Oregon Management & Advocacy Center, Inc. v. Mental Health Division, Department of Human Resources

774 P.2d 1113, 96 Or. App. 528, 1989 Ore. App. LEXIS 559
CourtCourt of Appeals of Oregon
DecidedMay 10, 1989
DocketCA A44666
StatusPublished
Cited by3 cases

This text of 774 P.2d 1113 (Oregon Management & Advocacy Center, Inc. v. Mental Health Division, Department of Human Resources) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Oregon Management & Advocacy Center, Inc. v. Mental Health Division, Department of Human Resources, 774 P.2d 1113, 96 Or. App. 528, 1989 Ore. App. LEXIS 559 (Or. Ct. App. 1989).

Opinion

DEITS, J.

Petitioner, Oregon Management and Advocacy Center (OMAC), a provider of mental health services, seeks review of a final order of a Mental Health Division (MHD) hearing officer. The order requires OMAC to reimburse MHD for overpayments in the amount of $43,752.99, suspends OMAC from participation in MHD’s medical assistance program until that amount is repaid and imposes conditions for it to reestablish its participation in the program. We affirm.

Pursuant to ORS 430.610 to ORS 430.700, MHD provides community based mental health services. Generally, the agency contracts with local governments that either provide the services or subcontract with local private agencies for the services. OMAC is a local private agency that provides “semi-independent living services,” a transition program for persons who are moving to independent living from residential care facilities for the mentally ill. Marion County entered an agreement with OMAC to begin providing the services in July, 1984.

MHD’s program is funded by state general fund monies and Medicaid medical assistance program monies under Title XIX of the Social Security Act, 42 USC § 1396a-1396i. At the beginning of the contract period, OMAC was paid from general fund monies. In January, 1985, the source of funding for patients of OMAC who were eligible for Title XIX was changed to Title XIX funds. OMAC was so advised and applied to MHD for a Medicaid vendor number, which was issued to it on January 16, 1985. OMAC was sent the number and the applicable administrative rules, specifically, OAR 461-13-005 through OAR 461-13-225, relating to the Medicaid assistance programs, OAR 309-13-000 through OAR 309-13-017, relating to Medicaid payment for community mental health services, and Title XIX billing and payment instructions.

The billing procedures under the Title XIX program were significantly different from those under the general fund program. Under the general fund program, OMAC did not have to bill for specific services but was paid a monthly stipend. However, in the Title XIX system, OMAC was required to submit monthly billings. The billing codes and definitions of services under the two programs were also different. Under [531]*531Title XIX, OMAC was required to keep records of services provided in each case file. In addition, it was required to establish a program of utilization review, a process for random internal review of the agency’s case files. OAR 309-13-005(6).

In December, 1985, MHD conducted a general review of services and billings by various service providers, including OMAC. It discovered that OMAC services and billings were unusually high. As a result, MHD conducted an audit, which revealed that there had been substantial overpayments to OMAC. MHD does not contend that OMAC knowingly or intentionally submitted false reimbursement requests. Rather, the overpayments apparently occurred because OMAC mischaracterized a number of the services as “individual therapy,” which has a high reimbursement value. The services should have been “socialization” services, which have a much lower reimbursement value. The audit also disclosed that OMAC had not maintained adequate records and had not established the required “utilization review” process.

MHD determined that OMAC had received an overpayment of $43,752.99. On April 17,1986, MHD sent a notice of sanction to OMAC, which contained the audit findings, including the amount of overpayment, and imposed additional conditions on OMAC’s continued participation in MHD’s medical assistance program. A contested case hearing was held before a MHD hearing officer, who issued an order upholding MHD’s action.

OMAC’s first assignment of error is that MHD does not have authority to decide the matter. OMAC argues that it had a contract with Marion County and that the county, not the state, is the true party in interest. However, even assuming that only the county could bring an action against OMAC for breach of contract, this is not a contract action. It is a regulatory proceeding brought to ensure that a user of federal funds complies with all requirements relating to the use of those funds. Under Title XIX, participating states must require providers receiving Medicaid funds to maintain adequate records and to make those records available to state and federal authorities. 42 USC § 1396(a)(27). MHD is designated as the appropriate state agency to carry out that responsibility. ORS 430.140. In accordance with that designation, MHD [532]*532has specific regulations requiring providers who receive Medicaid funds to maintain adequate records and authorizing MHD to proceed administratively when it determines that an overpayment of Medicaid funds had been made. Former OAR 309-13-005 and OAR 309-13-015. MHD has the requisite authority.

OMAC also argues that MHD lacks authority to impose the sanctions, because the only authority for them is in OAR 461-13-005 et seq, the rules of the Adult and Family Services Division (AFSD), not MHD and, under these rules, only the AFSD administrator may impose sanctions. OMAC argues that, in order to have the appropriate authority, MHD must rely on the provisions of OAR chapter 461 and that it cannot, because those rules were adopted by AFSD, not MHD, and because OAR 461-13-095 specifically provides:

“(Except as otherwise noted, imposition of sanctions will be at the discretion of the Administrator of the Adult and Family Services Division.)”

We conclude that MHD had the requisite authority. In addition to its own administrative rules that provide authority for it to act,1 its own rules specifically adopt by reference the procedures in OAR chapter 461. Former OAR 309-13-005(7). In addition, the authority to impose sanctions and to recover overpayments in OAR chapter 461 is given to “the Division,”2 which under OAR 461-13-005 includes AFSD, MHD and the Senior Services Division of the Oregon Department of Human Resources. Finally, not even the language of OAR 461-13-095, on which OMAC relies, compels the [533]*533conclusion that only AFSD has the authority to act. The provision states that it applies “except as otherwise noted.” Because other sections of OAR chapter 461 give MHD authority to impose sanctions, that section does not deprive MHD of authority.

OMAC also argues that the notice given was inadequate. Specifically, it contends that the notice of sanctions letter included only conclusions, did not inform OMAC of the laws or administrative rules authorizing the claim and was insufficient for it to prepare a defense or response. We disagree. The notice stated the authority for the action and gave a clear and detailed statement of the matters charged. The notice complied with both the notice requirements of OAR 461-13-095(3) and OAR 461-13-190(2), and with the requirements of ORS 183.415(2).

OMAC also contends that the hearings officer erred in overruling its objections to MHD’s evidence concerning the amount of overpayment, which was based on a statistical sampling procedure.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Villanueva v. Board of Psychologist Examiners
27 P.3d 1100 (Court of Appeals of Oregon, 2001)
Omac v. Health Div.
774 P.2d 1113 (Court of Appeals of Oregon, 1989)

Cite This Page — Counsel Stack

Bluebook (online)
774 P.2d 1113, 96 Or. App. 528, 1989 Ore. App. LEXIS 559, Counsel Stack Legal Research, https://law.counselstack.com/opinion/oregon-management-advocacy-center-inc-v-mental-health-division-orctapp-1989.