STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

INDIAN RIVER MEMORIAL )

HOSPITAL, INC., )

)

Petitioner, )

)

vs. ) Case No. 97-4794

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was held in this case on July 29, 1998, at Vero Beach, Florida, before Susan B. Kirkland, a duly designated Administrative Law Judge of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: John D. Buchanan, Jr., Esquire

Henry, Buchanan, Hudson, Suber & Williams, P.A.

117 South Gadsden Street Tallahassee, Florida 32301

For Respondent: Thomas Falkinburg, Esquire

Agency for Health Care Administration Fort Knox Building 3

2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308-5403 STATEMENT OF THE ISSUE

Whether Respondent should recoup Medicaid payments made to Petitioner for health care services provided to eight patients.

PRELIMINARY STATEMENT

By a Final Agency Action letter dated September 22, 1997, Respondent, Agency for Health Care Administration (Agency), notified Petitioner, Indian River Memorial Hospital, Inc., (Hospital), that the Agency was seeking to recoup Medicaid payments in the amount of $126,825.94. The basis for seeking this recoupment amount was the denials made by Keystone Peer Review Organization (KePro) for certain inpatient services rendered by the Hospital.

The letter informed the Hospital that KePro had performed a retrospective medical review and that "it was determined that either the inpatient or a portion of the length-of-stay was not medically necessary." An attachment to the letter listed 18 patients that KePro determined had received medically unnecessary care.

The Hospital requested an administrative hearing, and the case was forwarded to the Division of Administrative Hearings for assignment to an administrative law judge on October 15, 1997.

Petitioner and Respondent have settled the issues related to ten of the patients.

At the final hearing, Petitioner called Annette Barton Riley and Joseph Raymond de Jesus as its witnesses. Petitioner's Exhibits 1-13 were admitted in evidence. Respondent called Nevra Mansager as its witness. Respondent's Exhibits 1-4 were admitted in evidence. The deposition of Dr. John Sullenberger was admitted as Joint Exhibit 1. In addition, the parties stipulated

that depositions of the following could be used in lieu of live testimony: Dr. Raymond Dean, Dr. Bernard Frankel, Dr. William Moore, Dr. Mercedes Borromeo, and Dr. Joseph Altieri.

The parties agreed to file proposed recommended orders within ten days of the filing of the transcript. The transcript was filed on August 17, 1998. Petitioner filed two unopposed motions to extend the time for submitting proposed recommended orders, which motions were granted. The time for filing proposed recommended orders was extended to September 19, 1998. The parties' Proposed Recommended Orders have been considered in the rendering of this Recommended Order.

FINDINGS OF FACT

1. Petitioner, Indian River Memorial Hospital, Inc., (Hospital), has contracted with Respondent, Agency for Health Care Administration (AHCA), to provide services to Medicaid patients.

2. The parties have agreed that there is a dispute for Medicaid reimbursement for goods and services provided to eight patients: S.G., J.D., R.J., C.A., G.M., S.S., M.P., and C.T. The Agency has paid the Hospital for the services rendered to these eight patients and seeks to recoup the payment based on a

   retrospective review by a peer review organization, Keystone Peer Review Organization (KePro). The Agency claims that either the admission or a portion of the length-of-stay for the eight patients was medically unnecessary.

3. Services were provided to C.T. in 1994 and to the remainder of the patients at issue in 1995. Payment for Medicaid services is on a per diem basis. The rate for 1994 is $473.22 per day, and the rate for 1995 is $752.14.

4. The Agency contracted with KePro to do a review of the Medicaid payments to the Hospital. KePro employs nurses to review the patient files based on criteria on discharge screens. If the services meet the criteria, there is no further review and the payment is approved. If the nurse determines that the services do not meet the criteria on the discharge screens, the patient's files are reviewed by a board certified physician, who in this case would be a psychiatrist. If the physician determines that the services are not medically necessary, a letter is sent to the Medicaid provider, giving the provider an opportunity to submit additional information. Additional information submitted by the provider is reviewed by a board certified physician. If the doctor concludes that the services are still medically unnecessary, the provider is notified that that services do not qualify for reimbursement and the provider may ask for a reconsideration of the denial. If the provider seeks reconsideration, the file is reviewed by a physician, and the provider has an opportunity to be present during the review. If the physician determines that the services are medically unnecessary, KePro sends a letter to the Agency stating the reasons for denial. The denial letters that KePro sends to the

   Agency are reviewed by the Medical Director of KePro, who is not a psychiatrist.

