STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

THE DOCTOR'S OFFICE, d/b/a THE ) CHILDREN'S OFFICE, )

)

Petitioner, )

)

vs. )

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

Case No. 01-2831MPI

)

RECOMMENDED ORDER

Pursuant to notice, a final hearing was held in this case on December 17 and 18, 2001, and July 17 and 18, 2002, in

West Palm Beach, Florida, before William R. Pfeiffer, a duly- designated Administrative Law Judge of the Division of

Administrative Hearings.

APPEARANCES

For Petitioner: Charles D. Jamieson, Esquire

Ward, Damon & Posner, P.A. 4420 Beacon Circle

West Palm Beach, Florida 33407

For Respondent: Susan Felker-Little, Esquire

Agency for Health Care Administration 2727 Mahan Drive, Suite 3431

Fort Knox Building III Tallahassee, Florida 32308

STATEMENT OF THE ISSUES

The issues in this case are whether Petitioner received Medicaid overpayments, and, if so, what is the aggregate amount of the overpayments.

PRELIMINARY STATEMENT

This case involves an audit by the Agency for Health Care Administration (Agency) of Petitioner's paid Medicaid reimbursement claims for medical services alleged to have been provided between July 1, 1994 and June 30, 1996. Although the Agency's audit commenced in 1996, the Agency, for various reasons, delayed the completion of its audit for approximately four years. The Agency submitted its final audit report to Petitioner on July 17, 2000.

The final hearing in this matter initially commenced on December 17 and 18, 2001, at which time the Agency presented the live testimony of two witnesses: Sharon Dewey, a registered nurse, and Dr. Keith Wintermeyer, a pediatrician formerly employed by Petitioner. The Agency also submitted the deposition testimony of three witnesses in lieu of live trial testimony including: Ian W. McKeague, Ph.D., a statistician expert; Larry C. Deeb, M.D., a pediatrician; and Terri Robertson, an Agency employee. The Agency also offered documentary Exhibits 1 through 25, 27 through 45, and 53 through 56, all of which were received into evidence.

After two days of hearing, the Agency requested to temporarily continue the hearing to enable its expert witness, Dr. Deeb, to perform additional review of the audit information. Without objection by any party, the final hearing was continued to July 17, 2002.

Prior to reconvening for the conclusion of the final hearing, the Agency's legal counsel resigned from the Agency and new counsel filed a notice of appearance. The final hearing recommenced on July 17, 2002, and concluded on July 18, 2002, during which time the Agency presented additional live testimony from Ms. Dewey, and offered further deposition testimony of

Dr. Deeb, and two documentary exhibits, all of which were received into evidence.

The Petitioner presented the testimony of two witnesses, Dr. Marcia Malcolm, a pediatrician formerly employed by Petitioner, and Frances R. Colavecchio, Petitioner's corporate representative. Petitioner's Exhibit 1 was received into evidence.

The final hearing concluded on July 18, 2002, and in October 2002, Petitioner and the Agency each filed a Proposed Recommended Order containing proposed findings of fact and conclusions of law which have been duly considered in rendering this Recommended Order.

FINDINGS OF FACT

The Parties

1. Respondent, the Agency for Health Care Administration, is the single state agency charged with administration of the Medicaid program in Florida under Section 409.907, Florida Statutes.

2. Petitioner, The Doctor's Office, was a Florida corporation approved by the Agency to provide group Medicaid services. At all times relevant to this matter, Petitioner was owned entirely by non-physicians who employed salaried physicians to provide Medicaid services.

3. Petitioner, at all times relevant to this matter, offered physician services to Medicaid beneficiaries pursuant to a contract with the Agency under provider number 371236P-00.

4. Petitioner, pursuant to the specific terms in the contract with the Agency, agreed to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program, and Federal laws and regulations.

5. Petitioner, pursuant to its contract with the Agency, agreed to only seek reimbursement from the Medicaid program for services that were "medically necessary" and "Medicaid compensable."

   The Audit

   
   

6. In mid-1996, the Agency, pursuant to its statutory responsibility, advised Petitioner that it intended to audit Petitioner's paid Medicaid claims for the alleged medical services it provided between July 1, 1994 and June 30, 1996.

7. In September 1996, the Agency conducted an initial audit site visit, and randomly selected 61 patient files for review. The complete patient files, provided by Petitioner, were reviewed by Sharon Dewey, a registered nurse consultant and Agency employee, as well as Dr. Solenberger, a physician consultant and Agency employee. In accordance with its procedure, the Agency determined that Petitioner had submitted a total of 580 claims for reimbursement relating to the 61 patient files and had received full payment from the Medicaid program for each claim.

