frank wollandVs.gordon b. scott|Department of Children and F... -- eLawyers

Petitioner: JAY'S MEDICAL CENTER, INC.
Respondent: DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
Judges: STUART M. LERNER
Agency: Department of Children and Family Services
Locations: Miami, Florida
Filed: Mar. 25, 1993
Status: Closed
Recommended Order on Monday, May 22, 1995.
Latest Update: Dec. 02, 1996
Summary: Whether Petitioner was overpaid for those Medicaid claims which, according to the post-hearing submissions of the parties, remain in dispute.Examination of documentation furnished by provider reveals that provider was overpaid for various medicaid claims it submitted.

93-1613.PDF

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

JAY'S MEDICAL CENTER, INC., )

)

Petitioner, )

)

vs. ) CASE NO. 93-1613

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was conducted in this case on June 8 and 9, 1994, and July 25, 1994, in Miami, Florida, before Stuart M. Lerner, a duly designated Hearing Officer of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Frank Wolland, Esquire

Law Office of Frank Wolland 11601 Biscayne Boulevard North Miami, Florida 33181

For Respondent: Gordon B. Scott, Esquire

Senior Attorney

Agency for Health Care Administration 1317 Winewood Boulevard

Building B, Room 271 Tallahassee, Florida 32399-0700

STATEMENT OF THE ISSUE

Whether Petitioner was overpaid for those Medicaid claims which, according to the post-hearing submissions of the parties, remain in dispute.

PRELIMINARY STATEMENT

By letter dated February 9, 1993, the Department of Health and Rehabilitative Services 1/ (hereinafter referred to as the "Department") advised Petitioner that it had completed a review of a random sample of 468 Medicaid claims submitted by Petitioner for services rendered to 40 of Petitioner's patients during the period from July 1, 1990, through December 31, 1991, (hereinafter also referred to as the "audit period"), and that, based upon such review, and using a "generally accepted" "statistical formula for cluster sampling," it had determined that Petitioner had been overpaid $112,852.50 "for claims that in whole or in part [were] not covered by Medicaid." The letter further advised Petitioner that the Department intended to recoup this

overpayment, as well as to impose a $5,000.00 fine upon Petitioner for "violation of Medicaid policies" committed in connection with the submission of the claims for which Petitioner was allegedly overpaid.

On or about March 11, 1993, Petitioner filed a petition with the Department requesting a formal hearing on the matters referenced in the Department's February 9, 1993, letter. The case was transmitted to the Division of Administrative Hearings (hereinafter referred to as the "Division") on March 25, 1993, for the assignment of a Division hearing officer to conduct the formal hearing Petitioner had requested.

At the formal hearing, which was held on June 8 and 9, 1994, and July 25, 1994, 2/ three witnesses testified: Shelley Wolland, D.O., Petitioner's Medical Director; Phyliss Stiver, R.N., a Registered Nurse Consultant in the General Audit Unit within Respondent's Division of Program Integrity; 3/ and John Sullenberger, M.D., the Florida Medicaid Program's Chief Medical Consultant. 4/ In addition to the testimony of these three witnesses, a total of eleven exhibits (Petitioner's Exhibits 1 through 5 and Respondent's Exhibits

1 through 6) were offered and received into evidence.

During the course of the hearing, the parties agreed that they would litigate at hearing, and the Hearing Officer would address in his Recommended Order, the validity of only those individual sampled claims remaining in dispute, not the statistical method employed by the Department to determine the total overpayment made to Petitioner during the audit period. Pursuant to the parties' agreement, if the Hearing Officer disagreed with any of the findings of overpayment made by the Department with respect to these individual sampled claims, upon which the Department based its determination that Petitioner had been overpaid $112,852.50 for the total number of claims it submitted during the audit period, Respondent would recalculate the total overpayment and thereafter Petitioner would have the opportunity, if it so desired, to challenge the statistical method used by Respondent in recalculating the total overpayment.

The parties further agreed at hearing that, following such recalculation, Petitioner would also have the opportunity, if it so desired, to have the evidentiary record reopened so that it would be able to present evidence "as to the nature of the economic impact which the fine and overpayment recovery would have on [Petitioner] and whether or not that impact would be such as to impair its ability to offer Medicaid services."

Following the conclusion of the evidentiary portion of the hearing on July 25, 1994, the Hearing Officer, on the record, directed the parties to: (1) meet and confer and to file, within 45 days of the Hearing Officer's receipt of the complete transcript of the hearing, a written enumeration of those disputed

issues that the Hearing Officer needed to address in his Recommended Order; and

to file their proposed recommended orders no later than 60 days of the Hearing Officer's receipt of the complete transcript of the hearing. The Hearing Officer informed the parties that he would address in his Recommended Order "only those issues that [according to the parties' written enumeration of issues] remain[ed] in dispute, and no others."

The Hearing Officer received the complete transcript of the hearing on September 12, 1994. Respondent timely filed its written enumeration of issues on November 10, 1994. On February 24, 1995, Petitioner filed its written enumeration of issues, along with a motion requesting that it be considered by the Hearing Officer notwithstanding that it was untimely filed. 5/ By order
issued that same day, February 24, 1995, Petitioner's motion was granted. On February 28, 1995, Respondent filed a response to Petitioner's written enumeration of issues.

On April 10, 1995, after the Hearing Officer had granted three separate extensions of the deadline for the submission of proposed recommended orders, Petitioner and Respondent timely filed proposed recommended orders. These proposed recommended orders have been carefully considered by the Hearing Officer. Each contain, what are labelled as, "findings of fact." These "findings of fact" are specifically addressed in the Appendix to this Recommended Order.

FINDINGS OF FACT

Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made:

Jay's Medical Center
1. Jay's Medical Center (hereinafter referred to as "JMC") is a medical clinic located in a low income area in Miami.
2. It is staffed by three physicians, including Shelley Wolland, D.O., the clinic's Medical Director, 6/ and several support staff.
3. In general, the community JMC serves is poorly educated and has a relatively high incidence of medical problems.
4. Approximately 7,000 members of the community receive medical services at JMC, with anywhere from 40 to 80 patients receiving services in a single day.
5. Many of the clinic's patients are Medicaid recipients.
  
  The Provider Agreement
6. JMC is now, and has been since May of 1990, when it entered into a Non- Institutional Professional and Technical Medicaid Provider Agreement with the Department, authorized to provide physician services, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) services, and family planning services to its Medicaid patients eligible to receive such services.
7. The provider agreement between JMC and the Department provided as follows:
  1. The provider agrees that services will be provided to recipients of the Florida Medicaid Program without regard to race, color, religion, national origin, or handicap.
  2. The provider agrees to keep for 5 years complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billing made under
    the Medicaid program and agrees to furnish the State Agency and Medicaid Fraud Control unit upon request such information regarding any payments claimed for providing these services. Access to the pertinent patient records and
    facilities by authorized Medicaid program representatives will be permitted upon reasonable request. All records relating to Medicaid recipients are to be held confidential as provided under 42 CFR 431.305 and 306.
  3. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, Medicaid compensable and of quality comparable to those furnished by the provider's peers, and the services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting a claim.
    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. The provider in executing this agreement acknowledges that he understands that payment of Florida Medicaid claims is made from Federal and State funds
    and that any falsification, or concealment of
    a material fact, may be prosecuted under Federal and State laws.
  4. The providers of Independent Laboratory, Portable X-Ray Services, Home Health Services, Hospice and Rural Health Clinic Services agree to furnish the Office of Licensure and Certifi- cation a completed copy of Form HCFA-1513 (Ownership and Control Interest Disclosure Statement) in accordance with 42 CFR 455.104.
  5. The providers of Prescribed Drug Services agree to bill the Medicaid program no more than usual and customary charges and on request, to provide access to usual and customary pricing information.
  6. The Department agrees to notify the provider of any major changes in Federal or State rules
    and regulations relating to Medicaid.
  7. Payment made by the State Agency shall constitute full payment for services rendered to recipients under the Medicaid program. This includes situations when no payment is made to physicians when Medicare coinsurance claims are
    adjudicated due to Medicaid's payment methodology. The only exception is in specific programs when Medicaid coinsurance is required from the recipient.
  8. The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations.
  9. The agreement may be terminated upon thirty days written notice by either party. The Department may terminate this agreement in accordance with Chapter 120, F.S.
  10. This agreement becomes effective the date the signature of the authorized agent of the Office of Medicaid is affixed.
  11. The provider eligibility will be established at the latter of the date of licensure of the provider, if applicable, or ninety (90) days prior to receipt of the application.
  12. The provider shall be responsible for assuring that the signature on the claim form is appropriate for authorization. Persons authorized to submit Medicaid claims on behalf of the provider shall be limited to the provider, the provider's employees
    or authorized agent.
    
    Handbook Provisions
8. 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").
9. Chapter 10 of the MPP Handbook addressed the subject of "provider participation."
10. Section 10.9 of this chapter provided as follows: 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:

history,
physical examination,
chief complaint on each visit,
diagnostic tests and results,
diagnosis,
a dated, signed physician order for each service rendered,
treatment plan, including prescriptions for medications, supplies, scheduling frequency for follow-up or other services,
signature of physician on each visit,
date of service,
anesthesia records,
surgery records,
copies of hospital and/or emergency records that fully disclose services, and
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.

Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm

or microfiche must be legible when printed and viewed.

Chapter 11 of the MPP Handbook addressed the subject of "covered services and limitations."
Section 11.1 of this chapter provided as follows: INTRODUCTION
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 of this program must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient.
Delivery of the services in this manual must be done by or under the personal supervision of a physician or osteopath at any place of service.
Personal supervision is defined as the physician being in the building when the service was rendered. The physician must sign and date the medical record either on the date of service or within 24 hours.
Each service type listed has special policy requirements that apply specifically to it. These must be adhered to for payment.

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 1977, 1980, 1981, 1982, 1983,
1984, 1985, 1986, 1987 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.

