Tsoutsouris v. Shalala

977 F. Supp. 899, 1997 U.S. Dist. LEXIS 15746, 1997 WL 587006
CourtDistrict Court, N.D. Indiana
DecidedJune 11, 1997
DocketNo. 2:94-CV-208-RL-2
StatusPublished

This text of 977 F. Supp. 899 (Tsoutsouris v. Shalala) is published on Counsel Stack Legal Research, covering District Court, N.D. Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Tsoutsouris v. Shalala, 977 F. Supp. 899, 1997 U.S. Dist. LEXIS 15746, 1997 WL 587006 (N.D. Ind. 1997).

Opinion

MEMORANDUM AND ORDER

SPRINGMANN, United States Magistrate Judge.

On April 22, 1994, the Secretary of Health and Human Services (Secretary) found that Medicare Part B overpaid the Plaintiff and denied the Plaintiffs claims to waiver of the overpayment and limited liability of the overpayment. The Plaintiff filed suit in this Court seeking judicial review of both the finding of overpayment and the denial of the Plaintiffs waiver and limited liability claims. Because the decision of the Administrative Law Judge (ALJ) was supported by substantial evidence, the Court GRANTS the Defendant’s Motion for Summary Judgment and AFFIRMS the decision of the ALJ in all respects.

I.

Pursuant to Section 205(g) of the Social Security Act, the Plaintiff files suit to challenge' the decision of the ALJ finding that he was overpaid by Medicare Part B and denying his request to waive his recovery of the overpayment or limit his liability for the overpayment. 42 U.S.C. § 1395ff(b)(i) (Incorporating 42 U.S.C. § 405(g) by reference.). Because both parties have consented to the authority of the Magistrate, this Court has authority to decide the case pursuant to 28 U.S.C. § 636(c). Judicial review of the ALJ’s decision in this case is limited to determining whether the ALJ based his decision upon substantial evidence or legal error.

Regarding the “substantial evidence” standard, 42. U.S.C. § 405(g) states that “[t]he findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall, be conclusive ...” “Substantial evidence” is an evidentiary standard that will not be met by a showing of a mere scintilla of proof. Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 1427, 28 L.Ed.2d 842 (1971). However, if “such relevant evidence that a reasonable mind [902]*902might accept it as adequate to support a conclusion is shown, the ‘substantial evidence’ standard is deemed met”. Id.

In addition to the required showing of substantial evidence, this Court must also refrain from upholding the determination of the Secretary if the evidence before the Secretary was not properly evaluated because of an erroneous .view of the law, or legal error. Rohan v. Chater, 98 F.3d 966, 970 (7th Cir.1996); Marcus v. Califano, 615 F.2d 23, 27 (2nd Cir.1979).

The Plaintiff claims that the ALJ did not base his decision on substantial evidence because a physician testifying at the hearing before the ALJ acknowledged that some of the treatments the Plaintiff rendered were appropriate. Furthermore, the Plaintiff claims that the ALJ committed legal error, a sentence four, § 405(g), remand, by misinterpreting the pertinent portions of the Social Security Act relating to overpayment of medical services, primarily 42 U.S.C. § 1395gg(c). In addition, the Plaintiff requests that additional evidence be allowed before the Court in the form of additional testimony regarding the medical necessity of the Plaintiffs unreimbursed treatments; in essence, the Plaintiff is requesting a sentence six remand, § 405(g), on the basis of new material evidence. Finally, the Plaintiff states that this Court could not properly grant the Defendant’s Motion for Summary Judgment because there are factual issues present in the record that are to be determined by the trier of fact. This Court will take up.each of the Plaintiffs contentions in turn.

II.

Dr. George Tsoutsouris is a doctor and Medicare provider of podiatric medicine whose present practice is located in Hammond, Indiana. (R. 35, 421) In January 1991, Dr. Tsoutsouris was audited by Medicare Part B carrier, Blue Cross/Blue Shield of Indiana (Blue Cross). (R. 506) The Blue Cross audit consisted of a random examination of Dr. Tsoutsouris’ debridement services from January 1, 1990 through June 30, 1990. (R. 506, 507) All services examined had been billed to Medicare Part B for reimbursement and afforded payment by Medicare. (R. 501) In the course of conducting its audit, Blue Cross chose fifteen claims submitted by Dr. Tsoutsouris’ office for debridement of extensive eczematous or infected skin and reviewed Dr. Tsoutsouris’ office notes and records regarding the treatment of each patient represented by the claims. (R. 506, 621) Following Blue Cross’ review of Dr. Tsoutsouris’ office records, a Blue Cross nurse auditor called Dr, Tsoutsouris in attempt at further clarification of the office records which were noted as largely illegible. (R. 465, 506) Upon completion of the audit process, Blue Cross issued a summary report stating that the review of Dr. Tsoutsouris’ office records, in addition to the telephone conversation with Dr. Tsoutsouris, yielded a conclusion that his documentation was insufficient to substantiate a medical necessity behind his debridement claims. (R. 506) Furthermore, the Blue Cross summary report stated that Dr. Tsoutsouris’ medical reports and subsequent clarifications failed to give any information regarding evidence of medical progress in his treatments, such as a description of the size or severity of the ulcers being treated, as required by the Medicare guidelines regarding the reasonableness and necessity of frequent foot-care treatments. (R. 26, 506, 587, 621) Accordingly, Blue Cross then calculated the overpayments that Dr. Tsoutsouris received from the fifteen claims, $798.94, extrapolated the result across the population from which the audit sample was chosen and requested a refund from Dr. Tsoutsouris for $3,035.82. (R. 506-07, 621)

After receiving Blue Cross’ refund request, and timely paying the requested refund amount, Dr. Tsoutsouris requested that Medicare’s Postpayment Medical Review review the refund determination. (R. 20, 498) The Medical Review affirmed the refund determination stating that, for purposes of establishing medically necessary services, all fifteen cases consisted of unacceptable documentation due to Dr. Tsoutsouris’ illegible handwriting and frequent use of “as above.” (R. 498) Dissatisfied with this review determination, Dr. Tsoutsouris then requested a hearing before a Medicare Hearing Officer to [903]*903re-review the refund determination. (R. 501) After reviewing the audit results, the Blue Cross hearing officer determined that the standing refund determination was correct, with the exception of a minor $.15 adjustment, and noted that the lack of any notation as to the size, depth, or drainage of the foot ulcers at the initial treatment or throughout follow-up treatments made an assessment of the healing process impossible and undercut any attempt to show medical necessity. (R. 503) Dr. Tsoutsouris then requested a hearing before the ALJ. (R. 20)

A. Legal Framework

The Medicare program is set forth in Title XVIII of the Social Security Act. 42 U.S.C. § 1395 et seq.

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Related

Richardson v. Perales
402 U.S. 389 (Supreme Court, 1971)
Califano v. Yamasaki
442 U.S. 682 (Supreme Court, 1979)
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496 U.S. 617 (Supreme Court, 1990)
Shalala v. Schaefer
509 U.S. 292 (Supreme Court, 1993)
Melkonyan v. Sullivan
501 U.S. 89 (Supreme Court, 1991)
Papendick v. Sullivan
969 F.2d 298 (Seventh Circuit, 1992)
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506 U.S. 1050 (Supreme Court, 1993)

Cite This Page — Counsel Stack

Bluebook (online)
977 F. Supp. 899, 1997 U.S. Dist. LEXIS 15746, 1997 WL 587006, Counsel Stack Legal Research, https://law.counselstack.com/opinion/tsoutsouris-v-shalala-innd-1997.