Texas State Office of Administrative Hearings judges, the Honorable Howard Seitzman and the Honorable Catherine Egan, provided their final Proposal for Decision in the case of Houston’s Antoine Dental Center to HHSC Excecutive Director Dr. Kyle Janek on Thursday. Antoine Dental Center was under a 100% payment hold based on “credible allegations of fraud” for their Medicaid orthodontic billings by OIG investigators. ADC had been one of the top 25 billers of Medicaid for orthodontic services in the state from 2008 to 2011. The judges, in their initial decision last November, found that ADC had not committed fraud or any willful misrepresentation and ordered the payment hold discontinued.

In the process to a coming to final PFD which will be reviewed by HHSC administrative judges for a final decision, OIG and the defence had an opportunity to respond to the decision. The judges reviewed 62-pages of exceptions from OIG lawyers that were filed with them shortly after the initial decision.

In their letter to Dr. Janek, the judges wrote:

“On November 4, 2013, we issued the Proposal for Deeision (PFD) in this case. The Texas Health and Human Services Commission, Office of Inspector General (HHSC-01G) filed exceptions challenging most of the PFD. Antoine Dental Center (ADC) did not file exceptions, but did respond to HHSC-01G’s exceptions. After reviewing the exceptions and the response, we have concluded that the PFD in this case requires no substantive amendments.

“Although HHSC-01G’s exceptions are lengthy, the exceptions assert the same legal arguments raised during the hearing and in the written arguments. Those legal arguments are sufficiently addressed in the PFD. Additionally, the ALJs do not find it necessary to address either evidentiary objections that were not raised during the hearing. Nor do we address exceptions where the PFD contains the complete citation to the record and the exception is based upon only a partial record citation. And, while HHSC-01G repeatedly argued that we failed to follow HHSC’s policies in interpreting the law, beyond the law and the Manual analyzed in the PFD, the record contains no written policy governing “ectopic eruptions” during the relevant period. We find no need to alter our analysis or conclusions.”

In their exceptions, OIG wrote:

“In support of these Exceptions, the Inspector General will show: HHSC Medicaid policy provides a limited orthodontia benefit; Antoine Dental Center (ADC) submitted fraudulent or willfully misrepresented prior authorization requests and claims for reimbursement; ADC submitted claims for services not reimbursable; and ADC failed to maintain or provide records as required by law. Under applicable law and considering the prima facie evidence of record, the Inspector General has met his burden, and the Executive Commissioner should maintain the 100% payment hold against ADC.”

The judges apparently were not impressed with OIG’s further arguments and the fact that OIG lawyers totally discounted the initial PFD and its conclusions that eviscerated OIG’s case and payment hold.

TDMR makes available the ALJ’s letter to Dr. Janek and the OIG exceptions for download.