Court Opinion

ID: 9466127
Source: CourtListenerOpinion
Date Created: 2023-08-05 01:06:13.048456+00
Date Added: 2024-06-11T17:39:33.531926
License: Public Domain

PELL, Circuit Judge,
dissenting.
The majority opinion unfortunately perpetuates a rigidly anserine bureaucratic ruling to the detriment of an orderly handling of the needs of public health. I therefore respectfully dissent.
No one can seriously quarrel with a governmental desire to eliminate all unnecessary expenditures of public funds on social programs such as that here involved. The *737anti-factoring legislation was designed for that very purpose. Congress, on the other hand, recognized that there are legitimate clinics such as Michael Reese which are rendering services through salaried employees and expressly permitted the payment to be made to the corporate employer. Congress has thereby declared the policy that payments made directly to the employer are not violative of the anti-factoring precepts but are indeed payments to the party entitled thereto not to someone who has no legal claim.
The state here in an attempt to justify its wooden and unbending insistence on making payments to individuals known to the state not to be entitled thereto ultimately basically resorts to a Pandora’s box argument that Medicaid mills “and even factors will attempt to utilize this to their full advantage.” The case before us, however, involves a bona fide employer, the very kind contemplated in the Congressional exception to the requirement of direct payment to the individual; no one argues otherwise. The state has to do no more to fasten tight the lid of the famed troublous box than to require adequate documentary proof of the bona fide employer status. The majority opinion suggests that Michael Reese can require the physicians to list the clinic as their address. Elsewhere in the majority opinion there is reference to the state regulation requiring the physician “to designate one, and only one, street address.” Inasmuch as many of the physicians are also in private practice, I do not understand that the physicians can furnish more than one street address dependent upon whether they are in the private sector or the employment capacity as to a particular billing.
The state on this appeal emphasizes that the word “may” is permissive and argues therefore that the payment is discretionary and then leaps to the farther point that the exercise of that discretion is lodged with the state administrator. The majority opinion while not apparently relying expressly on the always arguable equation of “may” with permissiveness, nevertheless also concludes that the discretion is solely that of the state. Insofar as the significance of the word “may” is concerned, one need only riffle through the appropriate volume of Words and Phrases to be aware of the substantial attempts of judicial opinions to try to determine whether “may” means “shall” or merely something in the nature of “optional.” The cases, in the matter of the statutes, generally end up by referring to the intent of the legislature. Here, the guidance from legislative history does not seem to tell us much except Congress was concerned about excessive claims resulting from factoring. That concern was expressly delimited so as to exclude employers.
In any event, I agree with the majority that on the matter of legislative intent resort should be first had to the words of the enactment themselves. Here the basic statute, pre-exceptions, requires that the plan “must provide” that no payment shall be made to anyone other than the provider of the service. The exceptions clauses do not state that nevertheless the plan may provide for the payment to be made to the employer of the provider of service; instead the exceptions deal with the actual payment notwithstanding the mandatory language required for the plan. This could not very well have been worded in terms that in the event of employment the payment “shall” be made to the employer. Conceivably some employers might prefer that the physician directly do the billing with the amounts received to be credited against his salary obligation. In other words, the “may” in the statute just as logically, because it deals with the payment not the provisions of the plan, can be construed to refer to a discretion on the part of the employer to determine whether it or its employees directly shall bill for and receive payments.
The state by its unbending resistance to the orderly procedure whereby one source, instead of multiple providers, submits billings has demonstrably been detrimental to a valued public health service in this area. This is understandable when it is recalled that the physicians also frequently render services in their private practice for which payments are made. I do not deem it nec*738essary as did Judge Perry to reach the constitutional issue, although I regard the situation as it has developed as involving serious constitutional questions. In my opinion, the state has no choice in the case of a bona fide employer except to pay that employer, if the employer so desires, for the services rendered by its employees. Even, however, if the discretion were considered to rest only with the state rather than the employer, on the facts of the present case, there seems to me to be such a patent abuse of discretion that the injunction granted below should be affirmed.