STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
SIHAM K. TOMA, )
)
Petitioner, )
)
vs. ) CASE NO. 95-2419
) STATE OF FLORIDA, AGENCY FOR ) HEALTH CARE ADMINISTRATION, )
)
Respondent. )
)
RECOMMENDED ORDER
Notice was provided, and on January 25-26, 1996, a formal hearing was held in this case. Authority for conducting the hearing is set forth in Section 120.57(1), Florida Statutes. The hearing location was Tallahassee, Florida.
Charles C. Adams was the Hearing Officer.
APPEARANCES
For Petitioner: W. David Watkins, Esquire
Watkins, Tomasello and Caleen, P.A. 1315 East Lafayette Street, Suite B Tallahassee, Florida 32301
For Respondent: H. Wayne Mitchell, Esquire
Agency for Health Care Administration Fort Knox Building 3
2727 Mahan Drive
Tallahassee, Florida 32306-5403 STATEMENT OF THE ISSUES
Is Respondent entitled to recoup money from Petitioner, which was paid in accordance with the Medicaid reimbursement program?1
PRELIMINARY STATEMENT
On March 24, 1995, Respondent advised Petitioner that Respondent sought repayment of $19,404.89 for Medicaid reimbursement for services which Petitioner provided to Medicaid recipients. Petitioner contested the alleged overpayment. Respondent forwarded the case to the Division of Administrative Hearings on May 9, 1995 to consider the factual dispute between the parties concerning the alleged overpayment. Following one continuance, the case was heard on January 25-26, 1996.
Respondent requested that official recognition be made of statutes and rules in application for the period of January 1, 1990 through December 31, 1991, the period for which Respondent claims that Petitioner was overpaid for services provided to Medicaid recipients. The case proceeded on the basis that
Chapter 409, Florida Statutes, in effect in the applicable period had pertinence. In addition, official recognition was made of relevant provisions in Chapter 10C-7, Florida Administrative Code, in effect in that time period. Subpart A-C of Title 42, Chapter 441.50, 1990 Code of Federal Regulations, pertaining to the federal requirements for the Medicaid Early and Periodic Screening, Diagnostic Treatment Program (EPSDT), for purposes of qualifying for payment for providing these Medicaid reimbursable service was recognized in the relevant period. The Medicaid Physician Provider Handbook was recognized for the relevant time period. The Physician's Current Procedural Terminology Fourth Edition, for the relevant period was recognized. The Medicaid EPSDT Provider Handbook for the relevant time period was recognized.
At hearing, the parties agreed that the burden to prove the alleged overpayment resided with Respondent. That agreement was accepted by the Hearing Officer. In addition, the representation that the proof must be by a preponderance of evidence was found to be acceptable.
Petitioner testified in her own behalf. Petitioner presented the deposition testimony of Ms. Gayle Boltez. Respondent presented Ms. Lynn Troglauer and Dr. John Sullenberger as witnesses. Various exhibits were presented by the parties, as described in the index to the hearing transcript.
The hearing transcript was filed on March 1, 1996. The parties requested, and were granted leave, to submit late-filed Proposed Recommended Orders. The Proposed Recommended Orders were filed on May 13, 1996. As a consequence, the requirement for entering a Recommended Order within 30 days from the date upon which the hearing transcript was filed was waived. See, Rule 60Q-2.031, Florida Administrative Code. The Proposed Recommended Orders and Petitioner's Memorandum of Law have been considered in preparing this Recommended Order. The fact proposals by the parties are commented on in the Appendix attached to this Recommended Order.
FINDINGS OF FACT
General Discussion
Petitioner is a licensed physician who practices pediatric medicine in Florida. Her practice has been located in St. Augustine, Florida, for 23 years. She has been board-certified in pediatrics since 1972.
On November 2, 1982, Petitioner executed a Medicaid Provider Agreement with the State of Florida, Department of Health and Rehabilitative Services, Respondent's predecessor agency. At all times relevant to the inquiry the state agency conducting the Medicaid function in Florida was referred to as the Florida Medicaid Program. The executed Provider Agreement was accepted by the Florida Medicaid Program on December 10, 1982, enrolling Petitioner in the program.
In pertinent part, the Provider Agreement states:
* * *
The provider agrees to keep such records as are necessary to fully disclose the extent of services provided to individuals receiving assistance under the State Plan and agrees to furnish the State Agency upon request such information regarding any payments claimed for providing these services. Access to
these pertinent records and facilities by authorized Medicaid Program representatives will be permitted upon a reasonable request.
The provider agrees that claims submitted must be for services rendered to eligible recipients of the Florida Medicaid Program and that payment by the program for services
rendered will be based on the payment methodo- logy in the applicable Administrative Rule.
The Provider also agrees to submit requests for payment in accordance with program policies.
* * *
7. The provider and the Department agree to abide by the provisions of the Florida Administrative Rules, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations.
* * *
After being accepted as a Medicaid provider, Petitioner was assigned provider number 052775100.
As successor agency to the Department of Health and Rehabilitative Services, Respondent is responsible for the administration of the Florida Medicaid Program.
Among Respondent's responsibilities is the operation of a program to oversee the activities of Medicaid providers, to include recovery of overpayments for services given by Medicaid providers to Medicaid recipients.
In accordance with its authority, Respondent reviewed information concerning Petitioner's service activities as a Medicaid provider for the period of January 1, 1990 through December 31, 1991. To arrive at the amount claimed as overpayment, Respondent used a representative sampling of randomly-selected recipients for whom Petitioner had requested reimbursement for services provided during the relevant period. The number of recipients utilized in the sample was
From its review, and by imposition of a formula and methodology which inferred the overall experience for all recipients who received Medicaid services during the relevant period, Respondent calculated the alleged overpayment.
By extending the information found in the audit concerning the 30 recipients for the period of January 1, 1990 through December 31, 1991, Respondent determined that $27,384.82 was owed for overpayment. The results of this preliminary determination (provisional audit report) were made known to the Petitioner through correspondence dated November 4, 1994.
Further review of the sample medical records was conducted between persons representing Respondent, counsel for Petitioner, and Petitioner. This meeting took place on February 9, 1995. As a consequence, the overall amount of claimed overpayment was reduced from $27,384.82 to $19,404.89 for the subject time period. From that experience, a final agency audit report was completed. On March 24, 1995, this report was sent to Petitioner. Petitioner contested the proposed final disposition, leading to the hearing conducted to resolve the dispute between the parties over the amount claimed as overpayment.
At issue in the present proceeding is the question of whether the records maintained by Respondent are adequate to justify the reimbursement claims made in the instances where the sample group was provided medical services by Respondent. A related question is also raised concerning Petitioner's records, as they pertain to the level of service for which Petitioner claims reimbursement.
There is no contention by Respondent that Petitioner has committed fraud or acted dishonestly in submitting the requests for reimbursement for services rendered to Medicaid recipients. In all instances under discussion, where Petitioner sought reimbursement for services rendered, recipients were seen in an office visit.
To assist Petitioner in maintaining necessary records to identify the nature of services provided to Medicaid recipients, to identify levels of services provided, and to invoice Respondent for those services, Petitioner had been made aware of the pertinent Florida Statutes and rules, together with Medicaid Provider Handbooks and claims forms. That information was available to Petitioner when submitting claims for reimbursement for services provided for the 30 recipients in the sample for the period of January 1, 1990 through December 31, 1991.
Two categories of services by Petitioner are at issue. The first category concerns recipients who present with complaints which are addressed by the provider. The second category concerns EPSDT recipients. This category is a preventive health screening examination for Medicaid-eligible children and young people under the age of 21. Examples of both categories were found within the recipient sample audited by Respondent for the questioned period.
