{ "id": 3591252, "name": "DR. MARK MEYERS, M.D., Plaintiff-Appellant, v. ILLINOIS DEPARTMENT OF PUBLIC AID et al., Defendants-Appellees", "name_abbreviation": "Meyers v. Illinois Department of Public Aid", "decision_date": "1983-04-29", "docket_number": "No. 81\u20141828", "first_page": "288", "last_page": "293", "citations": [ { "type": "official", "cite": "114 Ill. App. 3d 288" } ], "court": { "name_abbreviation": "Ill. App. Ct.", "id": 8837, "name": "Illinois Appellate Court" }, "jurisdiction": { "id": 29, "name_long": "Illinois", "name": "Ill." }, "cites_to": [ { "cite": "675 F.2d 151", "category": "reporters:federal", "reporter": "F.2d", "case_ids": [ 1175597 ], "weight": 2, "pin_cites": [ { "page": "158" } ], "opinion_index": 0, "case_paths": [ "/f2d/675/0151-01" ] }, { "cite": "370 N.E.2d 511", "category": "reporters:state_regional", "reporter": "N.E.2d", "opinion_index": 0 }, { "cite": "69 Ill. 2d 27", "category": "reporters:state", "reporter": "Ill. 2d", "case_ids": [ 5456767 ], "opinion_index": 0, "case_paths": [ "/ill-2d/69/0027-01" ] }, { "cite": "352 N.E.2d 389", "category": "reporters:state_regional", "reporter": "N.E.2d", "year": 1977, "opinion_index": 0 }, { "cite": "40 Ill. App. 3d 436", "category": "reporters:state", "reporter": "Ill. App. 3d", "case_ids": [ 2970773 ], "year": 1977, "opinion_index": 0, "case_paths": [ "/ill-app-3d/40/0436-01" ] }, { "cite": "153 N.E.2d 52", "category": "reporters:state_regional", "reporter": "N.E.2d", "opinion_index": 0 }, { "cite": "14 Ill. 2d 553", "category": "reporters:state", "reporter": "Ill. 2d", "case_ids": [ 2769242 ], "opinion_index": 0, "case_paths": [ "/ill-2d/14/0553-01" ] }, { "cite": "422 N.E.2d 123", "category": "reporters:state_regional", "reporter": "N.E.2d", "opinion_index": 0 }, { "cite": "96 Ill. App. 3d 845", "category": "reporters:state", "reporter": "Ill. App. 3d", "case_ids": [ 12143076 ], "opinion_index": 0, "case_paths": [ "/ill-app-3d/96/0845-01" ] } ], "analysis": { "cardinality": 622, "char_count": 12274, "ocr_confidence": 0.724, "pagerank": { "raw": 2.029684737079775e-07, "percentile": 0.7464303903432208 }, "sha256": "0fb3ab2c0c660e109e89e169e26c2ff4d728703a7cedfa798023a546504d55df", "simhash": "1:37c2b9cde813e9ff", "word_count": 1963 }, "last_updated": "2023-07-14T18:05:13.547892+00:00", "provenance": { "date_added": "2019-08-29", "source": "Harvard", "batch": "2018" }, "casebody": { "judges": [], "parties": [ "DR. MARK MEYERS, M.D., Plaintiff-Appellant, v. ILLINOIS DEPARTMENT OF PUBLIC AID et al., Defendants-Appellees." ], "opinions": [ { "text": "JUSTICE LORENZ\ndelivered the opinion of the court:\nPlaintiff, 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.\nOn 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\u2019s case back to the IDPA for a redetermination of his termination as a provider.\nThe pertinent facts follow. In May of 1978, the Department audited Meyers\u2019 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 \u201cA,\u201d \u201cB,\u201d \u201cC,\u201d \u201cG,\u201d \u201cGP\u201d and \u201cK\u201d 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.\nHearings commenced on June 7, 1980. The Department called two auditors, their supervisor, and a Department statistician as witnesses.\nTaras 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 \u201cC\u201d type discrepancy is determined by comparing the documentation in the doctor\u2019s 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.\nThe 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.\nFylypowycz 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.\nThe 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.\nAuditing 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.\nPlaintiff 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.\nHe 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 \u201cC\u201d 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 plaintiffs eligibility to participate in the Medicaid program and authorized recoupment of $55,531.66.\nPlaintiff 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 \u201cC,\u201d affirmed recoupment of all overpayments due to \u201cC\u201d discrepancies in 1976, and reversed recoupment of \u201cC\u201d discrepancies from July 1975 to December 1975.\nPlaintiff 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 amount of $26,296.29 on June 23, 1981. Plaintiff appeals.\nWe note here for clarity that the issues on appeal concern only the \u201cC\u201d discrepancies encompassing misuse of procedure codes.\nPlaintiff does not contest either the Department\u2019s sampling method or its use of an extrapolation to determine the final recoupment amount nor any of the A, B, G, GP or K discrepancies on appeal.\nOpinion\nWe first address plaintiff\u2019s contention that the IDPA decision was against the manifest weight of the evidence.\nIt is well settled that under the Administrative Review Act, the findings and conclusions of the agency on questions of fact are \u201cprima facie true and correct\u201d (Ill. Rev. Stat. 1979, ch. 110, par. 274), now codified as section 3 \u2014 110 of the Code of Civil Procedure (Ill. Rev. Stat. 1981, ch. 110, par. 3 \u2014 110) and must be affirmed unless against the manifest weight of the evidence. (Cybularz v. Quern (1981), 96 Ill. App. 3d 845, 422 N.E.2d 123.) These provisions of the Administrative Review Act have been construed to mean that courts are not authorized to reweigh evidence or to make an independent determination of facts. (Menning v. Department of Registration & Education (1958), 14 Ill. 2d 553, 153 N.E.2d 52.) Thus, in order to reach the conclusion that a particular finding is against the manifest weight of the evidence, this court must be satisfied that an opposite conclusion is clearly evident. (Kreiser v. Police Board (1976), 40 Ill. App. 3d 436, 352 N.E.2d 389, aff\u2019d (1977), 69 Ill. 2d 27, 370 N.E.2d 511.) We are not so satisfied.