In re Surveillance & Integrity Review (SIRS)
| Decision Date | 16 May 2022 |
| Docket Number | A21-1206 |
| Parties | In the Matter of the Surveillance and Integrity Review (SIRS) Appeal by Matthew Wright. |
| Court | Minnesota Court of Appeals |
This opinion is nonprecedential except as provided by Minn. R Civ. App. P. 136.01, subd. 1(c).
Minnesota Department of Human Services File No. 37060
Jason Schellack, Nathaniel Gurol, Autism Advocacy & Law Center Minneapolis, Minnesota (for appellant Wright)
Keith Ellison, Attorney General, Peter Shaw, Assistant Attorney General, St. Paul, Minnesota (for respondent department)
Considered and decided by Connolly, Presiding Judge; Larkin, Judge; and Smith, Tracy M., Judge.
In this certiorari appeal, relator argues that respondent's decision to suspend him from participating in the Minnesota Health Care Program (MHCP) for three years is arbitrary and capricious and is unsupported by substantial evidence. We affirm.
The facts of this case are undisputed. Relator Matthew Wright resides with his girlfriend, the couple's child, and Wright's girlfriend's two children from previous relationships. All three children have special needs, and Wright's girlfriend's oldest child (Child 1) is autistic.
In August 2015, Wright entered into a provider agreement with respondent Minnesota Department of Human Services (department) to be a personal care assistant (PCA) and to provide community directed consumer support services (CDCS). CDCS is a program offered by Minnesota Medical Assistance (MMA) through which certain recipients may receive personal support services. MMA is administered by the department. See Minn. Stat. §§ 256B.04, subd. 1, .02, subd. 5 (2020). To ensure that MMA funds are properly spent, the department created the Surveillance and Integrity Review Section (SIRS), which is charged with "identifying and investigating fraud, theft, abuse, or error by vendors or recipients of health services through a program . . . that is administered by the department, and for the imposition of sanctions against vendors and recipients of health services." Minn. R. 9505.2160, subp. 1 (2021).
Wright began providing PCA services for Child 1 through Accra Care and, later, through Mains'1 FSE (Mains'1). Accra Care and Mains'1 are "MHCP enrolled provider[s] that can bill the state directly for services." Thus, to receive payment for the services, Wright submitted his time records to Accra Care, and later to Mains'1, who billed the MMA program and then paid Wright.
In June 2019, a county fraud prevention investigator filed a complaint with the department alleging that Wright was billing for time caring for Child 1 when the child could not have been receiving services. Following an investigation, a SIRS investigator determined that, between January 1, 2017, and July 22, 2017, Wright submitted numerous claims for payment when Child 1 was at an after-school program and was not available for services. The investigation determined that Wright's conduct resulted in 344 unallowed hours and an overpayment to Mains'1 of $6, 559.23. The department then issued a notice of suspension on May 26, 2020, informing Wright that his conduct constituted abuse under the program, and imposed a three-year suspension.
Wright appealed the suspension, and a hearing was held before an administrative law judge (ALJ) in January 2021. The SIRS investigator and his supervisor testified for the department. The supervisor testified that, in deciding to impose a three-year suspension, the department considered the appropriate statutory factors, including the nature, chronicity, and severity of Wright's conduct, as well as the effect Wright's conduct had on the health and safety of Child 1. The supervisor testified that some factors are given more weight than others and stated that the number of instances of overlap, the number of unallowed hours, the length of the review period, and the dollar amount of overpayment reflected the seriousness of Wright's conduct.
Wright testified at the hearing and admitted that there was "100 percent proof" of the overlaps alleged by the department and that there was "no contesting" the department's proof. But Wright claimed that he was unable to keep accurate timesheets because the system implemented by Mains'1 did not allow him to input more than one entry per day. According to Wright, he did not realize that he was engaging in wrongful conduct because he was told by a county social worker to group all of his services into one daily entry, rather than report them as separate entries.
