Greene v. Dep’t of Cmty. Health, 293 Ga. App. 201(2008)

Greene appealed denial of his application for Medicaid. The denial was affirmed by an administrative law judge. After review, the Commissioner adopted the findings of fact of the ALJ. The Commissioner addressed Greene’s specific arguments by explicitly noting the underlying evidence in the record supporting the ALJ’s decision and citing two cases: Atkinson v. Ledbetter (to support the proposition that the Commissioner could not make independent determinations of credibility of witnesses, because she did not preside at the initial hearing) and Commr. of Ins. v. Stryker, supra, 218 Ga. App. at 717 (1) (to support the proposition that findings of fact of an ALJ must be upheld unless they are not supported by “any evidence”).

Greene asserts that the Commissioner erred by applying Stryker to an internal agency review. Clearly, Stryker applies only to a superior court’s review of an agency’s decision and not to an agency’s review of an ALJ’s recommendation. The Commissioner’s review was not controlled by Stryker.

In this context, when an aggrieved party requests a hearing before an ALJ, the ALJ is a representative of the Department and, according to the statute, renders “a written recommendation” to the Commissioner based on an application of the Department’s substantive criteria to the party’s grievance. OCGA § 49-4-153 (b) (1). The ALJ’s role is to make a recommendation, and if the aggrieved party challenges the recommendation, it is then up to the Commissioner to either allow the recommendation to become the Department’s final decision (by taking no action), or to “affirm, modify, or reverse the decision appealed from.” Id. Thus, by this process, it is the Department that makes the ultimate decision as to how to resolve the aggrieved party’s claim.

[I]t is clear that the Department itself makes the ultimate decision on the merits of an aggrieved party’s claim. In doing so, the Department is constrained only by the governing statute (here OCGA § 49-4-153 (b) (1)) and principles of due process. See Bd. of Regents of State Colleges v. Roth (“a person receiving welfare benefits under statutory and administrative standards defining eligibility for them has an interest in continued receipt of those benefits that is safeguarded by procedural due process”) (citing Goldberg v. Kelly). Here, the statute imposes certain requirements on the Department’s final decision (e.g., it must be in writing and supported by findings of fact and conclusions of law), but it does not constrain the Department as to how it must consider the findings of fact in the ALJ’s recommendation. Accordingly, the Department was entitled, upon its review of the record, to adopt the ALJ’s factual findings and defer to such findings based on supporting evidence in the record. While the Department is free to rule for a claimant because it is statutorily authorized to do so, it is not free to rule against a claimant as a result of misapplying a judicial standard of review that does not apply to an internal agency review. Thus, we cannot affirm the superior court’s ruling, because we cannot say that the inappropriate use of the Stryker standard of review was harmless as a matter of law.

Note: 42 CFR § 431.205(d) requires that a Medicaid hearing system meet the due process standards of Goldberg v. Kelly, 397 U.S. 254 (1970). One could reasonably question whether an arbitrary standard (or no standard at all) meets those requirements.