Court Opinion

ID: 7321251
Source: CourtListenerOpinion
Date Created: 2022-07-25 21:18:36.686866+00
Date Added: 2024-06-11T16:19:51.887129
License: Public Domain

MICHELS, P.JAD.
(dissenting in part).
I would affirm in its entirety the final decision of the Acting Director of the Department of Human Services, Division of Medical Assistance and Health Services (DMAHS). I, therefore, respectfully dissent from that portion of the, majority opinion that reverses the Acting Director’s determination to disallow reimbursement of the Medicaid claims made by appellant SSI Medical Services, Inc. (SSI), listed in Attachment B of the initial decision of the Chief Administrative Law Judge.
Acting Director Wheeler reversed the initial decision of the Chief Administrative Law Judge that indicated that SSI’s Attachment B Medicaid claim forms were timely filed:
The Director REVERSES the recommended decision on the Attachment-B claims because he disagrees with the Chief ALJ’s findings and conclusions for two reasons.
The first reason is that the policy of the New Jersey Medicaid program has been that a provider of service must present “documentary evidence of filing” of the claims with the fiscal agent, Jewish Hospital and Rehabilitation Center v. DMAHS, 92 N.J.A.R.2d (DMA) 53, 58 [1992 WL 279813] (1992). As indicated in the holding of the above-cited case, this Division has historically required a higher standard for proof of timely filing of a claim than the general business practice with regard to processing and mailing set-forth in the line of cases on which the Chief ALJ relied in reaching her decision.
The reason for requiring a higher standard of proof concerning the timely filing of a Medicaid claim is two-fold. The first reason, which is not an issue in this case, is to protect the integrity of the Medicaid program which pays providers of service millions of dollars in both State and Federal funds. The second reason, which is in issue in this case, is to avoid a disallowance of the federal share of the Medicaid payments because a claim was not filed within twelve months from the date of service (42 CFR 447.45(d)) and to comply with the State legislative mandate set-forth in N.J.S.A 30:4D-7, that the Commissioner maximize federal funding.
The Director also rejects the Chief ALJ’s recommendation to process the Attachment-B claims for payment because the Petitioner’s proofs do not satisfy the requirements to create the presumption of receipt as set-forth in the line of cases relied on by the Chief ALJ. Specifically, in Lamantia v. Howell Twp., 12 N.J.Tax 347, 352-353 (Tax Court 1992), the court held that the proponent of the presumption of receipt must show that there was proper posting, that the article was placed in an appropriate receptacle or delivered to the post office, that the return address was on the envelope and that there was adequate postage on the envelope. However, in this case, the Petitioner’s proofs were not sufficient to satisfy these requisites. In the proofs presented, the Petitioner merely recited its customary mailroom procedure and its office practices for submitting Medicaid claim forms. *195The Petitioner never provided any evidence that the forms in question were placed in an envelope with the correct forwarding and return address, that the proper postage was affixed nor that the claims were placed in a proper mail receptacle or the post office.
Because the above-mentioned proofs were lacking, the Chief ALJ should not have invoked the presumption of timely receipt of the claims in favor of the Petitioner.
The Director further finds and concludes that the Respondent presented ample proof to rebut the presumption of timely receipt of the claims in question. Specifically, through the testimony of Unisys employees Robert Laverty and Audrey Atkinson (through an affidavit), it was shown that all the information in the Prudential computer for the relevant time period was transferred to the Unisys computer and that none of the claims at issue were received in a timely manner by either Prudential or Unisys.
Furthermore, the Director finds and concludes that if the testimony of the Petitioner’s witnesses, to the effect that they would resubmit claims after three or four months if no payment was received, is taken to its logical conclusion, it would mean that Prudential lost the same claims more than once. This appears to be highly unlikely and is not believable.
Therefore, the Director finds and concludes that the Petitioner is not entitled to a presumption of timely filing of the claims set-forth in Attachment>-B.
The Director also wishes to correct several errors in the Initial Decision. Specifically, the record should reflect that Pat Snyder (I.D. at Pg. 10) never testified. The tape of this proceeding indicates that the testimony attributed to Ms. Snyder was provided by Linda Nunziato who was the manager of the entire Medicaid claims processing unit at Prudential, including the durable medical equipment and supply claim unit which Ms. Snyder supervised.
The Director also disagrees with the Chief ALJ’s interpretation that the Petitioner had one year plus ninety days to submit the elaims in issue. Both the Federal and State regulations 42 CFR 447.45(d)(1) and N.J.A.C. 10:49-7.2(a)(1) requires providers to submit all claims no later than twelve months from the date of service.