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 discus- sion of findings.
. Intermediate level of service pertains to the evaluation of a new or existing condition compli- cated 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. 7/
Section 11.2 of Chapter 11 of the MPP Handbook provided in part, that "[t]reatment of an illness found by a physician during an EPSDT screening that requires considerable office time (30 minutes or more) to treat, may also be billed as an office visit on the appropriate claim form."
Another of the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement between JMC and the Department was the Medicaid EPSDT Provider Handbook (hereinafter referred to as the "EPSDT Handbook").
Chapter 10 of the EPSDT Handbook addressed the subject of "provider participation."
Section 10.8 of this chapter provided as follows: RECORD KEEPING
You must retain EPSDT 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.
  
  Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed.
Chapter 11 of the EPSDT Handbook addressed the subject of "covered services and limitations."
Sections 11.3 and 11.5 of this chapter provided that the components of an EPSDT preventive health screening examination were: a health and developmental history; unclothed physical assessment or examination; nutritional assessment; updating of routine immunizations, "as indicated by the recipient's age, health history, or population group;" laboratory tests, "as
indicated by the recipient's age, health history, or population group;" development assessment, vision, hearing and dental screening; and health education.
Section 11.7 of Chapter 11 provided, in part, as follows:

Under federal regulations the state must provide
for medically necessary treatment services diagnosed as a result of screening. Once the EPSDT recipient is screened and referred for treatment, any further diagnosis and/or treatment is then provided through the individual treatment service program. For example, if an EPSDT recipient is found to have
an abnormal laboratory test result, such as tuber- culin (TB) skin test, any further referral, diagnosis and treatment is considered diagnostic treatment under physician services.

Billing for a treatment visit at the time of a screening visit is only allowed when the illness is discovered during the screening examination. This treatment visit must be at least 30 minutes or more.

Treatment visits completed in conjunction with a screening visit must be billed on the HFCA-1500 and the fact that the visit is screening related must be noted on the claim form. Treatment procedure codes should be related to screening results as noted on the EPSDT 221 claim form.

An EPSDT screening should not routinely be completed on an obviously ill child, as the illness may distort the screening results. Sound professional judgment should be exercised in determining the appropriate- ness of screening an ill child. If screening results are questionable, treatment should be provided and the screening appointment rescheduled. If, however,
an illness is detected during a screening examination, the screening may be completed and treatment provided on the same date, billing the treatment on the appropriate Medicaid claim form. Billing for treat- ment on the same day as the screening evaluation should be done only when a detected illness or condition requires significant time and procedures
in addition to the time usually spent for a screening evaluation.

The Audit
Commencing in 1992, the Department conducted an audit of Medicaid claims submitted by JMC for services rendered from July 1, 1990, through December 31, 1991.
During the course of the audit, the Department examined the files of
40 patients (Patients 1 through 19 and 21 through 41, hereinafter also referred to by their initials) who had received services during the audit period.
Patient 1 (S.M.)

January 16, 1991, Visit
On January 16, 1991, S.M. presented at the clinic complaining of a sore throat and fever.
The attending physician determined that S.M. had an upper respiratory tract infection, as well as vaginitis.
Treatment was provided.
JMC billed this as a "comprehensive" visit (procedure code 90020) and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one (procedure code 90060), as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

January 29, 1991, Visit
S.M. next visited the clinic on January 29, 1991.
JMC billed this visit as a "limited" one (procedure code 90050) and payment was made accordingly.
Respondent does not dispute the appropriateness of such billing and payment. 8/

April 23, 1991, Visit
On April 23, 1991, S.M. presented at the clinic complaining of blood in her urine. She further indicated that she had recently had a Pap smear test, the results of which reflected a possible precancerous condition.
A pregnancy test revealed that S.M. was pregnant.
She was also diagnosed as having an upper respiratory tract infection, for which she was treated.
A gynecological referral was made.
JMC billed this visit as a "extended" one (procedure code 90070) and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

October 9, 1991, Visit and Streptococcal Test
S.M. visited the clinic again on October 9, 1991.
JMC billed this visit as an "extended" one and payment was made accordingly. It also sought and obtained separate payment for a streptococcal (hereinafter referred to as "strep") test (procedure code 86317) given during the visit.
Both parties are now in agreement that the billing and payment for the strep test was appropriate 9/ and that the office visit should have been billed and paid, not as an "extended" visit, but as an "intermediate" visit, as described in Chapter 11 of the MPP Handbook.

November 6, 1991, Visit Cerumen Removal and Strep Test
On November 6, 1991, S.M. presented at the clinic complaining of sinus problems and pustules on her nose.
She was diagnosed as having folliculitis, pharyngitis and sinusitis.
Treatment was provided.
JMC billed this visit as a "extended" one and payment was made accordingly. It also sought and obtained separate payment for impacted cerumen removal (procedure code 69210) and a strep test.
The parties are in agreement that the billings and payments for the impacted cerumen removal and strep test were appropriate. 10/ A dispute still exists, however, as to the appropriateness of JMC billing and receiving payment for an "extended" visit.
JMC's medical records pertaining to the visit, to the extent that they are legible, document that the visit was not an "extended" visit, but was merely an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. Moreover, these records were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. 11/ Accordingly, JMC should not have received any payment for this office visit.

Patient 2 (O.R.)

October 7, 1991, Billings
JMC billed and was paid for a "comprehensive" visit and other services (procedure codes 86317, 94010 and 94664) it claimed it rendered Patient 2, O.R., on October 7, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that, on that date, O.R. was seen at the clinic by a physician or that she received the other billed for services. Accordingly, payment should not have been made to Petitioner for an office visit of any type or for any of the other services Petitioner claimed it rendered O.R. on October 7, 1991.

October 22, 1991, Visit
On October 22, 1991, O.R. presented at the clinic with a fever, sore throat and high blood pressure. In addition, she complained that she was wheezing, suffering from headaches and had a runny nose. At the time of the visit, O.R. was five feet, two inches tall and weighed 206 pounds.
The attending physician determined that O.R. was suffering from asthma.
Using a nebulizer, he treated her with Ventolin.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

October 24, 1991, Visit, Routine Venipuncture and Therapeutic Injection
O.R. returned to the clinic two days later, on October 24, 1991, with respiratory problems. She was coughing and wheezing severely. Her throat was red.
The attending physician determined that O.R. had pharyngitis, pneumonia and severe asthma.
Treatment was provided. Medications were prescribed and oral instructions regarding medication administration and compliance were given.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "extended" one, as described in Chapter 11 of the MPP Handbook.
JMC also sought and obtained separate payment for a routine venipuncture (procedure code 36415) and a therapeutic injection for asthma (procedure code 90782).
The parties are in agreement that the routine venipuncture was appropriately billed and paid. The appropriateness of the billing and payment for a therapeutic injection, however, is still in dispute.
JMC's medical records, to the extent that they are legible, do not document that O.R. was given the billed and paid-for therapeutic injection on October 24, 1991. Accordingly, it should not have been paid for this service.

Patient 3 (T.F.)

January 31, 1991, Visit
On January 31, 1991, Patient 3, T.F., a ten-year old girl who had already begun menstruating, presented at the clinic with complaints of vomiting for the past two days, as well as cramps and abdominal pain. She further indicated that she had had her last menstrual period two weeks previous.
A physical examination, which included the genital and rectal areas, was conducted, a history was taken and a strep test was given.
The results of the strep test were positive.
The attending physician determined that T.F. had strep throat, for which she received treatment.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

September 19, 1991, Visit
On September 19, 1991, T.F. presented at the clinic complaining of a high fever and a sore throat. She further indicated that she had vomited earlier in the morning.
A physical examination, which did not include the genital area, was conducted, an updated history was taken and a strep test was given.
The attending physician determined that T.F. had tonsillitis.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 4 (K.W.)

October 3, 1991, Visit
On October 3, 1991, Patient 4, K.W., presented at the clinic. He had lower back pain, an upper respiratory tract infection, trauma to his right ankle and folliculitis.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.
November 4, 1991, Billings
JMC billed and was paid for an "extended" visit and another service (procedure code 86317) it claimed it rendered K.W. on November 4, 1991, but the medical records maintained by JMC do not contain legible, physician-signed and dated documentation substantiating that, on that date, K.W. was seen at the clinic by a physician or that he received the other billed-for service. Accordingly, payment should not have been made to Petitioner for any type of office visit or for the other service Petitioner claimed it rendered K.W. on November 4, 1991.

Patient 5 (S.W.)

October 19, 1990, Visit
JMC billed and was paid for a "comprehensive" office visit, in addition to an EPSDT screen (procedure code W9881), for services rendered to Patient 5, S.W., on October 19, 1990.
The parties are in agreement that the EPSDT screen was appropriately billed and paid. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute.
The medical records maintained by JMC do not contain legible, physician-signed and dated documentation justifying JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

October 29, 1990, Visit
S.W. again visited the clinic on October 29, 1990. This was a follow- up visit. She had been to the clinic four days previous with a high fever and complaining of a headache, stuffiness and a cough.
JMC billed S.W.'s October 29, 1990, visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

May 14, 1991, Visit
On May 14, 1991, S.W. presented at the clinic complaining of a cough.
She was diagnosed as having an upper respiratory tract infection.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

May 29, 1991, Visit
Two weeks later, on May 29, 1991, S.W. returned to the clinic for a follow-up visit. She was still coughing.
Tests taken before the visit revealed that, in addition to her respiratory problems, S.W. was suffering from iron deficiency.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

June 12, 1991, Visit
On June 12, 1991, S.W. paid another follow-up visit to the clinic.
During the visit, she admitted that she had not taken her medication "properly."
A spirometry test taken before the visit revealed "severe obstruction."
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 6 (B.F.)

July 12, 1990, Visit
On July 12, 1990, Patient 6, B.F., a 32-year old woman, presented at the clinic complaining of chest palpitations and abdominal pain.
A physical examination, which included an examination of the vaginal and pelvic areas, was conducted, a history was taken, tests were ordered and treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, a "comprehensive" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore not overpaid for this visit.

