft, abuse, or error by vendors or recipients of health services.” Minn. R. 9505.2160 (2021). DHS can impose sanctions and fines—including termination from the program—on Medical Assistance vendors who (among other things) commit “fraud, theft, or abuse.” Minn. Stat. § 256B.064, subds. 1a and 1b (2022). DHS can also “obtain monetary recovery from a vendor who has been improperly paid either as a result of conduct [including fraud, theft, or abuse] or as a result of a vendor or department error, regardless of whether the error was intentional.” Minn. Stat. § 256B.064, subd. 1c (2022).

This saga began nearly 8 years ago. SIRS’s first investigation of Trinity and Ayana began in 2015 following complaints about Trinity’s services. As part of that investigation, SIRS investigators conducted an onsite review of Trinity in March 2016. 1 The investigator reviewed and scanned some Trinity records from the period between January 1, 2015, to

1 Under Minnesota Rule 9505.2185, subpart 2 (2021), a vendor “shall grant the department access during the department’s normal business hours to examine health service and financial records related to a health service billed to a program.” SIRS also has the authority to “investigate vendors . . . to monitor compliance with program requirements for the purposes of identifying fraud, theft, abuse, or error in the administration of the programs,” Minn. R. 9505.2200, subp. 1 (2021), and this “authority to investigate extends to the examination of any person, document, or thing which is likely to lead to information relevant to the expenditure of funds,” id., subp. 3 (2021).

March 8, 2016. The investigator compared the documentation to billed claims and determined that Trinity had been overpaid $640,641.12 for nursing services, $277,187.30 for PCA services, and $2,599 for homemaking services. 2 The investigator did not contact Trinity regarding any problems that she found. In May 2016, DHS referred the matter to

2 Specifically, SIRS concluded that the overpayment included:

• $640,641.12 for nursing services. The investigator based her calculation on evidence of missing or insufficient documentation;

Licensed Practicing Nurses (LPNs) billed as Registered Nurses (RNs); overlapping shifts; and a failure to document time. The investigator used the following standards in calculating this overpayment: (1) a timesheet was not enough documentation to show that services were provided to a patient; and (2) an overpayment amount was calculated for the entire period of claimed time if there were no progress notes for the claim billed.

• $277,187.30 for PCA services. State law requires that PCA agencies maintain certain documentation including “time sheets for each personal care assistant” and a personal care plan for each recipient of care, which must be updated annually. Minn. Stat. § 256B.0659, subds. 7, 28(a)(4) (2022). The statute requires that care plans include “start and end date[s] of the care plan” and a plan for how the recipient will use PCA services over the course of the year. Id., subd. 7. The statute sets forth several requirements for the information that must be in the time sheet. Minn. Stat. § 256B.0659, subd. 12(c) (2022). The investigator found the following errors in Trinity’s records: no time documented on a timesheet; missing timesheets; missing other required components on the timesheet (signatures, provider number, activities completed, fraud statement); submission of time by PCAs who failed a background study; timesheets that had conflicting information for the service dates, service recipient, and PCA;

photocopied timesheets; and claims for services on dates when recipient was receiving inpatient care.

• $2,599 for homemaking services. The investigator found that timesheets for the billed services were missing altogether or were missing information about the time of service and other required components on the timesheets (such as signatures). The investigator also found examples in which Trinity billed for overlapping time when the same individual provided PCA services and homemaking services for the same recipient.

Minnesota’s Medicaid Fraud Control Unit. By January 2017, the case was closed without action.

Almost a year and a half later, on May 2, 2018, SIRS pursued further investigation.

In July 2018, a new SIRS lead investigator conducted a second onsite review of Trinity for service dates of March 1, 2017, to December 31, 2017. Following review of the records, the SIRS investigator determined that, for the time period, Trinity had been overpaid $52,660.10 for nursing services, $287,006.93 for PCA services, and $696.49 for homemaker services. The reasons for SIRS finding an overpayment were similar to the 2016 investigation. DHS concluded that termination was the appropriate sanction and that an immediate payment withhold was in order.

In February 2019, DHS sent Trinity and Ayana notices of termination from the program, as well as notices demanding return of overpayments and payment-withholding. Trinity and Ayana appealed.

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