The ninety day inquiry period allows providers a window of opportunity to question the status of a claim that was already submitted for processing. This ninety day inquiry period does not afford providers extra time to initially submit claims.
The Director also reverses the conclusion that the Medicaid claims processing unit at Prudential was a “black hole” that routinely lost claims. This statement is attributed to Unisys employees and are unsubstantiáted hearsay. Although the OAL rules of procedure are liberal in allowing the admission of hearsay statements into evidence, the residuum rule N.J.A.C. 1:1-15.5 requires that some competent evidence be presented to support the hearsay statements. Because there was no supporting evidence presented concerning elaims that were “lost” by Prudential, this conclusion is reversed.
*196I am satisfied from my review of the record that the final decision of the Acting Director is not arbitrary, capricious or unreasonable, and does not lack full support in the evidence. Henry v. Rahway St. Prison, 81 N.J. 571, 579-580, 410 A.2d 686 (1980); Campbell v. Dep’t of Civil Serv., 39 N.J. 556, 562, 189 A.2d 712 (1963). See Bd. of Educ. of Wayne v. Kraft, 139 N.J. 597, 603, 656 A.2d 430 (1995); Dennery v. Bd. of Educ., 131 N.J. 626, 641, 622 A.2d 858 (1993); Barone v. Dep’t of Human Servs., 210 N.J.Super. 276, 285, 509 A.2d 786 (App.Div.1986), aff'd, 107 N.J. 355, 526 A.2d 1055 (1987). 1
We must not lose sight of the fact that our role in reviewing the Acting Director’s findings and conclusions is limited. Pub. Serv. Elec. v. New Jersey Dep’t of Environ., 101 N.J. 95, 103, 501 A.2d 125 (1985); Gloucester County Welfare Bd. v. New Jersey Civil Serv. Comm’n, 93 N.J. 384, 390, 461 A.2d 575 (1983). As Justice O’Hern explained in George Harms Constr. v. Turnpike Auth., 137 N.J. 8, 27, 644 A.2d 76 (1994):
Courts can intervene only in those rare circumstances in which an agency action is clearly inconsistent with its statutory mission or with other State policy. Although sometimes phrased in terms of a search for arbitrary or unreasonable agency action, the judicial role is restricted to four inquiries: (1) whether the agency’s decision offends the State or Federal Constitution; (2) whether the agency’s action violates express or implied legislative policies; (3) whether the record contains substantial evidence to support the findings on which the agency based its action; and (4) whether in applying the legislative policies to the facts, the agency clearly erred in reaching a conclusion that could not reasonably have been made on a showing of the relevant factors. Campbell v. Department of Civil Serv., 39 N.J. 556, 562, 189 A.2d 712 (1963); In re Larsen, 17 N.J.Super. 564, 570, 86 A.2d 430 (App.Div.1952).
It is not our function to substitute our “independent judgment for that of an administrative body ... where there may exist a difference of opinion concerning the evidential persuasiveness of the relevant proofs.” Matter of Recycling & Salvage Corp., 246 N.J.Super. 79, 87, 586 A.2d 1300 (App.Div.1991) (citing First Sav. and Loan Ass’n of E. Paterson v. Howell, 87 N.J.Super. 318, 321-322, 209 A.2d 343 (App.Div.1965), certif. denied, 49 N.J. 368, 230 A.2d 400 (1967)). We cannot “weigh the evidence, determine the credibility of witnesses, draw inferences and conclusions from the *197evidence, or resolve conflicts therein.” Matter of Recycling, supra, 246 N.J.Super. at 87, 586 A.2d 1300; DeVitis v. New Jersey Raxing Comm’n, 202 N.J.Super. 484, 489-90, 495 A.2d 457 (App.Div.), certif. denied, 102 N.J. 337, 508 A.2d 213 (1985). See In re Tenure Hearing of Grossman, 127 N.J.Super. 13, 28, 316 A.2d 39 (App.Div..), certif. denied, 65 N.J. 292, 321 A.2d 253 (1974).