The Medicaid Physician Provider Handbook describes Petitioner's record-keeping responsibilities and the opportunity to review the records, wherein it states:
Record Keeping
You must retain physician records on services provided to each Medicaid recipient. . . .
Examples of the type of Medicaid records that must be retained are:
Medicaid claim forms and any documents that are attached,
treatment plans,
prior authorization information,
any third party claim information,
x-rays,
fiscal records, and
* * *
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.
* * *
Authorized state and federal staff or their authorized representatives may audit your Medicaid records. . . .
The Medicaid EPSDT Provider Handbook describes the components for the health screening examination. Those components are health and developmental history, unclothed physical assessment or examination, nutritional assessment, updating of routine immunizations, laboratory tests, developmental assessment, vision screening, and hearing screening. EPSDT services also include possible referrals for medical treatment, visual, dental and hearing services.
As to immunizations, there is a requirement for accountability for each vaccine administered. This means that the provider must maintain a record when vaccines are administered. In this case Petitioner met this requirement.
When a child appears for EPSDT screening the provider must always perform a health and developmental history, physical examination, vision screening, including a check of the eyes, hearing screening, including a check of the ears, developmental assessment and nutritional assessment.
This process contemplates the necessity for noting the results obtained in the screenings, normal or abnormal, as a means to track the child's health and development.
According to the Medicaid EPSDT Provider Handbook, the record keeping associated with the EPSDT screening process includes the need to be mindful of:
The purpose of a health and developmental history is to gather information about those diseases and health problems for which no standard screening test has been developed and to compile historical information about the child and the child's family. The
health and developmental history should also provide information on the child's brothers and sisters; growth history; conditions suffered by blood relatives; previous medications; immunizations or allergies;
and developmental history of the child and other family members.
Unclothed physical examination
The physical examination includes specific screening elements as appropriate for the child's age and health history, including:
General appearance.
Body measurements.
Skin examination.
Blood pressure.
Heart sounds.
Ausculation of lungs.
Pulse.
Palpation of abdomen of musculature, organs, masses.
Inspection of genitalia.
Vocalization and speech appropriate for age.
Facial features.
Chest configurations and respiratory movements.
Muscle tone.
Gross/fine motor coordination.
Inspection for scoliosis.
Ears, nose, and throat inspection.
The Department of Health and Human Services, Health Care Financing Administration, defines a developmental assessment as the range of activities surrounding the exami- nation of the child, adolescent, and young
adult in order to determine whether they fall within the normal range of achievement for
the child's age group and cultural background. The developmental assessment is performed at the time of screening for all ages. Infor- mation from the parent or other person who
has knowledge of the individual, observation, and talking with the individual are utilized in assessing the individual's behavior.
The following elements are recommended to be included in the developmental assessment of children of all ages:
Gross motor development, focusing on strength, balance, locomotion.
Fine motor development, focusing on eye-hand coordination.
Communication skills or language development, focusing on expression, comprehension, and speech articulation.
Self-help and self-care skills.
Social-emotional development, focusing on the ability to engage in social inter- action with other children/adolescents, parents, and other adults.
Cognitive skills, focusing on problem solving or reasoning.
The assessment of the child's nutritional status, eating habits, including the use of alcohol and tobacco, is taken at the time of the physical examination.
The guidelines for visual screening are listed below:
Birth through one year.
General external examination and evaluation of ocular motility.
Gross visual acuity examination with fixation test.
Testing light sense with pupillary light reflex test.
Intraocular examinations with ophthalmo- scope.
Two to five years.
Visual acuity for distance should be tested separately for each eye. The illiterate E test, the STYCAR (Screening Test for Young Children and Retardates) or the Lippman Matching Symbol Chart - HOTV may be utilized. Children from two to five years of age should be tested at 10 to 15 feet.
To determine muscle balance, a cover test and the Hirschberg test (corneal light reflex) should be given. Parents should be asked whether they notice the child's eyes ever turning in or out.
All individuals ages 5 through 20 years should be evaluated for distance visual acuity utilizing the illiterate E or the Snellen letters for a linear fashion. The testing should be at 20 feet.
Individuals who wear glasses should be tested while wearing their glasses.
Children should be tested using an appropri- ate test such as the Hear Kit, Weber, Rinne, or puretone along with history from the parent or guardian.
Beyond the instructions set forth in the Medicaid EPSDT Provider Handbook, which have been referenced, Petitioner has not received additional instructions from Respondent concerning the manner in which records should be maintained related to EPSDT screens performed.
In this case, Respondent does not question Petitioner's EPSDT screenings performed, as to the frequency and interval between screening examinations. Respondent has challenged the request for reimbursement for the EPSDT screens in the sample based upon the assertion that inadequate documentation exists to justify reimbursement for the screenings.
Having in mind the need to maintain adequate records to justify the treatment and claim for reimbursement for services, the Medicaid Physician Provider Handbook describes the basis for reimbursement for services provided to recipients. That reimbursement scheme is associated with six levels of service. Those levels of service are identified by procedure codes established in the underlying Physician's Current Procedural Terminology, Fourth Edition.
The levels of service in contest are limited, intermediate, extended, and comprehensive. The levels of service are defined as follows:
Limited is a level of service used to evaluate a circumscribed acute illness or to periodically reevaluate a problem in- cluding 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 discussion of findings.
Intermediate level of service pertains to the evaluation of a new or existing cond- ition complicated 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 judgement including a detailed history, review of medical records, examination, and a formal conference with
the patient, family, or staff; or a compar- able 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 history, system review, complete physical examination, and ordering appropriate tests and procedures.
The billing number codes set out in the Physician's Current Procedural Terminology, Fourth Edition, are related to new patients and established patients and the coding for the level of service is equated as:
New patient:
90010 limited service
90015 intermediate service
90017 extended service
90020 comprehensive service
Established patient:
90050 limited service
90060 intermediate service
90070 extended service
90080 comprehensive service
To be reimbursed for services provided, consistent with the Medicaid Physician Provider Handbook, Petitioner utilized the Illustration 4-1.VHCFA-1500 Claim Form.
To be reimbursed for Medicaid EPSDT screening performed, Petitioner utilized the Illustration 4-1.EPSDT Claim Form.
Respondent has not challenged the manner in which Petitioner prepared and submitted the claim forms in its sample audit.
For the period of January 1, 1990 through December 31, 1991, in the sample group for 30 recipients, Respondent did not disallow claims for reimbursement for services performed for recipients 6, 8, 20, 22, 23, 24, 27 and 28.
In addition, at hearing, Respondent agreed that the payment for services performed for Recipient No. 3, on August 17, 1991, should remain as claimed. Similarly, the payment for services performed for Recipient No. 15, on December 14, 1990, should remain as claimed. The payment for services performed for Recipient No. 21, on December 12, 1990, should remain as claimed. Finally, the payment for services performed for Recipient No. 19, on May 25, 1990, should remain as claimed.
At hearing, Petitioner agreed with Respondent that the services provided to Recipient No. 2, on August 17, 1991, should have been billed as a limited level of service.
Petitioner conceded that the claim for reimbursement for services to Recipient No. 21 rendered on February 10, 1990 should be as a limited level of service as Respondent contended.
Other contested payments must be resolved.
In the instance where Respondent has agreed to allow the claims for reimbursement to be honored, this would cause the ultimate claim for overpayment pursuant to the formula and methodology to be adjusted. That adjustment is not made on this occasion based upon the agreement by the parties to bifurcate consideration of the propriety of using the formula and methodology and the need to recalculate the overpayment claim by employing the formula and methodology.
Dr. John Sullenberger testified concerning the medical services provided to recipients. He identified the nature of the services. He is an expert in medicine. His practice had been as a board-certified thoracic- cardiovascular surgeon. He has not practiced as a general practitioner or pediatrician.