January 14, 1991, Visit
B.F. visited the clinic on January 14, 1991, complaining of lower abdominal discomfort, which, she claimed, she had been experiencing for the past two weeks.
The attending physician determined that, in addition to the abdominal discomfort B.F. was experiencing, she also had vaginitis.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

January 28, 1991, Visit
On January 28, 1991, B.F. presented at the clinic complaining of general malaise and a cough that she claimed she had had for four or five days.
The attending physician determined that B.F. was suffering from acute bronchitis.
Treatment was provided.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

April 24, 1991, Visit
On April 24, 1991, B.F. presented at the clinic complaining of chest pain, headaches and dizziness she had been experiencing for several days. She also had shortness of breath.
A physical examination, which included an examination of the genital and rectal areas, was conducted, an updated history was taken and tests were ordered.
The chest pain was determined to be non-cardiac in nature. It was thought to be caused by a tender rib.
Medication was prescribed to combat B.F.'s headaches and dizziness.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

May 1, 1991, Visit
On May 1, 1991, B.F. paid a followup visit to the clinic. She reported that she was still experiencing dizziness, but no longer had any chest pain or headaches. She further advised that she was unable to tolerate the medication that had been prescribed on the previous visit.
A rhythm strip test was administered.
A new medication was prescribed to combat B.F.'s dizziness.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 7 (C.C.)

July 23, 1991, Visit
On July 23, 1991, Patient 7, C.C., visited the clinic for the removal of a lesion from her nose by electrodesiccation.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 8 (L.F.)

October 21, 1991, Visit
On October 21, 1991, Patient 8, L.F., presented at the clinic complaining of a skin rash.
The attending physician determined that L.F. was suffering from impetigo, as well as bronchitis.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 9 (L.A.)

November 26, 1990, Visit
On November 26, 1990, Patient 9, L.A., presented at the clinic complaining of chest pain.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
The parties now agree that such billing and payment was appropriate and thus JMC was not overpaid for this visit.

March 28, 1991, Visit
On March 28, 1991, L.A. presented at the clinic complaining of chest and abdominal pain.

152.	The attending physician determined that the chest pain was	non-
cardiac in	nature and that L.A. was suffering from gastritis.
153.	Medication was prescribed.
154.	JMC billed this visit as an "extended" one and payment was	made

accordingly.

JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

May 6, 1991, Visit
On May 6, 1991, L.A. visited the clinic to obtain birth control pills.
JMC billed this visit as an "extended" one.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.
June 17, 1991, Visit
On June 17, 1991, L.A. presented to the clinic complaining of a sore throat and back pain. The latter ailment was the result of her having been hit in the back with a chair that was thrown at her at work.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

August 8, 1991, Debridement
On August 8, 1991, L.A. presented to the clinic complaining of a gash on her left leg that she had received the night before, as well as a headache and continuing back pain.
The leg wound was cleaned.
Necrotic tissue around the edge of the wound was removed.
JMC billed for a debridement (procedure code 11042) and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC.
JMC was therefore appropriately paid for this procedure.

September 27, 1991, Visit
On September 27, 1991, L.A. presented at the clinic complaining of diarrhea, a cold and postnasal drip.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

October 28, 1991, Visit
On October 28, 1991, L.A. presented to the clinic complaining of a sore throat. She further indicated that she had been exposed to the flu.
Treatment was provided.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 10 (B.W.)

February 26, 1991, Visit and EPSDT Screen
On February 26, 1991, Patient 10, B.W., who was then twelve years old, presented at the clinic for an EPSDT screen. complaining of an abscess behind her ear and a sore throat.
The screen was performed.
In addition, B.W.'s abscess was drained and her sore throat was treated.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 12/
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate.
These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

March 1, 1991, Billing
JMC billed and was paid for services rendered B.W. during an "intermediate" office visit it claimed took place on March 1, 1991, but the physician signed-medical records maintained by JMC, to the extent that they are legible, do not document that B.W. was seen that day at the clinic by a physician.
Payment for such an office visit therefore should not have been made.

March 13, 1991, Visit
On March 13, 1991, B.W. presented at the clinic with multiple, yet relatively uncomplicated, medical problems, including iron deficiency.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.

June 24, 1991, Visit
On June 24, 1991, B.W. presented at the clinic complaining of a skin rash.
She also had a slightly elevated temperature.
The attending physician determined that B.W had dermatitis.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

June 27, 1991 Visit
Three days later, on June 27, 1991, B.W. again visited the clinic. This time she had an abscess in the area of her left armpit.
The abscess was drained.
JMC billed this visit as an "extended" one and payment was made accordingly. 13/
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

October 18, 1991, Visit and EPSDT Screen
On October 18, 1991, B.W. presented at the clinic for an EPSDT screen complaining of an abscess in the area of her right armpit and a sore throat.
The screen was performed.
In addition, B.W.'s abscess was drained and her sore throat was treated.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 14/
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate.
These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

Patient 11 (T.M.)

October 30, 1990, Visit
On October 30, 1990, Patient 11, T.M., who was then six years of age, presented at the clinic for an EPSDT screen.
The screen was performed.
During the screen, a wart was discovered on T.M.'s left wrist.
The wart was removed. The procedure took approximately 15 minutes.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 15/
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

May 9, 1991, Visit
T.M. presented at the clinic on May 9, 1991, with an elevated temperature.
The attending physician determined that he had an upper respiratory tract infection.
Medication was prescribed.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 12 (D.W.)

November 30, 1990, Visit
On November 30, 1990, Patient 11, D.W., who was then three months old, presented at the clinic for an EPSDT screen. He had a stuffy nose.
The screen was performed.
The physician performing the screen determined that D.W. was suffering from an upper respiratory tract infection and otitis.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

December 14, 1990, Visit
On December 14, 1990, D.W. presented at the clinic. His mother reported that D.W. had a persistent cough.
D.W. was given a strep test, the results of which were negative.
The attending physician determined that D.W. still had an upper respiratory tract infection and otitis.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

December 17 and 27, 1990, Visits
D.W. visited the clinic on December 17, 1990, and again on December 27, 1990.
JMC billed these visits as "intermediate" ones and payments were made accordingly.
The parties agree that these billings and payments were appropriate.

January 21, 1991, Visit
On January 21, 1991, D.W. returned to the clinic with his mother. He had a fever of 102 degrees Fahrenheit, which, his mother reported, he had had for the past four days.
Following an examination and a strep test, the attending physician determined that D.W. had a strep throat and an ear infection.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

June 7, 1991, Visit
On June 7, 1991, D.W. presented at the clinic for an EPSDT screen.
The screen was performed.
During the screen, it was discovered that D.W had an ear problem, for which he received treatment.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office on this date.

June 21, 1991, Visit

254.	D.W. returned to the clinic on June 21, 1991, with	an ear infection
and a rash	behind his right ear.
255.	Treatment was provided.
256.	JMC billed this visit as an "intermediate" one and	payment was made

accordingly.

JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore not overpaid for this visit.

July 23, 1991, Visit
On July 23, 1991, D.W. presented at the clinic for an EPSDT screen.
The screen was performed.
During the screen, the attending physician determined that D.W. was suffering from diaper rash.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

Patient 13 (J.H.)

December 29, 1990, Visit and EPSDT Screen
On December 29, 1990, J.H., who was then three years of age, presented at the clinic for an EPSDT screen. She was suffering from constipation.
During the screen, the attending physician determined that J.H. also had vaginitis.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, there is no indication that J.H.'s teeth and gums were examined during the visit. Accordingly, JMC was not entitled to receive any payment for an EPSDT screen.
Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.

January 4, 1991, Visit
On January 4, 1991, J.H. presented at the clinic. She looked ill and had glassy eyes. It was reported that her temperature (taken with a rectal thermometer) had reached 104 degrees Fahrenheit at home. When her temperature was taken (again rectally) at the clinic, however, it was only 99.2 degrees Fahrenheit.
The attending physician determined that J.H. had a urinary tract infection and pharyngitis.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 14 (J.Y.)

April 20, 1991, Visit
On April 20, 1991, Patient 14, J.Y., a 25-year old woman suffering from obesity and hypertension, presented at the clinic to obtain a refill of medication that she had been given on a previous visit.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 15 (K.C.)

September 20, 1991, Visit
On September 20, 1991, Patient 15, K.C., who was then four years of age, presented at the clinic for an EPSDT screen.
The screen was performed.
During the screen, the attending physician determined that K.C. was suffering from an upper respiratory ailment.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and an "intermediate" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "intermediate" office visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

Patient 16 (D.W.)

December 17, 1991, Visit
On December 17, 1991, Patient 16, D.W., who was then eight years of age, presented to the clinic for an EPSDT screen.
During the screen, the attending physician determined that D.W. was suffering from dermatitis.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and an "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen lacks adequate supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 17 (R.G.)
There are no issues in dispute concerning any billings and payments made in connection with services JMC rendered to Patient 17, R.G.

Patient 18 (C.F.)

February 12, 1991, Visit
On February 12, 1991, C.F., a 25-year old woman, presented at the clinic complaining of profuse menstrual bleeding.
The attending physician determined that C.F. was simply having irregular menstrual periods and that medical intervention was not warranted.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

November 18, 1991, Visit
On November 18, 1991, C.F. returned to the clinic. She still had irregular menstrual periods and, in addition, she complained of a heavy discharge of breast milk from both of her breasts.
Tests were ordered.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

December 9, 1991, Visit
On December 9, 1991, C.F. again visited the clinic. This time she had an upper respiratory tract infection.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 19 (J.R.)

September 17, 1990, Visit
On September 17, 1990, Patient 19, J.R., who was then six months old, visited the clinic. 16/ He had, what his mother described as, a "bad cold."
The attending physician determined that J.R. had an upper respiratory tract infection and bronchitis.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

January 31, 1991, Visit
On January 31, 1991, J.R. presented at the clinic for an EPSDT screen.
The screen was performed.
During the screen, the attending physician determined that J.R. was suffering from a rash, a mild upper respiratory ailment, and a sore throat.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and an "extended" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "extended" office visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

February 26, 1991, Visit
On February 26, 1991, J.R. again visited the clinic. He had an ear infection and diaper rash.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

May 1, 1991, Visit
On May 1, 1991, J.R. paid another visit to the clinic. Diaper rash was still a problem.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

May 29, 1991, Visit
J.R. returned to the clinic on May 29, 1991.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that any of JMC's staff physicians provided medically necessary services to J.R. on this date. While these records do reflect that J.R. received an abbreviated physical examination during his visit to the clinic, they do not reveal why the examination was conducted or what conclusions the attending physician reached as a result of the examination.
Accordingly, JMC should not have received any payment for an office visit on this date.
Patient 21 (T.M.)

