AI Generated Opinion Summaries

This summary was computer-generated without any editorial revision. It is not official, has not been checked for accuracy, and is NOT citable.

Facts

• The New Mexico Attorney General’s Medicaid Fraud Control Unit filed a lawsuit against Behavioral Home Care, Inc. (BHC), alleging violations of the New Mexico Medicaid Fraud Act (MFA) and breach of contract. The State claimed BHC submitted billing for Personal Care Option (PCO) services provided by caregivers who had not undergone complete compliance with the Caregivers Criminal History Screening Act (CCHSA), constituting false, fraudulent, or excess payments under the MFA and a breach of contract (paras 1-2).

Procedural History

• Appeal from the District Court of Bernalillo County, C. Shannon Bacon, District Judge.
• Certiorari Granted, August 15, 2014, No. 34,805. Certiorari Dismissed, April 3, 2015, No. 34,805. Released for Publication April 21, 2015.

Parties' Submissions

• Plaintiff-Appellant (State): Argued that BHC’s billing for services provided by certain caregivers, who were not fully compliant with CCHSA, constituted false, fraudulent, or excess payments under the MFA and breached their contract. The State sought recovery for any overpayments, civil penalties for each overpayment and false representation, attorney fees, interest, and costs (paras 2, 9).
• Defendant-Appellee (BHC): Contended that the failure to comply with CCHSA regulations does not support MFA liability and that their non-compliance with CCHSA and its regulations was not actionable under the MFA because submission of criminal history screening applications for Medicaid caregivers was a condition of participation in Medicaid rather than a condition of Medicaid payment (paras 3, 10, 19-20).

Legal Issues

• Whether the district court correctly dismissed the State’s claims against BHC for failure to state a claim upon which relief can be granted under the MFA and for breach of contract (para 1).
• Whether BHC’s failure to comply with CCHSA regulations constitutes billing and payment fraud under the MFA (para 13).
• Whether the State is entitled to recover Medicaid overpayments and civil penalties under Section 30-44-8(A) of the MFA (para 31).

Disposition

• The district court’s Rule 1-012(B)(6) dismissals of the State’s complaint against BHC were affirmed (para 36).

Reasons

• The Court held that failure to comply with CCHSA regulations does not support MFA liability in this case, affirming the district court’s dismissal of the State’s claims. The Court distinguished between conditions of participation and conditions of payment, finding that BHC’s compliance with CCHSA was not a condition of Medicaid payment. The Court also found that the State failed to allege facts that would support any recoverable damages under federal and state Medicaid regulatory schemes for the breach of contract claim. The Court concluded that BHC’s alleged failure to adhere to CCHSA requirements did not constitute a violation of a condition of Medicaid payment that supports a Medicaid fraud cause of action under the MFA, nor did it provide a basis for common law contract remedies or damages where the State incurred no identified harm (paras 3, 13-35).