Dr. Sullenberger had reviewed the records in the sample group and assisted Respondent in its determination concerning the appropriate level of service for payment and the adequacy of Petitioner's records. Dr. Sullenberger offered his opinion concerning the care rendered and the records kept, as that
would influence assigning the proper level of care for reimbursement purposes and payment for EPSDT screening.
Petitioner testified concerning her records and the care provided to the recipients, as a means to address record keeping, assignment of levels of care and payment. She placed emphasis on the fact that in some instances a greater effort was made to attend the recipients due to their age and inability to cooperate in their care.
As described in the Medicaid Physicians' Provider Handbook, the levels of care ". . . 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".
In deciding the facts, the physician's insights have been relied upon in determining the extent to which Petitioner exercised these criteria.
However, the ultimate determination concerning the proper assignment of level of care has been made by the fact finder, as a means to resolve the factual dispute between the parties and offer recommendations concerning the appropriate legal outcome in this case.
Contested Claims Recipient No. 1 (K.H.):
K.H. was born August 1, 1981.
Petitioner provided services to K.H. on August 28, 1990. The services were billed at an extended level. Respondent asserts that the services should be compensated at an intermediate level.
Petitioner's medical records reflect that recipient's height, weight, and temperature, together with blood pressure were observed. The presenting complaint was a stomachache and fever. The temperature was 103 degrees Fahrenheit. According to the medical records, the recipient's ears, throat, neck glands, chest, and cardiovascular system were examined, and a complete blood count was done, with a SMA6 test to check kidney function. A mono spot was done. The recipient was checked for strep. The throat was inflamed. The strep culture revealed a positive result. Consequently, Petitioner prescribed an antibiotic to treat the condition. The child was observed to be somewhat obese. As would be expected, Petitioner explained the child's condition to the parent and the procedures to be followed in dealing with the problems. A urine culture was conducted to rule out possible urinary tract infection, which might be responsible for abdominal pain.
The proper billing for this visit was an intermediate level of service.
Petitioner rendered services to Recipient No. 1 on October 23, 1991. Her height and weight were recorded. Her blood pressure was taken. The visit was for a checkup based upon trouble which the child was having in school related to her behavior. The clinical examination results in the medical records reflect negative results. However, the records reflect that the child was obese and difficult to evaluate in her abdomen. The medical note refers to difficulty in feeling the liver and spleen and identifying any possible masses. A SMA24 was ordered as a means to address the behavioral problem. A thyroid profile was ordered to exclude the possibility of hyperthyroid condition, which
can make the child hyper. The child's urine was checked to see if a urinary tract infection had cleared up from a prior occasion.
The SMA24 was a complete examination of the liver function to check lipids and cholesterol, among other things. This test was principally designed to check the child's liver.
The clinical examination and tests that were ordered were designed to address possible physical causes for the child's behavior.
The medical record reflects that dietary instructions were also given. This was a counseling session with the parent to explain what would be advantageous in the diet and what would not be. At the same time, discussion was given concerning the advantage of exercise in dealing with the obesity. As was customary, the parent or guardian was made aware of the purposes of the tests that were ordered. For these services, the visit was billed as a comprehensive level. Respondent asserts that the level should have been a limited visit. The proper billing for this visit is a limited level of service.
Recipient No. 2 (T.S.):
This recipient was born on July 7, 1977.
On January 17, 1990, Petitioner rendered services to the recipient.
Petitioner mistakenly filed a claim for reimbursement for venipuncture, based upon confusion concerning the appropriate code number to be assigned. In fact, a throat culture had been performed, not a blood test. Eventually, this problem was rectified.
On January 17, 1990, Petitioner billed under a code related to venipuncture, which was a $2.00 charge. In fact, venipuncture was not performed on the recipient. In addition, the charge for a quick strep test performed on the recipient was miscoded. Instead of a quick strep test, it was coded for a bacterial culture. The bacterial culture code only paid $8.00. The quick strep test code, had it been utilized in requesting reimbursement, paid $11.00.
Having used the wrong codes, Petitioner was paid $2.00, to which she was not entitled, for venipuncture. Petitioner was paid $8.00 for the quick strep test, less than the normal $11.00.
On the same date, the child was seen by Petitioner complaining of right neck pain, spreading to his right ear. His blood pressure was taken. The reading was 140/85. By history, the recipient was known to have high blood pressure. The child's ears, nose, throat, glands, chest, and heart were checked. A throat culture was performed based upon inflammation which was observed in his throat. He had enlarged lymph nodes in his neck on one side. A strep culture was performed. Antibiotics were prescribed pending the results of the strep test. The blood pressure was considered elevated.
Petitioner billed this visit as an intermediate level. Respondent asserts that the level of service is a limited visit. The proper billing for this visit is a limited level of service.
Recipient No. 3 (P.J.):
The recipient was born on March 15, 1981.
Petitioner rendered services to P.J. on April 13, 1991. When the child was seen, she presented a complaint that bumps were on her tongue for a week. This was the first time that the recipient had been seen by Petitioner. Her weight, height, and blood pressure were taken and recorded. The recipient was given a thorough clinical examination. The clinical examination had no findings other than a small one-eighth-inch lesion on the tip of the recipient's tongue. At that time, it was assumed that the child may have bitten her tongue. The child was not believed to have infection, but her gums, tongue, and throat were examined. As part of the physical examination, the chest, heart, and cardiovascular system were also examined. The child's abdomen and genitalia were examined.
Petitioner billed the visit as a comprehensive visit based upon the fact that this was the initial visit for the recipient, not based upon the observations concerning the lesion on the tongue, which were not found to be a significant medical problem.
Patient history to include a list of illnesses, immunizations, and allergies for the recipient is set forth in a history and immunization record kept by Petitioner.
Respondent asserts that the level of service performed on April 13, 1991 was a limited level. The proper billing for this visit was a limited level.
Recipient No. 4 (V.K.):
V.K. was born on September 25, 1983.
Petitioner rendered services to V.K. on March 8, 1990. The child's weight and height were taken. She presented with a low-grade fever and a headache. Her bodily systems were examined. In the examination, Petitioner noted that her tonsils were covered with exudate. Otherwise, her condition was normal based upon a physical examination. A strep screen was performed, which revealed negative results. Petitioner prescribed an antibiotic based upon the appearance of the recipient's tonsils.
Petitioner considered recipient's presenting complaints to be vague. The problem with fever could have been based upon problems anywhere in the system. The child did not have a cold and the headache necessitated a good examination. The only findings by Petitioner related to the inflamed tonsils. As was customary, the recipient's condition was discussed with the parent.
The services were billed as a comprehensive visit. Respondent asserts that the services should have been billed as a limited visit. The proper billing for this visit was a limited level of service.
V.K. was seen on February 6, 1991. Her height and weight were taken. It was noted in the patient records that the presenting complaint was a cold with a lot of coughing. The recipient was also due to have surgery on February 20, 1991. Upon examination, the recipient had inflamed tonsils and nasal congestion. No other significant physical findings were observed. Petitioner prescribed medication for the congestion and an antibiotic for the child's throat condition.
The February 6, 1991 visit was billed as an extended service. Respondent asserts that the visit should be billed as a limited service. The proper billing for this visit is a limited level of service.
V.K. was seen again on April 13, 1991. As noted in the medical records, the child presented with a cold, low-grade fever, and severe coughing all of the time. A physical examination was made of all systems, and the recipient was found to have an inflamed throat. Otherwise, the physical examination revealed no significant findings. Petitioner prescribed an antibiotic for six days and a cough decongestant to attend the symptoms.
Petitioner billed this service as an intermediate visit. Respondent asserts that the proper billing is a limited service. The proper billing for this service is a limited level of service.
Recipient No. 5 (L.D.):
L.D. was born on May 25, 1983.