April 26, 1991, Visit
On April 26, 1991, Patient 21, T.M., who was then five years of age, presented at the clinic for an EPSDT screen. He had sickle cell anemia, but was doing well.
The screen was performed.
Following the screen, the attending physician recommended that T.R. continue taking folic acid and vitamins.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

Patient 22 ( K.C.)

August 28, 1990, Visit
On August 28, 1990, Patient 22, K.C., who was then six months old and had recently been exposed to hepatitis B, presented at the clinic for an EPSDT screen.
The screen was performed.
The attending physician did not believe that K.C. had contracted hepatitis B.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

Patient 23 ( K.G.)

July 10, 1990, Visit
On July 10, 1990, Patient 23, K.G., presented at the clinic complaining of a vaginal discharge.
The attending physician determined that K.G. was suffering from vaginitis.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

October 15, 1990, Visit
On October 15, 1990, K.G. presented at the clinic complaining of a rash in the area of her groin.
The attending physician determined that K.G. had folliculitis.
Treatment was provided.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

February 15, 1991, Visit
On February 15, 1991, K.G. presented at the clinic complaining of swelling in her legs. 17/
The attending physician determined that she had pinworms.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

March 8, 1991, Visit
On March 8, 1991, K.G. presented at the clinic complaining of rectal pain and a persistent cough.
The attending physician determined that K.G. had pharyngitis, pneumonia and an anal fissure.
Treatment, which included the use of an aerosol spray, was provided.
JMC billed this visit as an "extended" one and payment was made accordingly. 18/ 372. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook.

JMC was therefore not overpaid for this visit.

June 6, 1991, Visit
On June 6, 1991, K.G. visited the clinic complaining of weight gain and pain in her left side.
The attending physician determined that the pain was caused by gas and prescribed medication to combat the problem.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

June 28, 1991, Visit
On June 28, 1991, K.G. presented at the clinic complaining of a sore throat and a cough producing yellowish sputum. She claimed that she had had the sore throat for three to four days.
A strep test was given, the results of which were negative.
The attending physician determined that K.G. had bronchitis and pharyngitis.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

August 1, 1991, Visit
On August 1, 1991, K.G. presented at the clinic. 19/ She had a pararectal abscess and a urinary tract infection.
The abscess was drained. In addition, treatment was provided for the urinary tract infection.
JMC billed this visit as an "extended" one and payment was made accordingly. 20/
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

September 5, 1991, Visit
On September 5, 1991, K.G. presented at the clinic.
She had a cough and sore throat.
A strep test was given, the results of which were negative.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 24 (L.W.)

December 10, 1990, Visit
On December 10, 1990, Patient 24, L.W., who was then five years of age, presented at the clinic for an EPSDT screen.
The screen was performed.
As part of the screen, her weight was taken. She weighed only 30 pounds.

401.	Because she had a persistent cough	and a runny nose, a strep test was
given, the	results of which were positive.
402.	JMC billed for an EPSDT screen and	a "comprehensive" visit.
403.	The parties agree that the billing	and payment for an EPSDT screen

was appropriate. The billing and payment for a "comprehensive" visit, however, remains in dispute.

JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

July 2, 1991, Visit
On July 2, 1991, L.W. presented at the clinic. 21/
Her right breast was enlarged. In addition, she had pharyngitis and impacted cerumen in her ears.
A strep test was given, the results of which were negative.
Treatment, which included the removal of the impacted cerumen, was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly. 22/
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 25 (R.W.)

October 3, 1991, Visit
On October 3, 1991, Patient 25, R.W., who was then four months old, presented at the clinic for an EPSDT screen. 23/ He had an asthmatic condition and bronchitis.
The screen was performed.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 24/ JMC therefore should not have received any payment for an office visit on this date.

October 10, 1991, Visit
On October 10, 1991, R.W. presented at the clinic for another EPSDT screen. His asthma and bronchitis were much improved.
The screen was performed. No new problems were discovered.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 25/ JMC therefore should not have received any payment for an office visit on this date.

October 16, 1991, Visit
On October 16, 1991, R.W. returned to the clinic. His condition had worsened and he was crying in his mother's arms. In addition to the problems he had had previously, he now also had an ear infection.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

October 24, 1991, Visit
R.W. paid a follow-up visit to the clinic on October 24, 1991. His condition had improved since his last visit to the clinic on October 16, 1991.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that this visit, like R.W.'s prior visit to the clinic, was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 26 (E.W.)

September 16, 1991, Visit
On September 16, 1991, Patient 26, E.W., who was then four months old, presented at the clinic with a cold and cough.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen lacks sufficient supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 27 (C.S.) 26/

November 4, 1991, Visit and EPSDT Screen
On November 4, 1991, Patient 27, C.S., who was then seven months old, presented at the clinic. She was suffering from a cold.
Treatment was provided.
JMC billed for an EPSDT screen and an "extended" visit.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, these records contain no nutritional or developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received any payment for an EPSDT screen.
Furthermore, these medical records document that the visit was not an "extended" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.

Patient 28 (S.S.) 27/ May 15, 1991, Visit
On May 15, 1991, Patient 28, S.S., presented at the clinic complaining of keloid skin masses on both of her ears which, she indicated, she wanted removed.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
The parties now agree that the visit should have instead been billed as an "intermediate" one and that therefore JMC was overpaid for this visit.

May 29, 1991, Visit
On May 29, 1991, S.S. returned to the clinic for evaluation and treatment of her keloids.
JMC billed this visit as an "extended" one and payment was made accordingly.
The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on May 29, 1991.
June 12, 1991, Visit
On June 12, 1991, S.S. paid another visit to the clinic for further evaluation and treatment of her keloids.
JMC billed this visit as an "extended" one and payment was made accordingly.
The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on June 12, 1991.

July 10, 1991, Visit
On July 10, 1991, S.S. again visited the clinic for further evaluation and treatment of her keloids.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on July 10, 1991.

August 7, 1991, Visit
S.S. went back to the clinic on August 7, 1991, for further evaluation and treatment of her keloids.
JMC billed this visit as an "extended" one and payment was made accordingly.
The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit.

September 12, 1991, Visit
On September 12, 1991, S.S. presented at the clinic for additional evaluation and treatment of her keloids, which were scheduled to be removed the following day. She also had a sore throat.
JMC billed this visit as an "extended" one and payment was made accordingly.
The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit.
September 19, 1991, Visit
Only one of the keloids, the one on her left ear, was removed on September 13, 1991. Six days later, on September 19, 1991, S.S. visited the clinic for a postsurgical examination and to discuss the removal of the keloid on her right ear.
She presented at the clinic with a sore throat and earache.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

September 26, 1991, Visit
S.S. returned to the clinic on September 26, 1991. She had an abscess on her ear.
The abscess was incised and drained.
JMC billed this visit as a "comprehensive" one and payment was made accordingly. 28/
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

October 7, 1991, Debridement
On October 7, 1991, S.S. presented at the clinic complaining of continuing skin problems on and behind her ears.
An abscess and "raggedy" skin were discovered.
The abscess was incised and drained and the "raggedy" skin was removed.
JMC billed and was paid for a debridement.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC, and that therefore JMC was entitled to the payment it received for the debridement.
Patient 29 (T.J.)

January 28, 1991, Visit
On January 28, 1991, Patient 29, T.J., who was then one month old, was seen at the clinic. She had congenitally deformed ("toe[d] in") feet, multiple insect bites and diaper rash.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

January 30, 1991, Visit
T.J. returned to the clinic two days later. She had been vomiting for the past two days. In addition, she had a sore throat and an earache.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

April 22, 1991, Visit
On April 22, 1991, T.J. presented at the clinic for an EPSDT screen.
The screen was performed.
During the screen, it was determined that T.J. had dermatitis caused by insect bites.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.
April 24, 1991, Visit
On April 24, 1991, T.J. again visited the clinic. Her dermatitis was still causing her some discomfort.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.

Patient 30 (G.D.)

March 11, 1991, Visit
On March 11, 1991, Patient 30, G.D., who was then four years old, presented at the clinic for an EPSDT screen.
The screen was performed.
The screen revealed that G.D. had upper respiratory problems, as well as an umbilical hernia.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

April 22, 1991, Visit
G.D. was next seen at the clinic on April 22, 1991. He had pharyngitis.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

June 3, 1991, Visit
G.D. next visited the clinic on June 3, 1991. He had a mild upper respiratory tract infection.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 31 (H.C.)

October 15, 1990, Visit
On October 15, 1990, H.C., who was then 18 years old, presented at the clinic complaining of delayed menstruation.
She was given a pregnancy test, the results of which revealed that she was pregnant.
JMC billed and was paid for an EPSDT screen and an "extended" visit.
The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.

Patient 32 (R.M.)

February 12, 1991, Visit
On February 12, 1991, Patient 32, R.M., who was then four years old, presented at the clinic for an EPSDT screen.
The screen was performed.
The screen revealed impacted cerumen in R.M.'s ears.
The impacted cerumen was removed.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 29/
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

Patient 33 (C.W.)

December 3, 1990, Visit
On December 3, 1990, Patient 33, C.W., who was then four years old, presented at the clinic for an EPSDT screen.
The screen was performed.
The screen revealed impacted cerumen in C.W.'s ears and that R.M. had pharyngitis.
Treatment, including the removal of the impacted cerumen, was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 30/
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

August 22, 1991, Visit

534.

On August 22,

1991, C.W. presented at the clinic complaining of a

headache.

535.

The attending

physician determined that C.W. had pharyngitis.

536.

Treatment was

provided.

JMC billed and was paid for an EPSDT screen and an "extended" office visit.
The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.
October 7, 1991, Visit
On October 7, 1991, C.W. again visited the clinic.
JMC billed this visit as an "extended" one and payment was made accordingly.
The parties now agree that the visit should have instead been billed and paid for as a "limited" one, as described in Chapter 11 of the MPP Handbook.

October 10, 1991, Visit
Three days later, on October 10, 1991, C.W. returned to the clinic. She had tonsillitis, pharyngitis and an upper respiratory infection. Her temperature was 103.4 degrees Fahrenheit.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and an "extended" office visit.
The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.

