STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
AGENCY FOR HEALTH CARE )
ADMINISTRATION, as successor ) to DEPARTMENT OF HEALTH AND ) REHABILITATIVE SERVICES, )
)
Petitioner, )
)
vs. ) CASE NO. 92-1898
) LANDELINO C. CABRERA, M.D., )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, final hearing in the above-styled case was held in Tallahassee, Florida, on January 5 and May 25, 1993, before Robert T. Benton, Hearing Officer of the Division of Administrative Hearings. Mr. Benton has become unavailable. Pursuant to Section 120.57(1)(b)11, Florida Statutes, the case has been assigned to Robert E. Meale, who has determined that no additional evidence or argument is necessary for the preparation of the recommended order.
APPEARANCES
The parties were represented at the hearing as follows: For Petitioner: Attorney Karel Baarslag
Agency for Health Care
Administration
1317 Winewood Boulevard
Building 6, Room 271
Tallahassee, Florida 32399-0700
For Respondent: Attorney Steven W. Huss
1017-C Thomasville Road Tallahassee, Florida 32303
STATEMENT OF THE ISSUE
The issue in this case is whether Petitioner is entitled to repayment of sums that it claims that it overpaid to Respondent as Medicaid reimbursements.
PRELIMINARY STATEMENT
By letter dated February 18, 1992, Petitioner informed Respondent that, following a review of Medicaid claims submitted during 1989, Petitioner determined that it had overpaid Respondent by $21,188.18 and demanded that Respondent repay this amount. Respondent refused and demanded a formal hearing.
By stipulation, the parties determined that Petitioner has the burden of proof. The style has been reversed to identify the agency as Petitioner and Dr. Cabrera as Respondent, as ordered by Hearing Officer Benton during the hearing. (Tr. 689)
At the hearing, Petitioner called four witnesses and offered into evidence nine exhibits. Respondent called three witnesses and offered into evidence three exhibits. All exhibits were admitted. Petitioner's Exhibit 6 is Chapter
12 of the Medicaid Physician Provider Handbook (1/89). It is unclear whether Chapter 11 of the same handbook was admitted, although the witnesses and counsel repeatedly refer to the document, a copy of which is hereby admitted as Hearing Officer Exhibit 1.
The transcript was filed June 9, 1993. Each party filed a proposed recommended order, and rulings on proposed findings are in the appendix.
FINDINGS OF FACT
Respondent is a licensed Medicaid physician, who has signed a Medicaid provider agreement. His provider number is 056778700.
Effective July 1, 1993, the Agency for Health Care Administration assumed the duties of the Department of Health and Rehabilitative Services for administration of the Medicaid program, including reimbursing the claims of service providers. During 1989, these duties were borne by the Department of Health and Rehabilitative Services. The agencies shall be referred to jointly as Petitioner.
By letter dated February 18, 1992, Petitioner advised Respondent that Petitioner had determined that it had made overpayments of $21,188.18 in connection with Medicaid reimbursements. The letter cites four grounds for the overpayment claim: overutilization of laboratory testing, inappropriate billing of minimal level of office visits, overutilization of office visits, and inappropriate upgrading of billing codes.
The Medicaid program provides reimbursement to service providers on a "pay-and-chase" basis. In other words, claims are paid initially subject to preliminary review. Petitioner or its agent may later subject these claims to closer scrutiny during periodic audits. If overpayments are found, Petitioner obtains reimbursement from the service provider.
Section 11.1 of the Medicaid Physician Provider Handbook in effect for 1989 (Handbook) requires that covered services "must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient."
Section 11.1. of the Handbook instructs the physician to enter a code and description of services rendered on the claim form submitted to Respondent. The coding system is derived by the Health Care Financing Administration from the Physician's Current Procedural Terminology, Fourth Edition (CPT-4), which is a publication of the American Medical Association.
Section 11.1 of the Handbook identifies six levels of service for visit procedure codes. The levels of service reflect "varying skills, effort, responsibility, and medical knowledge to complete the examination, evaluation, diagnosis, treatment, and conference with the recipient about his illness or promotion of optimal health." The six levels are:
Minimal is a level of service supervised by a physician but not requiring his presence.
Brief is a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and exams.
Limited is a level of service used to evaluate a circumscribed acute illness or to periodically re-evaluate a problem including a history and examination, review of effectiveness of past medical management, the ordering and evaluation of appropriate diagnostic tests, the adjustments of therapeutic management as indicated and discussion of findings.
Intermediate level of service pertains to the evaluation of a new or existing condition complicated with a new diagnostic or management problem, not necessarily related to the primary diagnosis, that necessitates the obtaining of pertinent history and physical or mental status findings, diagnostic tests and procedures, and ordering appropriate therapeutic management; or a formal patient, family, or hospital staff conference regarding the patient's medical management and progress.
Extended level of service requires an unusual amount of effort or judgement including a detailed history, review of medical records, examination, and a formal conference with the patient, family, or staff; or a comparable medical diagnostic and/or therapeutic service.
Comprehensive level of service provides for an in-depth evaluation of a patient with a new or existing problem requiring the development or complete reevaluation of medical data. This service includes the recording of a chief complaint, present illness, family history, past medical history, personal history, system review, complete physical examination, and ordering appropriate tests and procedures.
CPT-4 illustrates the meaning of each of these service levels. Relevant examples are:
Minimal:
Routine immunization for tetanus.
Blood pressure determination for adequacy of control.
Removal of sutures from laceration.
Brief:
Examination of a patient with subconjunctival hemorrhage.
Examination of acute tonsillitis.
Examination of minor trauma.
Review of recent x-ray report and abbreviated discussion with patient under study.
Concurrent hospital care for minor secondary diagnosis.
Abbreviated evaluation of a hospitalized patient in stage of recovery from an uncomplicated renal colic.
Limited:
Treatment of an acute respiratory infection.
Review of interval history, physical status and control of a diabetic patient.
Review of hospital course, studies, orders and chest examination of patient with rheumatic heart disease recovering from acute congestive failure; revision of orders and limited exchange with nursing staff.
Review of interval history, physical status and adjustment of medication in a patient with compensated arteriosclerotic heart disease of chronic diuretic therapy.
Review of mental status findings, limited team conference (exchanging with nursing and ancillary personnel), and revision of medical management orders on a patient with a toxic psychosis.
Review of recent history, determination of blood pressure, auscultation of heart and lungs and adjustment of medication in essential hypertension.
Intermediate:
The evaluation of a patient with arteriosclerotic heart disease with recent onset of unstable angina previously on an adequate therapeutic program; this service involves a detailed interval history and physical examination and ordering of appropriate diagnostic tests and discussion of new therapeutic management.
Review of hospital studies and course in conjunction with a team conference (formal meeting with nursing and ancillary personnel) regarding medical management of a patient
with acute schizophrenic symptoms.
Review of interval history, re- examination of musculoskeletal systems and abdomen, discussion of findings, and
adjustment of therapeutic program in a patient with arthritic disorders with recently developed gastric complaints.
Reviewing school reports, developmental examinations, and/or psychometric tests in conference with parents of a child with a recurrent school problem.
Review of recent illness, re-examination of pharynx, neck, axilla, groin, and abdomen, interpretation of laboratory tests, and prescription of treatment in a patient with chronic lymphocytic leukemia not responding
to a previous management plan.
Conference with patient and/or family to review studies, hospital course, and findings in a teenager with acute hepatitis secondary to drug abuse.
Extended:
Re-examination of neurological findings, detailed review of hospital studies and course, and formal conference with patient
and family jointly concerning findings and plans in a diagnostic problem of suspected intracranial disease in a young adult.
Detailed intensive review of studies and hospital course and thorough re-examination
of pertinent physical findings of a patient with a recent myocardial infarction with complications requiring constant physician bedside attention.
Review of results of diagnostic evaluation, performance of a detailed examination and a thorough discussion of physical findings, laboratory studies, x-ray examinations, diagnostic conclusions and recommendations for treatment of complicated chronic pulmonary disease.
* * *
Section 11.25 of the Handbook describes Pathology Services, which include "serology," "clinical chemistry," and "pathology." Section 11.25 provides:
Pathology services performed as part of the examination and treatment of a Medicaid recipient at a hospital or physician's office may be paid under Physician Services program if performed by or under the personal supervision of a physician.
Pathology services performed in an independent lab are covered under the Independent Laboratory Services program. (See Independent Lab Manual.)
Pathology services include:
collection of specimens,
performing the tests, and
reporting the results.
If a physician's office does perform all three parts of the lab procedure, then payment is appropriate.
A specimen collected by a physician's office and referred to an independent laboratory can only be billed with a modifier -90. The physician's office may not be paid the max fee for the lab test. It is the independent laboratory's responsibility to bill for its own services.
Dipstick urines, hemoglobin, and/or hematocrit done as part of an office visit are not to be billed separately.
Payment for Pap Smears are limited to one female recipient per calendar year to a Pathologist. Obtaining a smear is considered part of a physician office visit.
Chapter 12 of the Handbook contains the maximum fees that Respondent will reimburse for various services under Medicaid.
The maximum fees for new patients are as follows:
Brief: | $30.00 |
Limited: | $30.00 |
Intermediate | $35.00 |
Extended: | $44.50 |
Comprehensive: | $50.00 |
The maximum fees for established patients are as follows:
Minimal: | $12.00 |
Brief: | $21.50 |
Limited: | $21.50 |
Intermediate: | $25.00 |
Extended: | $30.00 |
Comprehensive: | $45.00 |
Chapter 12 of the Handbook states that the maximum fee for a "venipuncture for collection of specimen(s)" is $2. Although a typical blood count, 1/ according to Chapter 12, is $12, simpler blood work bears fees of $1-
$3. 2/ This provides a reasonable basis for inferring that, in 1989, a physician could be reimbursed for drawing the blood (i.e., venipuncture), even if a commercial laboratory would be reimbursed for the blood work itself.
Recent revisions to the Handbook have resolved much of the ambiguity concerning relevant aspects of the Handbook as it existed in 1989, such as
differentiating between an intermediate office visit and a limited office visit. However, these revisions are inapplicable to the present case.
Patient #1 is AS. AS is aged eight years. AS visited Respondent one time in 1989: September 9. 3/
On September 19, AS visited the office and presented with a fungal condition on his right foot.
Because AS was a new patient, Respondent not only had to evaluate and treat the fungus, but he had to obtain a broader history and conduct a more extensive physical examination than would have been necessary with respect to an established patient.
Respondent billed the September 19 office visit as established-patient intermediate. Petitioner reduced the visit to established-patient limited, partly due to Respondent's misbilling the visit as though it were for an established patient.
The September 19 visit is new-patient intermediate.
The total underpayment on account of AS is $10. 4/
Patient #2 is LG. LG is a 26 year old female. LG visited Respondent two times in 1989: November 2 and 8.
Based on the record, including Petitioner Exhibit 1 and its proposed recommended order, Petitioner seeks no reimbursement for alleged overpayments in connection with either or both of these visits.
Patient #3 is JE. JE visited Respondent one time in 1989: January
16.
Based on the record, including Petitioner Exhibit 1 and its proposed
recommended order, Petitioner seeks no reimbursement for alleged overpayments in connection with the office visit by JE.
Patient #4 is DN. DN is a 25 year old female. DN visited Respondent one time in 1989: November 24.
DN was a new patient who was pregnant and suffered from high blood pressure and skin problems. She was taking medication for the hypertension. Respondent had to take an extensive history.
Respondent billed the visit as new-patient intermediate. Petitioner reduced the visit to new-patient limited.
The November 24 visit is intermediate.
No overpayment exists on account of DN.
Patient #5 is AF. AF visited Respondent two times in 1989: January 5 and October 24.
Respondent billed each visit as established-patient intermediate. Petitioner reduced the January 5 visit to established-patient limited and disallowed the October 24 visit. The October 24 visit was disallowed because of
a lack of result in the medical record to substantiate the existence of the lab work. There are no medical records or notations concerning the claimed October
24 visit.
The January 5 visit is limited, and the October 24 visit is disallowed for the reasons stated.
The total overpayment on account of AF is $28.50, representing $3.50 for January 5 and $25 for October 24.
Patient #6 is DH. DH visited Respondent two times during 1989: June 5 and 13.
Respondent billed both visits as established-patient intermediate. Petitioner reduced the June 13 visit to established-patient limited.
The June 13 visit is limited.
The total overpayment on account of DH is $3.50.
Patient #7 is JS. She visited Respondent one time in 1989: November
24.
Based on the record, including Petitioner Exhibit 1 and its proposed
recommended order, Petitioner seeks no reimbursement for alleged overpayments in connection with the office visit by JS.
Patient #8 is KB. KB visited Respondent two times in 1989: September
27 and November 20.
Based on the record, including Petitioner Exhibit 1 and its proposed recommended order, Petitioner seeks no reimbursement for alleged overpayments in connection with the office visit by KB.
Patient #9 is EM. EM is a 25 year old female. She visited Respondent two times in 1989: November 3 and 6.
On November 3, EM was a new patient suffering from multiple problems, including bronchitis, fatigue, nasal congestion, and respiratory distress. The medical records reveal a physical examination of EM's throat and nose in arriving at a diagnosis of upper respiratory infection. Respondent billed the visit as new-patient intermediate. Petitioner reduced the visit to new-patient limited. 5/
The November 3 visit is intermediate.
On November 6, EM returned for lab work. Respondent billed an established-patient minimal visit, urinalysis, blood count, and venipuncture.
Petitioner disallowed the minimal office visit because of a lack of documentation in the medical records to show that the service was actually provided. Petitioner disallowed the venipuncture because the collection of a specimen is part of the global fee when the test is performed in the physician's office. Petitioner allowed the urinalysis and blood count.
The correct billing of office visits exclusively for laboratory work repeatedly arises in this case. As in the other cases, the November 6 office
visit for blood work is in close proximity to another office visit. The claim for the minimal service on November 6 is disallowed due to questionable frequency and medical necessity. 6/
The correct billing of venipuncture also repeatedly arises in this case. Venipuncture is an identified service in CPT-4 and is a reimbursable service under the Handbook. Neither CPT-4 nor the Handbook incorporates venipuncture within one of the levels of service of office visits. In other words, neither the CPT-4 nor the Handbook provides that venipuncture cannot be billed separately. The reimbursement rates for some blood tests are less than
$2, so the venipuncture evidently is not included in the blood tests either. Thus, the separate claim for venipuncture is allowed.
The total overpayment on account of EM is $12.
Patient #10 is PM. PM is a 24 year-old female. She visited Respondent two times in 1989: July 24 and August 3.
On July 24, as a new patient, Respondent reported that she passed out and had fallen on a concrete floor and had been treated and released in a hospital emergency room following the incident. PM complained of continuing headaches and diarrhea and required an extensive evaluation.
Respondent billed the July 24 visit as new-patient intermediate. Petitioner reduced the visit to new-patient brief.
The July 24 visit is intermediate.
