Opinion ID: 1809210
Heading Depth: 1
Heading Rank: 2

Heading: Authority for Recoupment.

Text: Our review of the agency's recoupment order in light of the entire record convinces us that its authority to recoup payments made to petitioner was not dependent on any billing limitation contained in the CDT codes. Rather, the agency's authority for recoupment lies in the audit procedures contained in Iowa Administrative Code rule 441-87.4 (1987) and the actions that may be taken under Iowa Administrative Code rule 441-87.5(2)(c) as a result of audit findings. The latter regulation authorizes the agency to proceed with recoupment of overpayments pursuant to Iowa Code section 249A.5 (1991). The agency regulations define overpayment as follows: Overpayment means any payment or portion of a payment made to a provider which is incorrect according to the laws and rules applicable to the Medicaid program and which results in a payment greater than that to which the provider is entitled. Iowa Admin. Code r. 441-87.1. We agree with DHS's contention that multiple payments for duplicate or overlapping services qualify as an overpayment. In the present case, the DHS audit suggested a duplication of charges on petitioner's part based on separate charges for overlapping services. Petitioner submitted his claims using the CDT codes and has made no showing that the services that have been placed in issue were not accurately described by the code designations under which they were billed. It is apparent from the descriptions of these services contained in the CDT codes and from Exhibit 7 (an article from the Journal of American Dental Association, Vol. 117, August 1988), which explains the CDT codes, that the procedure designated 01205, topical application of fluoride (including prophylaxis), is merely a combination of procedure 01110, adult prophylaxis, and topical application of fluoride. Consequently, when a claim is made for the 01205 procedure, this necessarily includes the services that would be performed for the procedure described in code 01110. For this reason, petitioner's claims for code 01110 procedures duplicated the services identified and paid for by the agency in response to his claims under the 01205 code. It is similarly apparent from the CDT codes and Exhibit 7 that the 01110 procedure, adult prophylaxis, and the 04345 procedure, periodontal scaling performed in the presence of gingival inflammation, overlap. Consequently, petitioner's claims under the 01110 code were a duplication of claims paid for by the agency in response to his billing under code 04345. It is of course possible that petitioner in submitting his claim for services had divided the proper charge for the more inclusive procedures between those procedures and the lesser procedures that were included therein so that in combination the two charges reflected the proper fee. The amount of the charges submitted for each procedure suggests that this was not the case. Moreover, if this was the case it was incumbent upon petitioner to demonstrate that the fee had been so divided. He has failed to do so. We have considered all arguments presented and conclude that the judgment of the district court should be reversed. The case is remanded with directions to affirm the agency's order for recoupment of sums paid to petitioner. REVERSED AND REMANDED.