Court Opinion

ID: 9775422
Source: CourtListenerOpinion
Date Created: 2023-08-29 18:58:09.833262+00
Date Added: 2024-06-11T07:32:26.039688
License: Public Domain

PUDLOWSKI, Judge,
dissenting.
I respectfully dissent.
The Board filed a five count complaint against Dr. Boyd -with the AHC. The Board’s complaint sought a determination from the AHC that cause existed to discipline Dr. Boyd’s license under § 334.100 et seq RSMo. Count I sought to discipline her Missouri license for the unlicensed practice of medicine. The other two counts upon which the discipline was based pertained to the filling in of Medicaid (Count II) and Medicare (Count III) forms blank or partially in blank. Counts IV and V were dismissed by the Board.
After the Board imposed discipline on her license, Dr. Boyd appealed to the Circuit Court of St. Louis County. The circuit court affirmed and the complainant appealed to this court.
Our court reviews the decision of the administrative agency, the AHC, not the judgment of the circuit court. Kramer v. Mason, 806 S.W.2d 131, 134 (Mo.App.E.D.1991). On review we afford due weight to the experience and expertise of the agency, Hornsby v. Director of Revenue, 865 S.W.2d 662, 663 (Mo. banc 1993), and view the evidence in a light most favorable to the agency decision. Keesee v. Meadow Heights R-II School District, 865 S.W.2d 818, 823 (Mo.App.S.D.1993).
According to the Stipulation of Facts submitted by the parties to the AHC, Dr. Boyd received her license to practice medicine in the District of Columbia on April 25,1985; it remained active and in good standing through 1990. On September 12, 1988, she was hired by The People’s Health Centers (People’s) in St. Louis, Missouri. Dr. Boyd received her Missouri physician’s license on December 29,1988.
In relation to Count I, Dr. Boyd stipulated that she knew she was supposed to have a Missouri license to practice medicine and that she did not have one. She further admitted that she practiced medicine notwithstanding the fact that she did not have a license. With respect to Count I alone, Dr. Boyd consented to an order by the AHC that “... that cause (emphasis added) exists for the Board to take disciplinary action against Dr. Boyd’s Missouri medical license_”
I recognize that a stipulation as to a conclusion of law does not bind the Commission. Litigants cannot stipulate as to questions of law. State v. Biddle, 599 S.W.2d 182, 186 and n. 4 (Mo. banc 1980). Further, the Commission must independently and impartially review the facts of any case. Kennedy v. Missouri Real Estate Comm’n, 762 S.W.2d 454, 457 (Mo.App.E.D.1988). A stipulation as to there being cause to discipline must contain “sufficient facts to support the finding the parties seek.” Regulation s CSR 15-2.450(1)(a)2. The Commission, having reviewed the stipulated facts and applicable law, agreed that the record supports the suggested conclusion.
The Commission clearly found as to Count I that there was cause to discipline Dr. Boyd under § 334.100.2(6) which authorizes discipline for violating any provision of Chapter 334. Section 334.010 states that: “It shall be unlawful for any person not now a registered physician within the meaning of the law to practice medicine or surgery_” The majority, in its opinion, ignores the AHC’s determination in relation to Count I that cause exists to discipline Dr. Boyd’s license. The AHC stated that “Unlike § 334.100.2(4), § 334.010 requires no scienter, the action itself is a violation.” Thus, assuming arguen-do that I agree with the majority’s position regarding Counts II and III of the Board’s complaint, the Board shall have the ability and the discretion to impose discipline on Dr. Boyd’s license for the violation of § 334.010. Under §§ 334.100.3 and 334.100.4, the Board *319could have revoked her license for up to seven years or could have suspended her license for up to three years. The majority and Dr. Boyd are essentially arguing that the Board imposed too harsh a penalty upon Dr. Boyd. The majority cites no authority for its decision to remand. In reviewing the Board’s decision, we review the record in a light most favorable to the Board’s decision and disregard evidence that might support findings different from those of the agency. Clark v. Beeves, 854 S.W.2d 28, 31-32 (Mo.App.W.D.1993). Francois v. State Bd. of Registration for the Healing Arts, 880 S.W.2d 601, 603 (Mo.App.E.D.1994). I believe that the Board’s suspension of Dr. Boyd’s license, even absent the unprofessional and unethical conduct contained in Counts II and III, is supported by substantial and competent evidence: Dr. Boyd stipulated that she was guilty of the unauthorized practice of medicine and her license was subject to discipline. Therefore, I disagree with the majority. I would affirm the Commission’s finding as to Count I.
