STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

BILLY BEEKS, M.D., )

)

Petitioner, )

)

vs. ) CASE NO. 94-1365

) STATE OF FLORIDA, AGENCY FOR ) HEALTH CARE ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice1 the Division of Administrative Hearings, by its duly designated Hearing Officer, Claude B. Arrington, held a formal hearing in the above-styled case on May 16, 1995, in Fort Lauderdale, Florida.

APPEARANCES

For Petitioner: Billy Beeks, M.D., pro se

8401 North Miami Avenue Miami, Florida 33138

For Respondent: Karel Baarslag, Esquire

Agency for Health Care Administration Fort Knox Building One

2727 Mahan Drive

Tallahassee, Florida 32308-5403 STATEMENT OF THE ISSUES

Whether Petitioner was overpaid by the Florida Medicaid Program for services rendered during the period June 1, 1991, through May 30, 1993, and, if so, the amount of the overpayment.

PRELIMINARY STATEMENT

Petitioner (the provider) was, at the times pertinent to this proceeding, a practicing physician and a provider under the Florida Medicaid program.

Following an audit for the period June 1, 1991, through May 30, 1993, the Respondent (the Agency) asserted that the Provider had been overpaid for services billed to the Medicaid program. There is no contention that these alleged overstated billings are the product of fraud.

In the final audit report letter dated December 13, 1993, the Agency asserted that the amount of the overpayment was $60,753.25. The Provider timely requested a formal administrative hearing to challenge the alleged overpayment, the matter was referred to the Division of Administrative Hearings, and this proceeding followed.

At the formal hearing, the parties agreed that despite being designated as the respondent in this proceeding, the Agency has the burden of proof in this proceeding. Consequently, the Agency presented its case first.

In conducting an audit of a Medicaid provider, the Agency uses a statistical methodology that is a form of cluster sampling. The Agency examines a sample of files of patients who had received services for which the provider had been paid by Medicaid and determines whether the medical records maintained by the provider for those patients justify the billings to Medicaid. If the medical records do not justify the billings, the provider is deemed to have been overpaid for those services. The amount of the overpayment for all services rendered to the Medicaid program during the audit period is thereafter determined by the use of a formula. The validity of the statistical method employed by the Agency to determine the total overpayment made to the Provider during the audit period in this case was not at issue in this proceeding.

There were three categories of dispute between the parties. First, there was the dispute as to whether the medical records maintained by the Provider justified the levels of services billed to Medicaid. Since the amount of the Medicaid payment is dependent on the level of service billed, an overpayment results if the billing level is overstated. The second area of dispute was whether the medical records substantiate the billing as to certain patients for a screening examination provided for by federal and state law and referred to as "EPSDT," which is an acronym for "Early and Periodic Screening Diagnosis and Treatment." The Agency asserted that as to several patients, the Provider's medical records do not substantiate that the Provider completed all components of the EPSDT screening and that instead of billing for an EPSDT, the billing should be for a Limited (Level 2) office visit, which is a lower billing level. The third area of dispute was the separated billing by the Provider for urinalysis performed during the course of an office visit. The Agency asserted that a routine urinalysis should be considered as part of the office visit and not separately billed. The Provider offered no evidence or argument in opposition to this assertion.

When the Agency initially calculated the amount of the alleged overpayment, several of the patient records had not been located. Without these records to substantiate the billings for these patients, the amount of the alleged overpayment was calculated to be $60,753.25. After those additional records were provided by the Provider, the alleged overpayment was recalculated to be

$50,852.86, which is the amount the Agency asserted as being the amount of the overpayment at the beginning of the formal hearing. During the course of the formal hearing, the Agency's expert testified that the Provider's records substantiated certain billings that had previously been challenged by the Agency. Acceptance of the previously challenged billings by the Agency will result in an amount less than $50,852.56 when the overpayment is recalculated. The amount of the overpayment will have to be recalculated by the Agency based on the findings of fact contained herein by using its generally accepted statistical methodology.

