Ross v. Maine Department of Health & Human Services

CourtSuperior Court of Maine
DecidedNovember 12, 2019
DocketKENap-18-75
StatusUnpublished

This text of Ross v. Maine Department of Health & Human Services (Ross v. Maine Department of Health & Human Services) is published on Counsel Stack Legal Research, covering Superior Court of Maine primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Ross v. Maine Department of Health & Human Services, (Me. Super. Ct. 2019).

Opinion

STATE OF MAINE SUPERIOR COURT KENNEBEC, ss. CIVIL ACTION DOCKET NO. AP-18-75

BRUCE ROSS, DMD, Petitioner

v. DECISION AND ORDER (M.R. Civ. P. 80C)

MAINE DEPARTMENT OF HEALTH & HUMAN SERVICES, Respondent

Before the court is Petitioner Bruce Ross' (Ross) M.R. Civ. P. 80C Appeal of

Final Agency Action against the Maine Department of Health and Human Services

(DHHS or Department). For the reasons explained below, the court concludes that

the Petition for Review filed by Dr. Ross should be denied and the decision of the

Acting Commissioner should be affirmed.

BACKGROUND

Dr. Ross, DMD, who has been practicing dentistry since 1988, works in a solo

practice office in Rumford, Maine, and employs one dental hygienist, Maureen

Leavitt, and an officer manager, Jennifer Herbert. In early 2013, DHHS, Division

of Audit, initiated an audit of records and billings for dental services that Dr. Ross

provided to MaineCare members, for the period from February 1, 2008 to December

31, 2012. (CR 000033). Although Dr. Ross provided DHHS with the documents

1 requested by the agency, the Department claims that most of them were illegible and

unsigned. Based on a review of records within the audit time period, DHHS issued

a Notice of Violation dated January 29, 2016, seeking recoupment of $216,371.06.

The requested recoupment was based on a number of alleged violations, including

lack of legible documentation, failure to sign medical records as required by rule,

inaccurate or duplicate billing, and failure to adequately document some specific

services, among others.

Dr. Ross timely requested an informal review. After Herbert Downs, the

Director of the Audit Di vision, performed the informal review, DHHS reduced the

recoupment sought to $173,536.88. Dr. Ross then timely requested a de novo

administrative hearing, which was held in South Paris on July 10, 2017. That hearing

focused on a number of issues, including; whether Dr. Ross should have been

penalized at all for the illegible documents, and if so, whether the penalties levied

against him were justified by MaineCarerules; whether DHHS was justified in

seeking 100% recoupment for certain billings, and; whether DHHS sought to recoup

overpayments it had already recouped. On October 27, 2017, the Administrative

Hearing Officer issued her Recommended Decision, in which she recommended that

the Acting Commissioner affirm the recoupment sought of $173,536.88. A few days

later, on October 31, 2017, the Acting Commissioner, Bethany Hamm, issued her

Final Decision. Although she agreed with much of the Hearing Officer's

2 recommendations, her Final Decision found that DHHS "failed to properly exercise

its discretion in assessing a 20% penalty for Ross' violation of the signature

requirement." (CR 001170). She ultimately reduced the penalty for these violations

from 20% to 1%. As a result of this reduction, the final, extrapolated recoupment

number was reduced to $42,971.69. Dr. Ross now timely appeals. Oral argument

before this court was held on September 4, 2019.

STANDARD OF REVIEW

When an administrative agency's decision is appealed pursuant to M.R.Civ .

P. 80C, the court "reviews the agency's decision directly for abuse of discretion,

errors of law, or findings not supported by the evidence." Centamore v. Dep't of

Hum. Servs', 664 A.2d 369,370 (Me. 1995). "The focus of the appeal is not whether

the court would have reached the same conclusion as the agency, but whether the

record contains competent and substantial evidence, which supports the result,

reached by the agency." CWCO, Inc. v. Superintendent of Ins ., 1997 Me 226, ~ 6,

703 A.2d 1258. "The agency's interpretation of its own regulations is entitled to

considerable deference on judicial review. Such deference is particularly appropriate

in an area as complex as Medicaid reimbursement." Trull Nursing Home, Inc. v.