5. Dr. John Sullenberger, the Agency's Medicaid physician, reviews the KePro denial letters sent to the Agency, and

   99.9 percent of the time he agrees with the findings of KePro regarding whether the services were medically necessary.

   Dr. Sullenberger does not review the patient's charts when he does this review. The Agency sends a recoupment letter to the Medicaid provider requesting repayment for services provided.

6. Patient S.G., a 12 year-old boy, was being treated pursuant to the Baker Act. He was admitted to the Hospital on March 8, 1995, and discharged on March 25, 1995. The Agency denied Medicaid reimbursement for the admission and the entire length-of-stay for S.G. based on KePro's determination that it was not medically necessary for the services to S.G. to be rendered in an acute care setting because the patient was neither suicidal nor homicidal.

7. Three to five days prior to his admission to the Hospital, S.G. had attempted to stab his father. He also had further violent episodes, including jumping his father from behind and choking him and pulling knives on his parents. S.G. had a history of attention deficit and hyperactive disorder. He had been using multiple substances, such as alcohol, LSD, cocaine, and marijuana, prior to his admission. His behavior was a clear reference that he was suffering from a psychosis.

8. A psychosis is a significant inability to understand what is reality, including delusions of false beliefs, hallucinations, hearing and seeing things which do not exist, and ways of thinking that are bizarre. Psychosis is a reason to admit a patient, particularly combined with substance abuse.

9. S.G.'s treating psychiatrist noted that S.G. had tangentiality, which means that his thoughts did not stay together. He did not have a connection between thoughts, which is a sign of a psychosis. The chart demonstrated that S.G. had

   disorder thinking, which includes the possibility of a psychosis. There was also a reference in the charts to organic mental disturbance which could infer brain damage as the cause for the mental disturbance.

10. Two days after admission, there was an issue of possible drug withdrawal because S.G. was agitated and anxious and showed other symptoms. Drug withdrawal, psychosis, and a demonstration of overt violence require a stay in an acute care facility. There was some indication that S.G. was suicidal. While in the Hospital he was placed under close observation, which is a schedule of 15-minute checks to determine if the patient was physically out of harm's way.

11. S.G. was started on an antidepressant, Wellbutrin, because the treating physician thought S.G. was becoming increasingly depressed and was having trouble organizing his thoughts. Antidepressants, as contrasted to a medication such as an antibiotic, may take a minimum of two to three weeks before the patient will benefit from the full effect of the drug. It is difficult to stabilize the dosage for an antidepressant on an outpatient basis.

12. S.G. was taking Ritalin, which is commonly used for children with attention deficit, hyperactivity disorders.

13. During his stay at the Hospital, S.G. was engaging in strange behavior, including absence seizures. On March 16, 1995, he was still lunging and threatening harm. On March 20, 1995, he

    was still unstable and at risk. The dosage of Wellbutrin was

    increased. On March 21 and 22, 1995, S.G. was still threatening and confused. S.G. was discharged on March 25, 1995.

14. The admission and length-of-stay for S.G. were medically necessary.

15. Patient J.D. was a 16 year-old boy who was admitted to the Hospital on March 7, 1995, and discharged on March 14, 1995. The Agency denied the admission and entire length-of-stay based on KePro's determination that the patient was not actively suicidal or psychotic and services could have been rendered in a less acute setting.

16. J.D. was admitted from a partial hospitalization program pursuant to the Baker Act because he was observed by a health care professional banging his head against the wall and throwing himself on the floor. He had a history of depression and out-of-control behavior, including being a danger to himself and running away. At the time of his admission, he was taking Prozac.

17. Banging his head against the wall can mean that the patient is psychotic, can cause brain damage, and can be dangerous if the cause of the behavior is unknown. Admission to the Hospital was justified because the patient was extremely agitated and self abusive, requiring restraints and medication to decrease his agitation and self abusiveness. One of the tests administered during his hospital stay indicated that J.D. was a moderate risk for suicidal behavior.