Additionally, and perhaps most importantly, our review is limited solely to the final decision of the agency and not the initial decision of the Chief Administrative Law Judge. Adamar v. Dep’t of Law, 250 N.J.Super. 275, 295, 593 A.2d 1237 (App.Div.1991) (citing Pub. Advocate Dep’t v. Pub. Utils. Bd., 189 N.J.Super. 491, 507, 460 A.2d 1057 (App.Div.1983)). Thus, even if the Chief Administrative Law Judge’s findings, conclusions and recommendations may be reasonable, they do not control, and we are not free to substitute them in place of the Acting Director’s final decision. Adamar, supra, 250 N.J.Super. at 295-96, 593 A.2d 1237. Similarly, “[m]ere disagreement with an agency’s conclusion ... does not permit a court to reject that conclusion.” Bd. of Educ. of Wayne v. Kraft, 139 N.J. 597, 604, 656 A.2d 430 (1995) (citing Clowes v. Terminix Int’l, Inc., 109 N.J. 575, 587, 538 A.2d 794 (1988) and Goodman v. London Metals Exck, Inc., 86 N.J. 19, 28-29, 429 A.2d 341 (1981)).
Consequently, when the record is considered in light of these fundamentally sound principles, I am persuaded that the Acting Director’s decision to reject in part the Chief Administrative Law Judge’s findings, conclusions and recommendations, and disallow reimbursement of SSI’s Attachment B Medicaid claims should be affirmed.
The Acting Director properly held that SSI failed to satisfy its burden of proving the mailing of the Attachment B Medicaid claim forms and that, therefore, SSI was not entitled to the presumption that these forms had been delivered to DMAHS’ fiscal agent, Prudential Insurance Co. (Prudential). New Jersey courts historically have required actual proof of mailing before the presumption of delivery will inure to the party seeking the benefit of that *198presumption. The general rule is that there is a presumption that mail correctly addressed, stamped, and mailed was received by the party to whom it was addressed, absent a statute or contract provision respecting notice. That presumption is rebuttable and may be overcome by evidence that the mailing was never in fact received. Tower Management Corp. v. Podesta, 226 N.J.Super. 300, 304, n. 3, 544 A.2d 389 (App.Div.1988); Johnson & Dealaman, Inc. v. Wm F. Hegarty, Inc., 93 N.J.Super. 14, 20, 224 A.2d 510 (App.Div.1966); Szczesny v. Vasquez, 71 N.J.Super. 347, 354, 177 A.2d 47 (App.Div.1962). Stated differently, proof of mailing, correct addressing, and due posting of a letter raises the presumption that it was received by the addressee. Cwiklinski v. Burton, 217 N.J.Super. 506, 509, 526 A.2d 271 (App.Div.1987); Waite v. Doe, 204 N.J.Super. 632, 636, 499 A.2d 1038 (App.Div.1985), certif. denied, 102 N.J. 398, 508 A.2d 256 (1986). The conditions necessary to establish the presumption are: (1) the mailing was corrects ly addressed; (2) proper postage was affixed; (3) the return address was correct; and (4) the mailing was deposited in a proper mail receptacle or at the post office. Lamantia v. Howell Township, 12 N.J.Tax 347, 352 (Tax Ct.1992). See also 1A Wigmore on Evidence § 95 (Tillers rev. 1983).
In Cwiklinski, we elaborated on the standard for proof of mailing, particularly with respect to office custom. There, the trial court dismissed an automobile negligence complaint for having been mailed after the statute of limitations had expired. The evidence of mailing consisted of an affidavit from the plaintiffs’ attorney’s secretary claiming that, on a date five weeks before the statute of limitations expired, she typed the complaint, sealed it in an envelope, and placed it with other office mail that was normally hand-delivered to the post office each day. 217 N.J.Super. at 508, 526 A.2d 271. However, neither she nor anyone else testified that the envelope “was actually deposited at the post office.” Ibid.
In affirming the trial court’s dismissal of the complaint, we held that the secretary’s affidavit was insufficient to establish proof of mailing. We explained that evidence of office custom must be *199accompanied by evidence that the custom was followed in the particular case, and held that “testimony from one who actually mails the notices or letters is necessary to establish conclusively the fact of mailing.” Id. at 511, 526 A.2d 271. We further concluded that “there was a complete absence of the type of proof upon which our courts have insisted to establish that a letter has been mailed” because the secretary “did not state that the envelope in question was actually taken to the post office and mailed that day.” Ibid.
Here, as in Cwiklinsky SSI did not present proof to establish that the Medicaid claim forms listed in Attachment B were actually mailed. Instead, SSI’s proofs simply recite its office custom for mailing claim forms, without any proof that these procedures were actually followed with respect to the disputed forms. Most importantly, no one testified that these forms were in fact mailed, and SSI presented no written proof of such mailing.