On August 3, PM returned for lab work. Respondent billed an established-patient minimal visit, venipuncture, urinalysis, blood count, and blood chemistry.
Petitioner disallowed each of these items. The visit was disallowed because of a lack of documentation in the medical records to substantiate that the service was actually provided. The lab work was disallowed because the tests were not indicated for the stated medical condition.
The August 3 minimal office visit is disallowed due to questionable frequency and medical necessity. In the absence of better proof from Petitioner, 7/ upon which the risk of nonpersuasion rests, there is insufficient basis to find that such basic lab work was not indicated for PM, who had lost consciousness and was complaining of various problems following the fainting incident.
The total overpayment on account of PM is $12.
Patient #11 is XB. XB is aged one year. XB visited Respondent three times in 1989: March 7, 16, and 20.
On March 7, XB visited the office with a fever, congestion, coughing, and congestion. On March 16, XB returned suffering from severe diaper rash. Respondent billed these visits as established-patient intermediate, and Petitioner allowed these claims.
Respondent billed the March 20 visit as established-patient intermediate. Petitioner disallowed the claim due to a lack of result in the
medical record to substantiate that the service was provided. The charts do not indicate a visit on March 20.
The March 20 visit is disallowed for the reason stated.
The total overpayment on account of XB is $25.
Patient #12 is JR. JR is a 12 year old female. She visited Respondent three times in 1989: January 3 and 10 and April 25.
Respondent billed the January 3 and April 25 office visits as established-patient intermediate, and Petitioner allowed the claims.
On January 10, JR returned for lab work. Respondent billed an established-patient minimal visit, venipuncture and blood count. Petitioner allowed the blood count, but disallowed the venipuncture because collection of the specimen is considered part of the global fee when tests are performed in the physician's office. Petitioner also disallowed the minimal office visit as unnecessary.
The lab work was done in a separate office visit only one week after the earlier visit. The January 10 visit is disallowed due to questionable frequency and medical necessity. However, the venipuncture is allowed.
The total overpayment on account of JR is $12.
Patient #13 is CK. CK is aged 32 years. CK visited Respondent three times in 1989: June 22, 23, and 26.
On June 22, CK visited the office complaining of muscle pain and neck muscle spasm. On June 26, CK returned with complaints of weakness, as well as spasming.
Respondent billed the June 22 and 26 office visits as established- patient intermediate. Petitioner reduced both office visits to established- patient limited.
The June 22 visit is intermediate, and the June 26 visit is limited.
On June 23, CK returned for lab work. Respondent billed an established-patient minimal visit, venipuncture, urinalysis, and blood count.
Petitioner disallowed the June 23 visit and venipuncture for the usual reasons. Petitioner allowed the lab work.
The June 23 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
The total overpayment on account of CK is $15.50, representing $12 for June 23 and $3.50 for June 26.
Patient #14 is LG. LG is a 25 year old female. She visited Respondent three times in 1989: November 2, 7, and 8.
On November 2, 1989, as a new patient, LG visited the office complaining of vaginal itching. She had had a tubal ligation about two weeks earlier. Respondent billed the office visit as established-patient
intermediate, and Petitioner reduced the office visit to established-patient limited, partly because Respondent's office miscoded LG as an established patient when she was a new patient.
As a new patient, she required a more extensive history and physical examination, but this additional physician involvement is adequately reflected by recoding the first visit as new-patient limited.
On November 8, LG returned for a follow-up. The vaginal itching had subsided, although there was some discharge. The records observe that LG was "Here for test results." Respondent billed the November 8 visit as established- patient intermediate, and Petitioner reduced it to established-patient limited.
The November 8 visit is limited.
On November 7, LG returned for lab work. Respondent billed an established-patient minimal visit, venipuncture, urinalysis, glucose, and blood count. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner allowed the lab work.
The minimal visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
The total overpayment on account of LG is $10.50, representing $3.50 for November 8 and $12 for November 7 and a $5 underpayment for November 2.
Patient #15 is MT. MT is a 27 year old female. She visited Respondent four times in 1989: November 8, 10, 15, and 17.
On November 8, MT was a new patient asking for a pregnancy test and complaining of lower abdominal pain. Respondent billed the visit as new-patient intermediate, and Petitioner reduced the visit to established-patient brief.
The November 8 visit is new-patient limited.
On November 10, MT returned for the pregnancy test. Respondent billed an established-patient minimal visit, venipuncture, and pregnancy test. Petitioner disallowed the minimal office visit on the usual grounds. Petitioner disallowed the pregnancy test because only a collection fee is reimbursable when lab specimens are collected by a physician's office and referred to an outside laboratory. Petitioner allowed the venipuncture.
The November 10 visit id disallowed due to questionable frequency and medical necessity. The pregnancy test is disallowed for the reason stated.
On November 15, MT returned for the lab results. Respondent billed the visit as established-patient intermediate. Petitioner reduced the visit to established-patient brief.
The November 15 visit is limited.
On November 17, MT returned for a blood pressure check-up. Her blood pressure on her first visit was 122/82. On her second visit, her blood pressure was 150/100. On November 17, her blood pressure was 130/100. Respondent billed an established-patient intermediate visit, and Petitioner reduced it to established-patient brief.
The November 17 visit is brief.
The total overpayment on account of MT is $28, representing $5 for November 8, $13 for November 10, $3.50 for November 15, and $3.50 for November 17.
Patient #16 is KE. KE is a five year old female. She visited Respondent three times in 1989: October 5, 6, and 9.
On October 5, KE visited the office complaining of vomiting and congestion. She was a new patient. After a lengthy physical examination, Respondent diagnosed her as having an upper respiratory infection and gastritis. Respondent billed the visit as new-patient comprehensive, and Petitioner allowed the visit as billed.
On October 6, KE returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds.
The October 6 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On October 9, KE returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner disallowed the claim.
The October 9 visit is disallowed due to questionable frequency and medical necessity.
The total overpayment on account of KE is $37, representing $12 for October 6 and $25 for October 9.
Patient #17 is BM. BM is a 12 year old female. She visited Respondent three times in 1989: November 2, 3, and 6.
On November 2, BM visited the office complaining of vaginal itching and some burning on urination, as well as a request for a basketball physical. Diagnosing her condition as vulvitis and a urinary tract infection, Respondent gave her a school physical and billed the visit as established-patient comprehensive. Petitioner allowed the claim.
On November 3, BM returned for lab work. Respondent billed an established-patient minimal visit, blood count, urinalysis, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds.
The November 3 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 6, BM returned to the office for the results of the lab work. Respondent billed the visit as established-patient intermediate, and Petitioner disallowed the claim.
The November 6 visit is disallowed due to questionable frequency and medical necessity.
The total overpayment on account of BM is $37, representing $12 for November 3 and $25 for November 6.
Patient #18 is MS. MS visited Respondent four times in 1989: April 28, May 11, June 15, and October 23. Each visit was billed as established- patient intermediate, and Petitioner paid each claim accordingly except for the claim for the October 23 visit.
On October 23, MS presented with lesions on her hand, arm, face and abdomen from exposure to cats. Petitioner reduced this visit to established- patient limited.
The October 23 visit is limited.
The total overpayment on account of MS is $3.50.
Patient #19 is BB. BB is a one month old female. She visited Respondent three times in 1989: November 29, December 12, and December 15.
On November 29, BB visited the office for a two-week check-up, at which time she was suffering from diaper rash. On December 12, BB returned.
She still had the rash and was spitting up. The diagnosis remained diaper rash. On December 15, BB returned for a recheck because she was still spitting up and suffering from diaper rash.
Respondent billed the November 29 visit twice: once as established- patient comprehensive and once as established-patient intermediate. Petitioner disallowed the intermediate billing on the grounds of duplicate billing.
The November 29 visit is new-patient comprehensive.
Respondent billed the December 12 and 15 visits as established- patient intermediate, and Petitioner reduced the visits to established-patient limited.
The December 12 visit is intermediate, and the December 15 visit is limited. At the December 12 visit, it was apparent that the spitting up and diaper rash required more extensive evaluation and, if appropriate, treatment. The December 15 visit was merely a follow-up to the December 12 visit, and the rash had improved.
The total overpayment on account of BB is $23.50, representing $20 for November 29 and $3.50 for December 15.
Patient #20 is JA. JA is a two year old female. She visited Respondent three times in 1989: October 18, 19, and 20.
On October 18, JA visited the office with a cold. Respondent diagnosed her condition as an upper respiratory infection. Respondent billed the October 18 visit as new-patient comprehensive, and Petitioner allowed the claim.
On October 19, JA returned for lab work. Respondent billed for an established-patient minimal visit, urinalysis, blood count, and venipuncture. Petitioner disallowed the minimal office visit and venipuncture on the usual grounds.
The October 19 office visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On October 20, JA returned for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner disallowed the visit on the usual grounds.
The October 20 visit is disallowed due to questionable frequency and medical necessity.
The total overpayment on account of JA is $37, representing $12 for October 19 and $25 for October 20.
Patient #21 is GG. GG is 48 year old female. She visited Respondent five times in 1989: December 5, 6, 8, 11, and 14.
On December 5, GG visited the office to obtain a refill of prescriptions for arthritis and diabetes medications. She said that she was feeling fine, but occasionally had a pain in her head. In addition to diabetes and osteoarthritis, she also suffered from elevated cholesterol and essential hypertension. Her blood pressure was under control. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The December 5 visit is limited.
On December 6, GG returned for lab work. Respondent billed an established-patient minimal visit, blood chemistry, blood count, and venipuncture. Respondent disallowed the minimal visit for the usual reasons. However, Respondent allowed the venipuncture. Respondent disallowed the lab work because it was performed by a commercial laboratory.
The December 6 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed.
On December 8, GG returned to the office for the lab results. Evidently a second blood count was required due to the clotting of the first sample. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The December 8 visit is limited.
On December 11, GG returned to the office for a blood count and pregnancy test, which had been ordered during the December 8 visit. Respondent billed the visit as established-patient minimal, and Petitioner disallowed the claim for the usual reason. Respondent also billed a pregnancy test, blood count, and venipuncture. Petitioner disallowed the pregnancy test and blood count because the tests were performed by an outside laboratory. Petitioner disallowed the venipuncture for the usual reason.
The December 11 visit is disallowed due to questionable frequency and medical necessity. The pregnancy test and blood count are disallowed for the reasons stated. The venipuncture is allowed.
On December 14, GG returned for a "follow-up on lab work." She felt fine. Respondent reviewed the lab results with her. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited for the usual reason.
The December 14 visit is limited.
The total overpayment on account of GG is $45, representing $3.50 for December 5, $16 for December 6, $3.50 for December 8, $18.50 for December 11, and $3.50 for December 14.
Patient #22 is FC. FC is a 20 year old female. FC visited Respondent four times in 1989: June 5, 15, and 28, and July 13.
On June 5, FC visited the office for an annual physical. She is a developmentally disabled client of the Department of Health and Rehabilitative Services. She was a new patient. The June 5 physical exam was thorough. The diagnoses were mental retardation and impaired speech. Respondent billed the visit as established-patient comprehensive, and Petitioner allowed the claim. Respondent also billed for a urinalysis that, unlike lab work for other patients, he performed the same day of the office visit. Petitioner allowed the claim.
The June 5 visit is new-patient comprehensive.
On June 15, FC returned for a follow-up and a pap smear. She had some vaginal discharge. Respondent determined that she had cervicitis and prescribed amoxicillin. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim. Respondent also billed for a pap smear. Petitioner disallowed the claim because a pap smear is considered part of an office visit and is compensable only to pathologists.
The Handbook provides that the pap smear is not allowable when done as part of an office visit. Petitioner allowed a claim for an office visit, so the pap smear is not separately allowable.
On June 28, FC returned for the results of the pap smear, which results were unavailable. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The June 28 visit is disallowed due to questionable frequency and medical necessity.
On July 13, FC returned for the results of another pap smear. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The total overpayment on account of FC is $20, representing $25 for June 28 and a $5 underpayment for June 5.
Patient #23 is AL. AL is a 45 year old female. AL visited Respondent four times in 1989: August 7, 8, 9, and 11.
On August 7, AL, who weighs over 400 pounds, visited Respondent as a new patient for a physical. Respondent diagnosed morbid obesity and edema in the feet. Respondent billed the visit as new-patient comprehensive, and Petitioner allowed the claim.
On August 7, AL returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, blood count, and venipuncture. Respondent allowed everything but the minimal visit and venipuncture, which it disallowed on the usual grounds.
The minimal visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On August 9, AL returned for a follow-up and the results of the lab work. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
On August 11, AL returned for more results of the lab tests. Unlike other visits of other patients, as well as other visits of AL, Respondent's medical records fail even to note her blood pressure and pulse. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The August 11 visit is minimal.
The total overpayment on account of AL is $25, representing $12 for August 7 and $13 for August 11.
Patient #24 is DP. DP is a 28 year old female. She visited Respondent five times in 1989: August 29 and 30 and September 7, 12, and 15.
On August 29, DP complained of a constant cough. She had had brain surgery in the past. She had had brain shunts placed when she was child and again three months earlier. She had had a stroke. She had not had a menstrual period for three months. Respondent diagnosed her as having hydrocephaly and convulsive disorder, among other things. Respondent billed the visit as new- patient intermediate, and Petitioner allowed the claim.
On August 30, DP returned for lab work. Respondent billed an established-patient minimal visit, urinalysis, blood count, and venipuncture. Petitioner allowed the blood count, but disallowed the minimal visit and venipuncture on the usual grounds. Petitioner also disallowed the urinalysis because "dipstick urines ... done as part of an office visit are not to be billed separately."
The August 30 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed. The urinalysis is allowed. The Handbook prohibits allowing claims for dipstick urines "done as part of an office visit ...." This means as part of a reimbursable office visit. The August 30 visit is not reimbursable, so the duplication addressed by the Handbook is not involved in this urinalysis claim.
On September 7, DP returned for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The September 7 visit is limited.
On September 12, DP returned complaining of upper back pain. Respondent ordered chest and back x-rays. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The September 12 visit is limited.
On September 15, DP returned for the results of her x-rays, which were negative. Respondent billed the visit as established-patient intermediate, and Petitioner disallowed the claim due to questionable frequency and medical necessity.
The September 15 visit is minimal.
The total overpayment on account of DP is $32, representing $12 for August 30, $3.50 for September 7, $3.50 for September 12, and $13 for September 15.
Patient #25 is KS. KS is a four year old male. He visited Respondent five times in 1989: February 6, April 28, June 2, September 14, and October 23.
Except for October 23, the other visits were appropriately billed and paid. Respondent neglected to present claims for three visits in February, and, as explained in endnote 4, these visits will not be considered.
KS visited Respondent on October 23 complaining of lesions to his abdomen, back, and legs after exposure to cats. Diagnosing essentially a rash, Respondent billed the visit as established-patient intermediate. Petitioner reduced the visit to established-patient limited.
The October 23 visit is limited.
The overpayment on account of KS is $3.50.