18. During his hospital stay, it was discovered that J.D. had threatened to kill himself while at school. He had been in a partial treatment program during the day, but that environment was not working. There was violence in the home, and J.D. was becoming overtly depressed.

19. During his stay at the Hospital, J.D. was placed on close observation with 15-minute checks. His dosage of Prozac was increased.

20. The admission and length-of-stay for J.D. were medically necessary.

21. R.J., a 10 year-old male, was admitted to the Hospital on January 1, 1995, and discharged on February 9, 1995. The Agency denied Medicaid reimbursement based on a determination by KePro that the treatment in an acute care facility was not medically necessary because R.J. was not psychotic, not suicidal, and not a threat to others; thus treatment could have been provided in an alternate setting.

22. R.J. had been referred by a health care professional at Horizon Center, an outpatient center, because of progressive deterioration over the previous fourteen months despite outpatient treatment. His deterioration included anger with temper outbursts, uncontrollable behavior at school, failing grades, sadness, depressed mood, extreme anxiety, extensive worrying and a fear of his grandmother. R.J. also suffered from encopresis, a bowel incontinence. He was agitated, lacked

    energy, neglected his hygiene, experienced crying spells, and had difficulty concentrating.

23. R.J. needed to be admitted for an evaluation to rule out a paranoid psychosis. It was necessary to do a 24-hour EEG as opposed to a 45-minute EEG. In order to do a 24-hour EEG, the patient is typically placed in an acute care facility. The EEG showed abnormal discharge in the brain, which could be contributing to a psychiatric illness.

24. At school R.J. had smeared feces on the walls, behavior that could be seen in psychotic persons. There was evidence that he had been hitting and throwing his stepbrother and 3 year-old brother. He was fearful of his grandmother and, based on his family history, there was reason to fear her.

25. R.J. was placed on Buspar, a medication which generally takes two weeks to take effect.

26. Contrary to the Agency's determination, R.J. was disorganized. He was also violent in terms of threatening danger and extreme anger.

27. The admission and length-of-stay for R.J. at the Hospital were medically necessary.

28. Patient C.A., a 9 year-old male, was admitted to the Hospital on June 1, 1995, and discharged on June 12, 1995. The Agency disallowed one day of the length-of-stay based on a determination by KePro that the services provided on June 11, 1995, could have been provided in a less restrictive setting.

29. C.A. was admitted for violent and disruptive behavior. He also had an attention deficit, hyperactivity disorder and was taking Lithium and Depakote. These medications are used for patients who experience serious mood swings and abrupt changes in mood, going from depression to anger to euphoria. To be effective, medicating with Lithium and Depakote requires that the blood levels of the patient be monitored and the dosage titrated according to blood level. C.A. also was given Wellbutrin during his hospital stay.

30. On June 11, 1995, C.A. was given an eight-hour pass to leave the hospital in the care of his mother. The physician's orders indicated that the pass was to determine how well C.A. did in a less restrictive setting. He returned to the Hospital without incident. He was discharged the next day to his mother. The treatment on June 11, 1995, could have been provided in an environment other than an acute facility; thus the stay on

    June 11, 1995, was not medically necessary for Medicaid reimbursement purposes.

31. Patient G.M., an 11 year-old male with a history of being physically and sexually abused by his parents, was admitted to the Hospital on March 21, 1995, and was discharged on April 3, 1995. The Agency denied Medicaid reimbursement for inpatient hospital treatment from March 28 to April 3, 1995, based on KePro's determination that the length of hospital stay exceeded health care needs at an inpatient level and could have been

    provided in a less acute setting.

    
    

32. At the time of admission, G.M. had suicidal ideation. His school had reported that G.M. had mutilated himself with a pencil, banged himself on the knuckles, and told the school nurse that he wanted to die. Prior to admission, G.M. had been taking Ritalin. His treating physician took G.M. off the Ritalin so that she could assess his condition and start another medication after a base-line period. The doctor prescribed Clonidine for

    G.M. Clonidine is a drug used in children to control reckless, agressive and angry behavior. Clonidine must be titrated in order to establish the correct dosage for the patient.