Patient 34 (K.K.)

September 19, 1990, Visit
On September 19, 1990, Patient 34, K.K., who was then three years old, presented at the clinic for an EPSDT screen. He had a runny nose and a cough. His mother also complained that he was hyperactive.

549.	The screen	was performed.
550.	The screen	revealed that K.K. had impacted cerumen in his ears.
551. provided.	Treatment,	including the removal of the impacted cerumen, was
552.	JMC billed	and was paid for an EPSDT screen and a "comprehensive"

visit. 31/

The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.
December 17, 1990, Visit
On or about December 17, 1990, K.K. returned to the clinic.
He had dermatitis, as well as impacted cerumen in his ears. In addition, his mother was concerned about his behavior.
Treatment, including the removal of the impacted cerumen, was provided.
JMC billed this visit as an "extended" one and payment was made accordingly. 32/
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

January 3, 1991, Visit
On January 3, 1991, K.K. returned to the clinic for a physical examination for school.
During the visit, his mother complained that K.K.'s appetite for food had decreased.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

Patient 35 (T.B.)

November 15, 1990, Visit
On November 15, 1990, Patient 35, T.B., presented at the clinic for a physical examination for work.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.
December 20, 1990, Visit
T.B. returned to the clinic on December 20, 1990, complaining that she was not feeling well.
During the visit, impacted cerumen was removed from her ears.
JMC billed this visit as a "comprehensive" one and payment was made accordingly. 33/
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

July 18, 1991, Visit
On July 18, 1991, T.B. went to the clinic to obtain "medical certificates."
A routine physical examination was performed, but no history was taken.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

December 4, 1991, Visit
On December 4, 1991, T.B. presented at the clinic with "pink eye."
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 36 (D.W.)

January 2, 1991, Visit
On January 2, 1991, Patient 36, D.W., who was then 19 years of age, visited the clinic for a checkup.
The attending physician determined that D.W. had an iron deficiency and anemia, for which treatment was provided.
During the visit, family planning issues were also addressed.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

April 17, 1991, Visit
On April 17, 1991, D.W. presented at the clinic complaining that she had been feeling ill for two days. 34/ 592. A strep test was given, the results of which were negative.

The attending physician determined that D.W had tonsillitis and was still suffering from anemia.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

September 16, 1991, Visit
On September 16, 1991, D.W. presented at the clinic. She had a sore throat and vaginitis. 35/ In addition, she was now pregnant and still anemic.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and an "extended" visit. 601. The parties agree that the billing and payment for an EPSDT screen

was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute.

JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.

October 17, 1991, Visit
On October 17, 1991, D.W., who was still pregnant at the time, made a follow-up visit to the clinic. She complained of shortness of breath and tightness in her chest, as well as a sore throat.
A fetal examination was conducted.
A strep test was given, the results of which were negative.
The attending physician determined that D.W. had a urinary tract infection, sinusitis, pharyngitis and anemia.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit. November 14, 1991, Visit and Echography
D.W. returned to the clinic on November 14, 1991. She was in approximately the thirty-second week of her pregnancy and she was still suffering from a urinary tract infection and anemia. Her sinus condition was improving.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly. It also sought and received separate payment for an echography (procedure code 76855).
The parties now agree that JMC should not have been paid for an echography. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit.

December 3, 1991, Visit
A still-pregnant D.W. visited the clinic again on December 3, 1991, complaining of shortness of breath.
The attending physician determined that she was still suffering from a urinary tract infection and anemia.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.
December 10, 1991, Visit
A week later, on December 10, 1991, with her anticipated date of delivery approaching, D.W. returned to the clinic complaining of vaginal irritation and pain in her left wrist. Her urinary tract infection was improving.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 37 (E.A.)

September 27, 1991, Visit
On September 27, 1991, Patient 37, E.A., who was then seven weeks old, presented at the clinic with an upper respiratory infection, pharyngitis and thrush.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit. October 18, 1991, Visit
E.A. returned to the clinic on October 18, 1991, for an EPSDT screen. 633. The screen was performed.

The screen revealed that he still had an upper respiratory infection and thrush.
Treatment was provided.
JMC billed for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date.

November 20, 1991, Visit
E.A. visited the clinic again on November 20, 1991. He had a bad cough and a green discharge from his eyes and nose.
The attending physician determined that E.A. had an upper respiratory infection and pharyngitis, as well as a "foreign body" in his nose.
Treatment, including the removal of the "foreign body," was provided.
36/
JMC billed this visit as an "extended" one and payment was made
accordingly.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore entitled to the payment it received for this visit. November 21, 1991, Incision and Removal
JMC billed and was paid for an incision and removal of a "foreign body" (procedure code 10120) it claimed had been performed on E.A. at the clinic on November 21, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that E.A. received an incision and removal at the clinic on this date. Accordingly, payment should not have been made to JMC for this billed-for service.

Patient 38 (O.S.)

December 2, 1991, Visit and EPSDT Screen
On December 2, 1991, Patient 38, O.S., who was then three months old, presented at the clinic for an EPSDT screen. She had a cold and blotches all over her body and her hair was falling out.
The screen revealed that O.S. had tinea capitis, otodynia, and pharyngitis, as well as impacted cerumen in her ears.
Treatment, including the removal of the impacted cerumen, was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 37/
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete EPSDT screen was performed. For example, these records contain no developmental assessment, nor do they indicate that there was any health education given.
Accordingly, JMC should not have received payment for an EPSDT screen.
Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "extended" one, as described in Chapter
11 of the MPP Handbook. JMC was therefore overpaid for this visit.

December 9, 1991
O.S. returned to the clinic a week later on December 9, 1991. She had a new rash on her left arm.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 39 (T.G.)

September 5, 1991, Visit
On September 5, 1991, Patient 39, T.G., who was then three months old, presented at the clinic for an EPSDT screen. She had a stuffy nose and was crying. According to his mother, he had been crying for the past 12 hours.
The screen was performed.
A strep test was given, the results of which were negative.
The attending physician determined that T.G. had an ear infection, an upper respiratory tract infection and phayrngitis.
Treatment was provided.
JMC billed and was paid for an EPSDT screen and a "comprehensive" visit.
The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, justify JMC billing and receiving payment for, in addition to an EPSDT screen, only an "intermediate" office visit and not a "comprehensive" one. JMC was therefore overpaid for this visit.

September 19, 1991, Visit
T.G. returned to the clinic for a follow-up visit on September 19, 1991. He had diaper rash.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 40 (T.B.)

November 26, 1991, Visit
On November 26, 1991, T.B., a 62-year old man with a history of heart disease, hypertension and stroke, presented at the clinic with a periorbital abscess.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. 38/
JMC was therefore overpaid for this visit. November 29, 1991, Visit
Three days later, on November 29, 1991, T.B. returned to the clinic again complaining about the abscess.
The attending physician reevaluated the problem and referred T.B. to Jackson Memorial Hospital for treatment.
JMC billed this visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit.

Patient 41 (L.B.)

January 25, 1991, Visit
On January 25, 1991, Patient 41, L.B., who was then 19 years of age and had history of mental illness, presented at the clinic stating that she was pregnant and complaining, among other things, of abdominal pain.
She appeared to be confused and it was difficult to obtain an accurate history from her.
Treatment was provided.
JMC billed this visit as an "extended" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit. April 17, 1991, Visit
L.B. returned to the clinic on April 17, 1991, complaining of continuing abdominal pain, vaginal discharge, breast tenderness and nausea.
The attending physician determined that L.B. had vaginitis and a urinary tract infection.
Treatment was provided.
JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit. November 25, 1991, Visit
L.B. visited the clinic again on November 25, 1991. On this visit she complained of a rash.
The attending physician determined that L.B. had dermatitis. 694. Treatment was provided.

JMC billed this visit as a "comprehensive" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook.
JMC was therefore overpaid for this visit. December 6, 1991, Visit
On December 6, 1991, L.B. presented at the clinic claiming that there were things crawling on her scalp.
The attending physician determined that L.B. was demented.
He filled out a Social Security Administration form indicating that it was his opinion that L.B. was "not medically competent."
JMC billed this visit as an "intermediate" one and payment was made accordingly.
JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "intermediate" one, as described in Chapter 11 of the MPP Handbook.

Simple Mistake or Fraud?
There has been no allegation made, nor proof submitted, that any of the overbillings referenced above were the product of anything other than simple mistake or inadvertence.