Patient #26 is IS. IS is an 18 year old female. She visited Respondent six times in 1989: March 16 and November 1, 16, 17, 20, and 24. The March 16 visit was properly billed and paid.
On November 1, IS visited the office and complained of skin itching, rash, and soreness on her tongue. Respondent billed the visit as established- patient intermediate, and Petitioner allowed the claim.
On November 16, IS visited Respondent complaining of coughing up blood. Respondent diagnosed her with tonsillitis and bronchitis. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
On November 17, IS returned for lab work. Respondent billed an established-patient minimal visit, blood count, urinalysis, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds. Petitioner disallowed the urinalysis because the medical records failed to disclose the result.
The November 17 visit is disallowed due to questionable frequency and medical necessity. The venipuncture was allowed. The urinalysis is disallowed because the records do not contain the results.
On November 20, IS returned for the lab results and complaining that her fever was increasing despite taking the medicine that Respondent had prescribed. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The November 20 visit is limited.
On November 24, IS returned for a "recheck." Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The November 24 visit is limited.
The total overpayment on account of IS is $21.50, representing $14.50 for November 17, $3.50 for November 20, and $3.50 for November 24.
Patient #27 is SJ. SJ is a female. Petitioner miscopied the computer printout for this patient's records in Petitioner Exhibit 1, so it is impossible to tell from that exhibit the identity and extent of, and reason for, asserted overpayments. It is impossible to determine this omitted information by a preponderance of the evidence from the testimony. Petitioner has thus failed to prove any overpayments exist on account of SJ.
Patient #28 is FO. FO is a 58 year old male. He visited Respondent six times in 1989: July 24, 26, 27, and 31 and August 1 and 7.
On July 24, FO visited the office as a new patient. His history includes two heart attacks and a gunshot wound. He complained of stomach problems, diarrhea, vomiting, and nocturnal chills. Respondent diagnosed FO as suffering from gastroenteritis and urinary tract infection. Respondent billed the visit as new-patient intermediate, and Petitioner allowed the claim.
On July 26, FO returned for lab work. Respondent billed an established-patient minimal visit, blood count, blood gases, blood chemistry, urinalysis, and venipuncture. Petitioner allowed the blood count, urinalysis, and minimal visit, but disallowed the remainder. The blood gases and blood chemistry were disallowed because the records did not record the results. The venipuncture was disallowed for the usual reason.
The July 26 minimal visit is allowed due to the number of tests involved. The venipuncture is allowed. The medical records contain some results of the blood chemistry, so it is allowed. But the blood gas is disallowed.
On July 27, FO returned to the office complaining of stomach pain and swelling. Respondent determined that it was necessary to rule out peptic ulcers and ordered an upper gastro-intestinal series for the following day. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to established-patient limited.
The July 27 visit is limited.
On July 31, FO returned to the office to discuss the x-ray, which had revealed a hiatal hernia. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to established-patient limited.
The July 31 visit is limited.
On August 1, FO returned to the office complaining of burning in the stomach and anxiety. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to established-patient limited.
The August 1 visit is limited.
On August 7, FO returned to the office saying he was feeling better, but was nervous and could not rest well at night. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The August 7 visit is limited.
The total overpayment on account of FO is $17, representing $3.50 for July 27, July 31, August 1, and August 7 and $3 for July 26.
Patient #29 is OM. OM is a one-year old female. OM visited Respondent six times in 1989: January 30, February 14, March 3, April 11 and 14, and May 17.
The only visit in dispute is the visit of April 14. On April 11, OM visited the office due to an upper respiratory infection. Three days later she returned feeling better. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient brief.
The April 14 visit is limited.
The total overpayment on account of OM is $3.50.
Patient #30 is DR. DR is a four year old male. DR visited Respondent seven times in 1989: February 13 and 17, May 5, and November 3, 8, 9, and 13.
On February 13, DR visited the office due to breathing problems associated with an upper respiratory infection and asthmatic bronchitis. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
On February 17, DR returned to the office with scalp lesions due to dermatitis. The notes do not indicate that the February 17 visit was a follow- up to the February 13 visit. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to established-patient limited.
The February 17 visit is limited.
On November 3 and 8, DR visited the office due to tonsillitis and an upper respiratory infection. Respondent billed the visits as established- patient intermediate, and Petitioner allowed the claims.
On November 9, DR returned to the office for lab work. Respondent billed for an established-patient minimal visit, blood count, urinalysis, and venipuncture. Petitioner disallowed the minimal visit and venipuncture, but allowed the remainder.
The November 9 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 13, DR returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The November 13 visit is limited.
The total overpayment on account of DR is $21, representing $3.50 for February 17, $14 for November 9, and $3.50 for November 13.
Patient #31 is EL. EL is a 38 year old female. She visited Respondent seven times in 1989: March 30, April 4 and 6, and May 8, 11, 18, and 24.
On March 30, EL visited the office as a new patient for a physical and diagnosis of an upper respiratory infection. Respondent billed the visit as new-patient intermediate, and Petitioner allowed the claim.
On April 4, EL returned to the office for lab work. Respondent billed for an established-patient minimal office visit, blood count, urinalysis, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds, but allowed the other lab work.
The April 4 visit is disallowed for questionable frequency and medical necessity. The venipuncture is allowed.
On April 6, EL returned to the office for the lab results and a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to established-patient limited.
The April 6 visit is limited.
On May 8, EL returned to the office due to a recent fainting episode where she had been unconscious for two hours. Respondent gave her a physical examination, ordered a chest x-ray and brain scan, and billed the visit as established-patient intermediate. Petitioner reduced the visit to established- patient limited.
The May 8 visit is intermediate.
On May 11, EL returned to the office for the lab results and a follow-up visit. The brain scan revealed an irregularity, which required a CT scan. The chest x-ray revealed emphysema. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The May 11 visit is intermediate.
On May 18, EL returned to the office for the lab results. She was still complaining of dizziness and headaches with nausea. The brain scan was normal. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The May 18 visit is limited.
On May 24, EL returned to the office complaining of nervousness, but otherwise fine. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The May 24 visit is limited.
The total overpayment on account of EL is $22.50, representing $3.50 for April 6, May 18, and May 24 and $12 for April 4.
Patient #32 is JB. JB is a ten year old male. He visited Respondent seven times in 1989: January 17, March 20, April 3, May 23, May 24, May 25, and June 2.
The only visits in dispute are May 23-25. On May 23, JB visited the office following a visit to the emergency room the prior week due to bronchitis and some asthma. After performing a physical examination, Respondent diagnosed JB as suffering from lingular pneumonia. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
On May 24, JB returned for lab work. Respondent billed for an established-patient minimal office visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds.
The minimal visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On May 25, JB returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner disallowed the claim.
The May 25 visit is disallowed due to questionable frequency and medical necessity.
The total overpayment on account of JB is $37, representing $12 for May 24 and $25 for May 25.
Patient #33 is JS. JS is a 27 year old female. She visited Respondent eight times in 1989: September 6, 14, 15, 21, 26, and 29, and October 3 and 17.
On September 6, she visited the office as a new patient complaining of stomach pain and burning when urinating. Respondent diagnosed her as suffering from a urinary tract infection. Respondent billed the single visit as new-patient intermediate and established-patient intermediate. Petitioner allowed the former claim and disallowed the latter as duplicative.
The September 6 visit is new-patient intermediate.
On September 14, JS returned to the office for the lab results and complaining of vaginal itching. After a physical examination, Respondent diagnosed her with a vaginal deformity and collected a pap smear. Respondent billed for an established-patient intermediate visit and the pap smear. Petitioner allowed the claim for the visit, but disallowed the claim for the pap smear because it is considered part of the office visit.
The Handbook provides that the pap smear is not allowable when done as part of an office visit. Petitioner allowed a claim for an office visit, so the pap smear is not separately allowable.
On September 15, JS returned to the office, evidently for a urinalysis that had been ordered on the September 6 visit, but for some reason had not been performed previously. Respondent billed the urinalysis and the visit, which is not shown on his medical records, as established-patient minimal. Petitioner disallowed the visit for the usual reason, but allowed the urinalysis.
The September 15 visit is disallowed due to questionable frequency and medical necessity and lack of documentation.
On September 21, JS returned for the lab results. The pap smear results were not yet back from the lab. The urinalysis was negative. JS complained of headaches and a vaginal lesion, and Respondent determined it was necessary to rule out syphilis. Respondent billed the visit as established- patient intermediate, and Petitioner allowed the claim.
On September 26, JS returned to the office for a syphilis test. Respondent billed for the test and an established-patient minimal visit. Petitioner disallowed the claim for the minimal visit, which was not noted in Respondent's medical records, on the usual grounds. Petitioner allowed the claim for the syphilis test.
The September 26 visit is disallowed due to questionable frequency and medical necessity and lack of documentation.
The total overpayment on account of JS is $51, representing $25 for September 6, $2 for September 14, $12 for September 15, and $12 for September 26.
Patient #34 is LS. LS is a 32 year old female. She visited Respondent nine times in 1989: February 10, March 3, April 4, June 20, 22, and 26, September 12, and December 5 and 7.
On February 10, LS visited the office as a new patient. She complained of a cough and sore throat. Respondent gave her a physical examination, and he diagnosed an upper respiratory infection. Respondent billed the visit as new-patient intermediate, and Petitioner reduced the visit to new- patient limited.
The February 10 visit is limited.
On March 3 and April 4, Respondent billed two established-patient intermediate visits, but there are no notes reflecting visits on these days. Petitioner disallowed the visits due to lack of documentation.
The March 3 and April 4 claims are disallowed due to a lack of documentation.
On June 20, LS returned to the office due to injuries she received when she fell off of a porch a week earlier. Respondent ordered x-rays, a blood count, and a glucose test, evidently in response to complaints of weakness. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to established-patient limited.
The June 20 visit is limited.
On June 22, LS returned to the office for the lab work. Respondent billed an established-patient minimal visit, glucose, blood count, and venipuncture. Petitioner disallowed the venipuncture and minimal visit for the usual reasons.
The June 22 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On June 26, September 12, December 5, and December 7, LS visited the office. Each time, Respondent billed the visit as established-patient intermediate, and Petitioner reduced the claim to established-patient limited. The June 26 visit was a follow-up and is established-patient limited. The September 12 visit was for congestion and vomiting due to an upper respiratory infection and is established-patient limited. The December 5 visit was for cramping and diarrhea and is established-patient limited. The December 7 visit was a follow-up of the December 5 visit and is established-patient limited.
The total overpayment on account of LS is $84.50, representing $3.50 for June 20, June 26, September 12, December 5, and December 7, $5 for February 10, $25 for March 3, $25 for April 4, and $12 for June 22.
Patient #35 is MB. MB is an 18 year old female. She visited Respondent nine times in 1989: February 8, 9, 13, 14, and 20 and March 13, 15, 16, 20, and 21.
On February 8, MB visited the office complaining of a cough, elevated temperature, and decreased appetite. Respondent billed the visit as new-patient comprehensive, and Petitioner allowed the claim.
The February 8 visit is intermediate.
On February 9, MB returned for lab work. Respondent billed for an established-patient intermediate visit, urinalysis, and venipuncture. Petitioner disallowed the visit for the usual reasons, but allowed the venipuncture.
The February 9 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and lab work are allowed.
On February 13, MB returned for the lab results, which disclosed that she was anemic. Respondent determined that he had to rule out sickle cell anemia and ordered tests for sickle cell and blood chemistry. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to established-patient limited.
The February 13 visit is intermediate.
On February 14, MB returned to the office for the lab work. Respondent billed for an established-patient minimal visit, two sickle cell tests, two blood chemistries, and a test for urea nitrogen. Petitioner disallowed the duplicate billings, as well as the urea nitrogen because an outside lab billed for the service. Petitioner disallowed the minimal visit for the usual reason.
The duplicate billings are disallowed, as is the urea nitrogen test, for the reasons stated. The minimal office visit in disallowed due to questionable frequency and medical necessity.
On February 20, MB returned to the office for the lab results. The blood chemistry and sickle cell test results were satisfactory. Respondent billed an established-patient intermediate visit, and Petitioner reduced the visit to established-patient limited.
The February 20 visit is limited.
Petitioner disallowed a series of visits and tests due to the lack of any reference to them in the medical records. These items were a venipuncture on March 13; established-patient intermediate visit on March 15; established- patient minimal visit, urinalysis, and blood count on March 16; and
established-patient minimal visit, established-patient intermediate visit, blood count, and venipuncture on March 20. These claims are disallowed for the reasons stated.
On March 21, MB visited the office complaining of a loss of appetite. Respondent diagnosed anemia and billed the visit as established-patient intermediate. Petitioner disallowed the visit due to questionable frequency and medical necessity.
The March 21 visit is limited.
The total overpayment on account of MB is $140.50, representing $20 for February 8, $12 for February 9, $17 for February 14, $3.50 for February 20 visit, $84.50 total for March 13, 15, 16, and 20, and $3.50 for March 21.
Patient #36 is BW. BW is a 28 year old female. She visited Respondent ten times in 1989: February 8, 15, and 24, March 14, April 13, 17, and 20, May 11 and 18, and November 22.
On February 8, BW visited the office complaining of vaginal discharge and itching. Respondent diagnosed her condition as vaginitis and vulvitis. Respondent billed the visit as established-patient intermediate. Petitioner disallowed the claim due to a lack of documentation.
The February 8 visit is limited.
On February 15, February 24, and March 14, BW visited the office, but no record of her visits appears in her chart. Respondent billed each of these visits as established-patient intermediate. Petitioner disallowed each visit due to a lack of documentation.
The February 15, February 24, and March 14 visits are disallowed for the reason stated.
For each of the remaining six visits, Respondent billed the visit as established-patient intermediate. Petitioner reduced the visits of April 13, May 11, and November 22 to established-patient limited. Petitioner reduced the visit of April 17 to established-patient brief, and Petitioner reduced the visits of April 20 and May 18 to established-patient minimal.
On April 13, BW presented with a terrible headache, cough, aching chest, blood in urine, and abdominal pain. Respondent performed a physical examination and diagnosed her as suffering from an upper respiratory infection, bronchitis, vaginitis, and possible urinary tract infection. Respondent referred her for a chest x-ray, urinalysis, and blood count.
The April 13 visit is intermediate.
On April 17, BW returned for her x-ray results and a follow-up visit. The x-ray was normal. She stated that she was feeling better except for the headaches.
The April 17 visit is minimal.
On April 20, BW returned for the results of her blood count and urinalysis and complaining of headaches. The lab results were normal.
The April 20 visit is disallowed due to questionable frequency and medical necessity.
On May 1, BW returned to the office complaining of an in-grown toenail and milk discharging from her breasts. Respondent presented no claim for this visit.
On May 11, BW returned to the office for the results of a mammogram, which indicated that she had fibrocystic disease.
The May 11 visit is intermediate due to the fact that Respondent was able to base his diagnosis and treatment upon work performed in an unbilled visit 10 days earlier.