At the formal hearing, the Agency presented the testimony of Vicki Divens, a registered professional nurse, and of Dr. John Sullenberger, a physician. Ms. Divens and Dr. Sullenberger are consultants employed by the Agency's office of Medicaid Program Integrity. The Agency also offered twelve exhibits, each of which was accepted into evidence. Included among its exhibits were the depositions of four witnesses, Terri Robertson, Robert V. Peirce, Mark E. Johnson, Ph.D., and Joni Leterman, M.D. Ms. Robertson is an employee of the Agency who ran the statistical analysis of the Provider's billings. Mr. Peirce

is the administrator of the Agency's statistical Audit Section. Dr. Johnson is the chairman of the Department of Statistics at the University of Central Florida. Dr. Leterman, a physician who specializes in pediatric medicine, reviewed the Provider's medical records for the billings to Medicaid at issue in this proceeding.

The Provider offered no testimony at the final hearing, but presented a composite exhibit that purports to be reconstituted medical records that were prepared after the Agency issued its audit letter on December 13, 1993. These hearsay records were prepared by the Provider in preparation for this litigation and are not admissible. No consideration has been given to those records.

A transcript of the proceedings has been filed. At the request of the parties, the time for filing posthearing submissions was set for more than ten days following the filing of the transcript. consequently, the parties waived the requirement that a recommended order be rendered within thirty days after the transcript is filed. Rule 60Q-2.031, Florida Administrative Code. Rulings on the Agency's proposed findings of fact may be found in the Appendix to this Recommended Order. The Provider did not file a posthearing submittal.

FINDINGS OF FACT

1. The Agency for Health Care Administration (Agency) is the successor to the Department of Health and Rehabilitative Services as the single state agency responsible for the administration of the Medicaid program in the State of Florida. The Agency is required to operate a program to oversee the activities of Medicaid providers and is authorized to seek recovery of Medicaid overpayments to providers pursuant to Section 409.913, Florida Statutes. The division of the Agency responsible for the oversight of Medicaid providers is referred to as Medicaid Program Integrity.

   
   

2. On October 10, 1985, the Petitioner, Billy Beeks, M.D., (Provider) executed a Medicaid Provider Agreement which provided, in pertinent part, as follows:

   
   

   1. The provider agrees to keep complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billings made under the Medicaid program .

   2. . . . The provider agrees to submit Medicaid claims in accordance with program policies and that payment by the program for services rendered will be based on the payment methodology in the applicable Florida Administrative Rule. .

      8. The provider and the Department agree to abide by the provisions of the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida

      Medicaid Program and Federal laws and regulations.

      
      

3. Among the "manuals of the Florida Medicaid Program" referenced in paragraph 8 of the provider agreement was the Medicaid Physician Provider Handbook (hereinafter referred to as the "MPP Handbook").

4. Chapter 10 of the MPP Handbook addressed the subject of "provider participation." At the times pertinent to this proceeding Section 9 of Chapter

10 included the following:

RECORD KEEPING

You must retain physician records on

services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service.

Examples of the types of Medicaid records that must be retained are:

1. Medicaid claim forms and any documents that are attached,

2. treatment plans,

3. prior authorization information,

4. any third party claim information,

5. x-rays,

6. fiscal records, and

7. copies of sterilization and hysterectomy consents.

Medical records must contain the extent of services provided. The following is a list of minimum requirements:

1. history,

2. physical examination,

3. chief complaint on each visit,

4. diagnostic tests and results,

5. diagnosis,

6. a dated, signed physician order for each service rendered,

7. treatment plan, including prescriptions for medications, supplies, scheduling frequency for follow-up or other services,

8. signature of physician on each visit,

9. date of service,

10. anesthesia records,

11. surgery records,

12. copies of hospital and/or emergency records that fully disclose services, and

13. referrals to other services.

If time is a part of the procedure code prescription being billed, then duration of visit shown by begin time and end time must be included in the record. .

1. Medicaid payments are based on billing codes and levels of services provided. In setting the appropriate billing to Medicaid, the level of service is determined pursuant to the MPP Handbook. At all times pertinent to this proceeding Section 1 of Chapter 11 of the MPP Handbook included the following pertaining to "covered services and limitations":

   
   

   HCPCS CODES and ICD-9-CM CODES

   Procedure codes listed in Chapter 12 are

   HCPCS (Health Care Financing Administration Common Procedure Coding System) codes. These are based on the Physician's Current Procedural Terminology, Fourth Edition.