\nThe State of Illinois requires that physicians participating in its Medicaid program maintain detailed records of the nature and scope of the health care they provide to patients receiving assistance under the Illinois Public Aid Code. (Ill. Rev. Stat. 1979, ch. 23, par. 5 \u2014 5.) The Department of Public Aid conducts post-payment audits by examining randomly selected records for discrepancies in order to recoup any excess compensation paid because of improper billing practices. Discrepancies exist when no medical records are available to verify the submitted bills or when a billing code has been misused. Illinois Physicians Union v. Miller (7th Cir. 1982), 675 F.2d 151.\nIn the present case, plaintiff himself admitted that a receptionist filled in the procedure code on the billing form prior to any patient examination as a matter of office policy, and that he signed and submitted such forms without further review. Although plaintiff contends that he did not receive notice of the Department\u2019s documentation requirements and that the requirements were applied in an arbitrary-manner, a thorough examination of the record reveals an ample basis from which the opposite conclusion might be reached.\nSince we find evidentiary support in the trial court\u2019s affirmation of the Department\u2019s decision to terminate plaintiff and to recoup overpayments due to both 1976 \u201cC\u201d discrepancies as well as all 1975 and 1976 overpayments resulting from A, B, G, GP, and K discrepancies, plaintiff has not satisfactorily demonstrated that the opposite conclusion is \u201cclearly evident.\u201d Accordingly, we find that the findings are not against the manifest weight of the evidence.\nDefendant also argues that he was denied due process because the Department failed to give him notice of its documentation standards.\nIt is undisputed that the 1975 findings are not at issue, and plaintiff admits that he possessed the Handbook from at least April 1976 to December 1976. Thus, the only audit period at issue on appeal extends from January 1976 through April 1976.\nWith respect to this time period, plaintiff premises his due process argument upon his own testimony that he received the Handbook in April 1976, from a man at the clinic who received all of his business mail and forwarded it to him once a week, and therefore he lacked notice of the documentation standards.\nWe find that this argument lacks merit. Even assuming, arguendo, that plaintiff did not receive the Handbook until a late mailing in April 1976, there is no dispute that he did possess the CPT 2d which was in effect in 1975 and 1976. We have examined the record and the CPT 2d, while not as detailed as the successor Handbook, adequately sets forth the procedure code and a description of the documentation required for each code. Moreover, plaintiff himself admitted that a receptionist filled in the procedure code by following the clinic policy of billing all first visits as \u201c90020\u201d and subsequent visits as \u201c90070\u201d and he testified that he was not only aware of this practice but also signed the billing forms without adjusting the code to reflect the actual extent of the exam.\nIn Illinois Physicians Union v. Miller (7th Cir. 1982), 675 F.2d 151, 158, the court stated that \u201cwe do not believe it unreasonable to require a physician participating in publicly funded welfare programs to be thoroughly familiar with the Department\u2019s rules and regulations. Thorough knowledge is demanded on the part of the physician, not only for conducting an audit, but for submitting proper bills in the first place.\u201d\nAccordingly, we find that defendant was not denied due process and had adequate notice of the documentation standards promulgated by the Department.\nLastly, plaintiff argues that the trial court erred in its decision not to remand the case back to the Department for a redetermination of his eligibility to participate as a Medicaid vendor since his termination was based on \u201cC\u201d discrepancies and the trial court reversed the 1975 \u201cC\u201d recoupments.\nIn the present case, the termination was based solely on the \u201cC\u201d type of discrepancy. However, the record reveals that even after the partial reversal of the 1975 \u201cC\u201d recoupments, over 40% of the billings sampled were \u201cC\u201d discrepancies which occurred from April to December 1976 and which totalled almost $26,000, and there is ample evidentiary support for the trial court\u2019s denial of remandment.\nConsequently, we find that the trial court had a proper basis for its denial of remandment for a redetermination of plaintiff\u2019s eligibility.\nFor the foregoing reasons, the judgment of the circuit court of Cook County is affirmed.\nAffirmed.\nSULLIVAN and MEJDA, JJ., concur.\nE.g., the CPT 2d requires: \u201c90040 Visit office established patient, brief examination, evaluation and/or treatment, same or new illness\u201d in contrast to \u201c90070 Visit office established patient, extended, re-examination or re-evaluation.\u201d", "type": "majority", "author": "JUSTICE LORENZ" } ], "attorneys": [ "Harold G. Shapiro, of David Blumenfeld, Ltd., of Chicago, for appellant.", "Neil F. Hartigan, Attorney General, of Springfield (Ellen P. Brewin, Special Assistant Attorney General, of counsel), for appellees." ], "corrections": "", "head_matter": "DR. MARK MEYERS, M.D., Plaintiff-Appellant, v. ILLINOIS DEPARTMENT OF PUBLIC AID et al., Defendants-Appellees.\nFirst District (5th Division)\nNo. 81\u20141828\nOpinion filed April 29, 1983.\nHarold G. Shapiro, of David Blumenfeld, Ltd., of Chicago, for appellant.\nNeil F. Hartigan, Attorney General, of Springfield (Ellen P. Brewin, Special Assistant Attorney General, of counsel), for appellees." }, "file_name": "0288-01", "first_page_order": 310, "last_page_order": 315 }