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

• Ann Morrow & Associates (Morrow), a provider of behavioral healthcare services, was audited by the Human Services Department's (HSD) Medicaid behavioral health services manager in 2011. Following the audit, HSD began withholding payments to Morrow due to a credible allegation of fraud. The Attorney General’s Medicaid Fraud Control Unit later decided not to pursue Morrow for fraud. Subsequently, HSD issued two overpayment demands to Morrow totaling $441,997.05, citing issues such as lack of substantiating documentation, double billing, and billing for more time than was spent with clients (paras 2-3).

Procedural History

• District Court of Santa Fe County: The Administrative Law Judge (ALJ) recommended that Morrow reimburse all payments received for unsupported and up-coded claims, which was agreed upon by the MAD director (para 4).
• District Court: Affirmed the ALJ’s decision in November 2020, focusing on double billing and "up-coding" violations amounting to $130,575.80 (para 6).

Parties' Submissions

• Appellant-Petitioner (Morrow): Argued that it should be allowed to retain payments for the actual amount of time spent with clients, even if it billed for more units than were provided (para 5).
• Appellee-Respondent (HSD): Supported the policy of recouping the entire amount of an up-coded claim if the provider did not adjust the claim in a timely manner, relying on 8.351.2 NMAC and 8.302.2 NMAC (para 4).

Legal Issues

• Whether the State can recoup as an overpayment the entire amount it paid on a claim for medical services rendered when part of the services billed for were provided and part were not (para 1).

Disposition

• The Court of Appeals reversed the district court’s judgment and remanded the matter to the HSD ALJ for recalculation of the overpayment due in accordance with the Court's opinion (para 20).

Reasons

• The Court, with opinions by Judge Michael D. Bustamante, Judge Megan P. Duffy, and Judge Shammara H. Henderson concurring, found that the district court erred in its interpretation of the regulations governing recovery of overpayments. The Court concluded that HSD’s regulations do not explicitly allow for the recoupment of the entire amount paid on a claim when a provider has overstated the time spent in providing services. The Court determined that HSD is entitled to recoup only that portion of the amount it paid on a claim that was erroneously billed, not the entire payment for the claim. This interpretation was based on the language of the regulation, which indicates that overpayments are amounts paid in excess of the MAD allowable amount, and does not support the forfeiture of the entirety of the amount paid based on the submitted request (paras 11-19).