Dep 't ofHuman Servs., 461 A.2d 490,496 (Me. 1983). In particular, a party seeking

to overturn an agency's decision bears the burden of showing that "no competent

evidence" supports it. Stein v. Me. Crim. Justice Academy, 2014 ME 82, ~ 11, 95

3 A.3d 612. Ultimately, the court's review is limited to whether the agency's decision

is: (1) in violation of constitutional or statutory provisions; (2) in excess of the

agency's statutory authority; (3) made upon unlawful procedure; (4) affected by bias

or error of law; (5) unsupported by substantial evidence on the whole record; or (6)

arbitrary or capricious or characterized by abuse of discretion. 5 M.R.S. §

11007(4)(C).

DISCUSSION

DHHS' Summary Table

Dr. Ross first attacks the validity of the use by DHHS of a summary table for

the MaineCare claims. Because of the extensive findings and data that DHHS

accumulated (totaling 139 pages of spreadsheet data), the Department made a

summary table of 13 records as a representative sample of Dr. Ross' documentation

deficiencies in conjunction with the full spreadsheet. Dr. Ross contends that Janie

Turner, a DHHS employee who conducted the initial audit, compiled the summary

table using the same data, and he argues that the summary table "was not to

summarize the dental records themselves, but rather to summarize Janie Turner's

interpretation of those records." Dr. Ross challenges the summary table as being

impermissibly "interpretive," see State Office Sys., Inc. v. Olivetti Corp., 762 F.2d

843, 845-46 (10th Cir. 1985), and thus more than a simple compilation of

voluminous records, as contemplated by the rules of evidence. See M.R. Evid. 1006.

4 DHHS counters that Dr. Ross challenged the admissibility of the summary table only

after Acting Commissioner Hamm's Final Decision, meaning that his argument

should be deemed waived. Although Dr. Ross' original argument before the Hearing

Officer amounted to little more than claiming that the "DHHS spreadsheet is entitled

to no weight," it is sufficient for the court to decide the issue on the merits.

Nonetheless, the court agrees with DHHS that the Hearing Officer was

entitled to rely upon the summary table. This is because administrative hearings in

Maine do not follow the rules of evidence, see 10-144 C.M.R. Ch. 1, § VII(A)(3)

("Formal rules of evidence shall not be observed"), and instead allow for a much

broader range of evidence that would otherwise be excluded from a court of law,

see, e.g., 10-144 C.M.R. Ch. 1, §VII(A)(S)("Hearsay evidence shall not be excluded

because of its hearsay nature"). On this basis alone, Dr. Ross' contention that the

Hearing Officer improperly relied upon the summary tables fails. But even if the

Hearing Officer were required to rely on the Maine Rules of Evidence, the court

would still disagree with Dr. Ross. The Rules of Evidence give courts considerable

leeway in deciding what types of summaries to admit. See, e.g., United States v.

Bishop, 264 F.3d 535, 547 (5th Cir. 2001) (explaining that Rule 1006 is "broadly

interpreted").

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Related

United States v. Bishop
264 F.3d 535 (Fifth Circuit, 2001)
Downeast Energy Corp. v. Fund Insurance Review Board
2000 ME 151 (Supreme Judicial Court of Maine, 2000)
Centamore v. Department of Human Services
664 A.2d 369 (Supreme Judicial Court of Maine, 1995)
State v. Huff
171 A.2d 210 (Supreme Judicial Court of Maine, 1961)
Stewart v. Town of Sedgwick
2000 ME 157 (Supreme Judicial Court of Maine, 2000)
CWCO, INC. v. Superintendent of Ins.
1997 ME 226 (Supreme Judicial Court of Maine, 1997)
Richards v. Bruce
1997 ME 61 (Supreme Judicial Court of Maine, 1997)
Trull Nursing Home, Inc. v. State Department of Human Services
461 A.2d 490 (Supreme Judicial Court of Maine, 1983)
Haven Savings Bank v. Zanolini
3 A.3d 608 (New Jersey Superior Court App Division, 2010)
John S. Zablotny v. State Board of Nursing
2014 ME 46 (Supreme Judicial Court of Maine, 2014)
William F. Gallagher v. Penobscot Community Healthcare
2019 ME 88 (Supreme Judicial Court of Maine, 2019)
Stein v. Maine Criminal Justice Academy
2014 ME 82 (Supreme Judicial Court of Maine, 2014)

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Ross v. Maine Department of Health & Human Services, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ross-v-maine-department-of-health-human-services-mesuperct-2019.