8. On March 3, 1997, the Agency issued a Preliminary Agency Audit Report (PAAR), and advised Petitioner that it had over-billed Medicaid and received an overpayment from the program.

9. Shortly thereafter, the Agency auditors,

   
   

   Dr. Solenberger and Ms. Dewey, met with Frank Colavecchio, Petitioner's Corporate Representative, and discussed the Medicaid violations alleged in the review. During the meeting, the Agency requested Mr. Colavecchio to instruct Petitioner's

   staff physicians to review their records and provide a written rebuttal to the Agency's initial determinations.

10. Within days, and prior to any further action, the Agency placed the audit on indefinite hold. The Agency decided to delay the audit until certain proposed legislation relating to peer review and the integrity of the Medicaid reimbursement program was enacted. Two years later, Section 409.9131, Florida Statutes, was enacted during the 1999 legislative session and became law.

11. Shortly thereafter, in 1999, the Agency hired

    
    

    Dr. Larry Deeb, a board-certified, practicing pediatrician, to perform a peer review of Petitioner's practices and procedures. Dr. Deeb has performed similar medical records reviews for the Medicaid program since 1981 and possesses a thorough understanding of CPT coding and the EPSDT requirements.

12. Dr. Deeb received the medical files provided by Petitioner, and reviewed each patient file in the random sample, including the medical services and Medicaid-related claim records.

13. On November 11, 1999, Dr. Deeb completed his peer review of 564 of the 580 claims provided in the random sample and forwarded his findings to the Agency. Dr. Deeb advised the Agency that 16 reimbursement claims involved adult patients and he therefore did not review them.

14. Utilizing Dr. Deebs findings, the Agency employed appropriate and valid auditing and statistical methods, and calculated the total Medicaid overpayment that Petitioner received during the two year audit period.

15. On July 17, 2000, approximately four years after the original audit notification, the Agency issued its Final Agency Audit Report (FAAR). The Agency advised Petitioner that, based upon its review of the random sample of 61 patients for whom Petitioner submitted 580 claims for payment between 1994 and 1996, Petitioner received $875,261.03 in total overpayment from the Medicaid program during the audit period.

16. Petitioner denied the overpayment and requested a formal administrative hearing.

17. Following the initial commencement of the final hearing in this matter in December 2001, Dr. Deeb, again, reviewed the disputed claims and modified his opinion relating to 6 claims. Thereafter, the Agency recalculated the alleged overpayment and demanded Petitioner to pay $870,748.31.

    The Allegations

    
    

18. The Agency alleges that specific claims submitted by Petitioner, which were paid by the Medicaid program, fail to comply with specific Medicaid requirements and therefore must be reimbursed.

19. Since its inception, the Medicaid program has required providers to meet the Medicaid program's policies and procedures as set forth in federal, state, and local law. To qualify for payment, it is the provider's duty to ensure that all claims "[a]re provided in accord with applicable provisions of all Medicaid rules, regulations, handbooks, and policies and in accordance with . . . state . . . law." Section 409.913(5)(e), Florida Statutes (1993).

20. Medicaid manuals are available to all Providers.

    
    

    Petitioner, as a condition of providing Medicaid services pursuant to the Medicaid program, is bound by the requirements and restrictions specified in the manuals, and under the contract, is required to reimburse the Medicaid program for any paid claims found to be in violation of Medicaid policies and procedures.

21. The evidence presented at hearing established that Petitioner frequently violated various Medicaid policies and procedures. First, Petitioner repeatedly failed to comply with Section 10.9 of the Medicaid Physician's Provider

    Handbook, (MPPH), and Sections 409.905(9), 409.913(5)(e), 409.913(7)(e), and 409.913(7)(f), (1993, 1994 Supp. 1995, and

    1996), Florida Statutes, which require all medical services to be rendered by, or supervised by a physician, and attested to by the physician's signature. Medical records reflecting services

    for paid claims must be physician signature certified and dated, or the services are not defined as physician's services.