   
   

   Determine which procedure describes the service rendered and enter that code and description on your claim form. HCPCS codes described as "unlisted" are used when there is no procedure among those listed that describes the service rendered.

   
   

   Physician's Current Procedural Terminology, Fourth Edition, Copyright . . . by the American Medical Association (CPT-4) is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. The Health Care Financing Administration Common Procedure Coding System (HCPCS) includes CPT-4 descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials contained in CPT-4 which are copyrighted by the American Medical Association.

   
   

   The Diagnosis Codes to be used are found in the International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9- CM). A diagnosis code is required on all physician claims. Use the most specific code available. Fourth and fifth digits are required when available.

   
   

2. All billings pertinent to this proceedings are for patient office visits. Prior to amendments effective January 1, 1992, the MPP also provided in Section 1, Chapter 11, for six levels of service associated with the office visit procedure code. These levels of service, in ascending order of complexity, are "Minimal, "Brief", "Limited", "Intermediate", "Extended", and "Comprehensive". The least amount paid by Medicaid to a provider was for a "Minimal" level office visit. The level of payment immediately above the "Minimal" level were the "Brief" and "Limited" levels, which entitled a provider to the same payment. Immediately above the "Brief" and "Limited" levels, in ascending order of payment, were "Intermediate", "Extended", and "Comprehensive". Section 1, Chapter 11 of the MPP contained the following discussion of the six levels of service:

   
   

   There are six levels of service associated with the visit procedure codes. They require 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.

   These levels are:

   Minimal is a level of service supervised by

   a physician.

   Brief is a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and exam.

   Limited is a level of service used to evaluate a circumscribed acute illness or to periodically reevaluate 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 a hospital staff conference regarding the patient's medical management and progress.

   Extended level of service requires an unusual amount of effort or judgment 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 review, system review, complete physical examination, and ordering appropriate tests and procedures.

   
   

3. Chapter 11 of the MPP was amended, effective January 1, 1992. Instead of the six levels of service for office visits, five levels of service, referred to as "evaluation and management" (E/M) service codes were adopted. The E/M levels of service levels ranged from Level 1 to Level 5 in ascending order of complexity and payment. 1/

   
   

4. Section 1, Chapter 11 of the MPP, as amended January 1, 1992, provides the following discussion as to the development of the E/M service codes:

   
   

   The American Medical Association, in cooperation with many other groups, replaced the old "visit" codes with the new "evaluation and management" (E/M) service

   codes in the 1992 CPT. This is a result of the Physician Payment Reform which requires the standardization of policies and billing practices nationwide to ensure equitable payment for all services. The new E/M codes are a totally new concept for identifying services in comparison to the old visit codes. They are more detailed and specific to the amount of work involved.

   
   

5. Section 1, Chapter 11 of the MPP, as amended January 1, 1992, provides that the level of E/M codes are defined by the following seven components: Extent of History, Extent of Examination, and Complexity of Medical Decision- Making, Counseling, Coordination of Care, Nature of Presenting Problem, and time. 2/ After determining whether the office visit is for a new or established patient, Section 1, Chapter 11 of the MPP, as amended January 1, 1992, instructs the provider to determine the level of E/M services by taking into consideration the following three key components: Extent of History, Extent of Examination, and Complexity of Medical Decision-making.

   
   

6. Section 1, Chapter 11 of the MPP, as amended January 1, 1992, provides the following discussion under the subheading "Extent of History":

   
   

   There are four types of history which are recognized:

   Problem Focused - chief complaint; brief history of present illness or problem.

   Expanded Problem Focused - chief complaint; brief history of present illness; problem pertinent system review.

   Detailed - chief complaint; extended history of present illness; extended system

   review; pertinent past, family and/or social history.

   Comprehensive - chief complaint; extended history of present illness; complete system

   review; complete past, family and social history.

   
   

7. Section 1, Chapter 11 of the MPP, as amended January 1, 1992, provides the following discussion under the subheading "Extent of Examination":

   
   

   There are four types of examinations which are recognized:

   Problem Focused - an examination that is limited to the affected body area or organ system.