On May 18, BW returned to the office for test results. Respondent administered a breast examination, modified his diagnosis, and referred her to another doctor for a possible biopsy.
The May 18 visit is limited.
On November 22, BW returned to the office following a lumpectomy performed by the other doctor. She complained of pain in the kidneys, nervousness, pain in the breast, and frequency of urination. The diagnoses were urinary tract infection and surgical menopause.
The November 22 visit is intermediate.
The total overpayment on account of BW is $120, representing $3.50 for February 8, $25 for February 15, $25 for February 24, $25 for March 14, $13 for April 17, $25 for April 20, and $3.50 for May 18.
Patient #37 is BB. BB is a 53 year old female. She visited Respondent 10 times in 1989: May 1, 3, and 8, September 15 and 21, October 4, 13, and 26, November 15, and December 8.
On May 1, BB visited the office as a new patient complaining of chest congestion, coughing, diarrhea, and fever. Respondent diagnosed her with flu- like symptoms and asthmatic bronchitis. Respondent billed the visit as new- patient intermediate, and Petitioner allowed the claim.
On May 3, BB returned for lab work. Respondent billed an established-patient minimal visit, blood count and urinalysis. Petitioner disallowed the minimal visit.
The May 3 visit is disallowed due to questionable frequency and medical necessity.
On October 26, BB visited the office complaining of recurring pain in her hip and back due to osteoarthritis. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The October 26 visit is limited.
The total overpayment on account of BB is $15.50, representing $12 for the May 3 visit and $3.50 for the October 26 visit.
Patient #38 is WM. WM is a 59 year old male. He visited Respondent
11 times in 1989: January 27, February 27, April 28, May 29, June 27, July 31, August 29, September 22, November 3, November 29, and December 13.
Except for the June 27 visit, each of the visits involved no lab work. Respondent billed each visit as established-patient intermediate, and Petitioner reduced each visit to established-patient limited. The medical chart reveals little of WM's condition. For the most part, the notation is that the diagnosis is the same, and the earlier charts are not part of the record. It appears that his primary problem was hypertension, but he also suffered from high cholesterol, stomach problems, and possibly psychotic episodes, although these episodes are not referenced in the medical records for 1989. The records reveal a pattern of monthly visits with refilled prescriptions.
The visits of January 27, February 27, April 28, May 29, July 31, August 29, September 22, November 3, November 29, and December 13 are limited.
On June 26, WM's blood pressure had increased to 150/102 and his pulse was 104. Respondent did not bill the visit.
On June 27, WM returned to the office for lab work. Respondent billed for an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the venipuncture and minimal visit on the usual grounds. Petitioner disallowed the three tests due to a lack of result in the medical records.
The June 27 visit is minimal because the June 26 visit was unbilled. The three tests are disallowed for the reasons stated; the medical records fail to contain the results. The venipuncture is disallowed because the tests are disallowed.
The total overpayment on account of WM is $50, representing $3.50 for January 27, February 27, April 28, May 29, July 31, August 29, September 22, November 3, November 29, and December 13, and $15 for June 27.
Patient #39 is AA. AA is a two month old female. She visited Respondent nine times in 1989: February 23, March 20, 27, and 30, June 5, July
18 and 31, and October 16, 23, 25, and 30.
After the first visit, Respondent billed each visit as established- patient intermediate, except for a minimal visit on October 25 for lab work. Petitioner allowed each claim except it reduced the March 27 and 30 claims to established-patient limited and disallowed the minimal visit and venipuncture on October 25.
On March 20, AA visited the office with congestion, coughing, sneezing and constipation. Respondent diagnosed an upper respiratory infection.
On March 27, AA returned with a rash on her stomach. Respondent diagnosed AA as suffering a reaction to the amoxicillin he had prescribed on the March 20 visit. He also determined that it was necessary to rule out rubella.
The March 27 visit is intermediate.
On March 30, AA returned for a follow-up visit. She was doing better and the rash was disappearing.
The March 30 visit is limited.
On October 16, AA returned with a cold, congestion, and fever. She returned on October 23 not doing any better. On October 25, AA returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The October 25 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
The total overpayment on account of AA is $15.50, representing $3.50 for March 30 and $12 for October 25.
Patient #40 is GB. GB is a 60 year old male. He saw Respondent 14 times in 1989: January 6 and 13, February 10, March 9 and 10, April 14, May 18, July 13 and 14, August 11, September 22, October 25, and November 10.
On January 6, GB visited the office for lab work. Respondent billed for an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds. Petitioner disallowed the cholesterol test because the result was not recorded in the charts.
The January 6 visit is disallowed due to questionable frequency and medical necessity. The cholesterol test is disallowed for the reason stated. The venipuncture is disallowed because the cholesterol is disallowed.
On January 13, GB returned to the office. The purpose of the visit is unclear from the records, except to get refills of his prescriptions for high cholesterol and hypertension. He was doing well. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to established-patient limited.
The January 13 visit is limited.
On February 10, GB returned to the office, again stating that he felt fine. His blood pressure was the same as the last visit: 130/80. Respondent refilled his prescriptions and billed the visit as established-patient intermediate. Petitioner reduced the visit to established-patient limited.
The February 10 visit is limited.
On March 9, GB returned for lab work, again stating that he felt fine. Respondent billed for an established-patient minimal visit, cholesterol test, and venipuncture. Petitioner disallowed the claims for the same reasons that it disallowed the claims of January 6. However, the record entry of April
14 shows a cholesterol reading of 268 mg.
The March 9 visit is disallowed due to questionable frequency and medical necessity. The cholesterol test would be allowed, except that it appears from the March 10 entry that the test was performed by an outside lab.
The cholesterol test is disallowed for this reason. However, the venipuncture is allowed.
On March 10, GB returned to the office for the lab results, but they were not back from the National Health Lab. Respondent refilled his prescriptions. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 10 visit is limited.
On April 14, GB returned to the office for refills, again stating that he felt fine. His blood pressure was 150/102, which was higher than the previous visit. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to limited.
The April 14 visit is limited.
On May 18, GB returned for another cholesterol test. Respondent billed the visit the same as he billed the January 6 and March 9 visits, and Petitioner disallowed the claims for the same reasons. However, the next record entry, which is June 2, notes a cholesterol level of 262 mg.
The May 18 visit is minimal, with no billed visits within a month on either side, and the cholesterol test and venipuncture are allowed.
GB visited the office on July 13 and 14. Respondent billed both visits as established-patient intermediate, and Petitioner reduced both to limited. The July 13 visit was solely for the purpose of a cholesterol test. The July 14 visit, on which GB's blood pressure was 90/58, was for the lab results, which are set forth in the records.
The July 13 visit is disallowed due to questionable frequency and medical necessity. The July 14 visit is allowed as limited. The cholesterol test was not billed.
On August 11, GB returned to the office for either more lab work or lab results. His blood pressure was 110/60 and cholesterol was 185 mg, which are within normal limits. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 11 visit is limited.
On September 22, GB returned for refills of his prescriptions. His blood pressure was 120/80 and he was feeling fine. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 22 visit is limited.
On October 25, GB returned for more refills. Again saying that he felt fine, his blood pressure was 102/64. Respondent billed the visit as established-patient intermediate, and Petitioner reduced it to limited.
The October 25 visit is limited.
On November 10, GB returned for lab work. Respondent billed an established-patient minimal visit, potassium, blood count, and venipuncture.
Petitioner disallowed the claims for the same reasons it disallowed the claims of January 6, March 9, and May 18. However, the next entry, which is for November 24, notes a cholesterol level of 176 mg and a potassium value.
The visit of November 10 is disallowed due to questionable frequency and medical necessity. The lab tests and venipuncture are allowed.
On November 24, GB returned to the office for a check-up. His blood pressure was 120/80. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 24 visit is limited.
The total overpayment on account of GB is $101, representing $3.50 for January 13, February 10, March 10, April 14, July 14, August 11, September 22, October 25, and November 24, $18.50 for January 6, $14 for March 9, $25 for July 13, and $12 for November 10.
Patient #41 is LP. LP is a 22 year old female. She visited Respondent 13 times in 1989: January 25, February 28, March 28, April 3 and 4, May 16, June 21, August 10, September 29, October 2, and November 14, 15, and 17.
On January 25, LP visited the office for refills of medications. Her weight was 256 pounds and her blood pressure was 120/82. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 25 visit is limited.
On February 28, LP visited the office for refills of medications. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 28 visit is limited.
On March 28, LP visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 28 visit is limited.
On April 3, she returned to the office for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. It is unclear why the other tests were disallowed, as the results are noted in the April 4 entry.
The April 3 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and lab work are allowed.
On April 4, LP returned to the office for the lab results. Her blood pressure was 85/68 and her cholesterol was 149 mg. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 4 visit is limited.
On May 16, LP returned to the office for a follow-up visit. Respondent billed the visit as established-patient intermediate. Petitioner disallowed the visit due to frequency given LP's chronic ongoing condition.
The May 16 visit is disallowed for the reason stated.
On June 21, LP returned to the office with an upper respiratory infection that had lasted one day. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The June 21 visit is limited.
On August 10, LP visited the office for lab work. Respondent billed an established-patient minimal visit, established-patient intermediate visit, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner noted the duplicate billing for office visits, but appears not to have disallowed or reduced the intermediate visit.
On August 11, LP returned to the office for the lab results. Respondent did not bill the visit.
The August 10 visit is allowed as a limited visit because the August
11 visit was not billed. The lab work and venipuncture are allowed.
On September 29, LP visited the office for lab work. Respondent billed an established-patient minimal visit, cholesterol, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The September 29 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On October 2, LP returned to the office for the lab results and prescription refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 2 visit is limited.
On November 14, LP visited the office complaining of foot pain, missing her last menstrual period, and a cold. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 14 visit is limited.
On November 15, LP returned for lab work. Respondent billed an established-patient minimal visit, gonadotropin, lipoprotein, triglycerides, and venipuncture. Petitioner disallowed the minimal visit and venipuncture.
The November 15 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 17, LP returned for the lab results and check-up. A pregnancy test indicated that she was pregnant. The diagnosis was a high-risk pregnancy, evidently due to LP's hypertension, high cholesterol and obesity.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 17 visit is limited.
The total overpayment on account of LP is $80, representing $3.50 for January 25, February 28, March 28, April 4, June 21, October 2, November 14, and November 17, $12 for April 3, $25 for May 16, $12 for September 29, $12 for November 15, and a $9 underpayment for August 10.
Patient #42 is EB. EB is a 58 year old female. She visited Respondent 18 times in 1989: February 2 and 6, March 6 and 13, April 13, May 15 and 16, July 10 and 11, August 10 and 11, September 12 and 14, October 11 and 17, November 7 and 9, and December 7.
On February 2, EB visited the office for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual grounds.
The February 2 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On February 6, EB returned to the office for the lab results. The cholesterol was 205 mg. Blood pressure was 120/70. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to brief.
The February 6 visit is brief.
On March 6, EB returned for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol and venipuncture. Petitioner disallowed all claims because the frequency of the lab work was not justified.
The March 6 office visit and lab work are disallowed for the reason stated.
On March 13, EB returned to the office for the lab results and a follow-up visit. The cholesterol was 197 mg. The blood pressure was 100/60. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The March 13 visit is limited.
On April 13, EB visited the office for a follow-up visit. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The April 13 visit is limited.
On May 15, EB visited the office for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol, and venipuncture. Petitioner disallowed all claims due to excessive frequency of lab work.
The May 15 visit and lab work are disallowed for the reasons stated.
On May 16, EB returned to the office for the lab results. Her cholesterol was 281 mg. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The May 16 visit is limited.
On July 10, EB visited the office for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the claims due to excessive frequency.
The July 10 is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed due to excessive frequency. The venipuncture is disallowed because the cholesterol is disallowed.
On July 11, EB returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The July 11 visit is limited.
On August 10, EB visited the office for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner allowed the cholesterol and disallowed the minimal visit and venipuncture.
The August 10 visit is disallowed due to questionable frequency and medical necessity. The cholesterol and venipuncture are allowed.
On August 11, EB returned for her lab work. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The August 11 visit is limited.
On September 12, EB visited the office for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol, and venipuncture. Petitioner disallowed the claims due to excessive frequency.
The September 12 office visit and lab work are disallowed for the stated reason.
On September 14, EB visited the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The September 14 visit is limited.
On October 11, EB visited the office for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the claims due to excessive frequency.
The October 11 visit and lab work are disallowed for the reasons stated.
On October 17, EB returned to the office, apparently for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The October 17 visit is limited.
On November 7, EB visited the office for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the claims due to excessive frequency of lab work.
The November 7 visit and lab work are disallowed for the reason stated.
On November 9, EB returned for lab results and recheck. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The November 9 visit is limited.
On December 7, EB visited the office for a check up and refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited or brief.
The December 7 visit is limited.
The total overpayment on account of EB is $173, representing $3.50 for February 6, March 13, April 13, May 16, July 11, August 11, September 14, October 17, November 9, and December 7, $12 for February 2, $18 for March 6,
$21.50 for May 15, $18.50 for July 10, $12 for August 10, $19 for September 12,
$18.50 for October 11, and $18.50 for November 7.
Patient #43 is CM. CM is a 27 year old female. She visited Respondent 16 times in 1989: January 12, April 21, 24, and 28, May 18, 24, and 31, June 5, July 14 and 20, October 2, 6, and 17, November 3 and 6, and December 7.
On January 12, CM visited the office with chest congestion. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 12 visit is limited.
On April 21, CM visited the office complaining of a dry mouth and reporting a family history of diabetes. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 21 visit is limited.
On April 24, CM returned for lab work. Respondent billed an established-patient intermediate visit, blood count, urinalysis, blood chemistry, and venipuncture. Petitioner disallowed the venipuncture, reduced the visit to minimal, and disallowed the blood chemistry because an outside lab did the work.
The April 24 visit is disallowed due to questionable frequency and medical necessity. The blood chemistry is disallowed for the reason stated. The venipuncture is allowed.
On April 28, CM returned for a follow-up visit and lab results. Respondent diagnosed anemia. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 28 visit is limited.
On May 18, CM visited the office for lab work. Respondent billed an established-patient minimal visit, blood chemistry, cholesterol and venipuncture. Petitioner disallowed the visit and lab work due to excessive frequency.
The May 18 visit and lab work are disallowed for the stated reason.
On May 24, CM returned to the office for the lab results. Respondent diagnosed an upper respiratory infection. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 24 visit is limited.
On May 31, CM returned for more lab work. Respondent billed an established-patient minimal visit, blood chemistry, uric acid, and venipuncture. Petitioner disallowed the visit and tests due to excessive frequency.
The May 31 visit and lab work are disallowed for the stated reason.
On June 5, CM returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 5 visit is limited.
On July 14, CM visited the office for lab work. Respondent billed an established-patient minimal visit, blood gases, blood chemistry, and venipuncture. Petitioner disallowed the visit and tests due to excessive frequency.