22. In addition, Petitioner routinely failed to correctly document the provision of certain physician's assistant (P.A.) Medicaid services that require the personal supervision of a physician or osteopath. See Chapter 1 of the Physician Assistant Coverage and Limitations Handbook, March 1995, and Appendix D (Glossary) in the Medicaid Provider Reimbursement Handbook, HCFA-1500 (HCFA-1500). In addition, Petitioner failed to comply with Medicaid regulations that require an approved physician to be present in the facility when certain P.A. services are delivered and to attest to it by signature within twenty-four hours of service. See Section 11.1 of the MPPH, effective July 1994, and Sections 409.905, and 409.913 (1993, 1994 Supp., 1995, and 1996 Supp.), Florida Statutes.

23. The evidence presented at hearing also demonstrates that Petitioner repeatedly violated specific record keeping requirements located in Section 10.9 of the MPPH, Sections 10.6 and 11.5 of the Medicaid EPSDT Provider Handbook (EPSDT), and Sections 409.913(5)(e), 409.913(7)(e), and 409.913(7)(f), (1993, 1994 Supp., 1995, and 1996), Florida Statutes.

24. In addition, the Agency demonstrated that Petitioner occasionally failed to document support for the necessity of certain services or simply billed for services that were not

    medically necessary. As indicated, Medicaid policy limits a physician to bill only for services that are medically necessary and defines the circumstances and varying levels of care authorized. In fact, Section 11.1 of the MPPH, effective

    July 1994, provides in part:

    
    

    The physician services program pays for services performed by a licensed physician or osteopath within the scope of the practice of medicine or osteopathy as defined by state law . . . . The services in this program must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient. Delivery of all services in this handbook must be done by or under the personal supervision of a physician or osteopath . . . at any place of service . . . . Each service type listed has special policy requirements that apply specifically to it. These must be adhered to for payment.

    
    

25. The manual further provides clear guidelines defining authorized services for reimbursement which Petitioner apparently overlooked. For example, the manual defines the four types of medical history exams that Medicaid providers may conduct, the nature of the problems presented, and the appropriate and authorized tests.

26. The manual also identifies the varying degrees of medical decision-making complexity related to Medicaid services and provides instructions relating to the method of selecting

    the correct evaluation and management code for billing. Petitioner consistently violated coding restrictions.

27. Moreover, the Medicaid policy manual also outlines the specific procedures and billing requirements necessary for seeking payment for medical services including the early periodic screening for diagnosis and treatment (EPSDT) services. Chapter 10 and 11 of the MPPH specifically state that services that do not include all listed components of the EPSDT are not defined as an EPSDT, and upon audit, the Agency re-calculated Petitioner's medical services at the appropriate procedure code.

    Stipulation

    
    

28. Prior to the commencement of the hearing, the parties stipulated that certain paid claims were correctly determined by the Agency to be overpayments. Specifically, the parties agreed that portions of samples 1, 3, 14, 21, 28, 41, 46, 47, 51, 53, and 56 could not be claimed for reimbursement since lab services which are part of an office visit reimbursement and/or lab service fees performed by an independent outside lab are not permitted.

29. In addition, the parties agreed that specific portions of samples 1, 13, 14, 27, 28, 33, 35, 43, 46, 47, 52, 53, and 55 could not be claimed since Modifier 26 billing, the professional component, is only appropriate when the service is rendered in a hospital and Petitioner's services were rendered in an office.

    Pediatric Sample

    
    

30. With regard to the random sample of pediatric files, upon careful review, the evidence presented at hearing sufficiently demonstrates that Petitioner was overpaid the following amounts on the following paid claims for the following reasons:

    1. The prolonged physician's services billed to Medicaid were not documented as having been provided or medically

       necessary. Cluster Number	Date of Service	Procedure Code Billed and Paid	Overpayment
       1	1/18/1996	99354	$ 36.64
       1	5/14/1996	99354	$ 36.64
       13	9/25/1995	99354	$ 36.64
       19	9/28/1994	99354	$ 39.50
       21	12/18/1995	99354	$ 36.64
       28	3/06/1995	99354	$ 36.64
       42	6/04/1996	99354	$ 36.64
       43	12/19/1994	99354	$ 36.64
       47	9/28/1994	99354	$ 39.50
       47	10/17/1995	99354	$ 36.64
       51	4/05/1995	99354	$ 36.64
       53	11/02/1995	99354	$ 36.64
       56	5/01/1996	99354	$ 36.64

       
       

    2. The level of care billed to and reimbursed by Medicaid at the 99215 office visit procedure code level was improper since the level of care provided was at the 99213 office visit procedure code level.