CONCLUSIONS OF LAW
Effective July 1, 1993, by operation of Section 58 of Chapter 93-129, Laws of Florida, AHCA 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."
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, 39/ 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, Fla. Stat.
An overpayment occurs when a Medicaid provider receives monies beyond those to which, pursuant to the provisions of its provider agreement, it is entitled.
If the overpayment is the result of an "erroneous Medicaid claim" submitted by the provider, in addition to seeking repayment of these monies, AHCA may impose one of the following administrative sanctions against the provider: "[s]uspension for a specific period of time of not more than 1 year;" "[t]ermination for a specific period of time from more than 1 year to 20 years;" and "[i]mposition of a fine of up to $1,000 for each violation not exceeding a total fine of $25,000 in connection with any one audit or investigation." Each "erroneous Medicaid claim leading to an overpayment to a provider is considered, for purposes of [determining the maximum fine allowable], to be a separate violation." Section 409.913(9), Fla. Stat.
"In making a determination of overpayment to a provider, [AHCA must] use appropriate and valid auditing, accounting, analytical, statistical, or peer review methods, or combinations thereof." Section 409.913(12), Fla. Stat.
"When making a determination that an overpayment has occurred, [AHCA must] prepare and issue a[n agency] audit report to the provider showing the calculation of overpayments." Section 409.913(13), Fla. Stat.
The "audit report, supported by [agency] work papers, showing an overpayment to a provider constitutes evidence of overpayment." Section 409.913(13), Fla. Stat.
"In determining the appropriate administrative sanction to be applied, [AHCA must] consider:
1. The seriousness and extent of the violation or violations.
2. Any prior history of violations by the provider.
3. Evidence of continued violation within the provider's management control of Medicaid statutes, rules, regulations, or policies after written notification to the provider of improper practice or instance of violation.
4. Any pain and suffering inflicted by the provider on a recipient.
5. Any action by a licensing agency respecting the provider in any state in which the provider operates.
6. The extent to which a lesser sanction is sufficient to remedy the violation by the provider in the best judgment of [AHCA].
7. The apparent impact on access by recipients to Medicaid services if the provider is suspended or terminated, in the best judgment of [AHCA]." Section 409.913(10), Fla. Stat.
A provider who is the subject of an audit report that reveals an overpayment is entitled to an administrative hearing pursuant to Chapter 120, Florida Statutes, before AHCA takes final agency action ordering repayment and imposing a sanction. Section 120.60(3), Fla. Stat.
In the instant case, Petitioner requested such a Chapter 120 hearing after receiving written notice, in the form of a final audit report, that AHCA's predecessor, the Department, intended to recoup what the Department alleged were overpayments made to Petitioner totalling $112,852.50 and to impose a $5,000.00 fine upon Petitioner for "violation of Medicaid policies" committed in connection with the submission of the claims for which Petitioner was allegedly overpaid. According to the audit report, the Department had completed a review of a random sample of 468 Medicaid claims submitted by Petitioner for services rendered to 40 of Petitioner's patients during the period from July 1, 1990, through December 31, 1991, and that, based upon such review, and using a "generally accepted" "statistical formula for cluster sampling," it had determined that Petitioner had been overpaid $112,852.50 "for claims that in whole or in part [were] not covered by Medicaid."
At the Chapter 120 hearing held in this case, the parties requested the Hearing Officer, and the Hearing Officer agreed, to address in his Recommended Order only those sampled claims about which, as reflected by the parties' post-hearing written enumeration of issues, there remained a dispute following the hearing and to make recommendations on no other issues.
Having carefully considered the evidence adduced at hearing (including, most significantly, the documentation submitted by Petitioner in support of the sampled claims referenced in the parties' post-hearing written enumeration of issues), 40/ in light of the requirements governing the billing

and payment of these claims (as set forth in Petitioner's provider agreement with the Department), the Hearing Officer has made the following findings regarding these claims:

PATIENT	DATE	BILLING	APPROPRIATE ACTION
1	1/6/91	Comprehensive	Downgrade: Intermediate
	1/29/91	Limited	Allow
	4/23/91	Extended	Downgrade: Intermediate
	10/9/91	Strep test	Allow
	10/9/91	Extended	Downgrade: Intermediate
	11/6/91	Cerumen removal	Allow
	11/6/91	Strep test	Allow
	11/6/91	Extended	Disallow
2	11/7/91	Comprehensive	Disallow
	11/7/91	Other Services	Disallow
	10/22/91	Extended	Downgrade: Intermediate
	10/24/91	Routine	Allow
		Venipuncture
	10/24/91	Therapeutic	Disallow
		Injection
	10/24/91	Extended	Allow
3	1/31/91	Comprehensive	Downgrade: Extended
	9/19/91	Extended	Downgrade: Limited
4	10/3/91	Comprehensive	Downgrade: Intermediate
	11/4/91	Extended	Disallow
	11/4/91	Other service	Disallow
5	10/19/90	Comprehensive	Disallow
	10/29/90	Intermediate	Downgrade: Limited
	5/14/91	Comprehensive	Downgrade: Limited
	5/29/91	Extended	Downgrade: Intermediate
	6/12/91	Extended	Downgrade: Intermediate
6	7/12/90	Comprehensive	Allow
	1/14/91	Comprehensive	Downgrade: Intermediate
	1/28/91	Intermediate	Downgrade: Limited
	4/24/91	Comprehensive	Downgrade: Extended
	5/1/91	Intermediate	Downgrade: Limited
7	7/23/91	Intermediate	Downgrade: Limited
8	10/21/91	Comprehensive	Downgrade: Intermediate
9	11/26/90	Intermediate	Allow
	3/28/91	Extended	Downgrade: Limited
	5/6/91	Extended	Downgrade: Brief
	6/17/91	Extended	Downgrade: Intermediate
	8/8/91	Debridement	Allow
	9/27/91	Extended	Downgrade: Intermediate
	10/28/91	Intermediate	Downgrade: Limited
10	2/26/91	EPSDT Screen	Allow
	2/26/91	Comprehensive	Disallow
	3/1/91	Intermediate	Disallow
	3/13/91	Extended	Downgrade: Intermediate
	6/24/92	Extended	Downgrade: Limited
	6/27/91	Extended	Downgrade: Limited
	10/18/91	EPSDT Screen	Allow
	10/18/91	Comprehensive	Disallow
11	10/30/90	Comprehensive	Disallow
	5/9/91	Extended	Downgrade: Limited
12	11/30/90	Comprehensive	Disallow
	12/14/90	Extended	Downgrade: Intermediate

	12/17/90	Intermediate	Allow
	12/27/90	Intermediate	Allow
	1/21/91	Extended	Downgrade:	Intermediate
	6/7/91	Comprehensive	Disallow
	6/21/91	Intermediate	Allow
	7/23/91	Comprehensive	Disallow
13	12/29/90	EPSDT Screen	Disallow
	12/29/90	Comprehensive	Downgrade:	Intermediate
	1/4/91	Comprehensive	Downgrade:	Intermediate
14	4/20/91	Extended	Downgrade:	Intermediate
15	9/20/91	Intermediate	Disallow
16	12/17/91	Comprehensive	Downgrade:	Limited
18	2/12/91	Comprehensive	Downgrade:	Intermediate
	11/18/91	Extended	Downgrade:	Intermediate
	12/9/91	Extended	Downgrade:	Limited
19	9/7/90	Comprehensive	Downgrade:	Limited
	1/31/91	Extended	Disallow
	2/26/91	Comprehensive	Downgrade:	Intermediate
	5/1/91	Comprehensive	Downgrade:	Limited
	5/29/91	Extended	Disallow
21	4/26/91	Comprehensive	Disallow
22	8/28/90	Comprehensive	Disallow
23	7/10/90	Comprehensive	Downgrade:	Limited
	10/15/90	Intermediate	Downgrade:	Limited
	2/15/91	Extended	Downgrade:	Limited
	3/8/91	Extended	Allow
	6/6/91	Extended	Downgrade:	Limited
	6/28/91	Extended	Downgrade:	Limited
	8/1/91	Extended	Downgrade:	Intermediate
	9/5/91	Extended	Downgrade:	Limited
24	12/10/90	Comprehensive	Disallow
	7/2/91	Comprehensive	Downgrade:	Intermediate
25	10/3/91	Comprehensive	Disallow
	10/10/91	Comprehensive	Disallow
	10/16/91	Comprehensive	Downgrade:	Intermediate
	10/24/91	Extended	Downgrade:	Intermediate
26	9/16/91	Comprehensive	Downgrade:	Brief
27	11/4/91	EPSDT Screen	Disallow
	11/4/91	Extended	Downgrade:	Brief or
				Limited
28	5/5/91	Comprehensive	Downgrade:	Intermediate
	5/29/91	Extended	Disallow
	6/12/91	Extended	Disallow
	7/10/91	Intermediate	Disallow
	8/7/91	Extended	Downgrade:	Limited
	9/12/91	Extended	Downgrade:	Limited
	9/19/91	Comprehensive	Downgrade:	Intermediate
	9/26/91	Comprehensive	Downgrade:	Brief
	10/7/91	Debridement	Allow
29	1/28/91	Comprehensive	Downgrade:	Intermediate
	1/30/91	Extended	Downgrade:	Intermediate
	4/22/91	Comprehensive	Disallow
	4/24/91	Comprehensive	Downgrade:	Limited
30	3/11/91	Comprehensive	Disallow
	4/22/91	Extended	Downgrade:	Limited
	6/3/91	Extended	Downgrade:	Limited
31	10/15/90	Extended	Downgrade:	Limited

32	2/12/91	Comprehensive	Disallow
33	12/3/90	Comprehensive	Disallow
	8/22/91	Extended	Downgrade:	Limited
	10/7/91	Extended	Downgrade:	Limited
	10/10/91	Extended	Downgrade:	Intermediate
34	9/19/90	Comprehensive	Disallow
	12/17/90	Extended	Downgrade:	Intermediate
	1/3/91	Comprehensive	Disallow
35	11/15/90	Comprehensive	Downgrade:	Limited
	12/20/90	Comprehensive	Downgrade:	Brief or
				Limited
	7/18/91	Extended	Downgrade:	Brief or
				Limited
	12/4/91	Extended	Downgrade:	Limited
36	1/2/91	Extended	Downgrade:	Intermediate
	4/17/91	Extended	Downgrade:	Intermediate
	9/16/91	Extended	Downgrade:	Intermediate
	10/17/91	Comprehensive	Downgrade:	Intermediate
	11/14/91	Echography	Disallow
	11/14/91	Comprehensive	Downgrade:	Intermediate
	12/3/91	Extended	Downgrade:	Intermediate
	12/10/91	Extended	Downgrade:	Intermediate
37	9/27/91	Comprehensive	Downgrade:	Intermediate
	10/18/91	Comprehensive	Disallow
	11/20/91	Extended	Allow
	11/21/91	Incision and	Disallow
		removal
38	12/2/91	EPSDT Screen	Disallow
	12/2/91	Comprehensive	Downgrade:	Extended
	12/9/91	Comprehensive	Downgrade:	Intermediate
39	9/5/91	Comprehensive	Downgrade:	Intermediate
	9/19/91	Extended	Downgrade:	Intermediate
40	11/26/91	Comprehensive	Downgrade:	Intermediate
	11/29/91	Intermediate	Downgrade:	Limited
41	1/25/91	Extended	Downgrade:	Intermediate
	4/17/91	Comprehensive	Downgrade:	Intermediate
	11/25/91	Comprehensive	Downgrade:	Limited
	12/6/91	Intermediate	Allow

RECOMMENDATION

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

RECOMMENDED that the Agency for Health Care Administration adopt the findings made by the Hearing Officer regarding the sampled claims remaining in dispute in the instant case and use these findings to redetermine the total amount of Medicaid overpayments made to Petitioner during the audit period and the amount of the fine Petitioner should be required to pay for its erroneous billings during this period of time.

DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd of May, 1995.