The July 14 visit and lab work are disallowed for the stated reason.
On July 20, CM returned for the lab results. Respondent diagnosed CM as suffering from anemia. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 20 visit is limited.
On October 2, CM returned for lab work. Respondent billed for an established-patient minimal visit, blood count, and venipuncture. Petitioner allowed the blood count, but disallowed the minimal visit and venipuncture on the usual grounds.
The October 2 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On October 6, CM returned for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 6 visit is limited.
On October 17, CM returned for a recheck and more lab results. A sickle cell test proved negative. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The October 17 visit is limited.
On November 3, CM visited the office for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the claims because of excessive frequency.
The November 3 visit and lab work are disallowed for the stated reason.
On November 6, CM returned for lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 6 visit is limited.
On December 7, CM visited the office for stomach gas and shortness of breath. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 7 visit is limited.
The total overpayment on account of CM is $185, representing $3.50 for January 12, April 21, April 28, May 24, June 5, July 20, October 6, October 17, November 6, and December 7, $36 for April 24, $26.50 for May 18, $24.50 for May 31, 5, $25 for July 14, $12 for October 2, and $26 for November 3.
Patient #44 is MM. MM is a 31 year old female. She visited Respondent 18 times in 1989: April 21, 24, and 25, June 2, July 17, 18, and 21, August 4, September 12, 13, 20, October 11, 24, 25, 26, November 2 and 29, and December 8.
On April 21, MM visited the office as a new patient. She presented with head congestion, burning eyes, and painful urination. Respondent diagnosed her as suffering from upper respiratory infection, bronchitis, right external otitis, surgical menopause syndrome, and the need to rule out urinary tract infection. Respondent billed the visit as new-patient intermediate, and Petitioner allowed the claim.
On April 24, MM returned for lab work. Respondent billed an established-patient minimal visit, urinalysis, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds.
The April 24 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On April 25, MM returned for the lab results. Respondent reexamined her ears. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 25 visit is limited.
On June 2, MM visited the office for prescription refills. She was also suffering from an anxiety reaction. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 2 visit is limited.
On July 17, MM visited the office due to a fall in which she believed that she had broken one or more of her toes. Respondent told her to return July
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 17 visit is limited.
On July 18, MM returned complaining of pain in the injured foot. Evidently, she could not wait until her return appointment. After examining her, Respondent told MM to return on her scheduled appointment date. Respondent billed the visit as established-patient intermediate, and Petitioner disallowed the visit due to questionable frequency and medical necessity.
The July 18 visit is brief.
On July 21, MM returned for a recheck. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 21 visit is brief.
On August 4, MM visited the office due to a severe chest pain. She had gone to the hospital three days earlier with the pain. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 4 visit is limited.
On September 12, MM visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 12 visit is limited.
On September 13, MM returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture on the usual grounds.
The September 13 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On September 20, MM returned for lab results, but also due to an upper respiratory infection. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 20 visit is limited.
On October 11, MM visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 11 visit is minimal.
On October 24, MM visited the office complaining of sharp pain in both legs. Petitioner allowed the claim.
On October 25, MM returned to the office for lab work. Respondent billed an established-patient intermediate visit, urinalysis, blood count, and venipuncture. Petitioner reduced the visit to limited and disallowed the venipuncture.
The October 25 visit is minimal. The venipuncture is allowed.
On October 26, MM returned for a recheck and test results. The ultrasound test disclosed a pelvic mass. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to minimal.
The October 26 visit is minimal.
On November 2, MM returned for a recheck and refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 2 visit is limited.
On November 29, MM visited the office following abdominal-pelvic surgery performed by another doctor about two weeks earlier. The purpose of her visit was to get something to help her quit smoking. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 29 visit is limited.
On December 8, MM returned to the office for refills and a check-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 8 visit is limited.
The total overpayment on account of MM is $101.50, representing $3.50 for April 25, June 2, July 17, July 18, July 21, August 4, September 12, September 20, November 2, November 29, and December 8, $12 for April 24, $12 for September 13, and $13 for October 11, 25, and 26.
Patient #45 is HJ. HJ is a 41 year old female. She visited Respondent 19 times in 1989: January 12, 15, and 18, February 8, March 9, April
19 and 21, May 23 and 24, June 5, July 20, October 6, 16, 17, 26, and 27, November 22 and 28, and December 13.
On January 12, HJ visited the office. Her blood pressure was 140/100. Her weight was 262 pounds. Her pulse was 92. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 12 visit is limited.
On January 16, HJ returned to the office for lab work. Respondent billed an established-patient minimal visit, established-patient intermediate
visit, cholesterol, potassium, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The intermediate and minimal visits are disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On January 18, HJ returned for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 18 visit is limited.
On February 8, HJ visited the office due to a missed menstrual period. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 8 visit is limited.
On March 7, HJ visited the office for lab work. Respondent billed neither the lab work nor the office visit.
On March 9, HJ returned to the office for the lab results and a check-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 9 visit is limited.
On April 19, HJ visited the office for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The April 19 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On April 21, HJ returned for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 21 visit is limited.
On May 23, HJ visited the office for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The May 23 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On May 24, HJ returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 24 visit is limited.
On June 5, HJ returned to the office for a recheck. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 5 visit is limited.
On July 20, HJ visited the office for another check-up. Her blood pressure was 138/88. Her weight was 264 pounds. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 20 visit is limited.
On October 6, HJ visited the office to schedule a complete physical. Her blood pressure was 120/90, and her weight was 271 pounds. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 6 visit is limited.
On October 16, HJ returned for lab work. Respondent billed an established-patient minimal visit, blood count, urinalysis, and venipuncture. Petitioner disallowed the minimal visit for the usual reasons.
The October 16 visit is disallowed due to questionable frequency and medical necessity.
On October 17, HJ returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 17 visit is limited.
On October 26, HJ returned for lab work. Respondent billed an established-patient minimal visit and urinalysis. Petitioner disallowed the minimal visit for the usual reason.
The October 26 visit is disallowed due to questionable frequency and medical necessity.
On October 27, HJ returned to the office for the lab results and a recheck. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 27 visit is disallowed due to questionable frequency and medical necessity.
On November 22, HJ visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The November 22 visit is limited.
On November 28, HJ returned to get her refills as Respondent had instructed her a week earlier. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The November 28 visit is disallowed due to questionable frequency and medical necessity.
On December 13, HJ returned to the office "to check on meds before [Respondent] leaves this wk." Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The December 13 visit is limited.
The total overpayment on account of HJ is $172.00, representing
$3.50 for January 12, January 18, February 8, March 9, April 21, May 24, June 5,
July 20, October 6, October 17, November 22, and December 13, $32 for January 16, $12 for April 19, $12 for May 23, $12 for October 16, $12 for October 26,
$25 for October 27, and $25 for November 28.
Patient #46 is GM. GM is a 32 year old female. She visited Respondent 18 times in 1989: June 20 and 27, July 11, 12, and 27, August 3, 4, and 8, September 8, October 4, 5, 6, 25, and 26, November 15 and 17, and December 6 and 8.
On June 20, GM visited the office complaining of heartburn. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to brief.
The June 20 visit is limited.
On June 27, GM returned, evidently with the same complaints. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to brief.
The June 27 visit is limited.
On July 11, GM returned for lab work. Respondent billed an established-patient minimal visit, blood count, urinalysis, lipoprotein, cholesterol, triglycerides, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lipoprotein, triglycerides, and cholesterol because the frequency of the lab work was unjustified.
The July 11 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed. The lipoprotein, triglycerides, and cholesterol are allowed because there is no indication that they were previously billed in 1989.
On July 12, GM returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 12 visit is limited.
On July 27, GM returned for lab work. Respondent billed an established-patient minimal visit, triglycerides, cholesterol, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the triglycerides, cholesterol, lipoprotein tests due to excessive frequency.
The July 27 visit is disallowed due to questionable frequency and medical necessity. The cholesterol, triglycerides, and lipoprotein are disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On August 3, GM returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 3 visit is limited.
On August 4, GM returned for lab work. Respondent billed an established-patient minimal visit, lipoprotein, glutamyl transpeptidase, glutamic oxaloacetic transaminase, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lipoprotein due to excessive frequency. Petitioner disallowed the glutamyl transpeptidase and glutamic oxaloacetic transaminase for reasons not reflected in the record.
The August 4 visit is disallowed due to questionable frequency and medical necessity. The tests are allowed because Petitioner has not shown why they are not appropriate, except that the lipoprotein is disallowed due to excessive frequency.
On August 8, GM returned to the office for the lab results and complaining that she was burping a lot. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 8 visit is limited.
On September 8, GM visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 8 visit is limited.
On October 4, GM visited the office complaining of a sore throat. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 4 visit is limited.
On October 5, GM returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner allowed the cholesterol, triglycerides, and lipoprotein.
The October 5 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On October 6, GM returned to the office for the lab results. Her cholesterol level was 311 mg. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The October 6 visit is limited.
On October 25, GM returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol, triglycerides, and lipoprotein due to excessive frequency.
The October 25 visit is disallowed due to questionable frequency and medical necessity. The cholesterol, triglycerides, and lipoprotein are disallowed due to excessive frequency. The venipuncture is disallowed because the tests are disallowed.
On October 26, GM returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to minimal.
The October 26 visit is brief.
On November 17, GM returned for a recheck and refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 17 visit is disallowed due to questionable frequency and medical necessity.
On December 6, GM returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner allowed the triglycerides and cholesterol, which are different from the other triglycerides and cholesterol tests.
The December 6 visit is disallowed due to questionable frequency and medical necessity. The cholesterol and triglycerides are allowed. The venipuncture is allowed.
On December 8, GM returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 8 visit is limited.
The total overpayment on account of GM is $187, representing $3.50 for June 20, June 27, July 12, August 3, August 8, September 8, October 4, October 6, October 26, and December 8, $12 for July 12, $36.50 for July 27, $18 for August 4, $12 for October 5, $36.50 for October 25, $25 for November 17, and
$12 for December 6.
Patient #47 is IW. IW is a 60 year old female. She visited Respondent 20 times in 1989: January 18 and 19, February 10, 24, and 27, March
13 and 16, April 10, May 10 and 16, June 7, July 11 and 12, August 10 and 11, September 12, October 10 and 12, November 13, and December 11.
On January 18, IW visited the office for lab work. Respondent billed an established-patient minimal visit, blood count, blood gases, blood chemistry, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the remainder of the tests because the diagnosis was not documented in the records. The diagnosis on the chart is bronchitis.
The January 18 visit is disallowed due to questionable frequency and medical necessity. The tests are disallowed for the stated reason. The venipuncture is disallowed because the tests are disallowed.
On January 19, IW returned to the office for the lab results. Respondent billed the visit as established-patient intermediate. Petitioner disallowed the visit because the diagnosis was not documented.
The January 19 visit is limited.
On February 10, IW returned complaining of stiffness in the knees and tremors of the tongue and fingers. Respondent diagnosed Parkinson's Disease. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 10 visit is intermediate.
On February 24, IW returned for lab work. Respondent billed an established-patient minimal visit, blood count, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the two cholesterol tests and two glucose tests, as well as the blood count, because they were not indicated for the stated condition.
The February 24 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the stated reason. The venipuncture is disallowed because the lab work is disallowed.
On February 27, IW returned to the office for the lab results. IW complained of breathing complaints, and Respondent diagnosed an upper respiratory infection. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 27 visit is limited.
On March 13, IW visited the office complaining of coughing, runny nose, and stomach pain. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to brief.
The March 13 visit is limited.
On March 16, IW returned, but there is no entry in the chart. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 16 visit is disallowed as undocumented.
On April 10, IW returned for a follow-up visit. As a result of an upper gastrointestinal series done at the hospital on March 20, she was diagnosed with a hiatal hernia. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The April 10 visit is limited.
On May 10, IW visited the office for a follow-up visit. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 10 visit is limited.
On May 16, IW returned to the office because she broke her wheelchair and needed an appointment to get another wheelchair. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 16 visit is disallowed due to questionable frequency and medical necessity.
On June 7, IW returned to the office for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 7 visit is limited.
On July 11, IW returned for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The July 11 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On July 12, IW returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The July 12 visit is limited.
On August 10, IW returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol and triglycerides due to excessive frequency.
The August 10 visit is disallowed due to questionable frequency and medical necessity. The cholesterol and triglycerides are disallowed due to excessive frequency. The venipuncture is disallowed because the tests are disallowed.
On August 11, IW returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 11 visit is limited.
On September 11, IW visited the office for lab work. She was sent to the hospital. Respondent did not bill the visit.
On September 12, IW returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to brief.
The September 12 visit is limited.
On October 10, IW returned for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol, triglycerides, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the
usual reasons. Petitioner disallowed the glucose, cholesterol, and triglycerides due to excessive frequency.
The October 10 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the stated reason. The venipuncture is disallowed because the lab work is disallowed.
On October 12, IW returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 12 visit is limited.
On November 13, IW visited the office for a recheck. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 13 visit is limited.
On December 11, IW returned for refills. Respondent billed the visit as established-patient intermediate. Petitioner disallowed the claim due to frequency.
The December 11 visit is disallowed for the reason stated.
The total overpayment on account of IW is $261.50, representing $3.50 for January 19, February 27, March 13, April 10, May 10, June 7, July 12, August 11, September 12, October 12, and November 13, $50.50 for January 18, $27.50 for February 24, $25 for March 16, $25 for May 16, $12 for July 11, $27.50 for August 10, $30.50 for October 10, and $25 for December 11.
Patient #48 is CK. CK is a 60 year old female. She visited Respondent 21 times in 1989: January 10 and 11, February 10 and 13, March 20, 22, and 27, April 25 and 27, May 4 and 18, June 1, September 12 and 19, October 3, 17, 20, and 31, November 10 and 14, and December 12.
On January 10, CK visited the office complaining of hip and knee problems. She weighed 258 pounds. Her blood pressure was 132/80. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 10 visit is limited.
On January 11, CK returned for lab work. Respondent billed an established-patient minimal visit, glucose, potassium, and venipuncture.
Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The January 11 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On February 10, CK returned for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the potassium and cholesterol due to excessive frequency.
The February 10 visit is disallowed due to questionable frequency and medical necessity. The potassium test is disallowed for the stated reason.
However, there is no indication of a prior cholesterol test, so it is allowed. The venipuncture is allowed.
On February 13, CK returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 13 visit is limited.
On March 20, CK visited the office complaining of pain in her knees and chest. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 20 visit is limited.
On March 22, CK returned for lab work. Respondent billed an established-patient minimal visit and electrocardiogram. Petitioner disallowed the minimal visit for the usual reason.
The March 22 visit is disallowed due to questionable frequency and medical necessity.
On March 27, CK returned to the office for the lab results and suffering from an upper respiratory infection. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 27 visit is limited.
On April 25, returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner
disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the blood count due to excessive frequency.
The April 25 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and blood count are allowed.
On April 27, CK returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 27 visit is limited.