       Cluster Number	Date of Service	Overpayment
       1	9/14/1995	$ 34.14
       1	1/18/1996	$ 34.14
       1	5/14/1996	$ 34.14
       33	9/28/1994	$ 20.00
       47	10/17/1995	$ 34.14

       
       

    3. The level of care billed and paid at the 99215 office visit procedure code level was improper since the level of care that was provided was at the 99214 office visit procedure code

       level. Cluster Number	Date of Service	Overpayment
       53	5/31/1995	$ 21.69

       
       

    4. The level of care billed and paid at the 99205 office visit procedure code level was improper since the level of care that was provided was at the 99204 office visit procedure code

       level. Cluster Number	Date of Service	Overpayment
       25	7/27/1994	$ 2.00

       
       

    5. The level of care that was billed and paid at the 99205 office visit procedure code level was improper since the level of care that was provided was at the 99203 office visit procedure code level.

       Cluster Number	Date of Service	Overpayment
       35	5/11/1995	$ 37.96
       51	12/08/1994	$ 15.00
       55	11/21/1995	$ 37.96
       58	9/22/1995	$ 37.96

    6. The level of care that was billed and paid at the 99215 office visit procedure code level was improper since the level of care that was provided was at the 99204 office visit procedure code level.

       Cluster Number	Date of Service	Overpayment
       43	12/11/1994	($ 3.00) credit

       
       

    7. The level of care that was billed and paid at the 99205 office visit procedure code level was improper since the medical services provided and documentation supported an EPSDT visit.

       Cluster Number	Date of Service	Overpayment
       53	2/06/1995	$ 16.53

       
       

    8. The required components of the EPSDT were not documented as being performed at the office visit that had been claimed and paid as an EPSDT and therefore, the difference between the EPSDT payment received and the value of the procedure code for the documented level of office visit that occurred (i.e., 99214, 99213, 99212, 99211, or 99203), is deemed

    an overpayment. Cluster Number	Date of Service	Level of Visit	Overpayment
    1	7/28/1995	99213	$ 39.82
    3	6/28/1995	99213	$ 39.82
    5	3/03/1995	99203	$ 21.43
    6	7/07/1994	99213	$ 5.00
    10	8/17/1995	99212	$ 43.82
    12	1/31/1996	99204	$ 0.00
    14	5/31/1995	99213	$ 39.82
    18	10/04/1994	99213	$ 5.00
    18	1/29/1996	99214	$ 27.37
    20	8/25/1994	99213	$ 5.00
    21	12/11/1995	99214	$ 27.37
    29	8/17/1994	99212	$ 9.00

    Cluster Number	Date of Service	Level of Visit	Overpayment
    29	9/06/1995	99213	$ 39.82
    40	7/25/1994	99203	$ 0.00
    41	5/06/1996	99214	$ 27.37
    46	9/19/1994	99213	$ 5.00
    46	10/19/1995	99213	$ 39.82
    47	11/02/1994	99213	$ 5.00
    51	9/07/1995	99213	$ 39.82
    53	7/10/1995	99213	$ 39.82
    53	1/19/1995	99213	$ 39.82
    59	5/02/1996	99203	$ 43.39

    
    

    Adult Samples

    
    

31. At hearing, Petitioner disputed all of the Agency's findings relating to patients over the age of 21 and objected to Dr. Deeb, a pediatrician, performing any review of their files. While Dr. Deeb is not the appropriate peer to review adult patient files, the following adult claims did not require substantive peer review and resulted in overpayment due to the stated reason:

    1. There were not any medical records in existence to indicate that any medical services were performed.

       Cluster Number	Date of Service	Procedure Code Billed and Paid	Overpayment
       2	2/20/1995	99215	$ 53.00
       2	7/11/1995	99215	$ 59.14
       2	8/09/1995	99215	$ 57.14
       2	9/07/1995	99213	$ 23.00
       2	10/11/1995	99213	$ 23.00
       2	1/02/1996	99213	$ 23.00
       2	3/22/1996	73560/Rad.Ex.	$ 16.36
       2	4/01/1996	99215	$ 57.14
       2	4/05/1996	99213	$ 23.00
       2	4/23/1996	99213	$ 23.00
       15	2/16/1996	99213	$ 23.00
       15	2/19/1996	99215	$ 57.14
       16	5/14/1996	Blood Count	$ 8.00

       Cluster Number	Date of Service	Procedure Code Billed and Paid	Overpayment
       16	5/14/1996	UA	$ 3.00
       16	5/14/1996	99215	$ 57.14
       23	7/28/1994	99213	$ 23.00
       23	5/09/1995	72069/26 Rad.Ex.	$ 6.98
       23	5/09/1995	72069/Rad.Ex.	$ 17.45
       23	10/20/1995	99213	$ 23.00
       34	4/24/1996	99214	$ 35.45
       57	11/17/1995	99215	$ 59.14
       60	4/10/1996	99215	$ 57.14
       61	5/22/1995	99213	$ 23.00

       
       

    2. The medical records failed to contain the required physician's signature and date authenticating the fact that the services billed were performed by either P.A. Olsen or P.A. Avidon under physician supervision. The services provided by the non-physician employee were reviewed and down-coded by the Agency to the appropriate level physician's office visit code.