Petitioner saw the recipient for the first time on September 8, 1990. The recipient's height, weight, and blood pressure were recorded. The child had been sent home from school with inflammation in his eyes. The child's mother also reported that the child was hyperactive. A clinical examination was performed. No significant findings were made concerning the child's eyes. They were not observed to be inflamed. While attending the child, Petitioner did not observe any signs of hyperactivity. Nonetheless, an appointment was made for the child to be seen at the behavior clinic at Nemour's Hospital in Jacksonville, Florida. To perform the examination and observe the child's activities would take approximately 30 minutes.
Petitioner billed the visit as a comprehensive service. Respondent asserts that the visit should be billed as an intermediate service. The proper billing for the visit is an intermediate level of service.
Recipient No. 7 (T.R.):
T.R. was born on September 9, 1984.
On March 24, 1990, petitioner rendered services to T.R. The services were billed as an EPSDT screen. In particular, the child was brought to Petitioner to perform a school physical. The child's weight and height and blood pressure were taken and recorded. The child was examined physically and found to be normal. It was also noted that the child was a "healthy boy".
On this visit a student health examination form was filled out but not maintained. A copy of that form was retrieved noting the date of examination and information about the physical examination, to include the results of an eye examination. The results of that eye examination are also shown in the Petitioner's medical records for T.R.
No information is recorded in the health history portion to the student health examination form. The form notes that T.R. was a "healthy boy".
Petitioner contends that the student health examination form, which was executed for T.R., sufficiently responds to the need to address all mandatory screens. The student health examination form is insufficient to meet the requirements for mandatory screens.
Information was found in the records maintained by Petitioner related to circumstances at birth, family history, birth and development, feeding history, immunization and skin testing. Growth charts were also in evidence.
Rather than completely deny Petitioner reimbursement, Respondent converted the visit to a limited service visit. Sufficient services were provided to justify payment as a limited service visit.
On October 18, 1990, Petitioner provided medical services to T.R. At that time, the child's weight and height were taken. As reflected in the records, the child presented with an earache for the past two nights and a fever. A physical examination was performed on the child on this date. The ears were not found to be inflamed. The ears did have wax in them. The throat was inflamed. The child had a postnasal drip causing pressure in the ears, leading to an earache. The child was treated with antibiotics.
Petitioner billed for the visit as an extended service. Respondent asserts that the billing should be as a limited level of service. The proper billing for this visit is a limited service.
Petitioner saw T.R. on October 22, 1991. At that time, the child's weight and height were taken. He was being seen for a checkup. He was also having a problem holding his urine and had wet his bed the night before. A physical examination was made, with normal findings. The child was subject to a routine urinalysis to rule out bladder or kidney infection. There might be other explanations for the bed-wetting, to include nervousness. Upon examination, there were no obvious explanations for the problem.
Petitioner billed for this visit as an extended level of service. Respondent asserts that the level of service was a limited visit. The proper billing for this visit was a limited level of service.
Recipient No. 9 (A.N.):
A.N. was born on April 27, 1987.
Petitioner saw the recipient on February 23, 1990. A.N. was measured and weighed. The presenting complaint was congestion and a cough for a week. A physical examination was performed. His throat showed a little irritation but no inflammation. The nostrils appeared congested. No other significant findings were made concerning the child's condition. Petitioner prescribed medications for the cough and congestion. The child was also given vitamins.
As in all cases discussed, the parent was informed of the findings and future treatment.
Petitioner billed the visit as a comprehensive service. Respondent asserts that the service was a limited service. The proper billing for this visit was a limited level of service.
On November 12, 1990, the child was provided medical services by Petitioner. The child was weighed and his height recorded. The presenting complaint was vomiting and diarrhea for six to seven days. A physical examination was performed. Some tinea infection was found on the skin. Medications were prescribed and the parent instructed concerning those medications as a means to address the vomiting and diarrhea. In addition, a
prescription was given for a fungus infection on the face. The parent was instructed concerning the contagious nature of the fungus and its consequences.
Petitioner billed this visit as an extended level. Respondent asserts that the service is an intermediate level. The proper billing for this visit is an intermediate level of service.
On May 24, 1991, the child was seen by Petitioner for a school physical. The child was also seen for complaints that he had problems with bed- wetting and that his legs hurt. A school physical examination was performed. The child appeared to be healthy. Because the child complained of his legs hurting, Petitioner sent the child for laboratory work to rule out problems with anemia and to also examine his kidney function. A urine culture was also ordered for the child to rule out urinary tract infection. Petitioner filled out the student health examination form but did not maintain it for her records and has not retrieved it for hearing purposes. No other notations were made concerning the examinations for the school physical.
Growth charts were maintained.
Petitioner billed for an EPSDT screening. Petitioner did not bill for treatments associated with the physical complaints by the child. Respondent asserts that the billing should be for a limited service.
For reasons described in discussing the screening for Recipient Number 7, as well as the unavailability of the student health examination form for audit purposes, the billing for an EPSDT screening should not be allowed. In this connection results from vision screening were not available. For reasons that Respondent had allowed a claim for a limited service in substitution for the EPSDT screening reimbursement; and based upon the services provided in addressing the physical complaints, the proper billing is for a limited service.
Recipient No. 10 (K.L.):
K.L. was born on November 13, 1986.
Petitioner provided medical services to K.L. on March 18, 1991. The child was weighed and the height was recorded. In the visit it was indicated the child had been sent home last week from school with a fever. A physical examination was performed. The child was not especially cooperative and was difficult to examine. Significant findings in the examination were inflammation in the ears and throat. Petitioner prescribed antibiotics for the throat condition.
Petitioner billed the visit as a comprehensive service. Respondents asserts that the service is an intermediate level. The proper billing is an intermediate level of service.
Recipient No. 11 (R.H.):
R.H. was born September 21, 1989.
Petitioner saw R.H. on January 19, 1990. At that time, the child was weighed, her height and head circumference were also noted. The checkup that was being performed on R.H. was in the series envisioned by the EPSDT screening program. The physical examination conducted on the child indicated that this was a "healthy baby". The information that was recorded concerning the child's
height and weight and head circumference was for purpose of charting her growth compared to the expected growth.
A document was found with the child's records which related to information concerning her birth date, family history, early birth and development, and feeding history.
Growth charts were maintained.
The child was seen again on March 19, 1990 for a checkup and shots associated with the EPSDT program. The weight, height and head circumference were recorded. It was noted that the child was not sitting up yet. The physical examination was normal, notwithstanding the observation that the child was not yet sitting.
Petitioner billed the January 19, 1990 and March 13, 1990 visits through the EPSDT screening program. Respondent asserts that the billings should not be allowed. The billings were deficient in that necessary information was not provided for the health and developmental history, vision screening, hearing screening, developmental assessments and nutritional assessment.
For the January 19, 1990 and March 13, 1990 Respondent asserts that the proper reimbursement is as a limited level of service visit. That position is accepted.
Petitioner provided medical services to R. H. on June 6, 1990. At that time there was a complaint concerning the child having diarrhea lasting a week. The diarrhea cleared up and then reoccurred on the date the visit was made. The child was also congested. The physical examination revealed an offensive odor and loose stool in the child's diaper. The chest revealed bilateral rales, meaning there was mucus present. The child had thoracobronchi. Her throat was inflamed. The mother was instructed to take a stool specimen to the laboratory. Medication was prescribed for diarrhea and instructions given concerning its use. The child was provided a bronchodialator. The child was given a cough congestion medication. There was a suspicion the child had bowel infection as well as upper respiratory infection.
The visit was billed as an extended service. Respondent asserts that the proper classification is an intermediate service. The proper classification is an intermediate level of service.
Recipient No. 12 (F.W.):
F.W. was born on February 26, 1990.
