Court of Appeals of Missouri, Western District, Fourth Division
APPEAL FROM THE CIRCUIT COURT OF COLE COUNTY, MISSOURI. The Honorable Daniel R. Green, Judge.
Randall C. Cahill, for Appellant.
Ross A. Brown, for Respondent.
Before Division Four: Alok Ahuja, Chief Judge, Joseph M. Ellis, Judge and James E. Welsh, Judge. All concur.
Joseph M. Ellis, Judge
Appellant Lindenwood Care Corporation d/b/a Loving Care Home appeals from a judgment entered by the Circuit Court of Cole County affirming the decision by the Administrative Hearing Commission (" the Commission" ). The Commission determined that, due to Appellant's inadequate documentation of the personal care services provided to Medicaid recipients at Appellant's facility, the Department of Social Services, Mo. HealthNet Division (" the Division" ) had overpaid Appellant $177,812.64. For the following reasons, the decision of the Commission is affirmed.
Appellant is a residential care facility located in St. Louis, Missouri. In 2006, Appellant entered into a participation agreement with the Division in which it agreed to be a vendor in the Personal Care Program, a program in which the vendor receives reimbursement for providing personal care services to eligible Medicaid recipients. Personal care services include:
(1) assistance with dietary needs; (2) assistance with dressing and grooming; (3) assistance with bathing and personal hygiene; (4) assistance with toileting and continence; (5) assistance with mobility and transfer; (6) assistance with medication; and (7) assistance with medically related household tasks.
13 C.S.R. § 70-91.010(2)(B)1-7.
In the participation agreement, Appellant agreed to " comply with the Medicaid manual, bulletins, rules and regulations as required by the Division . . . in submitting claims for payment." The agreement further provided that " [a]ll services billed through the Medicaid Program are subject to post-payment review" including " unannounced on-site review of records." (Emphasis in original). The agreement also stated that " [f]ailure to submit or failure to retain documentation for all services billed to the Medicaid Program may result in recovery of payments from Medicaid services and may result in sanctions to the provider's Medicaid participation."
On January 20, 2010, the Division conducted an unannounced, post-payment review at Appellant's facility. Cathy Schulte, a Division employee, entered Appellant's facility, provided Appellant with a list of residents, and requested Appellant's billing records for the personal care services that Appellant provided to those residents from April 2009 through November 2009. In doing so, Schulte provided Appellant with a " Document Disclosure Statement" that stated that Appellant " received the attached list of claims and/or MO HealthNet participants" and understood that the Division was requesting the disclosure of " all documents supporting billings submitted to [the Division] or its agents for services billed" for those participants.
One of Appellant's employees signed the disclosure statement and provided Schulte with documents titled " personal care documentation record." Each record pertained to a particular resident and consisted of a grid in which three sets of six personal care tasks were listed in horizontal rows and the days of the month were listed in vertical columns. Employees would initial the box corresponding to the personal care service they were providing the resident on that particular day and shift. The records also included a space for " supervisor/client signature." The Division scanned these records as well as the residents' care plans that Appellant had on file. Care plans are plans developed by the Department of Health and Senior Services (" DHSS" ) that set forth the units of personal care services authorized for each Medicaid recipient.
On February 18, 2010, the Division issued a final decision in which it concluded that it had overpaid Appellant $181,261.95 for personal care services. The decision included an attachment, which explained that Appellant's billing errors fell into the following three categories:
A. There is no documentation of any services provided on this date/during this billing period
B. There is no entry for the participant's signature for certain dates of service on the time sheet documenting Personal Care delivered for this month and/or if signed, the signature on the timesheet has been identified as that of an employee of the provider
C: [Appellant] billed for the full allocation of Personal Care units for the period billed; the time sheet analyzed shows no services delivered on at least one day in that period
The decision indicated that state regulations permitted the Division to sanction Appellant for such errors and that repayment of the overpaid funds could be accomplished by the ...