STUART M. LERNER

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 22nd day of May, 1995.

ENDNOTES

1/ Effective July 1, 1993, by operation of Chapter 93-129, Laws of Florida, the Agency for Health Care Administration (hereinafter referred to as "AHCA" or "Respondent") became the state agency responsible for the administration of the Florida Medicaid program and, as a result, the Department of Health and Rehabilitative Services' successor in this proceeding.

2/ The hearing was originally scheduled for July 28 through July 30, 1993, but was continued on three occasions, once at Respondent's request and twice at Petitioner's request.

3/ The Division of Program Integrity is responsible for monitoring the billing and payment for Medicaid goods and services.

4/ Dr. Sullenberger has held this position for the past seven years. Prior to assuming this position he had been a practicing surgeon specializing in thoracic and cardiovascular surgery. He has never served as a family practice or primary care physician, nor has he ever treated drug abuse or sexual problems.

5/ Petitioner had previously received an extension of time to January 27, 1995, to file its written enumeration of issues.

6/ Dr. Wolland is neither a shareholder nor officer of the corporate entity that owns and operates JMC.

7/ The Physician's Current Procedural Terminology gives examples of these various levels of service. The examples given include, for a brief level of service, "[e]xamination of acute tonsillitis," and for a limited level of service, "[t]reatment of an acute respiratory infection."

8/ Whether, as Petitioner now argues, the visit was actually an "intermediate" one involving a higher level of service than a "limited" visit is an issue that need not be addressed since the visit was not billed as an "intermediate" visit.

9/ Respondent expressed such agreement in its response to Petitioner's written enumeration of issues.

10/ Respondent expressed such agreement in its response to Petitioner's written enumeration of issues.

11/ At hearing, the parties stipulated that, with respect to all medical records offered into evidence that did not bear the signature of the attending physician, the attending physician, if requested to, "would sign the chart" and "would testify that the work was done and that [it was his/her] work and [that (s)he] saw the patient at that time."

12/ JMC also sought and obtained separate payment for an incision and drainage (procedure code 10060). The parties agree that this billing and payment was appropriate.

13/ JMC also sought and obtained separate payment for an incision and drainage. The parties agree that this billing and payment was appropriate.

14/ JMC also sought and obtained separate payment for an incision and drainage. The parties agree that this billing and payment was appropriate.

15/ JMC also sought and received separate payment for the removal of the wart (procedure code 17340). The parties agree that this billing and payment was appropriate.

16/ J.R. had previously visited the clinic on July 30, 1990. At hearing, both parties agreed that this visit was appropriately billed and paid for as an "intermediate" one.

17/ K.G. had previously visited the clinic on January 10, 1991. JMC billed and was paid for this visit as an "extended" one. At hearing, the parties agreed that this January 10, 1991, visit should instead have been billed and paid for as an "intermediate" visit.

18/ JMC also sought and obtained separate payment for the aerosol treatment (procedure code 94664). The appropriateness of this billing and payment is not among the disputed issues listed in either Petitioner's or Respondent's written enumeration of issues and therefore has not been addressed in this Recommended Order.

19/ K.G. had previously visited the clinic on July 16, 1991. JMC billed and was paid for this visit as a "comprehensive" one. At hearing, Petitioner conceded that the visit was only an "intermediate" one.

20/ JMC also sought and received separate payment for an incision and drainage. The appropriateness of this billing and payment has not been challenged.

21/ L.W. had previously visited the clinic on March 7, 1991. At hearing, both parties agreed that this visit was appropriately billed and paid for as an "intermediate" one.

22/ JMC also sought and received separate payment for the impacted cerumen removal. Both parties agree that this billing and payment was appropriate.

23/ R.W. had previously visited the clinic on October 1, 1991. JMC billed and was paid for this visit as a "comprehensive" one. At hearing, the parties agreed that this October 1, 1991, visit should instead have been billed and paid for as an "extended" one.

24/ The Department had preliminarily determined during its audit to allow an office visit, but at the "brief" level, for October 3, 1991. Respondent now takes the position, however, that the "treatment [rendered that day to R.W.] was at a level that would not have warranted an office visit over and above the EPSDT screen."

25/ The Department had preliminarily determined during its audit to allow an office visit, but at the "brief" level, for October 10, 1991.

26/ Although in its written enumeration of issues Petitioner claims that a dispute exists concerning the billing and payment for an office visit by C.S. on July 24, 1991, as Respondent correctly points out in its response to Petitioner's written enumeration of issues "[t]here was no office visit billed for this patient on July 24, 1991." (Indeed, there is no indication in the record that C.S. was even at the clinic on that date.)

27/ Although in its written enumeration of issues Petitioner claims that a dispute exists concerning Petitioner's billing and receiving payment for an office visit by S.S. on February 6, 1991, as Respondent correctly points out in its response to Petitioner's written enumeration of issues "[t]here was no office visit billed [or paid for] this patient on February 6, 1991." (Indeed, there is no indication in the record that C.S. was even at the clinic on that date.)

28/ JMC also sought and received separate payment for the incision and drainage. The appropriateness of this billing and payment has not been challenged.

29/ JMC also sought and obtained separate payment for the impacted cerumen removal. This billing and payment has not been challenged.

30/ JMC also sought and obtained separate payment for the impacted cerumen removal. This billing and payment has not been challenged.

31/ JMC also sought and obtained separate payment for the impacted cerumen removal. This billing and payment has not been challenged.

32/ JMC also sought and obtained separate payment for the impacted cerumen removal. This billing and payment has not been challenged.

33/ JMC also sought and obtained separate payment for the impacted cerumen removal. This billing and payment has not been challenged.

34/ D.W. had previously visited the clinic on January 15, 1991. At hearing, Respondent conceded that this visit was appropriately billed and paid for as an "intermediate" one.

35/ D.W. had previously visited the clinic on July 19, 1991. This visit was billed and paid for as an "extended" one. At hearing, the parties agreed that this billing and payment was not appropriate and that instead the visit should have been billed and paid for as an "intermediate" one.

36/ There is no evidence that the removal was accomplished by making any sort of incision.

37/ JMC also sought and received separate payment for the impacted cerumen removal. This billing and payment has not been challenged.

38/ The records do not reveal that the treatment T.B. received during this visit included the incision or drainage of his abscess.

39/ 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.

40/ Rule 10C-7.061, Florida Administrative Code, which addresses the subject of "determination of [Medicaid] overpayments," provides that, upon request, a provider must supply "legible and accurate documentation" for "services or products billed to Medicaid" and "[i]f such documentation is not furnished by the provider, it will be concluded that the provider was not and is not entitled to payments for any products or services comprehended by the unfurnished documentation."

APPENDIX TO RECOMMENDED ORDER IN CASE NO. 93-1613

The following are the Hearing Officer's specific rulings on the "findings of facts" proposed by the parties in their post-hearing submittals:

Petitioner's Proposed Findings

1-4. Accepted and incorporated in substance, but not necessarily repeated verbatim, in this Recommended Order.

5. Not incorporated in this Recommended Order because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

6-7. Accepted and incorporated in substance.

To the extent that this proposed finding states that "there is no requirement as to when a chart is signed," it has been rejected because it is contrary to the greater weight of the evidence. Otherwise, it has been accepted and incorporated in substance.
First sentence: Accepted and incorporated in substance; Second sentence: Rejected as a finding of fact because it is more in the nature of a summary of testimony adduced at hearing than a finding of fact based upon such testimony; Third sentence: Not incorporated in this Recommended Order because, even if true, it would not have any impact on the outcome of the instant case.
Rejected as a finding of fact because it is more in the nature of a summary of testimony adduced at hearing, and argument regarding the weight to be given such testimony, than a finding of fact based upon such testimony. (The Hearing Officer, however, has considered this testimony and Petitioner's argument relating thereto in making his findings in the instant case).
Second, fourth and fifth sentences: Accepted and incorporated in substance; Remaining sentences: Rejected as findings of fact because they are more in the nature of summaries of testimony adduced at hearing, and argument regarding the weight to be given such testimony, than findings of fact based upon such testimony. (The Hearing Officer, however, has considered this testimony and Petitioner's argument relating thereto in making his findings in the instant case).

(There is no proposed finding of fact 12.) To the extent that this proposed finding suggests that, "in some cases," Petitioner should receive payment or credit for having provided a higher level of service than billed for and received, it has been rejected because it lacks sufficient
evidentiary/record support. Otherwise, it has been accepted and incorporated in substance.
First sentence: Accepted and incorporated in substance; Second sentence (which incorporates Schedule "A"): The proposed findings in Schedule "A" relating to the following claims have been accepted and incorporated in substance: Patient 2, 10/24/91 visit and routine venipuncture; Patient 6, 7/12/90 visit and 4/24/91 visit; Patient 8, 10/21/91 visit; Patient 9, 8/8/91 debridement; Patient 10, 2/26/91 EPSDT screen and 10/18/91 EPSDT screen; Patient 12, 11/30/90 EPSDT screen and 6/21/91 visit; Patient 17; Patient 23, 3/8/91 visit; Patient 28, 5/15/91 visit, 5/29/91 visit, 6/12/91 visit, 8/7/91 visit, 9/12/91 visit, 9/19/91 visit and 10/7/91 debridement; Patient 33, 10/7/91 visit; Patient 36, 11/14/91 echography; Patient 37, 11/20/91 visit; and Patient 41, 12/6/91 visit. The proposed findings in Schedule "A" concerning the following billed and paid-for services have been rejected because they relate to claims not included in the parties' post-hearing enumeration of claims in dispute: Patient 8, 10/21/91 EPSDT screen; and Patient 23, 3/8/91 aerosol treatment. The remaining proposed findings in Schedule "A" have been rejected because they are contrary to the greater weight of the evidence.

Respondent's Proposed Findings

1-15b. Accepted and incorporated in substance.

15c. First sentence: Accepted and incorporated in substance; Remaining sentences: Rejected because they are contrary to the greater weight of the evidence.

16a. First, third and fourth sentences: Accepted and incorporated in substance; Second and fifth sentences: Rejected because they are contrary to the greater weight of the evidence.

16b. Fourth sentence: Rejected because it is contrary to the greater weight of the evidence; Remaining sentences: Accepted and incorporated in substance.