Indeed, SSI has not proven any of the four conditions necessary to establish the presumption that Prudential received the disputed forms. None of the affidavits indicate that the forms were placed in an envelope with the correct forwarding and return addresses, that proper postage was affixed, and that the claim forms were placed in a proper mail receptacle or at the post office. Rather, SSI’s proof of mailing relies entirely on inferences that it argues should be drawn from evidence of its office custom. The total absence of actual proof establishing mailing prevents SSI from obtaining the benefit of the presumption of delivery.
Although the Acting Director may have characterized the statement by the former Director of DMAHS in Jewish Hosp. and Rehab. Ctr. v. Div. of Med. Assistance and Health Servs., 92 N.J.A.R.2d 53, 58, 1992 WL 279813 (1992), that “documentary evidence of filing is required for the petitioner to be able to claim Federal/State funds” as a “higher standard of proof’ in matters of this kind, I view this standard as being essentially equivalent to the proof of mailing standards articulated in Lamantia, Cwiklinski, Waite, Johnson & Dealaman, and Szczesny. In fact, the *200Director’s conclusion in Jewish Hosp. that the “general business practice does not indicate [with] sufficient certainty that these claims were filed within the requisite time period without additional documentation,” closely mirrors our holding in Cwiklinski
In any event, I would defer to the Acting Director’s interpretation of the law because he is charged with administering it. Merin v. Maglaki 126 N.J. 430, 436-37, 599 A.2d 1256 (1992). See also Chambers v. Klein, 419 F.Supp. 569, 578 (D.N.J.1976), aff'd, 564 F.2d 89 (3rd Cir.1977). This is particularly so because the Acting Director’s construction of the law is longstanding, “as opposed to [his] first application of a statute (and its implementing regulation) to a new situation.” State, Dep’t of Envir. Protection v. Stavola, 103 N.J. 425, 435, 511 A.2d 622 (1986). Further, since the Acting Director’s interpretation involves “ ‘housekeeping’ measures designed to facilitate processing of numerous claims,” I would defer to his interpretation. Mazza v. Sec. of Dept. of Health & Human Services, 903 F.2d 953, 959 (3rd Cir.1990).
Even assuming that the Acting Director relied upon a so-called “higher standard of proof,” to establish mailing, his reliance on this standard was reasonable. It was not contrary to our law or federal law. It was consistent with DMAHS’s past precedent in the Jewish Hosp. case. It was also consistent with the cognate federal regulation and achieved the state legislative mandate under N.J.S.A. 30:4D-7 to maximize federal funding. Lastly, even if the Acting Director could have chosen another standard, we should defer to his choice because it has a reasonable basis. See Cooper Dev. Co. v. First Nat. Bank of Boston, 762 F.Supp. 1145, 1151 (D.N.J.1991).
Further, while I generally agree with the principles recited by the majority that “[t]hose who have valid claims against the government ordinarily need not bear a heavier burden in proving those claims than claimants against private parties”; that “[i]n dealing with the public, the government must ‘turn square corners’ ”; and that the “government may not exploit litigational or bargaining advantages that might otherwise be available to private *201citizens,” they do not apply here and were not violated by the Acting Director. SSI was not faced with a “heavier burden” of establishing that the claim forms were received by Prudential, and DMAHS did not “exploit litigational or bargaining advantages” because the standard in Jewish Hasp, and in Cwiklinski are virtually identical. Moreover, whether or not this so-called “policy” “conform[s] to the modem concepts of the duty of government to the public” or is “contrary to the general rule that the traditional preponderance of the evidence standard applies to the vast majority of Administrative Agency matters” is irrelevant. The proof of mailing standard in New Jersey is not merely a “policy;” rather, it is a well-settled rule of law that was not violated by the Acting Director’s final decision.
Finally, I do not read Bruce v. James P. MacLean Firm, 238 N.J.Super. 501, 570 A.2d 49 (Law Div.), aff'd o.b., 238 N.J.Super. 408, 570 A.2d 1 (App.Div.1989), as requiring a reversal of the Acting Director’s final decision. Bruce is distinguishable because the result therein turned on the court’s analysis of the particular insurance statute at issue, one which required individual documentation of mailings as to some kinds of notices, but not as to others. Thus, the court deduced a legislative intent that did not require the insurance carrier to establish actual proof of the mass mailing, and allowed it to rely only on evidence of custom. There is no similar statutory pattern in this case. The regulation governing the time of claim submissions, N.J.A.C. 10:49-7.2, requires only that the various claims be “submitted” and “received” within the designated time period. The regulation is silent as to the documentation required to establish submission and receipt, and, therefore, the Acting Director was free to require actual proof of mailing, particularly in view of federal-funding implications involved in this matter.
Accordingly, I would affirm the final decision of DMAHS under review.