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Medicaid: Standard of Review in Appellate Cases & Interpretation of Statutes, Regulations and Manuals

In Georgia Department of Community Health v. Medders, 292 Ga. App. 439, 2008 Ga. App. LEXIS 804 (2008) the Court stated the appellate standard of review as follows: “In addressing this appeal, we are mindful of the narrow scope of judicial review applicable to administrative agency matters. A court cannot “substitute its judgment for that of the agency as to the weight of the evidence on questions of fact.” OCGA § 50-13-19(h). See also OCGA § 49-4-153(c) (standard of review set forth in OCGA § 50-13-19 applies to denied requests for medical assistance). And although a court may reverse or modify an agency decision under certain circumstances, those circumstances are limited to instances involving (1) a constitutional or statutory violation; (2) an action that exceeds the agency’s statutory authority; (3) unlawful procedure; (4) legal error; (5) clear error, given the record evidence as a whole; or (6) arbitrary or capricious agency conduct, or activity characterized by an abuse or clearly unwarranted use of discretion. OCGA § 50-13-19(h).

On appeal, we must defer to the administrative agency’s interpretation of applicable statutes and administrative rules, and the agency’s final decision is also entitled to deference. Dept. of Community Health v. Gwinnett Hosp. System, 262 Ga. App. 879, 882, 586 S.E.2d 762 (2003). As we have noted:

Agencies provide a high level of expertise and an opportunity for specialization unavailable in the judicial or legislative branches. They are able to use these skills, along with the policy mandate and discretion entrusted to them by the legislature, to make rules and enforce them in fashioning solutions to very complex problems. Thus, their decisions are not to be taken lightly or minimized by the judiciary. Review overbroad in scope would have the effect of substituting the judgment of a judge or jury for that of the agency, thereby nullifying the benefits of legislative delegation to a specialized body.

In Johnson v. Llewellyn, 194 Ga. App. 186 (1990), the Court held: “On appeal, the superior court was required to determine only whether there was `any evidence’ that appellee had not presented `convincing evidence’ to rebut the Department’s presumption. In view of appellee’s declining health [and the timing of the assignment which was several months after the sale of the home but only several weeks after the probability of appellee’s need for nursing home placement was discovered], there was at least some evidence to support the Department’s decision. [Cit.]. . . . Therefore, the superior court erred by reversing the Department’s decision that appellee was ineligible for medical assistance benefits.”

In Johnson v. Ellis, 174 Ga. App. 861 (1985), the Court stated: “The superior court judge cannot substitute his judgment for that of the department as to the weight of the evidence on questions of fact.” Ga. Dept. of Human Resources v. Holland, 133 Ga. App. 616, 618 (1) (211 SE2d 635) (1974); OCGA § 50-13-19 (h) (5). Therefore, the superior court erred by reversing the Department’s decision that appellee was ineligible for medical assistance benefits.” The standardon appeal regarding a review of facts decided below is whether there is any evidence to support the lower court’s findings.

Regarding the Agency’s regulation, in Dept. of Community Health v. Gwinnett Hosp. System, 262 Ga. App. 879, 882, 586 S.E.2d 762 (2003) (a certificate of need case), the Court stated: the “interpretation of a statute by an administrative agency which has the duty of enforcing or administering it is to be given great weight and deference.” Hosp. Auth. of Gwinnett County v. State Health Planning Agency, 211 Ga. App. 407, 408(2), 438 S.E.2d 912 (1993).

Implicit in the interlocking parts of the statutory scheme is the legislative intent that the [Division] use the considerations [listed in OCGA § 31-6-42] as a base, filling the interstices of the statutory considerations with the agency’s rules interpreting and implementing them. What was implicit in the statutory scheme has now been made explicit.

North Fulton Community Hosp. v. State Health Planning & Development Agency, 168 Ga. App. 801, 804(2), 310 S.E.2d 764 (1983).

In addition to giving deference to the Division’s statutory interpretation and application of its own rules and regulations, we accept its factfinding if it is supported by substantial evidence.