Pertaining to Counts II and III, Dr. Boyd stipulated that on September 12, 1988, she signed a Medicaid-Provider Enrollment Application. Dr. Boyd filled in her name, social security number, date of application, principal place of business address and telephone number. She then signed the application as the “Applying Provider.” On September 27, 1988, Dr. Boyd signed a second Medicaid-Provider Enrollment Application which had been filled in by someone other than herself. Also, on September 27, 1988, she signed two Missouri Medicaid Provider Questionnaires, which had been completed in large part. The only blank left was Block 17 which asked for the provider’s state license number. This block was left blank on each questionnaire when they were signed by Dr. Boyd. She was aware that the questionnaire asked for the state license number and she knew she left it blank. Dr. Boyd stipulated that she knew by signing the questionnaires with blanks that they could be filled in by someone else with incorrect information and she knew they could be mailed for processing and approval. People’s, not Dr. Boyd, mailed in the applications and questionnaires, along with a document purporting to be Dr. Boyd’s Missouri license pocket card and her diploma. The information received by the Missouri Division of Medical Services, Provider Enrollment Unit, reflected that her license number was 15143, her District of Columbia license number. The Board had not issued this license number to Dr. Boyd. As a result of the information provided to the Provider Enrollment Unit, Dr. Boyd received two Medicaid Provider numbers. At the time she filled in the Medicaid forms, Dr. Boyd knew that she was not licensed to practice the healing arts in Missouri. As part of her employment at People’s, Dr. Boyd was required to have a Medicaid provider number.
People’s received $3,922.25 for services rendered by Dr. Boyd from September 12, 1988 to December 20, 1988 which were claimed under the two Medicaid provider numbers issued to Dr. Boyd.
On September 29, 1988, Dr. Boyd signed an incomplete application for a Medicare provider number, knowing that the application called for a Missouri license number, she left this information blank. She further stipulated that when she signed the form, she knew or should have reasonably known that it could have been completed with incorrect information. At the time she signed the Medicare provider number application, Dr. Boyd was not licensed in Missouri.
After Dr. Boyd completed the application, People’s submitted it to Medicare. People’s also sent a document purporting to be Dr. Boyd’s Missouri license pocket card and her diploma. The application, which was processed, had her District of Columbia license number as her Missouri license number. Although Dr. Boyd did receive a Medicare provider number sometime in the fall of 1988, neither People’s nor Dr. Boyd applied for or received Medicare funds against the Medicare number issued to her.
In her first point on appeal, Dr. Boyd claims that the AHC erred as a matter of law and was in excess of its jurisdiction because her conduct, with respect to Counts II and III of the Board’s complaint, was not in the performance of the “functions and duties” of the medical profession. I disagree.
*320In Counts II and III, Dr. Boyd was charged with violating § 334.100.2(4) RSMo Supp.1987, which authorizes the Board to discipline a physician for:
Misconduct, fraud, misrepresentation, dishonesty, unethical conduct or unprofessional conduct in the performance of the functions and duties of any profession licensed or regulated by this chapter, including, but not limited to, the following: ....
In order to constitute cause to discipline under § 334.100.2(4), the unprofessional or unethical conduct must be “in the performance of the functions and duties” of the medical profession. Dr. Boyd argues that the signing of the applications for Medicaid and Medicare provider numbers was not part of the functions and duties of a physician. Further, she argues that because the applications were completed and submitted by her employer, People’s, she is less culpable. Dr. Boyd relies primarily upon Board of the Healing Arts v. Levine, 808 S.W.2d 440 (Mo.App.W.D.1991) in support of her argument.
In Levine, the Western District held in part that a non-treating physician who gave expert testimony was not in the performance of the functions and duties of the medical profession. The court also found under the facts that they did not establish that Levine obtained fees or other compensation by fraud, deception or misrepresentation. Id. at 441. Therefore, the court held that his license was not subject to discipline under § 334.100.2(5) RSMo Supp.1983 despite the fact that he had lied under oath while providing his expert testimony. Id. at 443. At a deposition, Levine testified that he had passed his specialty boards on his second attempt. At an unrelated trial, Levine testified under oath that it took him four attempts to pass his boards. The Board claimed that, in truth, it took him five attempts to pass his boards. Id. at 441.
