Tran v. State
926 N.W.2d 641
Neb.2019Background
- Ann Tran was a Nebraska Medicaid personal assistance services (PAS) provider from May 2015–Oct 2016 and signed provider service agreements (SPAs) requiring accurate claims and six-year record retention.
- DHHS suspended Tran’s Medicaid payments on Oct 7, 2016 and audited her billing after a fraud referral flagged overlapping service hours with other employment and among Medicaid clients.
- Audit identified 41 overlaps with Lincoln Public Schools payroll entries and multiple instances of overlapping billings between distinct Medicaid clients unrelated to school work.
- Tran admitted she prefilled timesheets based on estimated schedules, did not retain weekly timesheet copies, and could not produce requested records; she acknowledged up to ~$880 in overpayments.
- DHHS terminated Tran’s SPA and permanently excluded her from Medicaid; Tran administratively appealed, lost before the DHHS Director, then lost de novo review in district court and appealed to the Nebraska Supreme Court.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether competent evidence supports finding Tran billed overlapping services | Tran: timesheets reflected actual hours provided; overlaps stemmed from DHHS mistakes (e.g., LPS payroll inaccuracies) | DHHS: audit and independent instances show overlapping billings between Medicaid clients and inaccurate timesheets | Court: Competent evidence supports finding of overlapping billings; overlaps not explained away by payroll quirks or Tran’s estimated timesheets |
| Whether DHHS’s permanent exclusion was arbitrary or excessive | Tran: no intent to deceive, cooperated, would comply; lesser sanctions (education) appropriate | DHHS: provider breached SPA (false claims, failure to produce records), sanction is within Director’s discretion considering extent of violations | Court: Sanction was harsh but within agency discretion and not arbitrary, capricious, or unreasonable; district court’s affirmation stands |
Key Cases Cited
- Leon V. v. Nebraska Dept. of Health & Human Servs., 302 Neb. 81 (addresses APA review standard)
- Prokop v. Lower Loup NRD, 302 Neb. 10 (district court’s de novo review of agency discipline)
- Rainbolt v. State, 250 Neb. 567 (scope of judicial review of administrative sanctions)
- Gridiron Mgmt. Group v. Travelers Indem. Co., 286 Neb. 901 (presumption of correctness for agency decisions)
- Lingenfelter v. Lower Elkhorn NRD, 294 Neb. 46 (agency regulations as statutory law)