33. During his hospital stay, G.M. was yelling and threatening staff. He was placed in locked seclusion, where he began hitting the wall. G.M. was put in a papoose, which is similar to a straitjacket. The papoose is used when there is no other way to control the patient. The patient cannot use his arms or legs while in a papoose. This type of behavior and confinement was occurring as late as March 31, 1995.

34. G.M. was given a pass to go to his grandparents on April 2, 1995. He did well during his pass, and was discharged on April 3, 1995. Treatment in an acute facility was medically necessary through April 1, 1995. Treatment on April 2, 1995, could have been provided in a less acute setting.

35. Patient S.S., a 5 year-old male, was admitted to the Hospital on March 9, 1995, and was discharged on April 3, 1995.

    The Agency denied Medicaid reimbursement for the admission and entire length of his hospital stay based on a determination by KePro that S.S. was not psychotic or an immediate danger to himself or others and the evaluation and treatment could have been rendered in a less acute setting.

36. Prior to admission to the Hospital, S.S. was threatening suicide, ran into a chalk board at school, scratched his arms until they bled, and showed aggressive intent toward his sister, saying that he would kill her with a saw. S.S.'s condition had been deteriorating for approximately three months before his admission. At the time of admission, he had been suicidal, hyperactive, restless, and experiencing hallucinations. The hallucinations imply a psychosis. S.S. was put on Trofanil, an antidepressant which needs to be titrated. The patient's blood level had to be monitored while taking this drug.

37. During his hospital stay, S.S. was on close observation. All objects which he could use to harm himself were removed from his possession. After he ate his meals, the hospital staff would immediately remove all eating utensils.

38. On March 28, 1995, S.S. threatened to kill himself and became self-abusive. His blood level on March 31, 1995, was sub-therapeutic, and his medication dosage was increased. On April 1, 1995, S.S. had a temper tantrum.

39. The admission and length-of-stay for the treatment of

    
    

    S.S. were medically necessary.

40. Patient M.P., a 10 year-old male, was admitted to the Hospital on April 27, 1995, and was discharged on May 6, 1995. The Agency denied Medicaid reimbursement for the admission and entire length-of-stay based on a determination by KePro that the patient functions on an eighteen to twenty-four month level but is not psychotic and the treatment could have been provided in a less acute setting.

41. M.P.'s IQ is between 44 and 51. He was diagnosed with a pervasive development disorder, which is a serious lack of development attributed to significant brain damage. His condition had deteriorated in the six months prior to his admission. He had episodes of inappropriate laughter, fits of anger, hit his head, hit windows, and put his arm in contact with the broken glass through the window. At the time of his admission, he had a seizure disorder.

42. An EEG and an MRI needed to be performed on M.P. in order to evaluate his condition. M.P. had to have a regular EEG, a 24-hour EEG, and a neurological examination. The patient was aggressive, restless, and uncooperative. In order for the MRI to be performed, M.P. had to be anesthetized.

43. The admission and length-of-stay for M.P. were medically necessary.

44. Patient C.T., a 34 year-old female, was admitted to the Hospital on November 11, 1994, and was discharged on November 26, 1994. The Agency denied the treatment from November 17, 1994, to

    November 26, 1994, based on a determination by a peer review organization that the patient was stable by November 17, 1994, and psychiatric follow-up could have been performed in an outpatient setting.

45. C.T. was admitted for kidney stones. She did pass the kidney stones but continued to have severe pain. Her doctor asked for a psychiatric consult. The psychiatrist diagnosed C.T. as having a personality disorder, chronic psychogenic pain disorder, and an eating disorder. Her depressive disorder exacerbated pain.

46. C.T. had been given narcotics for the pain associated with the kidney stones. In order to assess her mental status, the physicians needed to taper the dosage of Demerol which she had been receiving. She was started on Sinequan, which is an anti-depressant given to alleviate the psychological condition and to help with the physical complaints. C.T. was later put on Vicodin, an oral narcotic, which seemed to bring the pain under control. The drugs used could cause a drop in blood pressure; therefore, they had to be titrated slowly. Her treating physician was trying to find an appropriate anti-depressant, while weaning the patient from intramuscular narcotics.