       Cluster Number	Date of Service	Proc. Code Pd./ P. Code Allowed	Overpayment
       2	6/30/1995	99215/99212	$ 36.14
       2	7/20/1995	99215/99213	$ 34.14
       2	7/28/1995	99215/99213	$ 34.14
       2	9/05/1995	99215/99212	$ 36.14
       8	4/17/1995	99205/99203	$ 35.96
       17	3/27/1995	99205/99203	$ 35.96
       23	5/09/1995	99215/99213	$ 32.14
       23	6/09/1995	99215/99213	$ 32.14
       34	4/23/1996	99205/99203	$ 35.96

       
       

    3. The medical records failed to contain the required physician signature authenticating the fact that the services were provided by a physician. The services provided were reviewed and down-coded by the Agency to the appropriate level physician's office visit code.

       Procedure Code

       Cluster Number	Date of Service	Billed and Paid	Overpayment
       2	6/14/1995	99215/99211	$ 45.14
       16	5/15/1996	99215/99211	$ 45.14
       61	5/05/1995	99205/99204	$ 14.53

       
       

    4. The provider improperly sought payment for lab services that were part of the office visit reimbursement and/or lab services performed by an independent outside lab.

       Cluster Number	Date of Service	Procedure Billed and Paid	Overpayment
       2	3/08/1996	UA	$ 3.00
       2	4/03/1996	UA	$ 3.00
       15	2/08/1996	UA	$ 3.00
       16	5/15/1996	Blood Count	$ 8.50
       16	5/15/1996	Blood Count	$ 8.00

       
       

    5. The provider improperly sought payment for Modifier 26 billings (professional component) which are only appropriate when the service is rendered in a hospital.

    Cluster Number	Date of Service	Procedure Billed and Paid	Overpayment
    2	2/17/1995	Radiologic exam	$ 6.98
    2	6/14/1995	Radiologic exam	$ 7.20
    8	4/17/1995	Tympanometry	$ 9.00
    16	5/13/1996	Radiologic exam	$ 5.45
    16	5/15/1996	Radiologic exam	$ 6.98

    
    

32. In addition to the policy and procedural violations, Petitioner, in egregious violation of the Medicaid program, admittedly submitted Medicaid claims for the services of specialist physicians (such as an allergist, OB/GYN, podiatrist, psychologists, and ophthalmologists) not within its Provider group, collected Medicaid funds based on those claims, and reimbursed the respective specialist.

33. While Petitioner's corporate representative,

    
    

    Mr. Colavecchio, was admittedly responsible for the coding and billing of the Medicaid services submitted for reimbursement, he was minimally aware of the Medicaid policy requirements and possessed limited working knowledge of CPT coding and EPSDT billing.

34. In addition, Petitioner's employees, Dr. Keith Wintermeyer and Dr. Marcia Malcolm, were only moderately familiar with the CPT coding and EPSDT component requirements. They provided little input to Petitioner regarding CPT coding and the sufficiency of certain physician's services relating to EPSDT billing.

    CONCLUSIONS OF LAW

    
    

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

36. Effective July 1, 1993, by operation of Section 58 of Chapter 93-129, Laws of Florida, the Agency was transferred "[a]ll powers, duties and functions, records, personnel, property, and unexpended balances of appropriations, allocations, or other funds of the Medicaid program within the Department of Health and Rehabilitative Services, as well as the infrastructure and support services that support the program,

    including, but not limited to, investigative, licensing, legal, and administrative activities."

37. The Agency is required to oversee the Florida Medicaid Program and recover any overpayments of Medicaid monies. See Section 409.913, Florida Statutes (1995), and Sections 409.913 and 409.9131, Florida Statutes (1999). "'Overpayment' includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake." Section 409.913(1)(d), Florida Statutes (1996 Supp.), and Section 409.913, Florida Statutes (1999). The Agency is authorized to recover overpayments made to Petitioner.