On May 4, CK returned for lab work. Respondent billed an established-patient minimal visit and blood count. Petitioner disallowed the minimal visit for the usual reason. Petitioner disallowed the blood count due to excessive frequency.
The May 4 visit is disallowed due to questionable frequency and medical necessity. The blood count is disallowed for the reason stated.
On May 18, CK returned to the office for the lab results and due to an upper respiratory infection. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The May 18 visit is limited.
On June 1, CK visited the office for a follow-up visit before going out of town. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 1 visit is disallowed due to questionable frequency and medical necessity.
On September 12, CK visited the office complaining of pain in her knees and lower back. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 12 visit is limited.
On September 19, CK returned complaining of sinus pain and fatigue. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 19 visit is limited.
On October 3, CK returned for a follow-up visit. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to brief.
The October 3 visit is disallowed due to questionable frequency and medical necessity.
On October 17, CK visited the office for a recheck and a lump on her eyelid. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 17 visit is limited.
On October 20, CK returned for lab work. Respondent billed an established-patient minimal visit, blood count, cholesterol, triglycerides, lipoprotein, potassium, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the blood count due to a lack of a result in the medical records. An entry for October 24, which was not billed, notes that problems with the blood count test rendered the results incomplete and questionable.
The October 20 visit is disallowed due to questionable frequency and medical necessity. The blood count and venipuncture are allowed.
On October 31, CK returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate. Petitioner allowed the claim.
The October 31 visit is limited.
On November 10, CK returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The November 10 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 14, CK returned to the office for the lab results and due to pain in the knee after a fall. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The November 14 visit is limited.
On December 12, CK returned to the office for the lab results and due to pain in the lower back. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 12 visit is limited.
The total overpayment on account of CK is $196, representing $3.50 for January 10, February 13, March 20, March 27, April 27, May 18, September 12,
September 19, October 17, October 31, November 14, and December 12, $12 for January 11, $20 for February 10, $12 for March 22, $12 for April 25, $24 for May 4, $25 for June 1, $25 for October 3, $12 for October 20, and $12 for November 10.
Patient #49 is MB. MB is a 57 year old female. She visited Respondent 23 times in 1989: January 16, February 6, 13, and 14, March 24,
April 24 and 25, May 15 and 16, June 13 and 19, July 18 and 24, August 29, 30,
and 31, September 21, 22, 26, and 28, October 24, November 21, and December 15.
On January 16, MB visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 16 visit is limited.
On February 6, MB visited the office due to a cough and cold.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 6 visit is limited.
On February 13, MB returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The February 13 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On February 14, MB returned to the office for the lab results. Her cholesterol level was 188 mg. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to brief.
The February 14 visit is limited.
On March 24, MB returned for a recheck. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 24 visit is limited.
On April 24, MB returned for lab work. Respondent billed an established-patient minimal visit, blood count, cholesterol, triglycerides,
lipoprotein, potassium, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the triglycerides and lipoprotein due to a lack of result noted in the medical records.
The April 24 visit is disallowed due to questionable frequency and medical necessity. The triglycerides and lipoprotein are not noted in the records, so they are disallowed for the reason stated. The venipuncture is allowed.
On April 25, MB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 25 visit is limited.
On May 15, MB returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol due to excessive frequency.
The May 15 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed for the reason stated. The venipuncture is disallowed because the cholesterol is disallowed.
On May 16, MB returned to the office for the lab results. Her cholesterol level was 261 mg. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The May 16 visit is limited.
On June 13, MB returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, two lipoproteins, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol due to excessive frequency.
The June 13 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed for the stated reason. The venipuncture is allowed.
On June 19, MB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate. Petitioner allowed the claim.
The June 19 visit is limited.
On July 18, MB returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner allowed the entire claim.
The July 18 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and cholesterol are allowed.
On July 24, MB returned to the office for the lab results. The cholesterol was 247 mg. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The July 24 visit is limited.
On August 29, MB returned for lab work. Respondent billed an established-patient minimal visit and venipuncture, as well as two types of cholesterol, triglycerides, lipoprotein. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed one set of cholesterol, triglycerides, and lipoprotein as duplicative, even though the two sets of tests measure different values.
The August 29 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed.
On August 30, MB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The August 30 visit is limited.
On August 31, MB returned for lab work. Respondent billed an established-patient minimal visit, lipoprotein, uric acid, transaminase, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the claim for all of the lab work because the results were not recorded in the medical records. An entry for September 21 indicates that the lab work was not done on August 31.
The August 31 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and lab work are disallowed for the reasons stated.
On September 21, MB returned for lab work. Respondent billed an established-patient minimal visit, uric acid, fat differential, glutamyl transpeptidase, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The September 21 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On September 22, MB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 22 visit is limited.
On September 26, MB returned for lab work. Respondent billed an established-patient minimal visit and electrocardiogram. Petitioner disallowed the minimal visit for the usual reason.
The September 26 visit is disallowed due to questionable frequency and medical necessity.
On September 28, MB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 28 visit is limited.
On October 24, MB visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 24 visit is limited.
On November 21, MB visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 21 visit is limited.
On December 15, MB visited the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 15 visit is limited.
The total overpayment on account of MB is $194, representing $3.50 for January 16, February 6, February 14, March 24, April 25, May 16, June 19,
July 24, August 30, September 22, September 28, October 24, November 21, and December 15, $12 for February 13, $30 for April 24, $18.50 for May 15, $16.50 for June 13, $12 for July 18, $12 for August 29, $20 for August 31, $12 for September 21, and $12 for September 26.
Patient #50 is LE. LE is a 58 year old female. She visited Respondent 25 times in 1989: January 25 and 27, February 8, 13,and 24, March 1
and 31, April 7, May 4 and 5, June 5, 7, 14, 15, 21, and 28, July 10 and 28,
September 13, October 13 and 19, November 15 and 16, and December 6 and 7.
On January 25, LE returned for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The January 25 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On January 27, LE returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 27 visit is limited.
On February 8, LE returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, digoxin, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The February 8 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On February 13, LE returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate. Petitioner disallowed the visit due to questionable frequency and medical necessity.
The February 13 visit is limited.
On February 24, LE returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The February 24 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On March 1, LE returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 1 visit is limited.
On March 31, LE returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol because an outside lab was doing the work.
The March 31 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed for the reason stated. The venipuncture is disallowed because the cholesterol is disallowed.
On April 7, LE returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 7 visit is limited.
On May 4, LE returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner
disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol due to a lack of result in the medical records. The cholesterol reading is in the May 5 entry, but the frequency of the test is excessive.
The May 4 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed due to excessive frequency. The venipuncture is disallowed because the cholesterol is disallowed.
On May 5, LE returned to the office for the lab results. Respondent billed the visit as established-patient intermediate. Petitioner disallowed the visit due to excessive frequency.
The May 5 visit is limited.
On June 5, LE returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The June 5 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed due to excessive frequency. The venipuncture is disallowed because the cholesterol is disallowed.
On June 7, LE returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 7 visit is limited.
On June 14, LE visited the office for a follow-up visit. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 14 visit is limited.
On June 15, LE returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the blood count due to a lack of documentation in the records that the work was done.
The June 15 visit is disallowed due to questionable frequency and medical necessity. The blood count is disallowed for the reason stated. The venipuncture is disallowed because the blood count is disallowed.
On June 21, LE returned for lab work. Respondent billed an established-patient minimal visit, blood count, urinalysis, cholesterol, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to a lack of documentation in the records that the work was done.
The June 21 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On June 28, LE returned to the office for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 28 visit is limited.
On July 10, LE returned for lab work. Respondent billed an established-patient minimal visit, urinalysis, cholesterol, glucose, lipoprotein and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to a lack of documentation that the work was performed.
The July 10 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On July 28, LE returned to the office for a follow-up. Respondent billed the visit as established-patient intermediate. Petitioner disallowed the claim due to excessive frequency.
The July 28 visit is disallowed due to questionable frequency and medical necessity.
On September 13, LE visited the office for her "monthly checkup."
She had recently gone to the hospital emergency room due to a urinary tract infection. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 13 visit is limited.
On October 13, LE returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to the lack of documentation that the work was done. The entry for October 19 shows the results for these tests. Her cholesterol was 224 mg.
The October 13 visit is disallowed due to questionable frequency and medical necessity. The cholesterol, lipoprotein, and venipuncture are allowed.
On October 19, LE returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 19 visit is limited.
On November 15, LE returned for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The November 15 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 16, LE returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate,. Petitioner disallowed the claim due to excessive frequency.
The November 16 visit is limited.
On December 6, LE returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The December 6 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed due to excessive frequency.
The venipuncture is allowed.
On December 7, LE returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 7 visit is limited.
The total overpayment on account of LE is $297.50, representing $3.50 for January 27, February 13, March 1, April 7, May 5, June 7, June 14, June 28,
September 13, October 19, November 16, and December 7, $12 for January 25, $12 for February 8, $12 for February 24, $18.50 for March 31, $18.50 for May 4,
$18.50 for June 5, $26 for June 15, $42 for June 21, $33 for July 10, $25 for July 28, $12 for October 13, $12 for November 15, and $14 for December 6.
Patient #51 is MT. MT is a 63 year old female. She visited Respondent 26 times in 1989: January 25 and 30, February 27, March 2, April 3
and 4, May 2 and 4, June 5, 6, 19, 20, 26, and 27, July 26, 27, and 31, August
4, September 15 and 19, October 5 and 17, November 10 and 14, and December 8 and
12.
On January 25, MT returned for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol, potassium, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The January 25 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On January 30, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 30 visit is limited.
On February 27, MT returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, potassium, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol and potassium due to excessive frequency.
The February 27 visit is disallowed due to questionable frequency and medical necessity. The cholesterol and potassium are disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On March 2, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 2 visit is limited.
On April 3, MT returned for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the potassium, glucose, and cholesterol due to excessive frequency.
The April 3 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On April 4, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 4 visit is limited.
On May 2, MT returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, potassium, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons, but allowed the lab work.
The May 2 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed.
On May 4, MT returned to the office for the lab results. Her cholesterol level was 219 mg. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The May 4 visit is limited.
On June 5, MT returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol due to excessive frequency.
The June 5 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed due to excessive frequency. The venipuncture is disallowed because the cholesterol is disallowed.
On June 6, MT returned to the office for the lab results. Her cholesterol level was 248. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 6 visit is limited.
On June 19, MT returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to excessive frequency.
The June 19 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On June 20, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 20 visit is limited.
On June 26, MT returned for lab work. Respondent billed an established-patient minimal visit, venipuncture, and cholesterol. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner allowed the cholesterol.
The June 26 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On June 27, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 27 visit is limited.
On July 26, MT returned for lab work. Respondent billed an established-patient comprehensive visit (although the reimbursement was only
$20), potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to excessive frequency.
The July 26 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On July 27, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 27 visit is limited.
On July 31, MT returned for lab work. Respondent billed an established-patient minimal visit, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The July 31 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On August 4, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 4 visit is limited.
On September 15, MT returned for lab work. Respondent billed an established-patient minimal visit, uric acid, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to excessive frequency.
The September 15 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed. The triglycerides are allowed. The cholesterol and lipoprotein are disallowed due to excessive frequency.
On September 19, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 19 visit is limited.
On October 5, MT returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to excessive frequency.
The October 5 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the reason stated. The venipuncture is allowed.
On October 17, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 17 visit is limited.
On November 10, MT returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The November 10 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 14, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 14 visit is limited.
On December 8, MT returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to excessive frequency.
The December 8 visit is disallowed due to questionable frequency and medical necessity. The lab work is disallowed for the reason stated. The venipuncture is disallowed because the lab work is disallowed.
On December 12, MT returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 12 visit is limited.
The total overpayment on account of MT is $311.50, representing $3.50 for January 30, March 2, April 4, May 4, June 6, June 20, June 27, July 27,
August 4, September 19, October 17, November 14, and December 12, $12 for January 25, $18 for February 27, $25 for April 3, $12 for May 2, $18.50 for June 5, $36.50 for June 19, $12 for June 26, $35.50 for July 26, $12 for July 31, $16 for September 15, $36.50 for October 5, $12 for November 10, and $20 for December 8.
Patient #52 is WS. WS is a 44 year old female. She visited Respondent 26 times in 1989: January 11, 13, 16, and 25, February 8 and 15,
March 21, 27, 29, and 30, April 12 and 26, May 22, June 21, 22, and 27, July 18
and 19, August 9 and 11, October 11, 12, 19, and 26, November 14, and December
8.
On January 11, WS visited the office. She had had surgery on December 12, 1988, to remove a fibroid tumor in her uterus. In addition to a post-surgery total hysterectomy, WS suffered from hypertension. Her blood pressure was 170/120. Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
On January 13, WS returned for lab work. Respondent billed an established-patient minimal visit, blood count, blood chemistry, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The January 13 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On January 16, WS returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 16 visit is limited.
On January 25, WS visited the office complaining of high blood pressure and a racing pulse. Her blood pressure was 180/120 and her pulse was
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 25 visit is limited.
On February 1, WS returned complaining of blurred vision, numb feet, and spasms in her neck, breast, and chest. Respondent did not bill this visit.
On February 8, WS returned complaining of a sore throat and cough.
Her blood pressure was 170/110 and pulse was 88. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 8 visit is limited.
On February 15, WS returned complaining of muscle spasms and blurred vision. Her blood pressure was 190/120 and pulse was 100. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 15 visit is limited.
On March 21, WS visited the office complaining of congestion.
Respondent billed the visit as established-patient intermediate, and Petitioner allowed the claim.
The March 21 visit is limited.
On March 27, WS returned for lab work. Respondent billed an established-patient minimal visit, blood count, cholesterol, potassium, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to excessive frequency.
The March 27 visit is disallowed due to questionable frequency and medical necessity. There is no indication in the record when Respondent previously conducted cholesterol, potassium, and glucose tests, so these are allowed. Respondent did a blood count on January 13, but the records suggest the possibility of anemia, so the blood count is allowed. The venipuncture is allowed.
On March 29, WS returned to the office for the lab results. She was also suffering from an upper respiratory infection and low back pain.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 29 visit is limited.
On March 30, WS returned for lab work. Respondent billed an established-patient minimal visit, glucose, and venipuncture. The glucose test is different from the one performed three days earlier. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the glucose as not indicated for the stated condition.
The March 30 visit is disallowed due to questionable frequency and medical necessity. The glucose and venipuncture are allowed.
On April 12, WS visited the office with a head cold. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 12 visit is limited.
On April 26, WS returned still complaining of the symptoms of a head cold. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 26 visit is limited.
On May 22, WS returned complaining of headaches and watery eyes. She needed her prescriptions refilled. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The May 22 visit is limited.
On June 21, WS returned complaining of a head cold and needing refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 21 visit is limited.
