Court Opinion

ID: 5488178
Source: CourtListenerOpinion
Date Created: 2022-01-10 02:20:05.219185+00
Date Added: 2024-06-11T08:33:43.156909
License: Public Domain

Smith, J. (concurring).
The Board for Professional Medical Conduct (BPMC) found that petitioner had practiced medicine negligently on two occasions, but did not suspend him from practice, choosing instead to impose a three-year period of probation. The Office of the Medicaid Inspector General (OMIG), relying on nothing but BPMC’s finding, prohibited petitioner from treating Medicaid patients—which, as a practical matter, makes it difficult if not impossible for petitioner to practice medicine. I agree with the majority that OMIG’s determination was arbitrary and capricious, but would rest that conclusion on the broader ground adopted by the Appellate Division.
I
BPMC is a unit within the Department of Health consisting of a majority of doctors and a minority of lay members (Public Health Law § 230 [1]). It is responsible for adjudicating professional misconduct complaints against doctors. A separate unit of the Department of Health, the Office of Professional Medical *705Conduct (OPMC) is responsible for investigating and prosecuting such complaints. OPMC conducted an investigation of petitioner’s treatment of two patients in 2006. The investigation led, in 2009, to a “Consent Agreement and Order” signed by petitioner, BPMC and OPMC, in which petitioner pleaded “no contest” to charges that his care and treatment of both patients “failed to meet accepted standards of care.” The agreement includes a two-page “Statement of Charges,” briefly describing the ways in which petitioner was said to have erred. Petitioner agreed to a 36-month period of probation, subject to 11 specific terms, among them that petitioner would “practice medicine only when monitored” by a doctor acceptable to OPMC, and that he would enroll in and complete a continuing education program.
After this agreement was signed, petitioner’s case came to OMIG’s attention. OMIG is also part of the Department of Health. It was created in 2006 to consolidate in a single office “Medicaid fraud detection, prevention and recovery functions” and to “streamline the state’s process of detecting and combating Medicaid fraud and abuse” (Public Health Law § 30). The statutes governing OMIG suggest that its primary focus should be on fraudulent and other excessive Medicaid billing, but its mandate is not expressly restricted in that way. A regulatory definition of “abuse” includes “payments for services which fail to meet recognized standards for health care” (18 NYCRR 515.1 [b] [1]).
Under another regulation, when OMIG receives notice that BPMC or some other agency has found a person guilty of “professional misconduct or unprofessional conduct,” OMIG “may immediately sanction the person” (18 NYCRR 515.7 [e] [regulation of Department of Social Services]; see Public Health Law § 31 [1] [transferring certain DSS duties to OMIG]). Possible sanctions include exclusion from the Medicaid program “for a reasonable time” (18 NYCRR 515.3 [a] [1]). An OMIG document in the record before us says that, when OMIG receives a consent order from OPMC, it “will obtain the full investigative file and consider the underlying facts to make an independent decision on whether exclusion is warranted,” but that did not happen in petitioner’s case. Rather, a registered nurse employed by OMIG as a “Health Surveyor” reviewed, as far as the record shows, only the Consent Agreement and Order, with its attachments. Having done so, the Health Surveyor concluded that petitioner’s “conduct was so negligent that the OMIG *706should . . . exclude him from participating as a provider in the Medicaid program,” and OMIG adopted that recommendation. The Health Surveyor’s reasons for concluding that the conduct was “so negligent” do not appear in the record.
It is undisputed that exclusion from the Medicaid program is a grave sanction for any doctor, even one who, like petitioner, primarily treats patients who are not Medicaid recipients (see Matter of Mihailescu v Sheehan, 25 Misc 3d 258, 261 [Sup Ct, NY County 2009] [“respondents do not deny petitioner’s assertion that, under Medicaid regulations, her continuing exclusion from the roster of Medicaid providers effectively bars any governmentally licensed or operated facility from hiring her”]). Petitioner asserted below that, after being listed on the Medicaid website as an excluded physician, he was notified by a private insurer that it would exclude him as a qualified provider, and that he expected to receive similar notices from other insurers. He also alleged that “it will be difficult if not impossible for him to secure or renew privileges at any area hospitals in the future if he is excluded from Medicaid.” OMIG does not specifically deny these assertions, though it points out that petitioner is not barred from treating non-Medicaid patients.
II
Petitioner argues that what has happened here is essentially a second-guessing of BPMC’s determination by OMIG. While BPMC, a board composed primarily of doctors and principally concerned with maintaining high standards of professional care, decided that petitioner should, subject to certain restrictions, be allowed to continue treating patients, OMIG decided, with no basis beyond the facts found by BPMC, that he could not treat Medicaid patients. I agree with petitioner that OMIG’s action was arbitrary and capricious for this reason.
Where the only issue is the professional quality of care being rendered, and where OMIG has no information before it that BPMC did not have, OMIG should defer to BPMC’s decision on whether a doctor may safely be allowed to furnish medical care. The majority of the lower courts that have considered this issue have so held (see Mihailescu, 25 Misc 3d at 265-267; Matter of Pearl v Office of the Medicaid Inspector Gen., 2009 NY Slip Op 32492[U] [Sup Ct, Albany County 2009]; Matter of Haluska v State of N.Y. Off. of State Medicaid Inspector Gen., Sup Ct, Chemung County, Apr. 7, 2010, O’Shea, J., index No. 2009-2774; Matter of Napoli v Sheehan, Sup Ct, Erie County, May 25, 2010, *707Drury, J., index No. 2009-14524; but see Matter of Halliday v State of N.Y. Off. of Medicaid Inspector Gen., Sup Ct, Albany County, July 2, 2010, Connolly, J., index No. 2575-10; Matter of Blab v Sheehan, Sup Ct, Albany County, Sept. 30, 2010, Sackett, J., index No. 4275-10).
I do not suggest that OMIG should be limited to examining cases of financial fraud and abuse, or that it has no role in considering whether a doctor’s treatment of patients meets professional standards. If OMIG had acted against petitioner on the basis of its independent investigation, and had not relied entirely on facts that BPMC had already found, I might find this to be a different case. Nor do I suggest that OMIG need defer to BPMC where something other than the care and treatment of patients is at issue. I might also think this a different case if BPMC’s discipline of petitioner were based on poor record-keeping. But it was in fact based exclusively on the quality of the care that petitioner gave his patients. In such a case, OMIG should not, in effect, review and reject BPMC’s determination that petitioner is fit to be trusted with patient care.
Judges Graffeo, Rivera and Abdus-Salaam concur with Judge Read; Judge Smith concurs in result in an opinion in which Chief Judge Lippman and Judge Pigott concur.
Order affirmed, with costs.