Opinion ID: 480275
Heading Depth: 1
Heading Rank: 2

Heading: other claims raised by appellant

Text: 17 The administrative law judge found that Mayers knew or should have known that the claims filed contained false information. The CMPAA specifically provides for liability if a person knows or has reason to know [that a medical item or service] was not provided as claimed. 42 U.S.C. Sec. 1320-7a(a)(1)(A) (1982). In spite of the clear wording of the statute, appellant contends that actual knowledge must be established to impose liability under the CMPAA. Appellant fails to cite any authority indicating that a more rigorous standard is constitutionally required before imposing a civil penalty. A criminal statute may constitutionally impose a fine or imprisonment based upon a defendant's negligent conduct. The Mayers, however, argue that a civil penalty may not be imposed where they knew or should have known that their conduct was wrongful. Such an argument must be rejected. 18 Appellants contend that the CMPAA and its implementing regulations are vague and ambiguous. Essentially, it is argued that one could reasonably interpret the definition of physician under the Social Security Act to encompass a chiropractor. Therefore, appellants conclude that the act fails to place them on reasonable notice that their conduct violated the CMPAA. 19 The Administrative Law Judge properly concluded that the Mayers were put on notice that their conduct violated the CMPAA. Each claim form submitted by the Mayers contained the following printed provision: 20 For services to be considered incident to a physician's professional service, (1) they must be rendered under the physician's immediate personal supervision by his/her employee, (2) they must be an integral, although incidental part of a covered physician's service, (3) they must be of kinds commonly furnished in physicians' offices, and (4) the services of nonphysicians must be included on the physician's bills. 21 The Social Security Act unambiguously provides that a chiropractor's services are not routinely covered. Such services are covered only with respect to treatment by means of manual manipulation of the spine (to correct a sublaxation demonstrated by X-ray to exist) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided. 42 U.S.C. Sec. 1395x(r) (1982). In light of the explicit detail in which Congress narrowly defined reimbursable chiropractic services, no individual could reasonably conclude that other services performed by a Doctor of Chiropractic medicine would be reimbursable. 22 The record shows that the Mayers engaged in an elaborate scheme of hiring physicians of foreign extraction for no purpose other than to obtain medicare billing numbers. The Administrative Law Judge found that the Mayers would not have done so if they honestly believed all chiropractic services were reimbursable. The record makes it clear that the Mayers continued to rubber stamp the signatures of physicians to Medicare claims during periods when the physicians were no longer employed. The Mayers intentionally prepared post-dated physicians orders after the Medicare investigation was begun. This effort to camouflage their path further refutes their assertion that they believed that all chiropractic services were covered by the Social Security Act. 23 The Mayers additionally claim that the Department of Health and Human Services failed to respond to their inquiry concerning the propriety of their conduct. This claim is without merit. The Mayers were specifically advised that services had to be ordered and supervised by a medical doctor for such services to be reimbursable. 24 The Administrative Law Judge heard nearly two weeks of testimony detailing the Mayers fraudulent conduct. The government entered into evidence 480 written exhibits at the Mayers' hearing. In spite of the voluminous record supporting each element of the Administrative Law Judge's decision, the Mayers argue that the determination was not supported by substantial evidence and was arbitrary and capricious. This claim is without merit. 25 Also without merit is appellant's argument that the Administrative Law Judge acted improperly by hearing evidence beyond the scope of the claims alleged by the government. The Administrative Law Judge properly heard evidence of aggravating facts in order to determine appropriate damages. 26 For the foregoing reasons, the decision of the Department of Health and Human Services is 27 ENFORCED.