47. On November 17, 1994, C.T. left her room and went to the hospital lobby, where she was found by nursing staff. C.T. was crying and saying that she was in pain and wanted to die. During her hospital stay, C.T. was in much distress; she would

    scream out that she was in pain. On November 18, 1994, she was found crying on the floor of the hospital chapel and had to be returned to her room.

48. It was the opinion of Dr. Bernard Frankel, an expert retained by the Hospital, that C.T. probably could have been discharged a day earlier.

49. The hospital stay for C.T. from November 17, 1994, to November 25, 1994, was medically necessary. The last day of her stay was not medically necessary.

    CONCLUSIONS OF LAW

    
    

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

51. The Agency is seeking to recoup an alleged Medicaid overpayment and has the burden to establish the overpayment by a preponderance of the evidence. South Medical Services v. Agency for Health Care Administration, 653 So. 2d 440 (Fla. 3rd DCA 1995); Southpointe Pharmacy v. Department of Health and Rehabilitative Services, 596 So. 2d 106 (Fla. 1st DCA 1992).

52. The Agency is charged with the oversight of the integrity of the Florida Medicaid Program. Section 409.913, Florida Statutes, requires the Agency

    . . . to ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum extent possible, and to recover the overpayments and impose sanctions as appropriate.

53. When a health care provider in the Florida Medicaid Program provides goods or services that are "inappropriate or medically unnecessary," the provider is deemed to have been overpaid and is subject to a recoupment action. Rule 59G- 9.030(2)(b)2, Florida Administrative Code.

54. "Medical necessity" is defined by both statute and administrative rule. Section 409.913(c), Florida Statutes, provides:

    'Medical necessity' or 'medically necessary' means any goods or services necessary to palliate the effects of a terminal condition, or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in an illness or infirmity, which goods or services are provided in accordance with generally accepted standards of medical practice. For purposes of determining Medicaid reimbursement, the agency is the final arbiter of medical necessity. Determinations of medical necessity must be made by a licensed physician employed or under contract with the agency and must be based upon information available at the time the goods or services are provided.

55. Rule 59G-1.010(166), Florida Administrative Code, amplifies the statutory definition and provides:

    "Medically necessary" or "medical necessity" means that the medical or allied care, goods, or services furnished or ordered must:

    1. Meet the following conditions:

       1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;

       2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient's

          needs;

       3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;

       4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available; statewide; and

       5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

    2. "Medically necessary" or "medical necessity" for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.

    3. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.

56. For the claims at issue, the Agency chose to use peer review to determine whether there had been an overpayment to the Hospital. Peer review is defined in Rule 59G-9.040(1)(j), Florida Administrative Code as:

    . . . an evaluation of the professional practices of a Medicaid provider by peers of the provider in order to assess the necessity, appropriateness and quality of care provided as such care is compared to that customarily furnished by the provider's peers and to recognized health care standards.

    The Agency contracted with Keystone Peer Review Organization to evaluate the health care services provided by the Hospital to

    eight patients at issue: C.A, J.D., S.G., R.J. G.M., M.P., S.S., and C.T. The agency seeks to recover Medicaid payments made for these patients, claiming that the services were medically unnecessary.

57. The Agency contends that the Hospital is limited to contesting whether the services were actually rendered to the patients and whether the dates for services were correct. The Agency views the role of the Administrative Law Judge in this proceeding as determining whether the denial was arbitrary and capricious, not whether a preponderance of the evidence supports the denial. This view is based on the language in Section 409.913(c), Florida Statutes, that the Agency is the final arbiter of what is a medical necessity. The Agency's argument is without merit.

58. The Agency relies on State of New York on Behalf of Bodnar v. Secretary of Health and Human Services, 903 F. 2d 122 (2nd Cir. 1990), for the proposition that the role of the Administrative Law Judge is to review the Agency's decision and determine whether it is supported by competent substantial evidence. The Agency is confusing an appellate court's standard of review of a lower tribunal's decision with the burden of proof in an administrative hearing. Section 120.57(1)(g), Florida Statutes, provides that all proceedings conducted pursuant to Section 120.57(1) shall be de novo. This means the Agency, in this case, must establish by a preponderance of the evidence that

    it is entitled to recoup Medicaid payments made to the Hospital.

