State v. Vainio

2001 MT 220, 35 P.3d 948, 306 Mont. 439, 2001 Mont. LEXIS 475
CourtMontana Supreme Court
DecidedNovember 7, 2001
Docket00-469
StatusPublished
Cited by8 cases

This text of 2001 MT 220 (State v. Vainio) is published on Counsel Stack Legal Research, covering Montana Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
State v. Vainio, 2001 MT 220, 35 P.3d 948, 306 Mont. 439, 2001 Mont. LEXIS 475 (Mo. 2001).

Opinion

JUSTICE NELSON

delivered the Opinion of the Court.

¶1 David G. Vainio (David), a licensed optometrist, was charged in the First Judicial District Court, Lewis and Clark County, with three counts of Medicaid fraud and one count of unsworn falsification to authorities. Following a jury trial, David was found guilty of two of the Medicaid fraud counts as well as the count of unsworn falsification to authorities. His sentences on the Medicaid fraud counts were deferred for five years and his six-month jail sentence on the other charge was suspended on conditions. David appeals his judgment and sentence. We reverse.

¶2 David raises several issues which we have tailored for clarity as follows:

¶3 1. Whether the District Court erred by failing to dismiss Count I on the grounds that it is based on the violation of an administrative policy which had not been adopted in compliance with the Montana Administrative Procedure Act (MAPA).

¶4 2. Whether Montana’s Medicaid fraud statute violates due process on void-for-vagueness grounds because it criminalizes violations of informal administrative policies.

¶5 3. Whether David’s conviction on Count II should be reversed because it was based on the violation of an administrative policy which had not been adopted in compliance with MAPA.

¶6 4. Whether David’s conviction on Count II violates due process because the State was not required to prove that David knowingly submitted false claims to Medicaid.

¶7 5. Whether the State introduced sufficient evidence to convict David on Count IV, unsworn falsification to authorities.

¶8 Because we determine that Issues 1, 3 and 5 are dispositive, we do not address Issues 2 and 4.

*441 Factual and Procedural Background

¶9 Medicaid is a publicly funded medical insurance program established to provide health-care coverage for persons who cannot otherwise afford coverage. The federal legislation establishing the Medicaid program is known as Title XIX of the Social Security Act. In 1967, the Montana Legislature chose to participate in the Medicaid program and authorized what is now the Department of Public Health and Human Services (DPHHS) to implement a state Medicaid program that complies with Title XIX and the federal regulations interpreting Title XIX. Section 53-6-101, MCA.

¶10 In 1977, Congress enacted the Medicare-Medicaid Anti-Fraud and Abuse Amendments to Title XIX. These amendments authorized the creation of state Medicaid fraud control units and made funds available for states to prosecute Medicaid fraud. 42 U.S.C. §§ 1396b(a) and (q). Initially, the Montana Legislature chose not to create a fraud control unit. However, in 1993, Congress mandated that all states participating in Medicaid establish fraud control units by 1995. Hence, the 1995 Montana Legislature established the Medicaid Fraud Control Unit within the Department of Justice. Section 53-6-156, MCA. At the same time, the Legislature enacted a statute under which the unit could prosecute fraud. Section 45-6-313, MCA.

¶11 The rules governing Montana’s Medicaid program at the time relevant to this case were set forth in Rule 46.12.101, et seq., ARM. (now Rule 37.82.101, et seq., ARM). DPHHS contracts with Consultec, a subsidiary of General American Life Insurance Company, to act as DPHHS’s fiscal agent by enrolling providers of services paid for by Medicaid and by processing claims submitted by the providers of those services. The Medicaid program is voluntary and medical providers are not automatically Medicaid providers. They must enroll with Consultec to become a Medicaid provider.

¶12 David initially enrolled with Consultec in 1979 and again in 1985. In early 1997, DPHHS mandated that all Medicaid providers re-enroll. Consequently, David re-enrolled with Consultec in April 1997.

¶13 On April 17, 1998, the State charged David with three counts of Medicaid fraud in violation of § 45-6-313(l)(a)(ii), MCA, and one count of unsworn falsification to authorities in violation of § 45-7-203, MCA. Count I of the information alleged that David committed Medicaid fraud by authorizing the submission of Medicaid payment claims for services performed by another licensed optometrist. Count II alleged that David committed Medicaid fraud by authorizing the submission of Medicaid payment claims for examinations of new patients who were actually established patients. Count III alleged that David committed Medicaid fraud by authorizing the submission of Medicaid payment claims for comprehensive examinations when less than comprehensive examinations were performed. And, Count IV alleged *442 that David committed unsworn falsification to authorities by omitting information on a Montana Medicaid Provider Enrollment Form.

¶14 The following is a summary of the facts and allegations pertinent to each charge.

Count I

¶15 In 1990, Leonard Vainio, David’s brother, who, at that time was also a licensed optometrist, left Montana to practice optometry in Washington. 1 In 1993, Leonard’s Montana Medicaid provider numbers were terminated because they were no longer being used. In November 1996, Leonard returned to Montana. By then, David owned more than a dozen optometric stores across the State. Leonard began performing optometric services in David’s two Missoula stores. David submitted claims to Medicaid under his provider number for services performed by Leonard even though other optometrists working for David used their own provider numbers. The State asserted that this billing practice is contrary to Medicaid policy.

Count II

¶16 Montana’s Medicaid program distinguishes between “new” and “established” patients. The term “new” patients refers to patients the optometrist has never seen before and to patients the optometrist has not seen in two years. Each of David’s stores sent their billing information to David’s main office in Deer Lodge which in turn billed Medicaid. The State alleged that between April 11, 1995, and December 31, 1997, David’s office submitted 210 claims for comprehensive examinations of “new” patients who should have been billed as “established” patients. At that time, Medicaid paid $44.53 for a comprehensive examination of a “new” patient and only $29.11 for a comprehensive examination of an “established” patient.

Count III

¶ 17 Because Leonard did not completely fill out the examination forms for several patients, the State alleged that David billed Medicaid for comprehensive examinations on those patients even though Leonard may have performed less than a comprehensive examination.

Count IV

¶18 In his 1997 Medicaid provider re-enrollment form, David answered “No” to the following question: “Are you the spouse, parent, child or sibling of other persons who have an ownership or control interest of 5% or more, OR is an agent or managing employee in this *443

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Cite This Page — Counsel Stack

Bluebook (online)
2001 MT 220, 35 P.3d 948, 306 Mont. 439, 2001 Mont. LEXIS 475, Counsel Stack Legal Research, https://law.counselstack.com/opinion/state-v-vainio-mont-2001.