   Expanded Problem Focused - an examination

   of the affected body area or organ system and other symptomatic or related organ systems.

   Detailed - an extended examination of the affected body area(s) and other symptomatic or related organ system(s)

   Comprehensive - a complete single system speciality examination or a complete multisystem examination.

8. Section 1, Chapter 11 of the MPP, as amended January 1, 1992, provides the following discussion under the subheading "Complexity of Medical Decision- Making":

   
   

   Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the following factors:

   
   

   The number of possible diagnoses and/or the number of management options that must be considered.

   The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.

   The risk of significant complications morbidity and/or mortality, as well as co- morbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

   
   

   There are four types of medical decision- making which are recognized:

   straightforward, low complexity,

   moderate complexity, and high complexity. 3/

   
   

9. Rule 10C-7.047, Florida Administrative Code, 4/ pertains to the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT), and provides, in pertinent part, as follows:

   
   

   1. Purpose. EPSDT is a comprehensive, preventive health care program for Medicaid- eligible children under age 21 that is designed to identify and correct medical conditions before the conditions become serious and disabling. Medicaid provides payment for EPSDT which allows entry into a health care system, access to a medical home (sic) and preventive/well child care on a regular basis. This periodic medical screening includes a health and developmental history, an unclothed physical examination, nutritional assessment, developmental assessment, laboratory tests, immunizations, health education, dental, vision and hearing screens, and an automatic dental referral for children age 3 and over.

      
      

10. A billing for an EPSDT screening is compensated by Medicaid at a rate that is higher than the rate for a Limited or Level 2 office visit.

    
    

11. A provider must document all components of the EPSDT screening in order to be entitled to payment for the screening. If all components of the

    EPSDT screening are not documented by a provider's records, Medicaid compensates the provider for a Limited or Level 2 office visit since the provider would have made sufficient contact with the recipient to justify that billing level.

    
    

12. When conducting an audit of a provider's billings to the Medicaid program, employees of Medicaid Program Integrity review the provider's medical records to determine whether the level of services billed are justified by the medical records. Medical records must contain sufficient documentation to substantiate that the recipient received necessary medical services at the level billed by the provider. A routine urinalysis performed during the course of an office visit should be billed as part of the office visit and not billed as a separate service.

    
    

13. Vicki Divens, a registered nurse, is a consultant employed by the Agency and was administratively responsible for the audit of the Provider's medical records. She conducted this audit pursuant to the Agency's rules and policies.

    
    

14. Ms. Divens obtained a report from Consultec, the Agency's fiscal agent, that provides identifying information as to all services that were billed to Medicaid by the Provider for the audit period of June 1, 1991, through May 30, 1993. This computer report reflects the date that each service was billed to Medicaid by the Provider, the name and Medicaid number of each recipient of the service, the codes which are used to describe the procedure of the service billed, the level of the service, the amount paid to the Provider, and the date of payment. For the audit period, there were a total of 1,712 Medicaid recipients who received services from the Provider, there were 9,054 separate billings for services to recipients, and there was a total of $259,305.01 paid by Medicaid to the Provider.

    
    

15. The Agency is authorized 5/ to employ a statistical methodology to calculate the amount of overpayment due from a provider where there has been overstated billings. The methodology used by the Agency is a form of cluster sampling that is widely accepted and produces a result that is recognized as being statistically accurate.

    
    

16. For the audit that is the subject of this proceeding, the Agency determined that 23 patient files would be the number of files necessary for the statistical analysis. The Agency established that sampling was adequate to perform the statistical analysis. The 23 recipients whose medical records would be analyzed were thereafter selected on a completely random basis.

    
    

17. Ms. Divens obtained from the Provider the medical records for the 23 patients that had been randomly selected for analysis. A total of 141 separate billings had been made for these 23 recipients during the audit period and each of those billings had been paid to the Provider by the Medicaid program. The medical records for the 23 recipients were thereafter reviewed by Dr. John Sullenberger, the Florida Medicaid Program's Chief Medical Consultant, who made the determination as to whether the medical records in the sampling justified the level at which Medicaid had been billed for each of the services.

    
    

18. Based on the overbillings found in the sampling, the Agency calculated an estimate of the overpayment for all Medicaid billings during the audit period by using a formula that is recognized as producing a statistically accurate result.

