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Meyers v. Illinois Dep't of Public Aid





Appeal from the Circuit Court of Cook County; the Hon. Arthur L. Dunne, Judge, presiding.


Plaintiff, Dr. Mark Meyers, filed a complaint in the circuit court of Cook County for judicial review of the administrative action of the Illinois Department of Public Aid (IDPA) terminating his eligibility as a vendor of medical services and determining that it was entitled to recoup $55,531.66 in payments made to plaintiff for medical services provided to Medicaid recipients. The circuit court affirmed in part, but reversed recoupment of certain discrepancies occurring from July through December 1975, and reduced the recovery to $26,296.29.

On appeal, plaintiff argues that (1) the IDPA decision was against the manifest weight of the evidence, (2) he was denied due process because the Department failed to give him notice of its documentation standards, and (3) the court erred by refusing to remand plaintiff's case back to the IDPA for a redetermination of his termination as a provider.

The pertinent facts follow. In May of 1978, the Department audited Meyers' billings for medical services allegedly rendered to public aid patients from July 1975 through December 1976. This audit, and subsequent re-audits conducted in May 1980 were based upon 1,010 billing procedure discrepancies which included "A," "B," "C," "G," "GP" and "K" type discrepancies, and which, when extrapolated, reached a total of $58,866.62. In December 1979, the Department notified Meyers of its intention to terminate his eligibility as a vendor of goods or services to recipients under the Medicaid program, and to recover the $58,866.62 in payments made to him for medical services rendered, pursuant to section 4.41 and 4.51 of the Rules for Department Actions Against Medical Vendors. These rules provided that the Department may recover money improperly or erroneously paid to a vendor who has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the program.

Hearings commenced on June 7, 1980. The Department called two auditors, their supervisor, and a Department statistician as witnesses.

Taras Fylypowycz, an IDPA auditor, testified that he audited medical records by comparing them to the billing made by a doctor in order to determine if they were in compliance with Department policy. He stated that a "C" type discrepancy is determined by comparing the documentation in the doctor's patient charts with the criteria for the particular procedure code used by the doctor for billing purposes. He defined a procedure code as a numerical identification for a type of visit which a doctor uses when he bills the Department for the services he had rendered.

The three sources of these procedure codes are the billing form, DPA-132, the Current Procedure and Terminology, Second Edition (CPT #2d), and the Handbook for Physicians (Handbook) promulgated by the Department.

Fylypowycz stated that the audit period for the plaintiff extended from July 1975 to December 1976. In the discrepant billings, the auditors found that where Meyers had billed the comprehensive exam codes 90020 and 90070/80, the proper codes would have been 90010 for new patients and 90040 for established patients.

The auditors applied the CPT 2d for services rendered prior to January 1, 1976, and the Physicians Handbook for services rendered thereafter. On cross-examination he stated that there was no listing of any documentational requirements for 1975 and that to his knowledge none had ever been sent to physicians.

Auditing supervisor Matthew Bachmann testified that the Handbook went into effect January 1, 1976; that it was mailed out to vendors in January, February, and March of 1976; and that the auditors were to apply the Handbook as of the beginning of January 1976.

Plaintiff testified on his own behalf that he was the only physician at the clinic and that he did not fill in or decide which procedure code would be filled. He stated that a receptionist filled in the code before the doctor had even seen the patient or documented any medical information, and that it was clinic policy to automatically bill all first visits as 90020 and all second visits as 90070.

He admitted that generally even a physician cannot determine how extensive an examination will be before he sees the patient. Although Meyers stated that he started to fill in the codes once he received the Handbook in 1976, from April 1976 to December 1976 over 40% of the billings contained "C" discrepancies. On the last day of the hearing, plaintiff supplied missing records and, following a re-audit, the recoupment amount was adjusted to $55,531.66. At the conclusion of this hearing, the hearing officer terminated plaintiff's eligibility to participate in the Medicaid program and authorized recoupment of $55,531.66.

Plaintiff filed a complaint in administrative review in the circuit court of Cook County. After hearing oral arguments, the trial court affirmed recoupment of all overpayments resulting from discrepancies other than type "C," affirmed recoupment of all overpayments due to "C" discrepancies in 1976, and reversed recoupment of "C" discrepancies from July 1975 to December 1975.

Plaintiff filed a motion for reconsideration requesting that the case be remanded back to the Department for a redetermination of the termination issue. The trial court denied this motion and entered the final recoupment ...

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