GAB Decision 439
Docket No. 82-159
June 17, 1983
New York State Department of Social Services;
Settle, Norval; Teitz, Alexander Ford, Cecilia
The New York State Department of Social Services (State) appealed
from a determination of the Regional Administrator, Health Care
Financing Administration (Agency), dated July 26, 1982, disallowing
federal financial participation in the amount of $33,279,025 claimed as
an increasing adjustment for prior quarters under title XIX of the
Social Security Act. The disallowance was taken on the ground that the
State's claim, submitted on its revised quarterly expenditure report
(QER) for the quarter ended December 31, 1980, duplicated claims for the
same expenditures submitted on the State's original and revised QERs for
the quarter ended September 30, 1980. During the course of the
proceedings before the Board, the State withdrew its appeal with respect
to $5,162,163. /1/ (State's brief dated November 15, 1982, p. 3;
letter from Ford to Rahmas and Klein dated December 14, 1982, pp. 2-3)
As explained below, the Board has determined that the remaining
$28,116,862 disallowance should be sustained. This decision is based on
written briefing by the parties as well as on the transcript of a
conference call held by the Board.
Were the Claims Duplicate Claims?
In its notice of appeal, the State acknowledged that "the major share
of the amounts in issue were in fact claimed in both the July/ September
and October/December quarters..." and that "the reclaiming was done
for
procedural (2) reasons so as to ensure that there was adequate time
available to submit documentation in support of claims...." (Letter from
Glasel to Putnam dated August 30, 1982, p. 1) This was consistent with
the written explanation submitted with the State's revised QER for the
quarter ended December 31, 1980, which stated that the revised QER
"contains claims in the amount of $33,791,525, which were included in
the..." revised QER for the prior quarter, /2/ and which offered "to
withdraw either claim upon receipt of your assurance that the claim
remaining in place will be reviewed in conjunction with the full
documentation we have produced." (Letter from Jones to Schreibeis dated
May 14, 1981, p. 1) The State also agreed during the course of the
proceedings before the Board that some of the claims involved at least
in part the same expenditures which were the subject of two other
appeals then pending before the Board regarding claims for the quarter
ended September 30, 1980 (Docket Nos. 82-131 and 82-153). (Letter from
Ford to Rahmas and Klein dated October 29, 1982, p. 3)
Based on the State's indication that some but not all of the amount
disallowed duplicated prior claims, the Board requested that the State
identify those amounts that did not represent duplicate claims. (Letter
from Ford to Glasel and Hunsaker dated September 14, 1982, p. 2) The
State, however, failed to do so, and instead submitted documentation
relating to expenditures totalling about $102 million which it contended
supported the $33,279,025 then in dispute as well as amounts claimed on
the QERs for the quarter ended September 30, 1980. (State's brief dated
November 15, 1982, pp. 1-2, and attachments) The State subsequently
denied that any of the claims at issue in the instant case duplicated
the amount involved in Docket No. 82-131. (Transcript of conference call
held on December 20, 1982, pp. 25-26, 35, 38-39) Later, the State argued
that "there is no requirement in law or regulation that an appellant
establish that amounts at issue do not represent duplicate claims...."
(State's brief dated January 4, 1983, p. 2)
We disagree with the State's position that it does not bear the
burden of showing that the claims are not duplicates of claims submitted
on the original and revised QERs for the quarter ended September 30,
1980. The disallowance rests on the Agency's finding that the claims
were duplicates. If that finding was erroneous, the State should be
able to offer some evidence to that effect since the State possesses all
of the documentation in support of the claims for both quarters. This
evidence need not be conclusive, but should at least provide some basis
for the Agency to re-examine its finding. Here, the State has provided
no explanation whatsoever for its (3) apparent position that there were
no duplicate claims. Moreover, the State's position is directly
contradicted by statements made by the State itself, at the time it
submitted the claims in dispute here to the Agency and when it first
appealed the disallowance of those claims to the Board, admitting that
the claims were, for the most part, the same as prior claims. In
addition, we note that the components of the $33,279,025 disallowance
figure identified by the State in briefing submitted to the Board are
identical in both description and amount to the breakdown in the notice
of disallowance of claims for the quarter ended September 30, 1980 which
the Agency found were duplicated by the $33 million claim. /3/
(Compare, State's brief dated November 15, 1982, p. 2 and letter from
Toby to Blum dated July 26, 1982, Exhibit A) Furthermore, the fact that
the State has documentation for expenditures in excess of the total
amount of the claims for the quarters ended September 30, 1980 and
December 31, 1980 does not prove that they were two separate claims. It
is possible that the documentation in excess of the amount of the claim
for the first quarter represents actual expenditures for which the State
never claimed reimbursement rather than an additional claim. Under
these circumstances, we find that the amount at issue here duplicates
the claim for the quarter ended September 30, 1980. /4/
Is the Agency Required to Review the Documentation Submitted in Support
of the Claim?
