vs.
Respondent.
) Case No. 02-1660MPI
Pursuant to notice, a formal hearing was held in this case by video teleconference on September 19, 2002, and by telephone on September 20, 2002, with the parties appearing from Miami, Florida, before J. D. Parrish, a designated Administrative Law Judge of the Division of Administrative Hearings.
For Petitioner: Anthony C. Vitale, Esquire
Anthony C. Vitale, P. A.
For Respondent: Jeffries H. Duvall, Esquire
Whether the Petitioner, Cesare Raoli, M.D., must reimburse the Respondent, Agency for Health Care Administration, for an
alleged overpayment of Medicaid funds for the audit period February 22, 1997 through February 22, 1999.
On March 4, 2002, the Respondent issued a Final Agency Audit Report that claimed the Petitioner owed $148,058.45 for an alleged overpayment of Medicaid funds. The audit period was identified as February 22, 1997 through February 22, 1999. The Respondent subsequently reduced the amount claimed to
$115,595.31. As is explained below, the claimed amount must be further reduced.
The Petitioner timely challenged the allegation of overpayment and sought an administrative review of the matter. The case was then forwarded to the Division of Administrative Hearings for formal proceedings on April 29, 2002.
After two uncontested continuances of the hearing, the matter was finally heard on September 19-20, 2002. In support of its claim of overpayment, the Respondent presented testimony from Bonnie Mills-Herrera, Dorothea Solomon, and Ian McKeague. The Respondent's Exhibits 1-7, and 11-21 were received in evidence. The Petitioner testified in his own behalf and presented Exhibits 5-7, 16, and 31, which were also admitted into evidence but were never filed with the Division of Administrative Hearings.
At the conclusion of the hearing the parties were to forward exhibits not previously provided. On February 4, 2003, the Respondent filed its Exhibit 14. The Petitioner did not represent any of his proposed findings of fact were based upon Petitioner's exhibits. Therefore, this Recommended Order is entered without consideration of the Petitioner's exhibits.
The Transcripts of the proceeding were filed on October 10, 2002, and November 22, 2002. A request for an extension of time within which to file proposed recommended orders was granted.
Both parties timely filed Proposed Recommended Orders that have been fully considered in the preparation of this order.
At all times material to the allegations of this case, the Respondent is the state agency charged with the responsibility of administering the Florida Medicaid Program.
At all times material to the allegations of this matter the Petitioner was a Medicaid provider. It is undisputed the Petitioner received payments for services rendered to Medicaid recipients during the period of time covered by the audit at issue in this proceeding. The audit period for purposes of this case was February 22, 1997 through February 22, 1999.
As a Medicaid provider the Petitioner is required to comply with a Medicaid Provider Agreement. Additionally, all services provided by the Petitioner must be fully and completely
documented by records maintained by the provider. Such records must comply with the Physicians Coverage and Limitations
Handbook, and the Florida Medicaid Provider Reimbursement Handbook.
In performing an audit such as the one at issue, the Respondent reviews the provider's records to verify that the appropriate documentation supports the amount paid to the provider for the service rendered. In this case the parties have not challenged the authenticity of the patient records. The parties stipulated to the use of all patient records addressed in this order.
In this case, the Respondent claims the psychiatric codes billed by the Petitioner (and paid by the Agency) are not supported by the documentation submitted by the Petitioner. In many instances the billing code was "down graded" to a lesser amount. As a result the difference between that paid and the amount documented is the amount of the overpayment sought. In other instances the documentation did not support any charge and the entire amount is claimed for reimbursement.
When a provider signs on to the Medicaid program the Respondent provides copies of the handbooks identified in paragraph 3. Additionally, although supplied at the time of enrollment in the program, the handbooks are also available thereafter.
When an audit is performed of a provider's records, the handbooks, billing codes, and types of services applicable for the type of provider are reviewed. In this case the Petitioner is a psychiatrist. The Agency reviewed Petitioner's records to determine if the service provided was medically necessary and properly documented.
For billing purposes when psychiatric codes 90805, 90806, 90807, 90808, 90809, 90812, 90813, 90815, or G0078 were used, the Petitioner was required to document the specific time spent providing the service to the recipient. In many instances the Petitioner's records did not include a specific time. The Petitioner conceded that he did not note the length of the time spent with the patient and that the specific time is required by the billing guidelines.
Similarly, when the records were reviewed at hearing, the Respondent conceded (and therefore eliminated) some of the disputed charges paid to the Petitioner. Consequently, the reimbursement amount now claimed by the Respondent is less than the amount previously sought.
In performing an audit such as the one at issue, the Respondent took a random sample of all claims filed by the Petitioner for the audit period. After the computer program generated and identified 41 claims randomly selected, the individual records were fully reviewed. The use of a random
sample of 41 (from 376) is statistically valid for purposes of extrapolating the results of the sample and applying it to the whole claims for the period of the audit. In fact, within a statistical certainty, the amount claimed in this cause based on the 41 records used is lower than the reimbursement amount actually owed by the Petitioner if all records were reviewed.
The Respondent established that its methodology in computing the overpayment was statistically valid. The Petitioner did not document or refute with any statistical or actual analysis that the methodology could not be accepted. Moreover, the Petitioner did not produce records to support an argument that the extrapolation is factually unreliable.
To fully review the 41 claims, the patient records associated with the claims were introduced at hearing. On a claim-by-claim basis each individual document was reviewed to determine if it was accurately billed to Medicaid. Listed by recipient number the claims totaled 218 entries.
The Respondent has acknowledged that there is no overpayment claimed for recipient numbers 5, 17, 20, 22, 30, and 34.