38. An overpayment occurs when a Medicaid provider receives more money than it is entitled. In the instant case, the Agency audited Petitioner in accordance with

    Section 409.913, Florida Statutes (1995); and it was completed in accordance with Sections 409.913 and 409.9131, Florida Statutes (1999).

39. The Agency has the burden of proving by a preponderance of the evidence that Petitioner received overpayments from the Medicaid program for Medicaid claims it submitted. See South Medical Services, Inc. v. Agency for

    Health Care Administration, 653 So. 2d 440 (Fla. 3d DCA 1995).

40. The Agency proved by a preponderance of the evidence that, in the circumstances indicated in the Findings of Fact, Petitioner received overpayment for specific Medicaid claims submitted during the audit period.

41. The Agency presented the undisputed testimony from Sharon Dewey, Terri Robertson, and Ian W. McKeague, Ph.D., that the Agency used a generally accepted, appropriate, and valid sampling method in selecting the random sample of 61 patients to be audited in this case. The Agency used generally accepted, appropriate, and valid sampling and statistical methods in determining that Petitioner received an overpayment.

42. While Petitioner generally questions the validity of the sampling and statistical methods used by the Agency to determine the aggregate overpayment, Petitioner failed to present any evidence to refute Dr. McKeague's credible expert testimony that the sampling and statistical methods used were appropriate and valid.

43. Dr. Larry C. Deeb performed the peer review of the random sample of patient files pursuant to Section 409.9131, Florida Statutes. He is a Florida-licensed physician, whose specialty is pediatrics, and has been in active practice as a pediatrician since 1980. He was an appropriate peer to review the medical records for the pediatric claims in this audit. He was not, however, an appropriate peer to review the services

    provided by the family practitioner to the few adult patients in the sample.

44. As set forth in the Findings of Fact above, there were several Medicaid claims paid for services performed by a P.A., not by or under the direct supervision of a physician, and such services do not constitute physician's services. See Medilab v.

    State of Florida, Agency for Health Care Administration, 17 FALR 3921 (1995).

45. The statutes, rules, and Medicaid handbooks including the MPPH, CPT, EPSDT, in effect during the audit period govern the dispute. See Toma vs. Agency for Health Care Administration, Case No. 95-2419 (Div. of Admin. Hearings 1996)(as incorporated in Toma vs. Agency for Health Care Administration, 18 FALR 4735 (Div. of Admin. Hearings 1996)).

46. On November 1, 1993, Petitioner legally executed a Medicaid provider agreement according to Section 409.907, Florida Statutes (1993), and agreed to abide by the provisions of the Florida Administrative Code, Florida Statutes, and the policies, procedures, and manuals of the Florida Medicaid Program.

47. Section 409.913(5), Florida Statutes (1993), specifically states that a provider participating in the Medicaid program has an affirmative duty to supervise and be responsible for the preparation and submission of accurate

    claims for payment from the program. It is the provider's duty to ensure that all claims "[a]re provided in accord with applicable provisions of all Medicaid rules, regulations, handbooks, and policies and in accordance with . . . state . . . law." Section 409.913(5)(e), Florida Statutes (1993).

48. While Petitioner made a notable effort to provide highly needed medical services, it routinely submitted incomplete and inaccurate claims for payment, consistently violated the terms of its provider agreement and provisions of law, and therefore received an overpayment.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is

RECOMMENDED that the Agency re-calculate the overpayment consistent with the Findings of Fact, and include only those identified violations in the cluster samples of the adult patient files, and issue a Final Order requiring Petitioner to reimburse, within 60 days, the Agency for the Medicaid overpayments plus any interest that may accrue after entry of the Final Order.

DONE AND ENTERED this 14th day of February, 2003, in Tallahassee, Leon County, Florida.

WILLIAM R. PFEIFFER

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 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 14th day of February, 2003.

COPIES FURNISHED:

Susan Felker-Little, Esquire

Agency for Health Care Administration 2727 Mahan Drive, Suite 3431

Fort Knox Building III Tallahassee, Florida 32308

Charles D. Jamieson, Esquire Ward, Damon & Posner, P.A.

4420 Beacon Circle

West Palm Beach, Florida 33407

Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building, Suite 3431 Tallahassee, Florida 32308

Rhonda M. Medows, M.D., Secretary Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building, Suite 3116 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: 01-002831MPI

Orders for Case No: 01-002831MPI