On February 27th, administrative law judge Rick Gilpin of Texas Health and Human Services Commission issued a final order in the “credible allegation of fraud” payment hold case of Antoine Dental of Houston, fully reversing the Proposal for Decision written by two State Office of Administrative Hearings (SOAH) judges last November.
ADC had been placed under a 100% payment hold in April of 2012 by the Texas Health and Human Services Commission Office of Inspector General (OIG) for “credible allegations of fraud” and willful misrepresentation in their orthodontic billings from 2008 to 2011. ADC had been one of the top 25 billers of Medicaid for orthodontic services in the state.
The SOAH judges, in their decision, found that ADC had not committed fraud or any willful misrepresentation and ordered the payment hold discontinued after listening to four days of testimony in June and spending five months crafting their decision. Yet the HHSC judge ordered the 100% payment hold against Antoine Dental to remain. Antoine Dental will apparently have to appeal to Travis County district court.
The Austin American-Statesman has already criticized the decision and its apparent lack of impartiality. Clearly, something is seriously wrong, not only constitutionally but morally, with HHSC being the investigator, accuser and prosecutor, judge and jury in this case.
The Gilpin reversal makes a mockery of the entire SOAH hearing process and any due process rights Antoine Dental Center as a Medicaid provider might have had. It makes it a waste for any Medicaid provider to ask for a SOAH hearing when HHSC will merely gut the decision when it is not in its favor. In this one case alone, it has wasted literally hundreds of thousands of state and provider dollars on legal fees.
“Cut And Paste” Justice
Something which has not been noticed or reported upon to this point which further highlights this injustice is that the judge apparently “cut and paste” a large part of his decision almost word-for-word straight from the HHSC-OIG document that was filed on behalf of Executive Commissioner Kyle Janek by Assistant Attorney General Raymond Winter to object to the initial SOAH decision.
TDMR has highlighted the HHSC decision to show the roughly 30 cut and pasted areas, which amounts to roughly 6 full pages of the 36 page decision. The PDF file contains notes which reference the page number the highlighted text came from in the OIG document which is also made available for comparison.
Pasted the Wrong Text
Worse, not only did the HHSC judge cut and paste, in one instance the cut and paste was clearly not the correct text.
On point number 46 of his Findings of Fact, he pasted copy relating to one dentist, Dr. Kanaan, when it should have been about another, Dr. Nazari.
46. Proposed FoF No. 46 states: Dr. Nazari was a credible witness and properly utilized the Manuals’ definition in scoring the HLD index.
Proposed Finding of Fact No. 46 is erroneous because the proposed finding ignores evidence that directly refutes Dr. Kanaan’s credibility…
Such a ridiculous error and process makes old style Texas frontier justice look much preferable. This decision is an embarrassment to the state of Texas and harmful to every Medicaid provider in the state.
As a result, TDMR is consulting with attorneys to file a complaint with US. Department of Health and Human Services Office of the Inspector General to request an investigation into HHSC’s apparent abuse of justice.