Neither our review nor the trial courts’ review of the Division’s decisions is de novo. They are reviews made with deference to the factual findings of the hearing officer appointed by the Board to decide the case. Only if these findings are not supported by substantial evidence, as defined by the statute, can the reviewing courts reject them, and nothing in our law gives the reviewing courts the right to reconsider those factual findings and make factual findings of their own. Either they are supported by substantial evidence or they are not. Further, “our duty is not to review whether the record supports the superior court’s decision but whether the record supports the final decision of the … administrative agency.” (Citation and punctuation omitted.) Sawyer v. Reheis, 213 Ga.App. 727, 729(1), 445 S.E.2d 837 (1994). Moreover, the superior courts cannot substitute their judgment for that of the hearing officer as to the weight of the evidence on questions of fact. Emory Univ. v. Levitas, 260 Ga. 894, 898(1), 401 S.E.2d 691 (1991).

Finally, [i]f arbitrary and capricious action is alleged the superior court must determine whether a rational basis exists for the decision made. This is a question of law…. By way of contrast to the “rational basis” standard of review, the term “arbitrary,” as defined in the Standard Dictionary, means, “fixed or done capriciously or at pleasure; without adequate determining principle; not founded in the nature of things; non-rational; not done or acting according to reason or judgment; depending on the will alone; absolutely in power; capriciously; tyrannical; despotic.

(Citations and punctuation omitted.) Sawyer v. Reheis, supra, 213 Ga. App. at 729-730(2), 445 S.E.2d 837.

Regarding statutory interpretation, the Court said:

In considering the application of this statute, we must “look diligently for the intention of the General Assembly, keeping in view at all times the old law, the evil, and the remedy.” OCGA § 1-3-1(a). Thus the cardinal rule in statutory construction is to ascertain the legislature’s intention and effectuate the purpose of the statute. Five Star Steel Contractors v. Colonial Credit Union, 208 Ga. App. 694, 696, 431 S.E.2d 712 (1993). …. “Statutes must be construed as well so [ ] as to square with common sense and sound reasoning. It is the duty of the court to consider the results and consequences of any proposed construction and not so construe a statute as will result in unreasonable or absurd consequences not contemplated by the legislature.” (Citation and punctuation omitted.) City of Brunswick v. Atlanta Journal & Constitution, 214 Ga. App. 150, 153(3), 447 S.E.2d 41 (1994).

In a non-Medicaid case, Doctors Hosp. of Augusta, LLC v. Alicea, 332 Ga. App. 529 (2015) where Georgia’s Health Care Advance Directive statute was construed, the Court of Appeals stated:

Statutory construction is a question of law, and our review is de novo. Hill v. First Atlantic Bank, 323 Ga. App. 731, 732 (747 SE2d 892) (2013). “In construing a legislative act, a court must first look to the literal meaning of the act. If the language is plain and does not lead to any absurd or impracticable consequences, the court simply construes it according to its terms and conducts no further inquiry.” (Punctuation and footnote omitted.) Savannah Cemetery Group v. DePue-Wilbert Vault Co., 307 Ga. App. 206, 207 (1) (704 SE2d 858) (2010). Furthermore, “in construing language in any one part of a statute, a court should consider the entire scheme of the statute and attempt to gather the legislative intent from the statute as a whole.” (Citation and punctuation omitted.) Walker County v. Tri-State Crematory, 292 Ga. App. 411, 414-415 (1) (664 SE2d 788) (2008). Different subsections of a statute should be read in pari materia, and we must strive to “reconcile them, if possible, so that they may be read as consistent and harmonious with one another.” (Punctuation and footnote omitted.) City of LaGrange v. Ga. Public Svc. Comm., 296 Ga. App. 615, 621 (2) (675 SE2d 525) (2009).

Regarding the Department’s manuals, in United Cerebral Palsy of Georgia v. Ga. Dep’t of Behavioral Health and Dev. Disabilities, 331 Ga. App. 616 (2015), the Court stated:

Although an administrative body’s interpretations of applicable statutes and implementing administrative rules are entitled to deference, see generally Hosp. Auth. of Gwinnett County v. State Health Planning Agency, 211 Ga. App. 407, 408(2), 438 S.E.2d 912 (1993), its interpretations of its manuals are not. Pruitt Corp., supra, 284 Ga. at 159-160(2), 664 S.E.2d 223.

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