She was seen by Petitioner on April 17, 1990. At that time the child's weight, height and head circumference were noted. It was noted that the child was receiving a soy formula. The child seemed to have elephant ears. A mild diaper rash was observed, otherwise, the child's physical examination revealed normal results. It was noted that the child was born at University Hospital in Jacksonville and was overdue at birth; however, the child was "ok" at birth.
The elephant ears would need treatment at a later date. Medication was prescribed for the diaper rash.
The parent was told about the problems with the child's ears and the treatment for diaper rash.
Petitioner billed this visit as a comprehensive service.
Respondent asserts that the appropriate level of service was limited. The proper billing for the visit was a limited level of service.
On May 11, 1990 the child was seen for an EPSDT checkup. The child's weight, height and head circumference were recorded. At that time the child was two months old. A physical examination was performed. It only revealed two lesions on the lower left abdomen which looked like infected bumps or possible scabies. An antibiotic cream was prescribed for this condition and its use was explained to the parent.
A document in the records maintained by the Petitioner entitled, Patient History Chart, contains information about the child's date of birth, birth history, family history, nutritional history and illness history. The document describes developmental history at age 16 weeks. A growth chart was also maintained.
On June 29, 1990, Petitioner saw the child again and weight, height and head circumference were noted. This was a routine check under the EPSDT program. It was noted that the child was doing well and that there was "no more spitting up". The physical examination revealed "an alert happy baby". There was some reference to the need to repeat a CBC study for blood count. The reason for repeating laboratory tests was based upon laboratory results received by Petitioner for laboratory work done on June 19, 1990. The parent was instructed to bring the child back for follow-up on July 30, 1990. That appointment was not kept.
On August 20, 1990, the child was seen for a checkup and to fill out information for referral to the WIC program to qualify for participation in that program. There is a form which is utilized to apply for participation in the WIC program. It concerns an assessment of nutritional risk factors as a means to gain participation in the WIC program. Petitioner indicates that the form was filled out, but it was not maintained by Petitioner in her records. Thus it was not available for examination as part of the audit process involved in this case.
On this date the physical examination revealed raised lateral lesions on the upper arm, abdomen and chest. These were reported to be mosquito bites. As noted the parent was advised to keep "an eye" on the condition for a week.
It was noted that the physical examination did not reveal any other findings.
Petitioner submitted bills under the EPSDT program for the visits on May 11, 1990, June 29, 1990 and August 20, 1990. Inadequate documentation was maintained to qualify for reimbursement for those charges for screens other than the physical examination. It is appropriate for Respondent to have paid for those visits as a limited level of service.
On November 21, 1990, Petitioner provided medical services to F.W. The weight of the child was noted. The child presented as having a cold for 2 days. A physical examination was conducted. The throat was found to be inflamed, the nostrils evidence nasal congestion. A yeast diaper rash was found. Antibiotics were prescribed for her throat together with decongestion drops.
This visit was billed as an intermediate level visit. Respondent asserted that the proper billing is as a limited level of service. The proper billing is as a limited service.
The child was seen again on February 16, 1991. She came for the visit because she had a cold for 2 - 3 days. She was throwing up the formula which she was receiving. Upon physical examination the child was found to have "pus" on her throat surface. A strep screen was conducted and the results were positive. Antibiotics were prescribed together with a decongestant for cough and congestion.
Petitioner billed this as an intermediate level service. Respondent asserts that the level of service is a limited level of service. The proper billing is as a limited level of service.
On July 24, 1991, a further EPSDT visit was made, together with an examination for WIC qualification. The WIC referral form was not maintained for review. Upon the physical examination, the weight and height were recorded.
The physical examination performed showed a mild diaper rash. Otherwise the child was found to be in acceptable health. The child was sent for a hemoglobin hematocrit for the purposes of the WIC qualification.
The Petitioner billed this as a EPSDT screening. Petitioner is not entitled to reimbursement for that screening in that the records maintained were insufficient to document the assessment process other than the physical examination. It was appropriate for Respondent to reimburse this visit as a limited level of service.
Recipient No. 13 (S.S.):
S.S. was born on July 2, 1991.
On July 5, 1991 Petitioner provided medical services to the child. The child's weight, length and head circumference were taken. The visit was the first checkup performed by Petitioner. The baby had been delivered at term through a normal delivery. The infant was found to have mild to moderate jaundice. Otherwise the physical examination did not reveal any significant findings. The cord clamp was removed. A test was ordered to determine the level of jaundice in the blood. The results of that test were recorded and discussed with the mother.
It was noted that the mother was breast feeding the infant and using formula as well.
This visit was billed as a comprehensive service. Respondent asserts that the service was an extended service. The proper billing for the visit was an extended level of service.
On July 16, 1991 the baby was brought in for a checkup. The checkup was in accordance with the EPSDT screening program. The child's weight, length and head circumference were taken. A physical examination was made. At that time the child was on formula. It was noted that the weight gain for the child was good. Medication was prescribed for thrush. Thrush is a fungus growth inside the mouth of babies.
Within the records maintained by Petitioner is a history and immunization document which reflects the date of birth and limited family history. Information related to the child's condition at birth is noted. In addition, there are growth charts.
Given the child's age relating to birth, information contained in the records satisfies the requirement to document information gained in the screens that were conducted on July 16, 1991. Therefore, the EPSDT reimbursement claim should be allowed. Respondent has authorized payment for this visit as a limited service. That is an inappropriate payment for the visit.
On August 2, 1991, a further visit was made. This visit was billed as an EPSDT screen. Petitioner believes that the visit was related to problems with the infant not tolerating her formula. This is born out by an office note which describes a change in the formula. That note also reflects the child's weight. The physical examination revealed normal circumstances with good weight gain. Petitioner conceded that the process engaged in addressing the child's needs on this visit might not have been done in the manner in which the July 16, 1991 examination was performed as to comprehensiveness.
The August 2, 1991 visit which was billed as an EPSDT screen should not be paid for under that billing code. The emphasis placed in the care rendered by Petitioner does not correspond to the EPSDT screening process. The decision by Respondent to pay for this visit as a limited service is acceptable.
On September 3, 1991 the child was brought in for a checkup and shots. The weight, height and head circumference were recorded. The physical examination was noted as normal and the child was described as "a healthy baby".
This visit was billed under the EPSDT screening program. There is insufficient documentation to justify reimbursement as an EPSDT screening concerning all screens other than the physical examination. The decision by the Respondent to pay for this visit as a limited service visit is acceptable.
On November 4, 1991, the child was seen for a checkup and shots. This visit was billed as an EPSDT screen. At the visit, the weight, height and head circumference were noted. The physical examination was noted as normal. As noted the child was cutting her lower incisors. It was noted that the baby was big for her age.
There is insufficient documentation to justify reimbursing Petitioner under the EPSDT program for the visit on November 4, 1991. The decision by Respondent to pay for the visit as a limited service is acceptable.
On December 11, 1991 the infant was seen again because she was experiencing a cough and runny nose. She was weighed and a physical exam was performed. It was noted that nostrils were irritated and the throat was irritated. It was noted that the child was drooling and teething. A decongestant was prescribed, together with nose drops and ear drops.
This visit was billed as an intermediate service. Respondents asserts that the visit should be billed as a limited service. The proper billing for this visit is as a limited level of service.
Recipient No. 14 (B.L.):
B.L. was born on August 25, 1987.
Petitioner provided medical services to the child on June 18, 1990. At the visit, the child's weight and height were taken. The presenting complaint was fever for 3 or 4 days and sand sores. The physical examination revealed that the child's tonsils were inflamed. Impetigo lesions were also found on the child's legs which corresponded to the description "sand sores". The child was provided an antibiotic by mouth and an antibiotic for the skin lesions. She was also provided vitamin drops. The oral antibiotic was given for inflamed tonsils. The infection on the skin and in the throat was possibly caused by the same process of infection. Explanation was provided to the parent concerning treatment of the impetigo.
