Opinion ID: 572143
Heading Depth: 2
Heading Rank: 4

Heading: Prior GAB Decisions

Text: 48 The Secretary's final contention is that two prior GAB decisions, New York State Dep't of Social Services, GAB Decision No. 537 (May 30, 1984) (Decision No. 537) and New York State Dep't of Social Services, GAB Decision No. 542 (June 4, 1984) (Decision No. 542) support the assurance requirement. A careful examination of these decisions, however, proves otherwise. 49 In Decision No. 537, New York submitted a QER estimating the amount of federal reimbursement to which it was entitled. The Secretary denied the State's claim, and the State appealed to the GAB. The GAB reversed the Secretary, holding that a QER need not contain an exact calculation of the State's entitlement to federal reimbursement. Rather, the state need only submit a figure which is as definite as reasonably possible under the circumstances. Decision No. 537 at 15. Moreover, the GAB held that HHS regulations did not require an instantly available compilation of the documentation supporting the QER. Since the State's estimates in Decision No. 537 were based on a computerized audit and review of available documentation and ancillary sources, the GAB held that the State had made a valid claim for federal reimbursement. 50 In Decision No. 542, the State submitted an estimated claim for federal reimbursement that was based solely on the experience and knowledge of a State employee. The GAB disallowed the State's claim for federal reimbursement, holding that the State must at least know where the documentation for the claim is and it could not submit a figure that was little more than an outright guess. 51 Neither Decision No. 537 nor Decision No. 542 supports the Secretary's argument. Both decisions focused on the State's use of estimated figures on the QER. As the GAB stated: [T]he real question is where did the figure [on the QER] come from? Decision No. 542 at 7 (quoting Decision No. 537 at 15). In this case, by contrast, there is no doubt where the figures on the QER came from. The State explained that the figures on the QER were an extrapolation from a sample of cases that the State had determined were eligible for Medicaid reimbursement. 52 It should not go unnoted that the Secretary has never questioned the validity of the State's estimate in this case. Rather, the issue in this case is the documentation a state must possess when filing its QER. This issue was not addressed by the GAB in either Decision No. 537 or Decision No. 542. The assurance requirement, therefore, cannot emanate from either of these decisions.