STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

STATE OF FLORIDA, DEPARTMENT ) OF HEALTH AND REHABILITATIVE ) SERVICES, )

)

Petitioner, )

)

vs. ) CASE NO. 81-536

)

NAGUI N. KHOUZAM, M.D., )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice the Division of Administrative Hearings by its duly designated Hearing Officer, K. N. Ayers, held a public hearing in the above styled case at Orlando, Florida, on June 4, 1981.

APPEARANCES

For Petitioner: Robert Weiss, Esquire

Staff Attorney Department of Health and

Rehabilitative Services Medicaid Program Office

1317 Winewood Boulevard, Suite 273

Tallahassee, Florida 32301

For Respondent: Nagui N. Khouzam, MD., pro se

310 South Dillard Street (Wingard Building) Winter Garden, Florida 32787

By letter dated February 24, 1981 the Department of Health and Rehabilitative Services (HRS), Petitioner, notified Nagui N. Khouzam, M.D., Respondent, that he had been overpaid $9,612.44 on medicaid claims submitted. These overpayments resulted from Respondent submitting bills for new patient treatment for patients previously seen by the Respondent. By letter dated March 3, 1981 Respondent requested an administrative hearing. At the hearing one witness was called by Petitioner, one witness was called by Respondent and five exhibits were admitted into evidence. There is no dispute regarding the facts in this case.

FINDINGS OF FACT

1. Spot audits of the accounts of medicaid providers disclosed a high proportion using incorrect code numbers in reporting patient visits. Specifically many were using the new patient code number for old patients treated for a new illness. Since most of the medicaid billing was processed by computers, a program was devised to screen the accounts of the 15,000 medicaid

   providers in Florida to determine the overcharges generated by this one billing error.

   
   

2. The auditing period from January 1, 1979 to October 27, 1980 was selected and a computer printout was obtained on each provider that was found to have overbilled HRS more than $100 during this period. One reason for selecting January 1, 1979 as the starting point was that Medicaid Information Update of January 1979 published by SDC Integrated Services, Inc. contained a notation that

   
   

   Procedure Codes 90000 - 90026 are to

   to be used when billing for new patients only. Once a patient has been seen by a physician, subsequent office visits are to be billed with procedure codes 90030 - 90087 (Florida Relative Value

   Studies, page 23.)

   
   

   Another reason was that Rule 10C-7.38, F.A.C., became effective January 2, 1979.

   
   

3. SDC Integrated Services is under contract to HRS to serve as its fiscal agent to receive and pay medicaid claims and issue provider numbers to participating physicians. It maintains a roster of those providers and publishes information bulletins which are mailed to all providers on its list to keep them current on correct medicaid billing procedures.

   
   

4. Respondent has been a medicaid provider since 1975. He is a board certified surgeon and has practiced medicine since 1952. He did not receive the medicaid information update of January 1979 (Exhibit 1)

   
   

5. Respondent, under the honest and sincere belief that the procedure was correct, used procedure codes 90000 - 90026 for new patients and for previously treated patients who returned with a new ailment. When he received information in October 1980 that he had been using the incorrect billing codes for previously treated patients, Respondent changed to the proper billing codes and procedure.

   
   

6. During the period January 1, 1979 to October 27, 1980 Respondent wrongly billed 1,944 office visits and was overpaid by HRS $9,612.44 for treatment of patients billed under procedure codes 90000 - 90026 who should have been billed under procedure codes 90030 - 90087. In the average medicaid office approximately 37 percent of the outpatients are new patients. Some 80 percent of Respondent's outpatients were billed as new patients during the audit period.

   
   

7. Respondent's principal objection is that he was not advised sooner that he was using incorrect procedure codes and received over $9,000 in excess payments before learning of the error. Respondent also contends that he performs numerous minor surgeries and gives shorts for which he does not bill medicaid. However, had he been aware of the proper billing procedures for new patients in January 1979, he would have billed properly.

   
   

   CONCLUSIONS OF LAW

   
   

8. The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of these proceedings.

9. Rule 10C-7.38, Florida Administrative Code, under subparagraph (1) Definitions provides:

   
   

   1. "New patient" means one new to the physician, office, or facility. The initial comprehensive history and examination need not be done at the time of the first visit.

   2. "Established patient" means one known to the physician and/or whose records are normally available.

      
      

10. Here the evidence is clear and uncontradicted that Respondent erroneously billed for established patients using billing codes for new patients; and, during the period January 1, 1979 through October 27, 1980 received excess payments of $9,612.44. While this error was not intentional on the part of Respondent and there is not even a suspicion of fraud, the Respondent has had the use and benefit of these excess funds for an extended period of time without cost to him.

From the foregoing it is concluded that Respondent has been overpaid

$9,612.44 from medicaid funds. It is, therefore,

RECOMMENDED that Respondent be required to repay this overpayment of

$9,612.44 on a reasonable schedule of payments over a period not to exceed one year.

ENTERED this 19th day of June, 1981 in Tallahassee, Leon County, Florida.

K. N. AYERS Hearing Officer

Division of Administrative Hearings The Oakland Building

2009 Apalachee Parkway

Tallahassee, Florida 32301

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 19th day of June, 1981.

COPIES FURNISHED:

Robert Weiss, Esquire Staff Attorney

Department of HRS Medicaid Program Office

1317 Winewood Boulevard, Suite 273

Tallahassee, Florida 32301

Nagui N. Khouzam, M. D.

310 South Dillard Street Wingard Building

Winter Garden, Florida 32787

Docket for Case No: 81-000536

Orders for Case No: 81-000536