As indicated above, we find that the Agency was correct that the
claim in the instant case duplicates the claim for the quarter ended
September 30, 1980. The significance of this finding is that, in a
prior decision (New York State Department of Social Services, Decision
No. 433, May 31, 1983), the Board found that documentation identical to
the documentation submitted in the instant case was not related to the
claims made on the QERs for the quarter ended September 30, 1980, and
sustained disallowances of a portion of those claims on the ground that
the claims were not adequately documented. Moreover, the Board found in
Decision No. 433 that the State had been afforded ample opportunity both
during the deferral procedure pursuant to 45 CFR 201.15 and during the
initial stages of the appeal before the Board to submit documentation
for the claims, and that it was not unreasonable for the Agency to
refuse to consider additional documentation. Since the claim here
duplicates (4) the claims for the quarter ended September 30, 1980, a
portion of which was at issue in Decision No. 433, it stands to reason
that the Agency should not be required to review the documentation
submitted in the instant case. By requiring the Agency to review the
same documentation as was involved in Decision No. 433 in support of the
same claim, the Board would effectively nullify Decision No. 433. Thus,
we find that it was proper for the Agency to summarily disallow the
claim in the instant case on the ground that it duplicated the claims
for the quarter ended September 30, 1980. Although we recognize that a
state generally is entitled to submit documentation in support of a
questioned claim, we do not believe that this right is compromised by
our conclusion here. We merely find that in view of the identity
between the claims for the quarters ended September 30, 1980 and
December 30, 1980, the opportunity to provide documentation for one
claim was sufficient.
We note finally the State's argument that the claim should not be
disallowed as a duplicate because the State did not intend to be
reimbursed twice for the same expenditures. (State's brief dated
November 15, 1982, p. 3) However, the objection here is not that the
State would be paid twice for the same expenditures. Rather, the
Agency's concern, which we find to be a valid one, is that it not be put
to the time and expense of considering repeated attempts by a state to
justify a particular claim. (Agency's brief dated December 16, 1983,
pp. 7-8) Thus, it is not relevant that there were final disallowances of
some of the claims which were duplicated by the instant claim,
eliminating to that extent the possibility of duplicate payment.
Conclusion
For the foregoing reasons, we find that the claim submitted on the
State's revised QER for the quarter ended December 31, 1980 duplicated
claims made on the State's original and revised QERs for the quarter
ended September 30, 1980, and that the Agency properly disallowed the
former claim on the ground that it was a duplicate claim. Additionally,
we find that further opportunities to document the amounts claimed
within the context of this appeal are not warranted. Accordingly, we
sustain the disallowance in the amount of $28,116,862. /1/ The portion
of the appeal which was withdrawn corresponded in description
and amount to the claim at issue in Docket No. 82-153. That appeal and
the portion of the instant appeal indicated here were both withdrawn
without prejudice in view of the fact that the Agency had paid another
claim which included the $5,162,163 subject to a later determination of
allowability. The Board stated, however, that the State could raise any
issues pertaining to the $5,162,163 only once before the Board (either
by reinstituting its appeal in Docket No. 82-153 or 82-159 or by
appealing from a subsequent disallowance of the claim already paid).
(Letter from Ford to Glasel and Klein dated December 7, 1982, p. 1;
letter from Ford to Rahmas and Klein dated October 29, 1982, p. 3)
/2/ The amount claimed on the revised QER for the quarter ended December
31, 1980 was $33,791,525. The Agency determined that this "included a
duplication of $33,279,025 in claims previously submitted..." and
disallowed the claim to this extent. (Letter from Toby to Blum dated
July 26, 1982, p. 1) /3/ The components were: "(1) $25,656,365 for an
estimated New York City adjustment; (2) $5,162,163 in Office of Mental
Hygiene outpatient claims; (3) $1,060,497 in Federal Financial
participation for SSI retroactive to the date of application for various
local upstate districts; and (4) $1,400,000 for Westchester and Nassau
County retroactive SSI claims." /4/ A total of $51,810,597 was
claimed for the quarter ended September 30, 1980: $24,310,597 on the
original QER and $27,500,000 on the revised QER. The amount originally
in dispute in the instant case duplicated $33,279,025 of the
$51,810,597. The withdrawal of $5,162,163 of the appeal leaves a
duplication of $28,116,862.
JULY 07, 1984