On June 22, WS returned for lab work. Respondent billed an established-patient minimal visit, blood count, cholesterol, potassium, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol because the medical records did not record any result.
The June 22 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed. However, the blood count and cholesterol are disallowed because, according to the June 27 entry, they were not done.
On June 27, WS returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 27 visit is limited.
On July 18, WS returned to the office for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 18 visit is limited.
On July 19, WS returned for lab work. Respondent billed an established-patient minimal visit, potassium, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the potassium and cholesterol due to excessive frequency.
The July 19 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed for the reason stated. The potassium and venipuncture are allowed.
On August 9, WS returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 9 visit is limited.
On August 11, WS returned to the office due to a cold and aching joints. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The August 11 visit is minimal.
On October 11, WS returned to the office with a cold and in need of refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 11 visit is limited.
On October 12, WS returned for lab work. Respondent billed an established-patient minimal visit, blood gases, blood chemistry, cholesterol, triglycerides, urinalysis, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The October 12 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On October 19, WS returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 19 visit is limited.
On October 26, WS returned for lab work. Respondent billed an established-patient minimal visit, different glucose test, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The October 26 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 14, WS returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 14 visit is limited.
On December 8, WS visited the office for refills and complaining of pain in both hands. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 8 visit is limited.
The total overpayment on account of WS is $167.50, representing
$3.50 for January 16, January 25, February 1, February 15, March 21, March 29,
April 12, April 26, May 22, June 21, June 27, July 18, August 9, August 11,
October 11, October 19, November 14, and December 8, $12 for January 13, $12 for March 27, $12 for March 30, $28.50 for June 22, $16.50 for July 19, $12 for October 12, and $12 for October 26.
Patient #53 is EB. EB is a 26 year old female. She visited Respondent 26 times in 1989: January 25, February 17 and 22, March 3, April 3,
6, 19, 20, and 24, May 5 and 17, June 7, 20, and 28, July 11, August 8, 28, and
29, September 15 and 18, November 2, 3, 7, 8, and 22, and December 1.
On January 25, EB visited the office for refills. She weighed 308 pounds. She complained of pain in her left side, and Respondent diagnosed a urinary tract infection. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 25 visit is limited.
On February 17, EB visited the office complaining of the symptoms of a head cold. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 17 visit is limited.
On February 22, EB visited the office complaining of numbness in her right arm and double vision. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 22 visit is limited.
On March 3, EB returned for a follow-up visit. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 3 visit is limited.
On April 3, EB visited the office for refills. She complained about a swollen left ankle and foot. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to minimal.
The April 3 visit is limited.
On April 6, EB returned for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 6 visit is brief.
On April 19, EB returned complaining that both feet were swollen and in pain. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 19 visit is limited.
On April 20, EB returned for lab work. Respondent billed an established-patient minimal visit, blood chemistry, and venipuncture.
Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The April 20 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On April 24, EB returned for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to minimal.
The April 24 visit is disallowed due to questionable frequency and medical necessity.
On May 5, EB returned for another follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to brief.
The May 5 visit is limited.
On May 17, EB returned to the office complaining of chest congestion and coughing. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 17 visit is limited.
On June 7, EB returned for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 7 visit is disallowed due to questionable frequency and medical necessity.
On June 20, EB returned for lab work. Respondent billed an established-patient minimal visit, blood gases, cholesterol, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The June 20 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On June 28, EB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 28 visit is limited.
On July 11, EB returned complaining of nervousness in her stomach and a spider bite. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to minimal.
The July 11 visit is minimal.
On August 8, EB returned for lab work. Respondent billed an established-patient minimal visit, established-patient intermediate visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner reduced the intermediate visit to minimal.
The August 8 visits are disallowed due to questionable frequency and medical necessity. However, the established-patient intermediate visit appears to have been misbilled for August 8 when it should have been billed for August
9. On August 9, EB returned for her lab results. Therefore, the established-
patient intermediate visit is allowed as a limited visit on August 9. The venipuncture is allowed.
882. On August 28, EB returned to the office complaining of swelling in her left hand and numbness in two fingers. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
883. The August 28 visit is limited.
884. On August 29, EB returned for lab work. Respondent billed an established-patient intermediate visit, potassium, glucose, blood count, and venipuncture. She complained of fainting spells, aching in her chest, and dizziness. Respondent conducted an extensive physical examination. Petitioner disallowed the venipuncture for the usual reasons.
885. The August 29 visit is intermediate. The venipuncture is allowed. 886. On September 15, EB returned complaining about swelling in her left
knee. Respondent billed the visit as established-patient intermediate, and
Petitioner reduced the visit to limited.
887. The September 15 visit is limited.
888. On September 18, EB returned for the same problem. Respondent billed the visit as established-patient intermediate. Petitioner disallowed the visit due to questionable frequency and medical necessity.
889. The September 18 visit is disallowed for the reason stated. 890. On November 2, EB returned for lab work. Respondent billed an
established-patient minimal visit, potassium, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The November 2 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 3, EB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 3 visit is limited.
On November 7, EB returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The November 7 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On November 8, EB returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 8 visit is limited.
On November 22, EB visited the office complaining of vaginal discharge and abdominal pain. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The November 22 visit is limited.
On December 1, EB returned to the office for the results of tests done at the hospital. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 1 visit is limited.
The total overpayment on account of EB is $207.50, representing $3.50 for January 25, February 17, February 22, March 3, April 3, April 6, April 19,
May 5, May 17, June 28, August 9, August 28, September 15, November 3, November 8, November 22, and December 1, $12 for April 20, $25 for April 24, $25 for June 7, $12 for June 20, $13 for July 11, $12 for August 8, $25 for September 18, $12 for November 2, and $12 for November 7.
Patient #54 is KM. KM is a 60 year old female. She visited Respondent 26 times in 1989: January 3, 12, 16, and 30, February 2, 6, 13, and
20, March 7, April 3, May 1, 2, and 11, June 6, 13, 23, 26, and 27, July 27 and
28, September 6 and 29. October 3 and 4, November 7, and December 5.
On January 3, KM visited the office complaining of pain in her knee and neck and headaches. Her cholesterol level was 299 mg. Her blood pressure was 170/110 and her pulse was 88. Respondent billed the visit as established- patient intermediate, and Petitioner reduced the visit to limited.
The January 3 visit is limited.
On January 12, KM returned for lab work. Respondent billed an established-patient minimal visit, potassium, cholesterol, lipoprotein, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The January 12 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On January 16, KM returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 16 visit is limited.
On January 30, KM returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The January 30 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On February 2, KM returned to the office for the lab results. Her cholesterol level was 320 mg. Her blood pressure was 140/90. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 2 visit is limited.
On February 6, KM returned for lab work. Respondent billed an established-patient minimal visit, thyroid stimulating hormone, free thyroxine index, true thyroxine, true triiodothyronine, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work because it was not indicated for the stated condition.
However, KM suffered from hyperthyroid disease.
The February 6 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed.
On February 13, KM returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 13 visit is limited.
On February 20, KM returned for a follow-up. She complained of numbness all over her body. Her blood pressure was up to 180/100. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 20 visit is limited.
On March 7, KM returned for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 7 visit is limited.
On April 3, KM returned for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 3 visit is limited.
On May 1, KM returned for lab work. Respondent billed an established-patient minimal visit, potassium, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The May 1 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On May 2, KM returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 2 visit is limited.
On May 11, KM returned complaining of a sore throat. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 11 visit is limited.
On June 6, KM returned for a follow-up. KM complained of a fall that she had suffered recently. Respondent referred her for x-rays. Respondent
billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 6 visit is limited.
On June 13, KM returned complaining that her tail bone was still sore. The x-rays revealed a compression fracture of her tail bone. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 13 visit is intermediate.
On June 23, KM returned complaining of lightheadedness when she arises, tingling in her arms, and discomfort in her upper chest. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 23 visit is limited.
On June 26, KM returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, potassium, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner rejected the lab work because the diagnosis was not documented. However, her cholesterol levels remained over 200 mg, and Respondent had routinely diagnosed her as having high cholesterol.
The June 26 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed.
On June 27, KM returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 27 visit is limited.
On July 27, KM returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The July 27 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and lab work are allowed.
On July 28, KM returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 28 visit is limited.
On September 6, KM returned due to an upper respiratory infection.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 6 visit is limited.
On September 29, KM returned due to bronchitis. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The September 29 visit is limited.
On October 3, KM returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, triglycerides, lipoprotein, potassium, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work due to excessive frequency.
The October 3 visit is disallowed due to questionable frequency and medical necessity. The cholesterol and triglycerides are disallowed for the reason stated. The venipuncture is allowed.
On October 4, KM returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The October 4 visit is limited.
On November 7, KM returned for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The November 7 visit is limited.
On December 5, KM returned for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The December 5 visit is limited.
The total overpayment on account of KM is $160, representing $3.50 for January 3, January 16, February 2, February 13, February 20, March 7, April
3, May 2, May 11, June 6, June 23, June 27, July 28, September 6, September 29,
October 4, November 7, and December 5, $12 for January 12, $12 for January 30,
$12 for February 6, $12 for May 1, $12 for June 26, $12 for July 27, and $25.50 for October 3.
Patient #55 is AN. AN is a 63 year old female. She visited Respondent 30 times in 1989: January 10, 12, 16, and 31, February 1, March 1
and 2, April 4 and 5, May 9, 11, and 31, June 1, 14, 19, 21, 26, 27, and 28,
July 10, 11, and 12, August 10 and 11, September 12, October 23 and 30, November
17 and 20, and December 5.
On January 10, AN visited the office complaining of arm pain and swollen feet. She weighed 252 pounds. Her blood pressure was 130/90 and her pulse was 100. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 10 visit is limited.
On January 12, AN returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner
disallowed the venipuncture for the usual reason. Petitioner disallowed the cholesterol due to excessive frequency.
The January 12 visit is disallowed due to questionable frequency and medical necessity. The records indicate no earlier cholesterols, so the cholesterol is allowed. The venipuncture is allowed.
On January 16, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The January 16 visit is limited.
On January 31, AN returned for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol and potassium due to excessive frequency. However, there is no indication in the records of an earlier potassium.
The January 31 visit is disallowed due to questionable frequency and medical necessity. The cholesterol is disallowed for the reason stated. The potassium and venipuncture are allowed.
On February 1, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The February 1 visit is limited.
On March 1, Respondent presented a claim for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the lab work because it was referred to an outside lab. The records make no mention of an office visit on March 1.
The March 1 claim is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed because it appears that an outside lab did the work. 970. On March 2, the next entry, AN returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The March 2 visit is limited.
On April 4, AN returned for lab work. Respondent billed an established-patient minimal visit, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The April 4 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On April 5, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The April 5 visit is limited.
On May 9, AN returned for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the
usual reasons. Petitioner disallowed the potassium and blood count because they were not indicated for the stated condition.
The May 9 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed.
On May 11, AN returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The May 11 visit is limited.
On May 31, AN returned for lab work. Respondent billed an established-patient minimal visit, potassium, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the potassium because it was not indicated for the stated condition.
The May 31 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed.
On June 1, AN returned to the office for the lab results. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 1 visit is limited.
On June 14, AN returned for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 14 visit is limited.
On June 19, AN returned for lab work. Respondent billed an established-patient minimal visit, glucose, blood gases, cholesterol, blood chemistry, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the glucose and blood gases because of a lack of a result in the medical records. The June 21 entry explains that the glucose test had to be repeated without saying why.
The June 19 visit is disallowed due to questionable frequency and medical necessity. The lab work and venipuncture are allowed.
On June 21, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 21 visit is limited.
On June 26, AN returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
The June 26 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
On June 27, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The June 27 visit is limited.
On June 28, AN returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the blood count as not indicated for the stated condition.
The June 28 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and blood count are allowed.
On July 10, AN returned for lab work. Respondent billed an established-patient minimal visit, electrocardiogram, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the electrocardiogram as not indicated for the stated condition, although why is not clear.
The July 10 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and electrocardiogram are allowed.
On July 11, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
The July 11 visit is limited.
1000. On July 12, AN returned for lab work. Respondent billed an established-patient minimal visit, blood count, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
Petitioner disallowed the blood count as not indicated for the stated condition.
1001. The July 12 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and blood count are allowed.
1002. On August 10, AN returned for lab work. Respondent billed an established-patient minimal visit, glucose, cholesterol, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons. Petitioner disallowed the cholesterol as not indicated for the stated condition-
-an unusual response as the cholesterol level was 311 mg.
1003. The August 10 visit is disallowed due to questionable frequency and medical necessity. The venipuncture and lab work are allowed.
1004. On August 11, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
1005. The August 11 visit is limited.
1006. On September 12, AN visited the office with a rash on her arms, legs, and shoulders, as well as pain in the low back and legs. Respondent
billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
1007. The September 12 visit is intermediate.
1008. On October 23, AN visited the office complaining of pain in her left foot and vaginal itching. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
1009. The October 23 visit is limited.
1010. On October 30, AN visited the office for a follow-up. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
1011. The October 30 visit is limited.
1012. On November 17, AN returned for lab work. Respondent billed an established-patient minimal visit, glucose, and venipuncture. Petitioner disallowed the minimal visit and venipuncture for the usual reasons.
1013. The November 17 visit is disallowed due to questionable frequency and medical necessity. The venipuncture is allowed.
1014. On November 20, AN returned to the office for the lab results.
Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
1015. The November 20 visit is limited.
1016. On December 5, AN returned for refills. Respondent billed the visit as established-patient intermediate, and Petitioner reduced the visit to limited.
1017. The December 5 visit is limited.
1018. The total overpayment on account of AN is $223.50, representing
$3.50 for January 10, January 16, February 1, March 2, April 5, May 11, June 1,
June 14, June 21, June 27, July 11, July 12, August 11, October 23, October 30, November 20, and December 5, $12 for January 12, $16.50 for January 31, $27.50 for March 1, $12 for April 4, $12 for May 9, $12 for May 31, $12 for June 19,
$12 for June 26, $12 for June 28, $12 for July 10, $12 for August 10, and $12 for November 17.
1019. The total overpayments on account of the 55 above-discussed patients amount to $4019.50.
1020. These 55 patients represent about 8.2 percent of the 670 Medicaid patients whom Respondent saw in 1989. The 55 patients represent $13,780 in total reimbursements for 1989 services of a total of $78,335.50 in total reimbursements. By claim amounts, the 55 patients represent about 17.6 percent of the total 1989 Medicaid claims.
1021. Petitioner extrapolates from the $4019.50 in overpayments a much larger total of estimated overpayments on account of all Medicaid patients whom Respondent treated in 1989. Applying Petitioner's method to the overpayments
determined on account of the 55 payments, Petitioner would assert that the total overpayment in 1989 is $18,143.