19. When Dr. Sullenberger initially reviewed the Provider's medical records, several of the medical files for recipients in the sampling had not been located. Without these records to substantiate the billings for these patients, no credit was given for those services. The amount of the alleged overpayment for all recipients during the audit period was initially calculated to be $60,753.25, which is the amount claimed in the Agency's final audit report letter dated December 13, 1993. Thereafter additional records were furnished to the Agency by the Provider and the alleged overpayment was recalculated to be

    $50,852.86, which is the amount the Agency asserted as being the amount of the overpayment at the beginning of the formal hearing. 5/

    
    

20. The following findings are made as to the billings that were in dispute at the formal hearing. The date of birth is given for each recipient to help identify the recipient. For office visits before January 1, 1992, the level of services are described as being "Minimal," "Brief," "Limited," "Intermediate," "Extended," or "Comprehensive." For office visits after January 1, 1992, the level of services are described as being Level 1, Level 2, Level 3, Level 4, or Level 5.

    
    

21. Patient 1 was born January 22, 1989. There were four billings for this patient at issue in this proceeding.

    
    

    1. On November 19, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On April 29, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On August 7, 1992, the Provider billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    4. On August 21, 1992, the Provider billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not

    justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

22. Patient 2 was born September 29, 1985. There were five billings for this patient at issue in this proceeding.

    
    

    1. On August 31, 1991, the Provider billed Medicaid for services rendered to this patient at the Extended level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On September 3, 1991, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On October 25, 1991, the Provider

       billed Medicaid for services rendered to this patient at the Extended level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    4. On February 7, 1992, the Provider billed Medicaid for an EPSDT for this

       patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been Level

       2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    5. On October 26, 1992, the Provider billed Medicaid for an EPSDT for this

    patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

23. Patient 3 was born May 9, 1985. There were two billings for this patient at issue in this proceeding.

    
    

    1. On May 22, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On January 20, 1993, the Provider

    billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

24. Patient 4 was born March 20, 1968. There was one billing for this patient at issue in this proceeding.

    
    

    A. On July 25, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

25. Patient 5 was born April 28, 1988. There were three billings for this patient at issue in this proceeding.

    
    

    1. On August 30, 1991, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

       Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On October 14, 1991, the Provider

       billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Intermediate

       level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On April 3, 1992, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

    Provider do not justify this billing and that this billing should have been at the Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

26. Patient 6 was born February 7, 1987. There was one billing for this patient at issue in this proceeding.

    
    

    A. On August 30, 1991, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

    Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

27. Patient 7 was born February 25, 1987. There were two billings for this patient at issue in this proceeding.

    
    

    On August 30, 1991, the Provider billed Medicaid for an EPSDT for this patient and he also billed for a urinalysis. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level and that the billing for the urinalysis should be included as part of the Limited level office visit. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

28. Patient 8 was born July 11, 1988. There were three billings for this patient at issue in this proceeding.

    
    

    1. On September 10, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level and he billed separately for an urinalysis for this patient during this visit. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Intermediate and that the urinalysis should be included in this billing. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On March 23, 1992, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

    Provider do not justify this billing and that this billing should have been at the Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

29. Patient 9 was born January 9, 1989. There were four billings for this patient at issue in this proceeding.

    
    

    1. On August 23, 1991, the Provider billed Medicaid for services rendered to this patient at the Extended level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On October 15, 1991, the Provider

       billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On April 20, 1992, the Provider billed Medicaid for services rendered to this patient at Level Four. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level Two. The Provider received an overpayment from the Medicaid program as a result of this billing.

    4. On April 21, 1993, the Provider billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level Two. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

30. Patient 10 was born August 30, 1988. There were three billings for this patient at issue in this proceeding.

    
    

    1. On September 4, 1991, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it

       is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited Level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On October 14, 1991, the Provider billed Medicaid for an EPSDT for this

       patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited Level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On July 21, 1992, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

    Provider do not justify this billing and that this billing should have been at the Level Two. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

31. Patient 11 was born September 17, 1989. There were fifteen billings for this patient at issue in this proceeding.

    
    

    1. On June 3, 1991, the Provider billed Medicaid for services rendered to this patient at the Extended level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On June 14, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On July 6, 1991, the Provider billed Medicaid for services rendered to this patient at the Intermediate level. Dr. Leterman was of the opinion that the medical records justified the Intermediate level billing (Leterman deposition, page 30), but Dr. Sullenberger testified the billing should be at the Limited level (Transcript, page 171). This conflict is resolved by finding

       that the medical records justify this billing at the Intermediate level so that no adjustment is necessary.