The ALJ found that the department "proved that on 81 occasions over a six-and-one-half-month period, [Wright] submitted timecards for providing PCA services to Child #1 that overlapped with times that Child #1 was attending an after-school program."[1] The ALJ also found that although Wright's conduct was "a wrong-headed attempt to simplify his bookkeeping," he "testified credibly about why he filled out the timecards the way he did," and he was not "trying to cheat or obfuscate." The ALJ then determined that the department "presented credible evidence that it had considered the nature, chronicity, and severity of [Wright's] conduct, but its consideration of the effect of [Wright's] conduct on the person receiving services was superficial." The ALJ concluded that the "severity of an administrative sanction must reflect the seriousness of the violation" and that the department's "sanction of a three-year suspension of [Wright's] license is not appropriate given the violations." Thus, the ALJ recommended that Wright's license be suspended for one year rather than three years.
The department filed exceptions to the ALJ's report, arguing that the commissioner of human services should affirm and impose a three-year suspension. The commissioner subsequently filed a final order suspending Wright from "participation as a provider in [MHCP] for three years." This certiorari appeal follows.
Wright challenges his three-year suspension from participating in MHCP. "Administrative-agency decisions enjoy a presumption of correctness and may be reversed only when they are arbitrary and capricious, exceed the agency's jurisdiction or statutory authority, are made upon unlawful procedure, reflect an error of law, or are unsupported by substantial evidence in view of the entire record." In re Revocation of Family Child Care License of Burke, 666 N.W.2d 724, 726 (Minn.App. 2003); Minn. Stat § 14.69 (2020). "The relator has the burden of proof when challenging an agency decision . . . ." Minn. Ctr. For Envtl. Advocacy v. Minn. Pollution Control Agency, 660 N.W.2d 427, 433 (Minn.App. 2003).
Minnesota law allows the commissioner to impose sanctions, including suspensions, against vendors for:
(1) fraud, theft, or abuse in connection with the provision of medical care to recipients of public assistance; (2) a pattern of presentment of false or duplicate claims or claims for services not medically necessary; [or] (3) a pattern of making false statements of material facts for the purpose of obtaining greater compensation than that to which the vendor is legally entitled[.]
Minn. Stat. § 256B.064, subd. 1a (2020). When imposing these sanctions, the commissioner must consider "the nature, chronicity, or severity of the conduct and the effect of the conduct on the health and safety of persons served by the vendor." Id., subd. 1b (2020). Minnesota Rule 9505.2165 defines "vendor" to include a PCA and defines "abuse" to include submitting repeated claims, or causing claims to be submitted (1) from which required information is missing or incorrect; (2) using procedure codes that overstate the level or amount of health service provided; or (3) for health services which are not reimbursable under the programs. Minn. R. 9505.2165, subps. 2(A)(1)-(3), 16a (2021).
Wright argues that the decision to impose a three-year suspension is "unsupported by substantial evidence in view of the entire record," and was "arbitrary and capricious." But, as the department points out, Wright "does not dispute the facts determined by [the department's] investigation or the finding [that] he engaged in sanctionable abuse." Instead, Wright only challenges the severity of the sanction imposed. The department contends that because Wright "is solely challenging the Commissioner's choice of sanction, does not dispute he engaged in sanctionable conduct, and does not dispute any of the ALJ's findings which were adopted by the Commissioner, the proper standard for reviewing [Wright's] claims is . . . the clear abuse of discretion standard."
We agree with the department. "[T]he severity of an administrative sanction must reflect the seriousness of the violation." Burke, 666 N.W.2d at 728. But an appellate court does not issue sanctions, and its review is limited to whether the sanctions imposed constituted a clear abuse of discretion. Id.; see In re Henry Youth Hockey Ass'n, License No. 02795, 511 N.W.2d 452, 456 (Minn.App. 1994) (), rev'd in part on other grounds, 559 N.W.2d 410 (Minn. 1994); Proetz v. Minn. Bd. of Chiropractic Exam'rs, 382 N.W.2d 527, 532-33 (Minn.App. 1986) (), rev. denied . Therefore, because Wright challenges only the severity of the sanction imposed by the commissioner, our review of that issue is limited to whether the commissioner abused its discretion by imposing a three-year suspension.
Wright agues that the department's suspension is excessive because the decision placed too much emphasis on certain...
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