Court Opinion

ID: 9476491
Source: CourtListenerOpinion
Date Created: 2023-08-05 05:57:17.576539+00
Date Added: 2024-06-11T17:45:21.056648
License: Public Domain

WIGGINS, Circuit Judge,
concurring in párt and dissenting in part:
I respectfully dissent from that portion of the opinion affirming the Larms’ convictions on the office visit counts. The Larms should not be criminally liable for making a false statement under 42 U.S.C. § 1396(h)(a)(l) when the statement they made was literally true under HMSA’s ambiguous published billing codes.
The Larms used code 90040 to bill HMSA for nurse-administered allergy shots when *785Dr. Lam was not in the office. This, the majority holds, is a false statement on an application for Medicaid because code 90040 requires that the physician personally have treated the patient. However, HMSA’s published guidelines defining code 90040 make no mention of the physician’s presence, requiring instead a “[b]rief examination, evaluation and/or treatment, same or new illness,” “including] a brief or interval history, examination, discussion of finding and/or rendering of service.” The Larms’ use of code 90040 was literally correct under HMSA’s definition. The administration of a shot is indisputably a “[b]rief ... treatment,” including a “rendering of service.”
I agree that an alternate code more closely tracked the type of service the Larms provided. The guidelines define code 90030 as “Minimal service: injections, minimal dressings, etc., not necessarily requiring the presence of a physician.” But the literal truth of the Larms' statement under code 90040 precludes a prosecution for making a false statement in an application for Medicaid under section 1396(h)(a)(l). See Bronston v. United States, 409 U.S. 352, 93 S.Ct. 695, 34 L.Ed.2d 568 (1973) (wily witness who succeeds in derailing questioner does not commit perjury so long as he speaks literal truth); United States v. Sainz, 772 F.2d 559, 662-65 (9th Cir.1985) (same); see also United States v. Poutre, 646 F.2d 685 (1st Cir.1980) (18 U.S.C. § 1001, prohibiting false statements to federal officials, cannot be invoked when an evasive statement is literally true).
When the government issues imprecise billing codes, physician-providers should not have to guess at their meaning at the risk of criminal prosecution under section 1396(h)(a)(l). If HMSA wishes to restrict the use of code 90040 to services physically provided by the physician, it can do so. But the government cannot subject a physician to prosecution for falsely stating that he complied with the physical presence requirement unless it precisely articulates that requirement. Bronston, 409 U.S. at 362, 93 S.Ct. at 601 (“Precise questioning is a predicate for the offense of perjury”); Sainz, 772 F.2d at 564 (a witness “cannot be forced to guess at the meaning of the question to which he must respond upon peril of perjury”).
Nor was the ambiguity cured by the HMSA claims examiner’s oral advise to the Larms that code 90040 was proper only if the physician personally treated the patient. A government employee’s oral advise on the interpretation of an unclear government regulation is too weak a foundation upon which to base a false statement prosecution. The inherent uncertainties of oral interpretations counsel against such a prosecution. The physician-provider has no basis to evaluate whether the employee’s interpretation is the agency’s official one. Indeed, it is conceivable that the physician could receive conflicting advise from different government employees on the interpretation of the regulation.
Absent an authoritative agency interpretation — preferably published — clarifying the agency’s ambiguous billing codes, it is improper to prosecute a doctor for pressing a reasonable code interpretation. See United States v. Dahlstrom, 713 F.2d 1423, 1428 (9th Cir.1983) (prosecution under 26 U.S.C. § 7206(2) for willful filing of false tax returns is inappropriate for a taxpayer’s advocating a tax shelter, the legality of which was “completely unsettled by any clearly relevant precedent”) (citing United States v. Garber, 607 F.2d 92, 100 (5th Cir.1979) (a criminal prosecution under section 7206 “is an inappropriate vehicle for pioneering interpretations of tax law”)), cert. denied, 466 U.S. 980, 104 S.Ct. 2868, 80 L.Ed.2d 835 (1984); see also Bell v. United States, 349 U.S. 81, 88-84, 75 S.Ct. 620, 622, 99 L.Ed. 905 (1955) (rule of lenity requires resolving ambiguity in criminal statute in favor of defendant).
The Larms’ use of code 90040 was literally true under HMSA’s ambiguous guidelines. The claims examiner’s oral advice did not cure the ambiguity. Consequently, the Larms’ convictions on the office visit counts should not stand.