    4. On July 15, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    5. On July 20, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    6. On August 5, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    7. On August 20, 1991, the Provider billed Medicaid for services rendered to this patient at the Extended level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    8. On October 30, 1991, the Provider

       billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    9. On November 25, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the

       medical records maintained by the Provider do not justify this billing and that this billing should have been at the Intermediate level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    10. On December 27, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing. (See, Leterman deposition, page

        34)

    11. On January 28, 1992, the Provider

        billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    12. On February 25, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    13. On July 7, 1992, the Provider billed Medicaid for services rendered to this patient at Level 3. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    14. On December 9, 1992, the Provider billed Medicaid for an EPSDT for this

        patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    15. On May 3, 1993, the Provider billed Medicaid for services rendered to this patient at Level 3. Based on the evidence presented, it is found that the medical

    records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

32. Patient 12 was born July 12, 1970. There were four billings for this patient at issue in this proceeding.

    
    

    1. On January 3, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On January 13, 1992, the Provider

       billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On February 3, 1992, the Provider

       billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    4. On March 10, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

33. Patient 13 was born August 22, 1990. There was one billing for this patient that was initially at issue in this proceeding. On August 22, 1990, the Provider billed Medicaid for an EPSDT for this patient. When Dr. Sullenberger, the Agency's expert, initially reviewed the Provider's medical records pertaining to this billing, he thought that the billing should be reduced to a Limited level office visit. The amount of overpayment claimed by the Agency at the beginning of the formal hearing was based on this billing being at a Limited level. At the formal hearing, Dr. Sullenberger testified that on further consideration, he believed that the medical records justified this billing as an

    EPSDT, so that no adjustment was necessary. Based on his testimony, it is found the medical records maintained by the Provider justify this billing and no adjustment is necessary.

    
    

34. Patient 14 was born October 23, 1990. There were nine billings for this patient at issue in this proceeding.

    
    

    1. On September 27, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Intermediate level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On October 11, 1991, the Provider

       billed Medicaid for services rendered to this patient at the Extended level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On October 21, 1991, the Provider

       billed Medicaid for services rendered to this patient at the Intermediate level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    4. On December 17, 1991, the Provider billed Medicaid for services rendered to this patient at the Extended level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    5. On January 31, 1992, the Provider

       billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    6. On May 19, 1992, the Provider billed

       Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

       Provider do not justify this billing and that this billing should have been at Level 2.

       The Provider received an overpayment from the Medicaid program as a result of this billing.

    7. On June 4, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    8. On July 7, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    9. On May 7, 1992, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

    Provider do not justify this billing and that this billing should have been at Level 2.

    The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

35. Patient 15 was born November 9, 1990. There was one billing for this patient at issue in this proceeding.

    
    

    A. On September 24, 1991, the Provider billed Medicaid for services rendered to this patient at the Comprehensive level. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Limited level. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

36. Patient 16 was born September 14, 1991. There were two billings for this patient at issue in this proceeding.

    
    

    1. On March 13, 1992, the Provider billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing

       should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On March 1, 1993, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

37. Patient 17 was born February 9, 1992. There were two billings for this patient at issue in this proceeding.

    
    

    1. On November 7, 1992, the Provider billed Medicaid for an EPSDT for this

       patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On November 25, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. When Dr. Sullenberger, the Agency's expert, initially reviewed the Provider's medical records pertaining to this billing, he thought that the billing should be reduced to a Level 2 office visit. The amount of overpayment claimed by the Agency at the beginning of the formal hearing was based on this billing being at Level 2. At the formal hearing, Dr. Sullenberger testified that on further consideration, he believed that the medical records justified this billing at Level 3. Based on that testimony, it is found that this billing should have been at the Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

38. Patient 18 was born July 6, 1992. There were six billings for this patient at issue in this proceeding.

    
    

    1. On August 12, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On August 17, 1992, the Provider billed

       Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and than this billing

       should have been at Level 4. 6/ The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On September 18, 1992, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    4. On October 9, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and than this billing

       should have been at Level 3. 7/ The Provider received an overpayment from the Medicaid program as a result of this billing.