Dr. Boyd has attempted to characterize her actions as mere “administrative” oversights that were as far removed from the actual care of patients as giving expert testimony. Dr. Boyd ignores the fact that she was a salaried employee of People’s and her employment contract required her to have a Medicaid provider number. Obtaining a Medicaid number was an integral part of Dr. Boyd’s practice of medicine at People’s. Applying for a provider number was expected of her as a physician and it was a duty that she assumed as part of her practice at People’s.
Dr. Boyd has focused her arguments on issues such as patient treatment and patient health and safety. In Levine, the Western District stated that the elements of function or duty included any “function,” “duty,” “obligatory task,” “moral or legal obligation” or act “expected of’ a physician. Id. at 443. The court went on to point out that § 334.100.2 RSMo Supp.1983 and 1986 listed twenty-one offenses for which the Board could cause a complaint to be filed. Of the twenty which applied to physicians, only three related directly to patient care. The other seventeen, the court pointed out, related to patient care only indirectly, if at all. Id. In making this point, the court was indicating that “[i]f the legislature had wanted to regulate the conduct of a physician acting as a non-treating medical witness, it would have statutorily so provided. The mention of one thing in a statute implies the exclusion of another.” Id.
In 1987, the legislature amended § 334.100.2. Prior to those amendments, the statute under which the Board attempted to discipline Dr. Levine authorized discipline for:
(4) Obtaining or attempting to obtain any fee, charge, tuition or other compensation by fraud, deception or misrepresentation;
(5) Incompetency, misconduct, gross negligence, fraud, misrepresentation or dishonesty in the performance of the functions and duties of any profession licensed or regulated by this ehapter[.]
The 1987 amendments added a nonexclusive list of the functions and duties of the medical profession at paragraphs (4)(a) through (q). When the legislature added those paragraphs, it was partially defining the scope of a physician’s functions or duties. Some of the paragraphs directly concerned the diagnosis and treatment of the sick and others do not: specifically see subdivisions (l) through (p) relating to a physician’s conduct toward the Board and subdivision (q) regarding ad*321vertising. Most significantly was the addition of the following language: “including, but not limited to, the following!!.]” § 334.100.2(4) RSMo Supp.1987 (emphasis supplied). Expressly in the statute, the legislature has elucidated the fact that the list contained in § 334.100.2(4)(a)-(q) is only illustrative of the types of activities which would subject a physician’s license to discipline. Therefore, although the holding in Levine might be instructive for some purposes, the Western District’s 1991 interpretation of the 1986 statute is not determinative of the phrase “functions and duties” as used in the 1987 amended statute.
In construing a statute substantially the same as § 334.100.2(5), our court held in Cooper v. Missouri State Board of Pharmacy, 774 S.W.2d 501, 504 (Mo.App.E.D.1989), that a pharmacist’s submission of false Medicaid claims supported the findings of “dishonesty and misrepresentation in the performance of his duties as a licensed pharmacist in violation of § 338.055.2(5) RSMo 1986.” If the efforts to obtain compensation from Medicaid are within the functions and duties of the pharmacy profession, I believe that it is reasonable to conclude that they are within the functions and duties of the medical profession. Furthermore, obtaining fees for services rendered has long been considered as part of the practice of medicine. See Hughes v. State Board of Health, 348 Mo. 1236, 159 S.W.2d 277, 280 (1942).
The fact that the Medicare and Medicaid reimbursements would have been paid to People’s, her employer, does not effect this line of reasoning. Salaried employee’s are expected to obtain reimbursement for their services even if the payment goes directly to the employer. Although the forms that Dr. Boyd filled out were not claim forms, they were a necessary predicate to People’s receiving reimbursement from Medicare and Medicaid and integral to that process. The reimbursement was obtained by misrepresentation.
Therefore, I would hold that the AHC did not err in finding that completing and executing Medicare and Medicaid forms was within the functions and duties of a physician. I would deny point I.
In her second point, Dr. Boyd challenges the AHC’s finding that the stipulated conduct she engaged in constituted “unethical” and “unprofessional” actions on the grounds that it was not supported by competent and substantial evidence because there was no evidence that she provided incorrect or false information. I disagree.