This visit was billed as an extended service. Respondent asserts that these visits should be reimbursed as an intermediate service. The proper billing for this service is as an intermediate level of service.
The child was seen again on August 13, 1990. Her weight and height were recorded. On this visit the mother was worried about the child possibly being deaf. In addition, there was concern about the child being hyperactive based upon the child's discharge from day care for reason that the daycare staff could not control her. The physical examination revealed normal results. However the child was observed to be very hyperactive. The child was referred for a hearing examination and a short course of Ritalin was prescribed to address the hyperactivity.
This visit was billed as an extended service. Respondent asserts that the visit should be billed as an intermediate service. The proper billing is as an intermediate level of service.
On December 6, 1991, the child was seen again. Her weight and height were recorded. The presenting complaint was a fever since yesterday and a bad cough. Upon physical examination the throat and tonsils were found to be inflamed. A strep screen was performed and the results were negative. Antibiotics were prescribed for the inflammation of the throat and tonsils. A decongestant cough medicine was prescribed. Medication was prescribed for the fever.
Petitioner billed this visit as an intermediate service. Respondent asserts that it should be reimbursed as a limited service. The proper billing is as a limited level of service.
Recipient No. 15 (D.T.):
D.T. was born on November 27, 1990.
On December 1, 1990, Petitioner provided services to D.T. This was the first visit for the infant. The weight, height and head circumference were taken. As reported, things went well at birth. The mother was breast feeding the child. Upon physical examination the child was found to be mildly jaundiced Inquiry was made concerning the blood group for the mother and infant. The results did not to prove to be significant. The clamp was removed from the cord.
Information was maintained concerning the family history, birth and development and feeding history. This information was recorded on a sheet which related the date of birth that had been mentioned and had space provided for information concerning immunizations.
This visit was billed as a comprehensive service. Respondent asserts that it should have been billed as an intermediate service. The proper billing is as an intermediate level of service.
On December 11, 1990, the infant was seen again for a checkup. This visit was billed through the EPSDT screening program. The weight, height and head circumference were recorded. It was noted that the mother was still breast feeding the child. It was noted that the child had good weight gain. It was noted that the infant was a "healthy baby". Vitamins were given to the mother in view of her breast feeding.
Given the child's age in proximity to birth the documentation provided justifies reimbursement as an EPSDT screening. The decision by the Respondent to reimburse as a limited service was unacceptable.
On February 11, 1991, the infant was seen again for a checkup. The basis for the checkup was related to the EPSDT screening program. The weight, height and head circumference were recorded. The mother was still breast feeding the infant. The physical examination revealed that the eyes were matting. Otherwise, the examination revealed no significant findings. Eye drops were prescribed for the problem with the eyes.
A growth chart was maintained.
The visit was billed as a EPSDT service. That billing is not justified in the documentation was not maintained related to developmental assessment, vision screening, and hearing screening.
The decision by Respondent to pay for the services as a limited service is acceptable.
Recipient No. 16 (J.M.):
J.M. was born on February 13, 1990.
On May 26, 1990, Petitioner provided medical services to J.M. At that time the weight, height and head circumference were recorded. The child was experiencing bleeding from his circumcision. The child also had a cold. The circumcision was checked by Petitioner. It appeared well healed with no bleeding. Petitioner prescribed antibiotic cream for the condition. The left eye was found to be crusty upon physical examination. Neosporin was administered for the eye. Nasal congestion drops were provided.
This visit was billed as a comprehensive service. Respondent asserts that the service was an intermediate service. The proper billing for this for the visit is an intermediate level of service.
Recipient No. 17 (T.V.):
T.V. was born on June 23, 1979.
Petitioner provided medical services to T.V. on December 18, 1990. This was a visit following hospitalization for acute asthma. It was reported that the child was still having an occasional cough. A physical examination was
performed. The mother was instructed concerning the need to continue Ventalin tablets as a bronchial dilator for asthma. Medication was prescribed for the cough.
This visit was billed as an extended service. Respondent asserts that the visit was a limited service. The proper billing is as a limited level of service.
On October 14, 1991 the child was seen for a school physical. This was billed as an EPSDT screening. At the time the child was seen the blood pressure was recorded. A student health form was filled out, but not maintained in Petitioner's records.
At this visit it was reported that the child was having an acute asthma attack for the last 2 or 3 days with symptoms being worse at night.
Following the physical examination, Petitioner determined to prescribe Ventalin and cough medicine to address the asthma.
Petitioner billed this service as an EPSDT screen. Inadequate documentation was maintained to justify reimbursement as an EPSDT screen other than the physical examination. Respondent's decision to reimburse the visit as a limited level of service is acceptable.
Recipient No. 18 (B.K.):
B.K. was born on March 23, 1989.
On November 22, 1991, Petitioner provided medical services to B.K. The presenting complaints were a cold and ear ache, off and on for a period of 2 months. The child was weighed and measured. The physical examination revealed that the throat was inflamed and the nasal mucus membrane was inflamed. A prescription was given to addresses the child's condition.
The visit was billed as a comprehensive service. Respondent asserts that the visit was an intermediate service. The proper billing is as an intermediate level of service.
Recipient No. 19 (T.S.):
T.S. was born on July 16, 1989.
On January 19, 1990, the child was seen for a checkup. This visit was treated as an EPSDT screening. The infant was still on formula. The physical examination revealed no significant findings. The child was described as "healthy baby". It was noted that the child was not sitting up yet.
The records contain a document with information related to the date of birth, family history, birth and development information when the child was born and feeding history.
Petitioner's records also contain growth charts.
The bill for EPSDT screening should not be paid based upon the failure to maintain the records justifying the request, other than the physical examination. The Respondent's choice to reimburse the visit as a limited service is acceptable.
On April 23, 1990 the child was seen for a further checkup. This visit was billed under the EPSDT screening. The growth charts that have been described revealed that the child was "under the curve". The chart had been plotted more frequently because the baby had been born premature. On this visit the child was weighed, his height and head circumference were noted. The formula he was receiving was noted. The physical examination was normal. It was noted that the child was a "healthy baby". It was noted that the child would take weight on his feet and was playful.
The request to reimburse for this visit as an EPSDT screening is not appropriate in that inadequate records were maintained to justify that billing for the mandated screens, other than the physical examination. The decision by Respondent to pay for this visit as a limited service is acceptable.
On May 7, 1990 the child was seen. The presenting complaint was a cold, and his nose would bleed when wiped. During the physical examination the nostrils were checked and found to be irritated but no bleeding was noted. The child's throat was inflamed. Antibiotics was prescribed for the inflamed throat and a decongestant was prescribed for cough.
This visit was billed as an intermediate service. Respondent asserts that it was a limited service. The proper billing is a limited level of service.
On June 25, 1990, the child was seen for a checkup. The visit was billed as an EPSDT screen. When the child was seen the height, weight and head circumference were recorded. The physical examination revealed normal findings with the exception that it was noted that the child had "not gained adequate weight". A blood test was made. A TB test was administered. These tests were noted in the office notes. The TB test was also noted in the immunization record.
The billing as an EPSDT screen is unacceptable based upon inadequate documentation maintained to justify the billing, other than the physical examination. Respondent's decision to reimburse Petitioner for a limited service is acceptable.
On October 15, 1990, the child was seen for a checkup. The weight, height and head circumference were recorded. The physical examination showed that the left ear was inflamed. Otherwise no findings were made. The child was described as a "healthy baby". An antibiotic was prescribed for the ear infection as noted.
