2020 Ohio 5488
Ohio Ct. App.2020Background
- Cecilia Katsande, an Ohio DODD-certified independent Medicaid provider, was audited for services billed from July 1, 2011 through June 30, 2014; DODD/ODM assessed $53,568.32 in overpayments.
- DODD requested APC (homemaker personal care), AOC (on site/on call), and ATN (transportation) service documentation; Katsande submitted recreated APC/AOC records and claimed ATN records were destroyed in a vehicle accident.
- DODD auditors found discrepancies between billed units and the submitted documentation, discovered that Katsande disclosed the accident and recreated records only after an auditor informed her of monetary findings, and noted inconsistencies about the accident date.
- An email from the service coordinator (admitted in the administrative hearing) stated she did not recall being told about the accident and that Katsande usually kept records at her own home.
- The DODD hearing examiner found Katsande’s explanation not credible, recommended affirming the overpayment, the ODM director adopted that recommendation, the Franklin County Common Pleas Court affirmed, and this appeal followed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether ODM's overpayment adjudication was supported by reliable, probative, substantial evidence | Katsande: agency order not supported by substantial evidence; examiner relied on improper inferences | ODM: record (documents, testimony, recreated records, omissions) supports findings | Affirmed — agency order supported by reliable, probative, substantial evidence |
| Admissibility/reliability of service-coordinator email (hearsay) | Katsande: email is inherently unreliable hearsay and prejudicial | ODM: administrative hearings allow hearsay; email from a witness with personal knowledge was probative and not the sole basis | Affirmed — emails not inherently unreliable and properly weighed as part of the record |
| Credibility determination of Katsande’s testimony about destroyed/recreated records | Katsande: examiner improperly discredited her; testimony was sole reasonable explanation | ODM: inconsistencies (date, timing of disclosure), lack of corroboration, and reconstructed records justify disbelief | Affirmed — credibility determinations are for the hearing examiner and were not an abuse of discretion |
| Whether a claimed calamity (accident) entitles provider to waiver/defense to recoupment | Katsande: destruction by accident should excuse missing records or trigger waiver | ODM: provider must maintain/produce records; unexplained omissions, recreated records, and inaccuracies do not bar recovery | Held — no waiver; calamity claim did not overcome agency’s statutory authority to recover overpayments |
Key Cases Cited
- Pons v. Ohio State Med. Bd., 66 Ohio St.3d 619 (Ohio 1993) (framework for judicial review of agency orders)
- Our Place, Inc. v. Ohio Liquor Control Comm., 63 Ohio St.3d 570 (Ohio 1992) (definition and meaning of "reliable" evidence)
- Univ. of Cincinnati v. Conrad, 63 Ohio St.2d 108 (Ohio 1980) (deference to administrative resolution of evidentiary conflicts)
- Simon v. Lake Geauga Printing Co., 69 Ohio St.2d 41 (Ohio 1982) (relaxed evidentiary rules in administrative proceedings)
- Haley v. Ohio State Dental Bd., 7 Ohio App.3d 1 (Ohio Ct. App. 2d Dist. 1982) (agencies not bound by strict courtroom rules of evidence)
- Black v. State Bd. of Psychology, 160 Ohio App.3d 91 (Ohio Ct. App. 2005) (hearsay is not precluded in administrative hearings)
- In re Petition for Annexation, 52 Ohio App.3d 8 (Ohio Ct. App. 10th Dist. 1988) (when hearsay is admitted, trier must assess reliability and weight)