The standard of review for this case is whether the AHC’s decision is supported by competent and substantial evidence; whether the decision of the AHC was arbitrary, capricious, unreasonable or an abuse of discretion. Curtis v. Board of Police Commissioners of Kansas City, 841 S.W.2d 259, 261 (Mo.App.W.D.1992). The AHC action is arbitrary and capricious only if there is no substantial evidence to support it. State ex rel. Baer v. Campbell, 794 S.W.2d 690, 691 (Mo.App.E.D.1990). “Substantial” evidence is that evidence which supports the discretionary determination of the agency. Curtis v. Board of Police Commissioners of Kansas City, 841 S.W.2d at 261.
The AHC relied upon the Affidavit of the expert, Douglas Wheeler, D.O., and paragraphs 11 through 35 of the Stipulation of Facts, as the sole factual and opinion evidence upon which it based its decision.
The Board has submitted a motion asking this court to vacate its order of February 17, 1995 and reconsider its denial of the Board’s request to supplement the Record on Appeal to include the Affidavit of Douglas Wheeler, D.O. and the deposition testimony of Dr. Boyd. I would deny the motion.
In Perez v. Board of Registration for the Healing Arts, 803 S.W.2d 160 (Mo.App.W.D. 1991), the AHC suspended a doctor’s license for ethical violations involving a sexual relationship with a patient. The doctor challenged the suspension without expert testimony to instruct the trier of fact as to the applicable ethical and professional standards within the medical community. In denying the doctor’s challenge, the Western District stated that: “It was not necessary for the Commission to receive expert testimony. The facts presented herein were sufficient to allow inexperienced persons to draw a fair and intelligent opinion on whether Dr. Perez *322engaged in dishonorable, unethical or unprofessional conduct of a character likely to deceive, defraud or harm the public.” Id. at 164.
In Dr. Boyd’s case, I find that expert testimony is also unnecessary. Based solely upon the stipulated facts that are properly part of the record, I would agree that Dr. Boyd’s conduct was unethical and unprofessional.
I find instructive the definitions of unethical and unprofessional from Webster’s Third New International Dictionary, pp. 2494 and 2506 (unabridged 1983) which the AHC cited. Unethical is not conforming to professionally endorsed principles and practices. Unprofessional is not characteristic of, or not befitting, a member of a profession.
Dr. Boyd knew that she was signing an application to provide services for which Medicare and Medicaid would reimburse People’s for her services. She knew that she did not have the Missouri license needed to provide medical services but would provide them anyway. She left the “state license number” space blank without providing an explanation of the status of her Missouri license. Her contract with People’s provided that she would have a Medicaid provider number. On both the Medicare and Medicaid provider applications which Dr. Boyd signed as the applying provider was the following statement:
By the signature below, I certify that all answers and information given to this application are true and that there has been no material misrepresentation or omissions. I also understand that I must supplement this information if due to change of ownership or other changes, it become (sic) materially different than reported herein.
Dr. Boyd attempts to hide behind the fact that when she signed the forms they were blank or partially blank. However, she admitted that she knew or reasonably should have known that it could have been completed with incorrect information. Further, by her signature, she certified that the answers were true and that there were no material misrepresentations or omissions. I consider leaving the Missouri license number space blank at the time of the signing to be material. Moreover, the record does not show any attempt by Dr. Boyd to supplement her applications upon receipt of her Missouri license number in December, 1988, as required by the form. This is more than “ ‘careless’ completion of documents for Medicare and Medicaid payments” as the majority asserts. To allow Dr. Boyd to go unpunished when she admitted that she knew or should have known that the form could have been completed with incorrect information is improper. If the majority seeks an element of scienter, I believe it is contained in her admission that she knew or should have known that the form could have been completed with incorrect information. I believe that this is culpable conduct particularly in light of the declaration directly above Dr. Boyd’s signature on the Medicare and Medicaid forms. Therefore, I would affirm the AHC’s determination that Dr. Boyd’s conduct was both unprofessional and unethical. I would deny point II.
Dr. Boyd’s third point contends that the Board used unlawful procedure and denied her a fair trial because it: 1) failed to admit character evidence in the form of letters; 2) failed to admit into evidence and consider records of prior disciplinary proceedings; and 3) allowed the Board’s legal advisor to rule on evidentiary matters, despite the fact that the legal advisor and the attorney prosecuting the matter were both from the Attorney General’s Office. I disagree.