17a. To the extent that this proposed finding suggests that the patient presented with only "two problems," it has been rejected because it is contrary to the greater weight of the evidence.

17b.-18d. Accepted and incorporated in substance.

18e. Rejected because it is contrary to the greater weight of the evidence.

19a. First and third sentences: Accepted and incorporated in substance; Second sentence: Rejected because it is contrary to the greater weight of the evidence.

19b.-19c. Accepted and incorporated in substance.

19d. First and third sentences: Accepted and incorporated in substance; Second and fourth sentences: Rejected because they are contrary to the greater weight of the evidence.

19e. To the extent that this proposed finding refers to a May 1, 1994, visit, it has been rejected because it lacks sufficient evidentiary/record support. To the extent that it refers to a May 1, 1991, visit, it has been accepted and incorporated in substance.

Accepted and incorporated in substance.
First and second sentences: Accepted and incorporated in substance; Third sentence: To the extent that this proposed finding suggests that the patient only had impetigo and no other problem, it has been rejected because it is contrary to the greater weight of the evidence. Otherwise, it has been accepted and incorporated in substance; Fourth sentence: Rejected because it is contrary to the greater weight of the evidence.

22a. Accepted and incorporated in substance.

22b. To the extent that this proposed finding refers to a July 6, 1991, visit, it has been rejected because it lacks sufficient evidentiary/record support. To the extent that it refers to a May 6, 1991, visit, it has been accepted and incorporated in substance.

22c. Accepted and incorporated in substance.

22d. Third sentence: Accepted and incorporated in substance; Remaining sentences: Rejected because they lack sufficient evidentiary/record support.

22e.-22f. Accepted and incorporated in substance.

23a. First four sentences: Accepted and incorporated in substance; Fifth sentence: Not incorporated in this Recommended Order because it would add only unnecessary detail to the factual findings made by the Hearing Officer; Sixth sentence: Rejected because it is contrary to the greater weight of the evidence.

23b.-23e. Accepted and incorporated in substance.

23f. First, fourth and fifth sentences: Accepted and incorporated in substance; Second, third and seventh sentences: Rejected because they are contrary to the greater weight of the evidence; Sixth sentence: Not incorporated in this Recommended Order because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

24a. Last sentence: Not incorporated in this Recommended Order because it would add only unnecessary detail to the factual findings made by the Hearing Officer; Remaining sentences: Accepted and incorporated in substance.

24b. To the extent that this proposed finding refers to a July 9, 1991, visit, it has been rejected because it lacks sufficient evidentiary/record support. To the extent that it refers to a May 9, 1991, visit, it has been accepted and incorporated in substance.

25a.-25c. Accepted and incorporated in substance.

25d. To the extent that this proposed finding refers to a June 8, 1991, visit, it has been rejected because it lacks sufficient evidentiary/record support. To the extent that it refers to a June 7, 1991, visit, it has been accepted and incorporated in substance.

25e. First three sentences: Accepted and incorporated in substance; Remaining sentences: Rejected because they are contrary to the greater weight of the evidence.

25f.-28. Accepted and incorporated in substance.

29. Third sentence: Rejected because it is contrary to the greater weight of the evidence; Remaining sentences: Accepted and incorporated in substance.

30.-31a. Accepted and incorporated in substance.

31b. Last sentence: Rejected because it is contrary to the greater weight of the evidence; Remaining sentences: Accepted and incorporated in substance.

31c.-35c. Accepted and incorporated in substance.

35d. Last sentence: Rejected because it is contrary to the greater weight of the evidence; Remaining sentences: Accepted and incorporated in substance.

35e.-37d. Accepted and incorporated in substance.

38. Second sentence: Rejected as a finding of fact because it is more in the nature of a summary of testimony than a finding of fact based upon such testimony; Remaining sentences: Accepted and incorporated in substance.

39-40f. Accepted and incorporated in substance.

40g. Last sentence: Rejected because it is contrary to the greater weight of the evidence; Remaining sentences: Accepted and incorporated in substance.

40h. Accepted and incorporated in substance.

40i. First and third sentences: Accepted and incorporated in substance; Second and fifth sentences: Rejected because they are contrary to the greater weight of the evidence; Fourth sentence: Not incorporated in this Recommended Order because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

41a.-42c. Accepted and incorporated in substance.

43. To the extent that this proposed finding refers to a October 15, 1991, visit, it has been rejected because it lacks sufficient evidentiary/record support. To the extent that it refers to a October 15, 1990, visit, it has been accepted and incorporated in substance.

44.-45c. Accepted and incorporated in substance.

45d. First and third sentences: Accepted and incorporated in substance; Second and fourth sentences: Rejected because they are contrary to the greater weight of the evidence.

46a.-48a. Accepted and incorporated in substance.

48b. First sentence: Accepted and incorporated in subtance; Second sentence: Rejected because it is contrary to the greater weight of the evidence.

48c.-48g. Accepted and incorporated in substance.

49a. Third sentence: Rejected because, even if true, it would not have an impact upon the outcome of the instant case; Remaining sentences: Accepted and incorporated in substance.

49b. Accepted and incorporated in substance.

49c. Last sentence: Rejected because it is contrary to the greater weight of the evidence; Remaining sentences: Accepted and incorporated in substance.

49d.-53c. Accepted and incorporated in substance.

53d. Last sentence: Rejected because it is contrary to the greater weight of the evidence; Remaining sentences: Accepted and incorporated in substance.

COPIES FURNISHED:

Frank Wolland, Esquire

Law Office of Frank Wolland 11601 Biscayne Boulevard North Miami, Florida 33181

Gordon B. Scott, Esquire Senior Attorney

Agency for Health Care Administration 1317 Winewood Boulevard

Building B, Room 271 Tallahassee, Florida 32399-0700

Sam Power, Agency Clerk

Agency for Health Care Administration The Atrium, Suite 301

325 John Knox Road Tallahassee, Florida 32303

Jerome H. Hoffman, General Counsel Agency for Health Care Administration The Atrium, Suite 301

325 John Knox Road Tallahassee, Florida 32303

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 10 days in which to submit written exceptions. Some agencies allow a larger period of time 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: 93-001613

Issue Date	Proceedings
Dec. 02, 1996	Supplemental Final Order filed.
Jul. 19, 1995	Final Order filed.
May 22, 1995	Recommended Order sent out. CASE CLOSED. Hearing held 06/8-9/94 & 07/25/94.
Apr. 10, 1995	Respondent's Proposed Recommended Order filed.
Apr. 10, 1995	Petitioner's Proposed Recommended Order; Order (For HO Signature) w/cover letter filed.
Mar. 30, 1995	Order sent out. (motion granted)
Mar. 29, 1995	(Petitioner) Motion for Continuance; Cover Letter filed.
Feb. 28, 1995	Response to Petitioner`s response to order for written enumeration of issues filed.
Feb. 24, 1995	Petitioners' response to order for written enumeration of issues filed.
Feb. 24, 1995	Motion for extension of time (Petitioner) filed.
Nov. 29, 1994	Order sent out. (ruling on motion hearing of 11/28/94)
Nov. 21, 1994	(Petitioner) Motion for Continuance filed.
Nov. 17, 1994	Order sent out. (Proposed RO's due 12/9/94)
Nov. 16, 1994	(Respondent) Motion for Extension of Time to File Proposed Recommended Order filed.
Nov. 12, 1994	(Respondent) Response to Order for Written Enumeration of Issues filed.
Sep. 12, 1994	Transcript of Proceedings (Volumes I, II/tagged) filed.
Aug. 09, 1994	Transcript of Proceedings (2 Vols) filed.
Aug. 09, 1994	(Respondent) Notice of Filing filed.
Jul. 27, 1994	CASE STATUS: Hearing Held.
Jun. 10, 1994	Order sent out. (hearing rescheduled for 7/25/94; 10:30am; Tampa; and will continue on the morning of 7/26/94)
Jun. 06, 1994	(Respondent) Proposed Prehearing Stipulation; Notice of Appearance filed.
Apr. 15, 1994	(Respondent) Notice of Taking Deposition filed.
Apr. 08, 1994	(Respondent) Case Status Report filed.
Feb. 08, 1994	Order sent out. (hearing rescheduled for 6/8-10/94; 9:00am; Miami)
Feb. 01, 1994	(Respondent) Motion to Continue Final Hearing filed.
Dec. 09, 1993	Order sent out. (Re: notification of hearing location)
Oct. 06, 1993	Order sent out. (hearing rescheduled for 2/16-18/94; 9:00am; Miami)
Oct. 04, 1993	(Respondent) Motion for Continuance filed.
Jun. 23, 1993	Order sent out. (hearing set for 10/13-15/93) 9:00am; Miami)
Jun. 16, 1993	(Petitioner) Motion for Continuance filed.
Jun. 14, 1993	Motion for Continuance filed.
Apr. 26, 1993	(Petitioner) Response to Initial Order filed.
Apr. 22, 1993	Order Requiring Prehearing Stipulation sent out.
Apr. 22, 1993	Notice of Hearing sent out. (hearing set for July 28-30, 1993; 11:00am; Miami)
Apr. 15, 1993	(Respondent`s) Notice of Response to Petitioner`s Request for Production of Documents filed.
Mar. 30, 1993	Initial Order issued.
Mar. 25, 1993	Notice; Request for Administrative Hearing; Agency Action ltr. filed.

Orders for Case No: 93-001613

Issue Date	Document	Summary
Jul. 17, 1995	Agency Final Order
May 22, 1995	Recommended Order	Examination of documentation furnished by provider reveals that provider was overpaid for various medicaid claims it submitted.

Source: Florida - Division of Administrative Hearings

JAY'S MEDICAL CENTER, INC. vs DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES, 93-001613 (1993)

Docket for Case No: 93-001613

Orders for Case No: 93-001613

Frank Wolland

Frank Wolland

Jeff Goodman

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JAY'S MEDICAL CENTER, INC. vs DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES, 93-001613 (1993)

Docket for Case No: 93-001613

Orders for Case No: 93-001613

Lawyers who claimed

Frank Wolland

Frank Wolland

Jeff Goodman

Counsels

Cites

USC (3)

Florida Laws (2)

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