The visit was billed as a EPSDT screen. Inadequate documentation was maintained to justify the billing as an EPSDT screens, other than the physical examination. Respondent's decision to reimburse the visit as a limited service is acceptable.
On January 15, 1991, the child was seen for a checkup and shots. The weight, height and head circumference were recorded. Upon physical examination, the left ear was noted to be inflamed, "mild to moderate". Otherwise the examination was normal.
This visit was billed as an EPSDT screen. Inadequate records were maintained to justify reimbursement for the mandated EPSDT screens, other than the physical examination. Respondent's decision to reimburse the visit as a limited service is acceptable.
Recipient No. 21 (M.C.):
M.C. was born on January 17, 1985.
On February 2, 1990, Petitioner provided medical services to M.C.
The child was weighed and measured. The child was seen because she had been coughing a lot off and on. When the physical examination was made her ears were found inflamed. She had rales in her right chest with poor air expansion of the lung. The left chest showed bronchial breathing which indicated that there was not full expansion when breathing. The child was sent for an x-ray to rule out the presence of pneumonia. The child was prescribed an antibiotic and cough medication and a ventalin elixir to assist in breathing and to open the airways. The antibiotic was for the problem with the ear. Petitioner explained the child's condition to the mother.
This visit was billed as a comprehensive service. Respondent asserts that the service was an intermediate service. The proper billing is as an intermediate level of service.
On February 6, 1990, the child was seen again as a follow-up. The ears were improved. The throat had improved. The chest still showed bronchial breathing and bilateral wheezing. Therefore, the condition had not completely cleared up. Consequently, the antibiotic was changed.
This visit was billed as an extended service. Respondent asserts that it was an intermediate service. The proper billing was as an intermediate level of service.
The child had been seen in the emergency room on March 11, 1990 for problems with strep throat.
On March 16, 1990 Petitioner provided medical services to the child as a follow-up to the condition observed in the emergency room. At the office visit the mother reported that she had difficulty giving the antibiotic to the child orally. Petitioner observed that the throat appeared improved, but some blisters still were present. Because the child would not take the oral medication Petitioner gave the child an inter-muscular injection of penicillin.
This visit was billed as an intermediate level service. Respondent asserts that the service is a limited service. That proper billing for the service is as a limited level of service.
The child was seen on July 13, 1990. At that time her height and weight were taken. Her presenting complaint was a cough. The child's throat appeared inflamed. Otherwise the physical findings were unremarkable. The child was given an antibiotic to treat the throat condition as well as a decongestant for the cough.
This visit was billed as an intermediate service. Respondent asserts that the service was a limited service. The proper billing was as a limited level of service.
The child was seen on November 12, 1990. Her height and weight were recorded. The basis for the visit was a reported cough. The physical examination revealed mild inflammation in her throat. Otherwise the findings were unremarkable. The child was given a decongestant and cough medicine.
Petitioner billed this visit as an intermediate service. Respondent asserts that it was a limited service. The proper billing is as a limited level of service.
Recipient No. 25 (L.N.):
L.N. was born on November 19, 1985.
On October 15, 1991, Petitioner provided medical services to the child. The weight, height and blood pressure were recorded. The child presented with a complaint of a sore throat for 2 - 3 days with a fever. When the physical examination was made the throat was found to be inflamed, the tonsils were inflamed and enlarged. The nostrils were congested. A strep screen was performed and found to be negative. Because the throat was quite inflamed and lymph nodes were swollen, indicating severe infection unrelated to strep, a prescription for penicillin was prescribed.
This visit was billed as an extended service. Respondent asserts that the service was a limited service. The proper billing was as a limited level of service.
The child was seen on December 9, 1991, the presenting complaint was a fever the day before. There was no report of sore throat or cough. Upon the physical examination the tonsils were found to be inflamed, the lymph nodes were markedly enlarged. A strep screen was performed. On this occasion it proved positive. The patient was prescribed an antibiotic.
Petitioner billed this visit as an extended service. Respondent asserts that the visit was a limited service. The proper billing was as a limited level service.
On December 23, 1991, the child was seen by Petitioner. At this time a complaint was a fever of 24 hours duration with a cough. The tonsils were inflamed. Petitioner prescribed an antibiotic and cough medicine.
Petitioner billed for the visit as an intermediate service. Respondent asserts that it was a limited service. The proper billing was as a limited level of service.
Recipient No. 26 (Baby Boy T):
Baby Boy T was born July 31, 1991.
On December 23, 1991 the child was seen for a check up and shots. This visit was an EPSDT screen. The weight, height and head circumference were recorded. A physical examination was conducted. This child had been born premature, at thirty-five weeks gestation.
A document concerning the birth, family history and feeding history was maintained. It spoke of the child's condition within the first week. The child had weighed 5 pounds 11 ounces when born.
Separate from the document recording birth information, family history, early birth and development, and early feeding history, Petitioner recorded that on December 23, 1991 that the examination was normal with the exception that the child had gained weight, but still not sufficient weight since birth. Another abnormality was a hernia. The child was referred for surgery to address the hernia.
A growth chart was maintained in the Petitioner's records.
Petitioner billed this visit as an EPSDT screen. Petitioner did not maintain sufficient records to justify payment for the mandated screens, other than the physical examination. Respondent's decision to pay for this visit as a limited service is acceptable.
Recipient No. 29 (M.M.):
M.M. was born on September 17, 1986.
On December 2, 1991, Petitioner provided medical services to M.M. On that date the child's temperature, weight and height were recorded. The presenting complaint was a fever, an earache. A physical examination revealed wax in the ears. The throat and tonsils were inflamed. A strep screen was performed and found to be negative. The child was prescribed an antibiotic for the inflammation and a medication for possible fever.
Petitioner billed for this visit as a comprehensive service. Respondent asserts that it is an intermediate service. The proper billing as an intermediate level of service.
Recipient No. 30 (R.C.):
R.C. was born on March 26, 1970.
On August 8, 1990, Petitioner provided medical services to R.C. The reason for seeing R.C. was to perform a college physical. The recipient was blind. She was weighed, her height recorded and blood pressure taken. The physical examination was normal, except for her blindness. During the visit
R.C. reported that she had been having headaches behind her eyes. MMR immunization was given to assist in meeting college entry requirements. R.C. was sent to a laboratory for CBC and Differential SMA-25.
Petitioner billed this visit as a comprehensive service. Respondent asserts that it was an intermediate service. The proper billing was as an intermediate level of service.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of this proceeding pursuant to Section 120.57(1), Florida Statutes.
The audit process which led to the claim for overpayment was initiated by the Department of Health and Rehabilitative Services as Administrator for the Florida Medicaid Program in accordance with Chapter 93- 129, Section 58, Laws of Florida (1993). The Agency for Health Care Administration succeeded the Department of Health and Rehabilitative Services as Florida Medicaid Program Administrator.
Respondent has the burden of proving that Petitioner has been overpaid for the Medicaid services delivered to recipients. See Florida Department of Transportation v. J.W.C., 396 So.2d 778 (Fla. 1DCA 1981). This proof must be by a preponderance of evidence.
The statutes, rules, Medicaid Physician Provider Handbook and Medicaid EPSDT Provider Handbook in effect during the period for which the services were provided govern the outcome of the dispute.
When Petitioner decided to become a Medicaid provider she executed a document agreeing to keep records necessary to fully disclose the extent of services being provided under the Medicaid program and to furnish the state agency administering the program information concerning payments claimed for providing the services. In addition, Petitioner agreed to abide by the provisions of the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and federal laws and regulations. This commitment was made on November 2, 1982 and continued through the period in dispute.
Pertinent to Petitioner's participation in the Medicaid program are various provisions in Section 409.907, Florida Statutes (1991), which state:
409.907 Medicaid provider agreements.
The department may make payments for medical assistance and related services rendered to Medicaid recipients only to a person or entity who has a provider agreement in effect with the department, who is performing services or supplying goods in accordance with federal, state, and local law, . . .
