Hall v. Bowen

• Court: U.S. District Court — Western District of Arkansas
• Writing for the Court: H. FRANKLIN WATERS
• Citation: Hall v. Bowen, 648 F.Supp. 166 (W.D. Ark. 1986)
• Decision Date: 01 October 1986
• Docket Number: Civ. No. 85-5128.
• Parties: Billy V. HALL, M.D., Plaintiff, v. Otis BOWEN, Secretary of Health and Human Services, Defendant.

648 F. Supp. 166

Billy V. HALL, M.D., Plaintiff, v. Otis BOWEN, Secretary of Health and Human Services, Defendant.

Civ. No. 85-5128.

United States District Court, W.D. Arkansas, Fayetteville Division.

October 1, 1986.

J.L. Hendren, Bentonville, Ark., for plaintiff.

Charlene M. Seifert, Asst. Regional Counsel Office of the General Counsel U.S. Dept. of Health and Human Services, Dallas, Tex., and J. Michael Fitzhugh, U.S. Atty., Fort Smith, Ark., for defendant.

MEMORANDUM OPINION AND ORDER

H. FRANKLIN WATERS, Chief Judge.

Plaintiff, Billy V. Hall, M.D., seeks judicial review of a final decision of the Secretary of Health and Human Services pursuant to 42 U.S.C. § 405(g). This matter is presently before the court on cross-motions for summary judgment. Based upon the court's review of nearly 8,000 pages of administrative record developed below, the court affirms the decision of the Secretary.

I. Facts

Billy V. Hall, M.D., is a physician practicing in Gravette, Arkansas, and has practiced there since July of 1951. At the time Dr. Hall began his practice, Gravette was a small town located in the northwest corner of Arkansas. At the present, Dr. Hall treats patients from Arkansas, Missouri and Oklahoma. On July 20, 1983, Dr. Hall was notified by the Office of Health Financing Integrity (OHFI), now known as the Office of the Inspector General (OIG — and hereinafter referred to as OHFI/OIG for purposes of this opinion) that he had been excluded from participation in the Medicare and Medicaid programs for a period of five years based upon certain alleged failures of Dr. Hall to meet the obligations placed upon him by section 1160 of the Social Security Act.

II. Administrative History

Dr. Hall originally came under the scrutiny of the Secretary in 1975 when the Gravette Medical Center was scheduled for review by the Arkansas Foundation for Medical Care (AFMC) pursuant to 42 C.F.R. § 463.6. On September 11, 1980, the Medical Evaluation Committee of AFMC reviewed the results of three studies performed at Gravette Medical Center. Based upon that review, AFMC determined that plaintiff had violated his obligations under section 1160(a) of the Social Security Act. The AFMC notified plaintiff of its findings by letter dated October 14, 1980. Pursuant to 42 C.F.R. § 474.4, Dr. Hall was given an opportunity to submit additional evidence at a January 8, 1981, meeting with the AFMC; however, at that time Dr. Hall apparently refused to discuss the cases involved and requested that the AFMC's recommended sanction be forwarded to the Secretary. By a letter dated August 21, 1981, AFMC afforded Dr. Hall another opportunity to submit additional evidence about specific cases. Dr. Hall eventually met with the AFMC committee and board members on January 28, 1982, at which time Dr. Hall made a case-by-case presentation. Once more, the AFMC concluded that the case histories before it reflected that Dr. Hall had furnished services that were not medically necessary, that he had provided services which did not meet professionally recognized standards of care, and that he had failed to provide adequate documentation to support the need for care or the reason for rendering a particular treatment.¹

Consequently, the Secretary advised plaintiff on July 21, 1982, that he would be excluded from participation in the Medicare and Medicaid programs. Dr. Hall again submitted exhibits, explanations and arguments to the OFHI/OIG, but on July 20, 1983, he was notified that he would in fact be excluded from participation in the programs.

Dr. Hall then requested a hearing before an administrative law judge (ALJ). A full hearing was held on January 16-27, 1984. On September 6, 1984, the ALJ issued his decision in which he recommended that the exclusion be affirmed. Plaintiff subsequently sought review of the hearing decision before the Appeals Council. Oral arguments were heard, and on June 5, 1985, the Appeals Council upheld the five-year suspension. The decision of the Appeals Council became the final decision of the Secretary. It is that decision of which Dr. Hall seeks review in this court.

III. Statutory and Regulatory Provisions

At the times relevant to this action section 1160 of the Social Security Act imposed various obligations upon health care providers.² Specifically, health care practitioners were obligated to assure that any services ordered or provided by the practitioner to beneficiaries and recipients

(1) will be provided only when, and to the extent, medically necessary;

(2) will be of a quality which meets professionally recognized standards of health care; and

(3) will be supported by evidence of medical necessity and quality.

During the time of Dr. Hall's review, the obligations of section 1160 were enforced through a system of professional standards review; these professional standards reviews were effectuated through professional standards review organizations (PSRO). In Arkansas, AFMC was designated by the Secretary as the local PSRO and was made up of doctors of medicine or osteopathy. 42 U.S.C. § 1320c-1(1)(A). As PSRO for Arkansas, AFMC was responsible for determining whether services rendered were medically necessary, whether the quality of such services met professionally recognized standards of health care, and whether, if provided in a hospital on an in-patient basis, such services should be provided on an in-patient basis, whether the services could be provided more effectively on an out-patient basis or more economically in an in-patient health care facility of a different type.

Through various statutory and regulatory mechanisms, the PSRO was empowered to inquire as to whether the provision of services by a physician involved potential or actual violations of his or her statutory obligations. If in fact the PSRO did identify an actual violation, it was to recommend possible sanctions based upon: (a) the type offense involved; (b) the severity of the offense; (c) the anticipated deterrent effect of the recommended sanction; (d) the previous sanction record of the provider; and (e) other factors relevant to the case. 42 C.F.R. § 474.6. Having done so, the PSRO was then required to notify the physician of its determination and to provide the practitioner with an opportunity to submit evidence and request further review. 42 U.S.C. § 1320c-10.

In addition, the PSRO was required to submit its findings and recommendations to OHFI/OIG. If OHFI/OIG concurred in the PSRO's determination, it could impose its sanction upon delivery of written notice to the physician. A dissatisfied practitioner could seek review before an ALJ and, if necessary, before a district court.

IV. Standard of Review

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