    5. On November 5, 1992, the Provider

       billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    6. On December 18, 1992, the Provider billed Medicaid for services rendered to this patient at the Level 5. When Dr. Sullenberger, the Agency's expert, initially reviewed the Provider's medical records pertaining to this billing, he thought that the billing should be reduced to a Level 2 office visit. The amount of overpayment claimed by the Agency at the beginning of the formal hearing was based on this billing being at Level 2. At the formal hearing, Dr. Sullenberger testified that on further consideration, he believed that the medical records justified this billing at Level 3. Based on the testimony of Dr. Sullenberger and that of Dr. Leterman, it is found that this billing should have been at Level 3.

    The Provider received an overpayment from the Medicaid program as a result of this billing.

39. Patient 19 was born June 12, 1989. There was one billing for this patient at issue in this proceeding.

    
    

    A. On February 9, 1993, the Provider billed Medicaid for an EPSDT for this

    patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

40. Patient 20 was born May 18, 1987. There was one billing for this patient at issue in this proceeding.

    
    

    A. On July 27, 1992, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the

    Provider do not justify this billing and that this billing should have been at Level 2.

    The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

41. Patient 21 was born April 27, 1988. There were four billings for this patient at issue in this proceeding.

    
    

    1. On January 12, 1993, the Provider

       billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On February 17, 1993, the Provider billed Medicaid for an EPSDT for this patient. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. March 8, 1993, the Provider billed Medicaid for services rendered to this patient at the Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    4. On April 16, 1993, the Provider billed Medicaid for services rendered to this

    patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

42. Patient 22 was born August 10, 1992. There were three billings for this patient at issue in this proceeding.

    
    

    1. On December 28, 1992, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    2. On February 9, 1993, the Provider

       billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at the Level 3. The Provider received an overpayment from the Medicaid program as a result of this billing.

    3. On February 22, 1993, the Provider billed Medicaid for services rendered to this patient at Level 4. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 2. The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

43. Patient 23 was born May 23, 1993. There was one billing for this patient at issue in this proceeding.

    
    

    A. On May 26, 1993, the Provider billed Medicaid for services rendered to this patient at Level 5. Based on the evidence presented, it is found that the medical records maintained by the Provider do not justify this billing and that this billing should have been at Level 3 The Provider received an overpayment from the Medicaid program as a result of this billing.

    
    

    CONCLUSIONS OF LAW

    
    

44. The Division of Administrative Hearings has jurisdiction of the subject matter of and the parties to this proceeding. Section 120.57(1), Florida Statutes.

45. Effective July 1, 1993, all responsibility for the administration of the Medicaid program in Florida was transferred from the Department of Health and Rehabilitative Services to the Agency for Health Care Administration. See, Section 58, Chapter 93-129, Laws of Florida.

    
    

46. Among the powers transferred to AHCA were the power to recover overpayments made to Medicaid providers "either through simple mistake or fraud" and the power to impose administrative sanctions against providers "not in compliance with provisions of departmental policy manuals or handbooks which have been adopted by reference as rules in the Florida Administrative Code, state laws, federal rules and regulations, a provider agreement between that department and the provider, or certifications found on claim forms submitted by the provider or authorized representative as such provisions apply to the Medicaid program." AHCA still possesses these powers. Sections 409.335 and 409.913, Florida Statutes. At all times material to the instant case, both the MPP Handbook and the EPSDT Handbook were "adopted by reference as rules in the Florida Administrative Code," the former in Rule 10C-7.038, Florida Administrative Code, and the latter in 10C-7.047, Florida Administrative Code.