1022. Petitioner's method begins by taking all of Respondent's 1989 Medicaid patients and arraying them by the size of total claims per patient. Petitioner then divides the patients into five strata, so that each stratum contains patients whose total claims are equal to the total claims of the patients in each of the other strata. Obviously, the first stratum contains considerably more patients than the fifth stratum, in which the higher per- patient claims of relatively fewer patients equal the lower per-patient claims of relatively many patients in the first stratum.
1023. Next, Petitioner selects 55 patients for detailed analysis--11 patients from each stratum. The patients in the first stratum are designated Patient ##1-11. The patients in the fifth stratum are designated Patient ##45-
55. These are the patients addressed in detail in this recommended order.
1024. The total overpaid on account of Patient ##1-11 stratum is $71. The total reimbursements on account of these 11 patients was $522. The ratio of $71 over $522 is 0.136. The total reimbursements on account of all of the patients in the first stratum were $15,738. Multiplying $15,738 by the ratio of 0.136, the extrapolated result would be that $2140.37 has been overpaid on account of all of the patients in the first stratum.
1025. The total overpaid on account of Patient ##12-22 is $266. The total reimbursements on account of these 11 patients was $1054. The ratio of $266 over $1054 is 0.252. The total reimbursements on account of all of the patients in the second stratum were $15,722.50. Multiplying $15,722.50 by the ratio of 0.252, the extrapolated result would be that $3962.07 has been overpaid on account of all of the patients in the second stratum.
1026. The total overpaid on account of Patient ##23-33 is $234. The total reimbursements on account of these 11 patients was $1852.50. The ratio of $234 over $1852.50 is 0.126. The total reimbursements on account of all of the patients in the third stratum were $15,806. Multiplying $15,806 by the ratio of 0.126, the extrapolated result would be that $1991.56 has been overpaid on account of all of the patients in the third stratum.
1027. The total overpaid on account of Patient ##34-44 is $1066.50. The total reimbursements on account of these 11 patients was $3601.50. The ratio of
$1066.50 over $3601.50 is 0.296. The total reimbursements on account of all of the patients in the fourth stratum were $16,111.50. Multiplying $16,111.50 by the ratio of 0.296, the extrapolated result would be that $4769 has been overpaid on account of all of the patients in the fourth stratum.
1028. The total overpaid on account of Patient ##45-55 is $2382. The total reimbursements on account of these 11 patients was $6750. The ratio of
$2382 over $6750 is 0.353. The total reimbursements on account of all of the patients in the fifth stratum were $14,957.50. Multiplying $14,957.50 by the ratio of 0.351, the extrapolated result would be that $5280 has been overpaid on account of all of the patients in the fifth stratum.
1029. As noted above, the total of the extrapolated estimates of the amounts overpaid on account of patients in each of the five strata would be
$18,143. However, the validity of this extrapolation is entirely dependent upon whether Petitioner proves that the 55 patients were randomly selected. Absent
such proof, Petitioner has proved overpayments of only $4019.50, which is the total amount of overpayments proved on account of the 55 patients.
1030. Petitioner has in fact failed to prove that the 55 patients were randomly selected from all of the 1989 patients. In testifying, two witnesses employed by Petitioner assumed that the 55 patients were randomly selected. A computer consultant selected the 55 patients for audit, and Petitioner's witnesses candidly admitted that they really did not know how the 55 patients are selected.
1031. The only other evidence of the manner in which the 55 patients were selected is Petitioner Exhibit 7, which displays all 670 patients and the 55 patients selected. The title of the document is a "disproportionate stratified random sampling." But no witness could testify that the section process was indeed random.
1032. Without proof that the 55 patients were selected randomly, such as by a random number generator, Petitioner fails to justify extrapolating from this 55-patient sample statistically valid data concerning the extent of total overpayments to Respondent for 1989. The assumptions of two witnesses, plus the title of a computer printout, is scant evidence on which to base a finding of overpayments equal to over four times those shown on account of the 55 patients. The failure here is not in the attempt to extrapolate, but in Petitioner's failure to establish the key condition of random selection.
CONCLUSIONS OF LAW
1033. The Division of Administrative Hearings has jurisdiction over the subject matter and the parties. Section 120.57(1), Florida Statutes.
1034. Section 409.913(12) authorizes Petitioner to recover overpayments and specifically allows Petitioner to use valid statistical means to prove the amount of overpayments.
1035. Petitioner has proved that it overpaid a total of $4019.50 to Respondent on account of 55 Medicaid patients in 1989. Petitioner has not proved that the 55-patient sample was randomly selected and thus may not extrapolate from the data additional sums that it claims to have overpaid.
Based on the foregoing, it is hereby
RECOMMENDED that the Agency for Health Care Administration enter a final order requiring Respondent to repay the sum of $4019.50.
ENTERED on January 24, 1994, in Tallahassee, Florida.
ROBERT E. MEALE
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, FL 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings on January 24, 1994.
ENDNOTES
1/ Codes 85023, 85024, or 85025, for instance.
2/ For example, Code 85000 pays $1.50, Code 85007 pays $2, Code 85009 pays
$2.50, Code 85012 pays $3, Code 85014 pays $1, and Code 85018 pays $1.50.
3/ Actually, references to the number of office visits for each patient refer to the number of visits for which Respondent submitted claims. Sometimes patients visited Respondent, but he submitted no claims. Sometimes Respondent submitted claims, but the patient did not visit, or else no one recorded the visit on the medical records.
4/ The scope of this proceeding is to review the claims submitted by Respondent on account of 55 patients in 1989. But for a failure in proof of the manner of selection of the 55-member sample, the data yielded by this exercise would have been extrapolated to describe the extent of overpayment on account of all of Respondent's Medicaid patients in 1989. For this reason along, it is crucial that each 1989 claim for the 55 patients be analyzed and adjusted, if appropriate.
This recommended order will determine for each patient the extent of 1989 overpayments or underpayments. A claim challenged by Petitioner may yield a larger overpayment than that which Petitioner seeks, or it may yield an underpayment. A claim not challenged by Petitioner, but paid on account of one of the 55 patients, may yield an overpayment or underpayment, as long as the claim was submitted by Respondent. In some cases, unchallenged claims that are part of a series of claims have been considered.
Unsubmitted claims will not be considered because there is a chance that the patient was not Medicaid-eligible when the service was provided. It is assumed that Petitioner routinely and accurately determines Medicaid eligibility on all submitted claims.
5/ On Petitioner Exhibit 1, Petitioner miscalculated the claimed overpayment as
$3.50 with the notion "50," which is an abbreviation for the numerical code, 90050, signifying an established-patient intermediate visit. The $3.50 difference is the difference between the established-patient intermediate and established-patient limited visits. The difference between an new-patient intermediate visit ($35) and established-patient limited visit ($21.50) is
$13.50. More likely, Petitioner intended merely to reduce the visit to new- patient limited, for which the reimbursement is $30. Thus, the claimed overpayment should be $5. This is the proposed reduction in Petitioner's proposed recommended order at p. 10.
6/ For the benefit of working patients, Respondent maintains office hours that make it difficult to perform lab tests while the patient is in the office for an intermediate or limited visit during which the patient will be examined by Respondent. Notwithstanding the commendable purpose claimed for the unconventional office hours, such an arrangement does not justify a multiplicity of claims office visits when lab work could and, from a reimbursement perspective, should be performed in a single visit.
7/ Respondent's witness, Mr. Weatherford implicitly acknowledges this omission in Respondent's case when he boldly predicts: "[Dr. Marraccini] would have also testified as to the medical necessity of the urinalysis, the automated, multichannel chemistry test, and the complete blood count . . .." (Tr 714)
Neither of Petitioner's experts, Dr. Conn nor Dr. Deeb, addressed the medical necessity of the August 3 lab work. Petitioner's proposed recommended order optimistically cites to Dr. Conn's testimony where he incorporates what appears to be Petitioner Exhibit 1 (not Petitioner Exhibit 7 as cited by Petitioner) as the explanation for the denial. Petitioner Exhibit 1 contains a computer printout on each patient in which Petitioner records a code identifying the reason for disallowance and the amount of the resulting overpayment. The reason here is, as noted above, that the lab work was not indicated for the stated medical condition. But neither Petitioner Exhibit 1, nor any other exhibit, explains why not.
APPENDIX TO RECOMMENDED ORDER, CASE NO. 92-1898
Treatment Accorded Proposed Findings of Petitioner 1-3: adopted or adopted in substance.
4-12: rejected as subordinate.
13-14: rejected as unsupported by the appropriate weight of the evidence. 15-26: rejected as recitation of evidence.
27: rejected as subordinate.
28-29: adopted or adopted in substance except that the title of Petitioner Exhibit 7 does not establish the random sample. The person who ran the computer program to select the 55 patients could establish that the sample was random.
30: rejected as irrelevant. 31: rejected as irrelevant.
32: rejected as recitation of evidence. 33: adopted or adopted in substance.
34-40: rejected as recitation of evidence.
Treatment Accorded Proposed Findings of Respondent 1-6: adopted or adopted in substance.
7: rejected as recitation of evidence. 8-10: adopted or adopted in substance.
11: rejected as unsupported by the appropriate weight of the evidence and recitation of evidence.
12-13: rejected as recitation of evidence. 14: adopted or adopted in substance.
15-17: rejected as irrelevant.
18: rejected as recitation of evidence. 19: rejected as irrelevant.
20: rejected as recitation of evidence.
COPIES FURNISHED:
Douglas M. Cook, Director
Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, Florida 32308
Harold D. Lewis, General Counsel Agency for Health Care Administration The Atrium, Suite 301
325 John Knox Road Tallahassee, Florida 32303
Sam Power, Agency Clerk
Agency for Health Care Administration The Atrium, Suite 301
325 John Knox Road Tallahassee, Florida 32303
Attorney Karel Baarslag
Agency for Health Care Administration 1317 Winewood Boulevard
Building 6, Room 271
Tallahassee, Florida 32399-0700
Attorney Steven W. Huss 1017-C Thomasville Road Tallahassee, Florida 32303
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least 10 days in which to submit written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
| Issue Date | Proceedings |
|---|---|
| Jun. 07, 1994 | Final Order filed. |
| Feb. 14, 1994 | Respondent`s Exceptions to Recommended Order filed. |
| Jan. 24, 1994 | Recommended Order sent out. CASE CLOSED. Hearing held January 5 and May 25, 1993. |
| Jul. 30, 1993 | Respondent`s Proposed Recommended Order filed. |
| Jul. 28, 1993 | (Petitioner) Proposed Recommended Order filed. |
| Jul. 09, 1993 | Order sent out. (Re: Motion for extension of time.) |
| Jul. 08, 1993 | Respondent`s Motion for Extension of Time to File Proposed Recommended Order filed. |
| Jun. 11, 1993 | CASE STATUS: Hearing Held. |
| Jun. 09, 1993 | Transcript (vols 3-6) filed. |
| May 24, 1993 | Final Hearing Held 5/24-25/93; for applicable time frames, refer to CASE STATUS form stapled on right side of Clerk's Office case file. |
| May 14, 1993 | Amendment to Pretrial Stipulation filed. |
| Mar. 10, 1993 | Notice of Hearing sent out. (hearing set for 5-24-93; 10:00am; Tallahassee) |
| Feb. 02, 1993 | Transcript (Vols 1&2) filed. |
| Jan. 05, 1993 | CASE STATUS: Hearing Held. |
| Nov. 23, 1992 | (Respondent) Re-Notice of Taking Deposition filed. |
| Nov. 10, 1992 | Order sent out. (parties shall file their prehearing stipulation no later than 12-11-92) |
| Oct. 15, 1992 | Order sent out. (hearing set for October 20, 1992 is continued until 1-5-93) |
| Oct. 15, 1992 | Amended Notice of Hearing sent out. (hearing set for 1-5-93; 10:00am;Talla) |
| Oct. 15, 1992 | Joint Motion for Continuance filed. |
| Oct. 13, 1992 | (Respondent) Notice of Taking Deposition (2); Amendment to Respondent`s Witness List filed. |
| Oct. 13, 1992 | (Respondent) Request for The Issuance of Subpoenas filed. |
| Aug. 18, 1992 | Order sent out. (Re: Rescheduled date of hearing) |
| Aug. 18, 1992 | Amended Notice of Hearing sent out. (hearing set for 10/20/92; 10:00am; Tallahassee) |
| Aug. 17, 1992 | (Respondent) Motion for Continuance filed. |
| Aug. 14, 1992 | (Respondent) Notice of Taking Deposition filed. |
| Aug. 12, 1992 | Joint Prehearing Stipulation filed. |
| Aug. 11, 1992 | (Respondent) Notice of Taking Deposition filed. |
| Aug. 11, 1992 | Respondent`s Pre-Hearing Stipulation filed. |
| Aug. 11, 1992 | (unilateral) Prehearing Stipulation w/cover ltr filed. |
| Jul. 31, 1992 | (Petitioner) Amended Petition for Administrative Hearing; Motion for Leave to File First Amended Complaint filed. |
| Jul. 27, 1992 | Order sent out. (Petitioners` counsel`s notice of withdrawal granted) |
| Jul. 22, 1992 | (Landelino C. Cabrera) Notice of Withdrawal filed. |
| Jul. 06, 1992 | Order sent out. (time for filing the prehearing stipulation is extended to 8-11-92) |
| Jun. 24, 1992 | Order sent out. (hearing set for 7-15-92, is continued to 8-18-92, in accordance with amended notice of even date) |
| Jun. 24, 1992 | Amended Notice of Hearing (as to date only) sent out. (hearing set for 8-18-92; 10:00am; Tallahassee) |
| Jun. 19, 1992 | (Petitioner) Notice of Taking Deposition Duces Tecum filed. |
| Jun. 18, 1992 | (Petitioner) Motion for Continuance filed. |
| Jun. 15, 1992 | (Petitioner) Notice of Appearance filed. |
| May 22, 1992 | (Petitioner) Notice of Appearance filed. |
| May 15, 1992 | Order sent out. (request for qualified representative to be Mr. Weatherford is denied) |
| May 15, 1992 | Order sent out. (re: prehearing stipulation) |
| May 15, 1992 | Notice of Hearing sent out. (hearing set for 7/15/92; 10:00am; Tallahassee) |
| Apr. 23, 1992 | (Respondent) Motion to Determine "Qualified Representative"; Response to Initial Order filed. |
| Apr. 13, 1992 | (correction of ltr dated 4/8/92) Letter to RTB from Robert E. Weatherford (re: Initial Order) filed. |
| Apr. 10, 1992 | Ltr. to RTB from Robert E. Weatherford re: Reply to Initial Order filed. |
| Apr. 09, 1992 | Letter to RTB from Robert E. Weatherford (re: Petitioner`s representation) filed. |
| Mar. 30, 1992 | Initial Order issued. |
| Mar. 26, 1992 | Notice; Petition for Formal Hearing; Agency Action letter filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Jun. 06, 1994 | Agency Final Order | |
| Jan. 24, 1994 | Recommended Order | HCA proves right to medicaid reimbursement of $4019.50 based on 55 patients, but not extrapolated sum of $18,143 due to failure to prove random sample. |