    
    

59. The Agency's reliance on the final arbiter language in Section 409.413(c), Florida Statutes, is misplaced. The statute means that the Agency is not bound by a determination of either the Hospital or KePro that the services provided were medically necessary. However, it does not mean that if the Agency's intended decision is challenged in an administrative proceeding that the decision is cloaked with a presumption of correctness. If challenged, as in this administrative proceeding, the Agency must establish by a preponderance of the evidence that the services for which it seeks recoupment were medically unnecessary.

60. The Agency also relies on Department of Transportation v. Groves-Watkins Constructors, 530 So. 2d 912 (Fla. 1988), for the proposition that the role of the Administrative Law Judge is to determine whether the denial was arbitrary or capricious. The court in Groves-Watkins was dealing with the competitive bidding process and noted the strong judicial deference that had been accorded agency decisions regarding competitive bidding. Id. at 913. The decision in Groves-Watkins was limited to the public bidding process. It should be noted that after the Groves- Watkins case, Section 120.57(3), Florida Statutes, was enacted to provide that in competitive bidding cases, except those dealing with the rejection of all bids, the Administrative Law Judge was to conduct a de novo proceeding. If the Legislature had intended

    that Section 120.57 proceedings for challenges to the Agency's determination of medically necessary Medicaid services only be reviewed based on an arbitrary and capricious standard, it could have so stated as it did for the review of bid cases in which all bids are rejected.

61. Section 409.913(5), Florida Statutes, provides:

    
    

    The written findings of the applicable peer- review organization are admissible in any court or administrative proceeding as evidence of medical necessity or the lack thereof.

    
    

62. The letters from KePro denying the Medicaid services at issue as medically unnecessary are evidence of the lack of medical necessity. However, the letters are cursory and do not provide much information on the basis for KePro concluding that the services were not medically necessary. Dr. Sullenberger, the Agency's Medicaid physician, did little to enlighten the Administrative Law Judge for the reasons in concluding that the services were not medically necessary. Dr. Sullenberger's review consisted mainly of reading the KePro letters and not reviewing the patients' files.

63. The Hospital presented the testimony of each patient's treating physician as well as an expert witness who had reviewed the patients' files. The treating physicians and the expert witness testified in detail with references to the patients' files on why they believed that the Medicaid services provided were medically necessary.

64. With the exception of one day of service provided to G.M., one day of service provided to C.T., and one day of service provided to C.A., the preponderance of the evidence does not establish that the services provided were not medically necessary. The evidence does establish by a preponderance of the evidence that services provided to G.M on April 2, 1995; to C.A. on June 11, 1995; and to C.T. on November 26, 1994, were not medically necessary.

65. The Agency is entitled to recoup $752.14 from the Hospital for one day of service provided to G.M. The Agency is entitled to recoup $473.22 from the Hospital for one day of service provided to C.T. The Agency is entitled to recoup

$752.14 from the Hospital for one day of service provided to C.A. The Hospital is not entitled to recoup for the remainder of services provided to these patients and for any of the services provided to J.D., S.G., R.J., M.P., and S.S.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered requiring Indian River Memorial Hospital, Inc., to pay to the Agency

$752.14 for one day of service provided to G.M., $752.14 for one day of service provided to C.A., and $473.22 for one day of service provided to C.T. and finding that the Hospital is not liable for payment for any of the other services at issue in this proceeding.

DONE AND ENTERED this 2nd day of November, 1998, in Tallahassee, Leon County, Florida.

SUSAN B. KIRKLAND

Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847

Filed with the Clerk of the Division of Administrative Hearings this 2nd day of November, 1998.

COPIES FURNISHED:

Thomas Falkinburg, Esquire

Agency for Health Care Administration Fort Knox Building 3

2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308

John D. Buchanan, Jr., Esquire Henry, Buchanan, Hudson, Suber

& Williams, P.A.

117 South Gadsden Street Tallahassee, Florida 32302

Sam Power, Agency Clerk

Agency for Health Care Administration Fort Knox Building 3

2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308

Paul J. Martin, General Counsel Agency for Health Care Administration Fort Knox Building 3

2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within 15

days from the date of 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: 97-004794

Orders for Case No: 97-004794