    
    

47. The Agency has established in this proceeding that the Provider received overpayments from the Medicaid program as a result of his erroneous billings. Section 409.913(12), Florida Statutes, provides, in pertinent part, as follows:

    
    

    In making a determination of overpayment to a provider, [the Agency] shall use appropriate and valid auditing, accounting, analytical, statistical, or peer review methods, or combinations thereof. Appropriate statistical methods may include, but are not limited to, sampling and extension to the

    population . . . and other generally accepted statistical methods. . .

    
    

48. Pursuant to Section 409.913(8)(h), Florida Statutes, the Agency is authorized to impose sanctions against a provider who fails to comply with Medicaid policy manuals. Pursuant to Section 409.913(8)(j), Florida Statutes, the Agency is authorized to impose sanctions against a provider who submits a false or erroneous medicaid claim that resulted in overpayment. The range of penalties may be found in Section 409.913(9), Florida Statutes. In this proceeding, the Agency only seeks repayment of the amount that has been overpaid to the Provider by the Medicaid program. The Agency does not seek to impose additional sanctions against the Provider.

    
    

49. The evidence in this proceeding establishes that the Provider has received an overpayment from the Medicaid program and that the Agency is authorized to recoup that overpayment.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency enter a final order that adopts the findings of

fact and conclusions of law contained herein and that the Agency recalculate the

total amount of the overpayment during the audit period based on the findings of fact contained herein.

DONE AND ENTERED this 23rd day of August, 1995, in Tallahassee, Leon County, Florida.

CLAUDE B. ARRINGTON

Hearing Officer

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 23rd day of August, 1995.

ENDNOTES

1/ There were no Level 1 services at issue in this proceeding. Dr. Sullenberger considered the billing codes constituting Level 2 services comparable to the former "Brief" or "Limited" levels of service and he referred to those billings as being either Limited Level or Level 2 billings. Dr.

Sullenberger considered the billing codes constituting Level 3 services comparable to the former "Intermediate" level of service and he referred to those billings as being either Intermediate Level or Level 3 billings. Dr. Sullenberger considered the billing codes constituting Level 4 services comparable to the former "Extended" level of service and he referred to those billings as being either Extended Level or Level 4 billings. Dr. Sullenberger considered the billing codes constituting Level 5 services comparable to the former "Comprehensive" level of service and he referred to those billings as being either Comprehensive Level or Level 5 billings.

2/ Time was not the controlling factor in determining the appropriate E/M level of service for any of the billings involved in this proceeding and none of the level of billings turned on the factors of Counseling or Coordination of Care.

3/ A table is included in Section 1, Chapter 11 of the MPP, as amended in January 1, 1992, to assist the provider in determining the appropriate category of the medical-decision making. It is not necessary to reproduce that table in this Recommended Order.

4/ This rule has subsequently been transferred and renumbered as 59G-4.080, Florida Administrative Code.

5/ See, Rule 59G-9.030, Florida Administrative Code.

6/ That those records were not initially produced has no relevance as to any issue presented at the formal hearing since those records were subsequently produced and the amount of the alleged overpayment was recalculated based on those records.

7/ Medicaid had initially allowed billing at a limited level. The Agency's expert testified that he considered the intermediate level to be more appropriate.

APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 94-1365

The Provider did not file a posthearing submittal. The Proposed Recommended Order did not contain paragraphs numbered 8 and 9. The following rulings are made on the proposed findings of fact submitted on behalf of the Petitioner:

1. The proposed findings of fact in paragraphs 1-7 and 10- 13, are adopted in material part by the Recommended Order.

2. The proposed findings of fact in paragraphs 14, 15, 17- 33, 35-61, 63- 69, 71-82 are adopted in part by the Recommended Order and are subordinate in part to the findings made.

3. The proposed findings of fact in paragraphs 16, 34, 62, 70 are rejected to the extent the proposed findings are contrary to the findings made.

COPIES FURNISHED:

Karel Baarslag, Esquire

Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building One Tallahassee, Florida 32308-5403

Billy Beeks, M.D.

8401 North Miami Avenue Miami, Florida 33138

Sam Power, Agency Clerk

Agency for Health Care Administration 2727 Mahan Drive, Suite 33431

Tallahassee, Florida 32308-5403

Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 33431

Tallahassee, Florida 32308-5403

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 ten 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.

Docket for Case No: 94-001365

Orders for Case No: 94-001365