As to recipient number 1, the Petitioner withdrew his
challenge to the overpayment as to all claims submitted for April 7, 1998.
As to recipient number 2, the Petitioner withdrew his challenge to the overpayment as to the claim dated August 12, 1997.
As to recipient number 3, the Petitioner did not either submit documentation to support the claims or specify the time spent with the patient. Accordingly, the Respondent has established the overpayment for this recipient.
As to recipient number 4, the Petitioner did not specify the time spent with the patient. Accordingly, the Respondent has established the overpayment for this recipient.
As to recipient number 6, the Petitioner did not either submit documentation to support the claims or specify the time spent with the patient. Accordingly, the Respondent has established the overpayment for this recipient.
As to recipient number 7, the Petitioner withdrew his challenge to the claim overpayment for December 6, 1997. The Respondent withdrew its overpayment claim for two of the codes for May 4, 1998, however the third claim for that date had no documentation and should be reimbursed.
As to recipient number 8, the Petitioner conceded the overpayment amount.
As to recipient number 9, there was no documentation to support the claim billed therefore the overpayment is established.
As to recipient number 10, the Petitioner either withdrew his challenge to the overpayment or presented no documentation to support the claim as billed. Therefore, the overpayment is established as to this recipient.
As to recipient number 11, the Respondent conceded the claim for June 30, 1998, therefore this overpayment must be eliminated. As to the other two dates of services, the Petitioner did not provide a specific time in the record. Accordingly the overpayment has been established for
December 18, 1998 and January 25, 1999.
As to recipient number 12, either the Petitioner failed to document a specific time in the record, did not document the examination claimed, or withdrew his challenge to the overpayment. Therefore, the overpayment as to this recipient has been established.
As to recipient number 13, the Petitioner failed to document the service. Therefore, the overpayment as to this recipient has been established.
As to recipient number 14, the Petitioner failed to document the specific time spent with the recipient. Therefore, the overpayment as to this recipient has been established.
As to recipients numbered 15, 16, 18, 19, 21, 23, 24, 28, 29, 32, 33, 36, 37, 38, 39, and 41, either the Petitioner withdrew his challenge to the amount of overpayment claimed,
supplied no documentation to support the claim, or the Respondent conceded the original claim amount. Accordingly, while not in the amount originally claimed by the Agency, an overpayment for these recipients has been established.
As to recipient number 25, the Respondent has conceded the claims dated July 8 and July 10, 1998. As to the other claims for this recipient, the Petitioner either provided no documentation to support the amount of the claim or failed to document the specific time spent with the recipient. Therefore, the Respondent has established an overpayment as to this recipient.
As to recipient number 27, the Petitioner has conceded the correct billing code for the date of service April 19, 1998, should have been 99215, thereby supporting the overpayment claim. The Respondent conceded the code billing for the second service of that date.
As to recipient number 31, either the Respondent conceded the billed amount, or the Petitioner agreed to a reduced code billing, or no time was specified, or the Petitioner withdrew his challenge to the overpayment. Therefore, although not in the amount of its original overpayment claim, the Agency has established an overpayment as to this recipient.
As to recipient numbers 35 and 40, either the Petitioner withdrew his challenge to the overpayment claim, did not perform the service billed, or provided no documentation to support the service billed. Therefore, the overpayment as to this recipient has been established.
As to every instance where the specific time spent with the recipient was not documented, the medical records provided by the Petitioner were the sole source of information available to the Respondent. No medical expertise is necessary to determine whether or not the specific time was posted on the records. Similarly, where no document was provided to support a claim, medical expertise is not required to disallow such claim.
It is undisputed that the Petitioner served Medicaid- eligible recipients. Additionally, there is no claim that the recipients served (and whose records were reviewed) were not eligible for the service provided.
The Petitioner did not willfully or fraudulently overstate the claims.
In order to perform a "peer review of records," the Respondent's agent does not have to directly interview the recipient regarding the services rendered.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of these proceedings. Section 120.57, Florida Statutes.
The Respondent bears the burden of proof in this cause to establish by a preponderance of the evidence that an overpayment should be reimbursed. Except as conceded and withdrawn at hearing, the Respondent has met its burden.
First, the Respondent has established that the audit report appropriately supports an overpayment claim. Second, the Petitioner has admitted he did not specify the time spent with recipients as is more fully noted above. Additionally, the Petitioner bears the legal burden of retaining records so that they can be reviewed, and if such records are deficient, he must explain the charges posted and paid. He has not done so. The Medicaid Program requires that participating providers maintain appropriate records so that after-the-fact audits support the payments made to the provider. In this case the Petitioner's records were woefully inadequate in most instances.
Additionally, it is concluded that the methodology employed by the Respondent to procure the random sample and extrapolate the results of that audit to all claims for the audit period is statistically sound. The Respondent established that if anything, the calculated amount due to be reimbursed is
most likely less than the actual amount owed were the Agency able to audit all records instead of the sample.
Finally, while a peer review of records is important to determine medical necessity, in this case the absence of records and the admitted lack of a specified time noted for the time spent with a recipient do not mandate a medical review. On their face Petitioner's records failed to document a specific time spent with the patient.
Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a Final Order requiring the Petitioner to reimburse the state for an overpayment of Medicaid funds. Such overpayment must be calculated using the revised amounts for each of the recipients identified in this record and extrapolating the total to claims for the entire audit period.
DONE AND ENTERED this 14th day of February 2003, in Tallahassee, Leon County, Florida.
J. D. PARRISH Administrative Law Judge
Filed with the Clerk of the Division of Administrative Hearings this 14th day of February, 2003.
Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive
Jeffries H. Duvall, Esquire
Anthony C. Vitale, Esquire Anthony C. Vitale, P.A.
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.
