Boise Group Homes, Inc. v. Idaho Dept. of Health and Welfare

• Decision Date: 09 June 1993
• Docket Number: No. 19893,19893
• Citation: 854 P.2d 251,123 Idaho 908
• Court: Idaho Supreme Court
• Parties: , Medicare & Medicaid Guide P 41,657 BOISE GROUP HOMES, INC., Petitioner-Appellant, v. IDAHO DEPARTMENT OF HEALTH AND WELFARE, Respondent. Lewiston, October 1992 Term

Page 251

854 P.2d 251

123 Idaho 908, Medicare & Medicaid Guide P 41,657

BOISE GROUP HOMES, INC., Petitioner-Appellant, v. IDAHO DEPARTMENT OF HEALTH AND WELFARE, Respondent.

No. 19893.

Supreme Court of Idaho,

Lewiston, October 1992 Term.

June 9, 1993.

Pierce & Stoddard, Boise, for appellant. Steven M. Stoddard argued.

Larry EchoHawk, Idaho Atty. Gen., Bradford D. Goodsell, Deputy Atty. Gen., Boise, for respondent. Bradford D. Goodsell argued.

TROUT, Justice.

I. BACKGROUND AND PRIOR PROCEEDINGS

Boise Group Homes (BGH) is a health care provider which contracts with the Idaho Department of Health and Welfare (the Department) to provide medical services to Idaho citizens. The Department administers the Medicaid program in Idaho which includes reimbursing health care providers such as BGH for approved costs of services to patients.

In 1986 as in prior years, BGH submitted a statement to the Department seeking reimbursement for the costs of a consultant to provide psychological services to its Medicaid patients. At that time, the allowable reimbursement rate for psychological consultants was twenty six dollars per hour. According to the Medicaid regulations, consultant fees in excess of the allowable In the final audit report for the year ending in September, 1987, the Department refused to reimburse BGH for consultant fees in excess of those allowed by the regulations. As a result, BGH was not reimbursed for $1,989.75 in consultant fees. The administrator of the Division of Welfare approved the Department's final audit and on October 16, 1990, an administrative hearing officer affirmed that decision. BGH appealed to the district court which affirmed the decision of the Department denying reimbursement.

[123 Idaho 909] rate would be paid only if the health care provider documented its unsuccessful effort to obtain services at the allowable rate.

II. SCOPE OF REVIEW

A court which is reviewing an agency decision may not substitute its judgment for that of the administrative hearing officer on questions of fact. Van Orden v. State, Dep't of Health & Welfare, 102 Idaho 663, 667, 637 P.2d 1159, 1163 (1981). Furthermore, the reviewing court may reverse the agency's decision or remand for further proceedings only if substantial rights of the appellant have been prejudiced. I.C. § 67-5215(g). On appeal, this Court reviews an agency's decision independently of the district court's appellate decision. Dovel v. Dobson, 122 Idaho 59, 61, 831 P.2d 527, 529 (1992). We will uphold an agency's finding of fact if such finding is supported by substantial and competent evidence. Id. at 62, 831 P.2d at 530.

III. BGH DID NOT MAKE THE NECESSARY EFFORT UNDER THE MEDICAID REGULATIONS TO OBTAIN A PSYCHOLOGIST AT THE ALLOWABLE RATE

The sole issue for review is whether there is substantial and competent evidence to support the hearing officer's finding that BGH did not make the necessary effort to obtain a psychologist at the allowable rate. The provider reimbursement manual provides that consultant fees in excess of the allowable rate are not reimbursed "unless the provider has documented an effort to obtain consultant services at the allowed rate and has been unable to do so. Documentation would include at a minimum, recruitment advertising for the services." IDAPA 16.03.10115,15.

In the present case, the hearing officer found that BGH did not make a sufficient effort to obtain a psychologist at the allowable rate of twenty six dollars per hour. The Medicaid regulations only require that a provider hire a psychologist who has a master's degree from an accredited program and experience or training in the field of mental retardation. 42 C.F.R. § 442.490(a). BGH argues that it advertised for higher qualifications because a psychologist must be licensed in order to practice in Idaho and the licensure provisions require more than the Medicaid regulations. ¹ We find it unnecessary to reach this issue because, even accepting BGH's interpretation, the record supports the hearing officer's conclusion that BGH did not adequately document its inability to obtain a qualified consultant at the allowable rate.

The president of BGH, Richard Davis, advertised for services in The Idaho Statesman. The advertisement requested qualifications over and above those required by the Medicaid regulations and state licensure standards. BGH's advertisement requested a psychologist with a Ph.D., graduate training...