At the hearing before the Board to determine the discipline to be imposed on her license, Dr. Boyd offered two exhibits into evidence: 1) Exhibit 1, which consisted of letters from numerous individuals concerning her abilities as a physician, her assistance to the community and her personal and professional reputation; and 2) Exhibit 2, which consisted of a written record of all previous published disciplinary actions taken by the Board from December 5, 1987 through the date of the hearing. After conferring with its legal advisor, the Board denied admission of the evidence. We review the exclusion of the evidence, ex gratia, despite Dr. Boyd’s counsel’s failure to make the required offer of proof. § 536.070(7) RSMo 1994; Bauer v. *323Custom, Trailer Repair, Inc., 829 S.W.2d 104, 106 (Mo.App.E.D.1992).
The letters Dr. Boyd sought to introduce appear to be hearsay which is not within any recognized exception. They are out-of-court statements offered to prove the truth of the matter asserted, i.e., her character, reputation and professional abilities. Even though the Board may have been able to admit the letters, Franklin v. Board of Directors, 772 S.W.2d 873, 883 (Mo.App.W.D.1989), under ordinary circumstances, hearsay evidence could not be considered competent and substantial evidence to support the determination of the AHC. Hacienda Enterprises No. 2, Inc. v. Smarr, 841 S.W.2d 807, 811 (Mo.App.E.D.1992). Dr. Boyd was able to present character evidence to the Board from four live witnesses. These witnesses included a Roman Catholic priest, a research director for an educational and advocacy center for maternal and child health services, the president of a company that provides consulting services to physicians and hospitals and a registered nurse. They provided their personal opinion of Dr. Boyd and, to an extent, testimony of her reputation in the community. The exclusion of letters offering character evidence which would have been partially repetitious, cumulative and of questionable probative value did not prejudice Dr. Boyd. The Stipulation of Facts contained substantial and competent evidence to uphold the decision of the Board. I would hold that the Board did not abuse its discretion in excluding Exhibit 1. The exclusion of the evidence did not result in a substantial or glaring injustice nor unduly prejudice Dr. Boyd.
As for Exhibit 2, the summaries of orders of discipline imposed by the Board in other cases, the Board did not commit error in refusing its admission. Section 621.110 RSMo 1994 states that at a hearing, such as the one held by the Board to determine the discipline to impose on Dr. Boyd’s license, “[t]he agency may receive evidence relevant to said issue from the licensee or any other source.” The discipline imposed by the Board in every case since 1987 is not necessarily relevant to the facts and circumstances under which Dr. Boyd’s license was disciplined. Although of dubious relevance and probative value, there is no indication that the Board did not consider its other most recent decisions when deciding the amount of discipline appropriate in this case. The punishment imposed by the Board was well within the range of available punishments. The Board’s action was supported by substantial and competent evidence, §§ 334.100.3 and 334.100.4. Accordingly, I find no abuse of discretion in failing to admit Exhibit 2.
Because I found that the Board did not commit error nor abuse its discretion in excluding Dr. Boyd’s Exhibits 1 and 2,1 find no merit in her contention that the Board erred in allowing its legal advisor to rule on eviden-tiary matters, despite the fact that the legal advisor and the attorney prosecuting the matter were both from the Attorney General’s Office. I would deny Point III.
In her final point on appeal, Dr. Boyd asserts that the order disciplining her license: 1) is unsupported by competent and substantial evidence based upon the whole record; 2) is arbitrary, capricious and unreasonable; and 3) constitutes an abuse of discretion. I disagree.
Dr. Boyd argues that the entirety of the uncontroverted evidence before the Board indicated that she is of good character, is a competent and caring physician and dedicated to delivery of medical services to the indigent.
Dr. Boyd apparently ignores the Stipulation of Facts when asserting this final point. She stipulated that she knew that she was required to have a Missouri license to practice medicine and that she did not have one. She further admitted that she practiced medicine notwithstanding the fact that she did not have said license. She stipulated that “her actions ... constituted ‘misconduct’ and ‘unprofessional’ behavior ...” and “... that cause exists for the Board to take action against Dr. Boyd’s Missouri medical li-cense_” Furthermore, Dr. Boyd stipulated to conduct pertaining to the Medicare and Medicaid forms, Counts II and III of the Board’s petition, which both the AHC and this court has deemed “unethical” and “unprofessional.”
*324Therefore, despite the good character evidence which Dr. Boyd properly submitted to the Board, I find that there was competent and substantial evidence to uphold the imposition of discipline on Dr. Boyd’s license. The decision by the Board was not arbitrary, capricious or unreasonable nor did it amount to an abuse of discretion. I would deny Point IV.
I would affirm in all respects the decision of the AHC and the imposition of discipline imposed on Dr. Boyd’s license by the Board in all respects.