Price v. Adult & Family Services Division

600 P.2d 918, 42 Or. App. 403, 1979 Ore. App. LEXIS 3276
CourtCourt of Appeals of Oregon
DecidedOctober 1, 1979
DocketNo. 2-2601-MXA498-7, CA 12888
StatusPublished
Cited by1 cases

This text of 600 P.2d 918 (Price v. Adult & Family Services Division) 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
Price v. Adult & Family Services Division, 600 P.2d 918, 42 Or. App. 403, 1979 Ore. App. LEXIS 3276 (Or. Ct. App. 1979).

Opinions

RICHARDSON, J.

Petitioner, a recipient of Aid to Dependent Children (ADC), appeals an order of the Adult and Family Services Division (AFSD) which denied her request for payment for four psychotherapy sessions.

The parties filed a stipulation, including exhibits, in lieu of a record for review. The stipulation indicates that petitioner was hospitalized in July, 1977, for emotional problems. Upon her discharge she was referred by her physician to a psychologist for psychotherapy. On August 1, 1977, petitioner was interviewed by a psychologist who recommended psychotherapy for not more than ten sessions. On the same day the psychologist made a written request of AFSD to authorize payment for the therapy sessions. In conformance with AFSD rule 461-22-010, the request included a diagnosis, set out the treatment modality and described the objectives of the treatment.

The request was denied on August 18, 1977, with a notation on the request form, "no indication of child care problems.” The psychologist was notified of the denial of payments on September 9, 1977. After the intake interview on August 1, 1977, petitioner had four therapy sessions with the psychologist on August 15, August 26, September 12 and September 19, 1977. Petitioner had two therapy sessions after denial of the request for authorization of the medical services.

Petitioner requested a hearing. Prior to the hearing petitioner’s attorney requested an explanation of the denial and received a written response that denial of payment was pursuant to the agency’s "Guide for Physicians Services Rule #416-14-021 [sic 461-14-021].” This rule is inapplicable to petitioner’s request for payment because it only relates to in hospital psychotherapy and to limited services by a physician. Petitioner applied for authorization for medical services with a psychologist, which services are controlled by Rule 461-11-000, et seq.

[406]*406Two hearings were conducted by a hearings officer of AFSD. In the first hearing the only explanation offered for the agency’s denial of payment was the cryptic reference on the request form, i.e., "no indication of child care problems,” and the statement in the letter to petitioner’s counsel that the payments were denied pursuant to Rule 416-14-021 {sic; 461-14-021). The hearings officer concluded this explanation was inadequate and remanded the claim to the agency for a more detailed explanation.

In response the manager of the Health Program and Policy Unit sent the following memorandum:

"* * * The denial of authorization for payment for psychotherapy in this instance, was done in accord with the guide material which provides authority to the Medical Assistance Section to provide prior authorization on all psychotherapy requests.
"The State Office is under no constraint to justify a decision of this nature. The payment is based entirely upon funds available. At the time the request was received, budget management was the responsibility of the State Office. Priorities had been established for approval of treatment, and this treatment was denied in accord with those priorities. Because these priorities are relevant only to the authorization process, they are not published.
"The reference to the child in the decision was merely to indicate that this decision was not based upon a child’s problems, but rather on the problems of an adult. * * * ”

In a supplemental order, the hearings officer made the finding of fact, based on the above quoted memorandum, that the payments were denied on the basis of nonavailability of funds and in accord with priorities established by the agency for approval of various forms of treatment. He ordered the agency to pay for the diagnostic intake interview but upheld denial of payment for the four therapy sessions.

A series of AFSD rules provide that ADC recipients are eligible to receive payment for treatment by a [407]*407psychologist, OAR 461-05-905, 461-13-000(2), 461-22-000, if funds are available and the treatment is determined to be medically necessary, OAR 461-05-907, 461-13-010.

ADC recipients are reimbursed for the cost of any diagnostic intake examination by a psychologist without prior agency approval, OAR 461-22-010(1). However, payment for ongoing psychotherapy requires prior authorization by the agency. OAR 461-22-010(3) provided:1

"Psychotherapy, including psychological counseling, requires prior authorization of payment by the Division. Requests must be in writing and include diagnosis, treatment modality, and goals and objectives of the treatment. Approval of payment is usually given for no more than 15 hours of therapy for each request. * * * ”

Petitioner argues OAR 461-22-01(3), insofar as it is used by the agency to deny medically necessary treatment to a recipient, is contrary to federal statutes and regulations respecting the federal Medicaid program. We have examined the statute and regulations cited by petitioner and conclude they do not prevent utilization of a prior authorization policy. The state in administering the program and the federal contributions is given broad authority to supervise the payment process. E.g., 42 USC § 1396a(a)(30). The federal government has not preempted the right of the state to require prior authorization of medical assistance or to deny medically necessary benefits on other grounds such as unavailability of funds.

In her other three assignments of error petitioner contends: (1) there is not substantial evidence to support the hearings officer’s conclusion the agency’s denial was proper; (2) the agency’s decision to the extent it is based on unpublished criteria, not promulgated as a rule, is invalid; and (3) the hearings officer’s [408]*408decision lacks substantial reasoning illustrating a nexus between the facts and conclusion.

AFSD argues the payments were denied because of lack of funds and the court has no authority to order AFSD to expend funds it does not have. AFSD also contends that petitioner, by seeking treatment without prior authorization, took the risk her request would be denied.

We first discuss the agency’s claim that the request for payment can be denied because the medical treatment was received without prior authorization. A literal reading of OAR 461-22-010(3) would seem to support the agency’s contention. However, we do not construe the rule to mean that petitioner assumes the risk of payment if she obtains the treatment prior to agency authorization. Having made the request for payment prior to receipt of any medical treatment, petitioner assumes the risk of payment for the treatment received only if the agency’s denial of her request is proper. If it is subsequently determined the agency’s denial of payment was improper, the agency will be required to make the payments for the treatments received subsequent to the request. If the agency’s action is determined to be improper and the request for payment should be honored, the agency assumes no greater risk of expenditure of funds than if the petitioner had waited until the full appellate process had been completed before receiving the treatment. The risk that the agency’s denial was proper is assumed by the petitioner or the treating doctor. We conclude the action of the agency in denying any payment is reviewable.

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Related

Glover v. Adult & Family Services Division
613 P.2d 495 (Court of Appeals of Oregon, 1980)

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Bluebook (online)
600 P.2d 918, 42 Or. App. 403, 1979 Ore. App. LEXIS 3276, Counsel Stack Legal Research, https://law.counselstack.com/opinion/price-v-adult-family-services-division-orctapp-1979.