Each provider agreement shall require the provider to comply fully with all state and federal laws pertaining to the Medicaid program, . . .
Each provider agreement shall be a voluntary contract between the department and the provider, in which the provider agrees to comply with all laws and rules pertaining to the Medicaid program when furnishing a service or goods to a Medicaid recipient and the department agrees to pay a sum, determined by fee schedule, payment
methodology, or other manner, for the service or goods provided to the Medicaid
recipient. . . .
The provider agreement developed by the department, in addition to the requirements specified in subsections (1) and (2), shall require the provider to:
* * *
Maintain in a systematic and orderly manner all medical and Medicaid-related records as the department may require and as it determines necessary for the services or goods being provided.
Retain all medical and Medicaid-related records for a period of 5 years to satisfy all necessary inquiries by the department.
* * *
(5) The department:
* * *
(c) May adopt, and include in the provider agreement, such other requirements and stipulations on either party as the depart- ment finds necessary to properly and efficiently administer the Medicaid program.
Additional information related to record keeping requirements is set forth at Rule 10C-7.030(2)(m), Florida Administrative Code, which states:
(m) "Medical records" means those dated and legible records corresponding to office, home, nursing home, hospital, outpatient, emergency room and any other place of service supporting claims submitted to the Florida Medicaid program. In group practices, one record shall be kept with chronological entries by the specific practitioner who rendered the service. For reimbursement purposes such records shall include:
Dates of services;
Patient's name and date of birth;
Name and title of person performing the service, when it is someone other than the billing practitioner;
Chief complaint on each visit;
Pertinent medical history;
Pertinent findings on examination;
Medications administered or prescribed;
Description of treatment, when applicable;
Recommendations for additional treatments or consultations; and
Tests and results.
See also Rule 10C-7.030(8), Florida Administrative Code, which states:
The provider of Medicaid service shall furnish the Department with all information regarding all claims submitted by that provider to the Medicaid program and shall permit access to all Medicaid patient and fiscal records and provider facilities for the purpose of auditing, investigation, program monitoring, and utilization review by federal and state agencies connected with administration of the program. Complete and accurate patient and fiscal records that fully justify and disclose the extent of the services rendered and billings made shall be
maintained, and copies furnished upon request by the provider of the Medicaid services.
Said records shall be retained for 5 years from the date of billing.
The Rule pertaining to Medicaid Physician Services at 10C- 7.038(5)(a), Florida Administrative Code, describes reimbursements for services for medical care and EPSDT checkups where it states:
2. Reimbursement for physician service shall be limited to one visit per physician per recipient per day, except for emergency services as defined in paragraph
10C-7.038(2)(d), F.A.C.
* * *
5. Well-baby checks are excluded from the physician services program. Payment for a well-baby check is limited to the early and periodic screening diagnosis and treatment program as specified in section 10C-7.047, F.A.C.
* * *
12. Payment for new and established patients shall be made in accordance with the depart- ment's maximum allowable amounts for such patients.
Section 409.905(9), Florida Statutes (1991) defines physicians services wherein it states:
PHYSICIAN SERVICES. The department shall pay for services and procedures rendered to a recipient by, or under the personal super- vision of, a person licensed under state
law to practice medicine or osteopathy. These services may be furnished in the physician's office, the Medicaid recipient's
home, a hospital, a nursing facility, or else- where, but shall be medically necessary for the treatment of an injury, illness, or disease within the scope of the practice of medicine or osteopathy as defined by state law. The department shall not pay for services that are clinically unproven, experimental, or for purely cosmetic purposes.
Rule 10C-7.038(2)(u), Florida Administrative Code, describes physician's services as:
. . . Medical care provided by a doctor of medicine or osteopathy within the scope of practice as defined by state law; and provided in the recipient's home, a hospital, a long term care facility, a physician's office, or elsewhere; and including profess- ional components of radiological and patho- logical procedures related to such medical
care as requested by the physician rendering such medical care.
Section 409.905(2), Florida Statutes (1991) describes the provision and payment for periodic screening such as the EPSDT program wherein it states:
EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND
TREATMENT SERVICES. The department shall pay for early and periodic screening and diagnosis of a recipient under age 21 to ascertain physical and mental problems and conditions and provide treatment to correct or ameliorate these problems and conditions. These services include all services deter- mined by the department to be medically necessary for the treatment, correction,
or amelioration of these problems, including personal care, private duty nursing, durable medical equipment, physical therapy, occupational therapy, speech therapy, respiratory therapy, and immunizations.
Section 409.266, Florida Statutes (1989) provided for reimbursement for medical services and early periodic screening such as EPSDT activities, together with the power to adopt rules to implement the Medicaid program in existence at that time.
Rule 10C-7.047(1), Florida Administrative Code, identifies the reason for providing services under the EPSDT program where it states:
Purpose. EPSDT is a comprehensive, preventive health care program for Medicaid- eligible children under age 21 that is designed to identify and correct medical conditions before the conditions become serious and disabling. Medicaid provides payment for EPSDT which allows entry into a health care system, access to a medical home and preventive/well child care on a regular basis. This periodic medical screening includes a health and developmental history, an unclothed physical examination, nutri- tional assessment, developmental assessment, laboratory tests, immunizations, health
education, dental, vision and hearing screens, and an automatic dental referral for children age 3 and over.
In accordance with Rule 10C-7.047(3), Florida Administrative Code, the recipients are eligible for EPSDT services from birth through the birth month of the 21st year of life.
Section 10C-7.047(11), Florida Administrative Code, establishes the opportunity for Respondent to conduct audits on claims submitted for payment under the EPSDT program where it states:
Audits. The provider shall furnish the department with all information regarding claims submitted or paid for services provided to eligible recipients and shall permit access to all records and facilities for the purpose of claim audit, program monitoring, or utilization review by duly authorized representatives of federal and state agencies. Complete and accurate records which fully disclose the extent of services shall be retained for the period of time required by state and federal law.
As described before, the Medicaid Physician Provider Handbook identifies record keeping necessary for medical services provided to recipients. As discussed, the handbook identifies the service levels by definition. It uses the code system for billing purposes that is found in the Physician's Current Procedural Terminology, Fourth Edition.
In this case, where there was a dispute concerning the service levels, the physician's records together with explanations provided concerning those records were available to resolve the dispute. The explanations identified by Petitioner could be and were used by the medical experts to assist in describing the medical services rendered as a means for the fact finder to ultimately conclude the proper level for reimbursement. Petitioner was not allowed to offer explanations concerning the services provided that did not originate from physician's records created on or about the time the medical services were provided.
As identified, the Medicaid EPSDT Provider Handbook calls for the performance of screens in health and developmental history, physical examination, vision screening, including a check of the eyes, hearing screening, including a check of the ears, developmental and nutritional assessment at each visit. The EPSDT Provider Handbook and the statutes and rules contemplate recording information for health and physical examination, developmental history, developmental assessment, nutritional assessment and results of vision and hearing screening on each visit.
Section 409.335, Florida Statutes (1989) and (1991) allow Respondent to recover overpayments for medical services and to disallow EPSDT screening payments when mistakes are made by the provider.
Moreover, Rule 10C-7.061, Florida Administrative Code, grants that authority. That rule establishes a further reminder for the provider to document the billings for services provided to allow Respondent to determine whether Medicaid payments were in order.
For reasons described in the fact finding, Petitioner was overpaid for services provided in the instances discussed. In addition, the EPSDT screens were not sufficiently documented to allow payment under that program, other than the two instances identified. Nonetheless, medical services were always provided upon the dates when EPSDT screening visits were made and Petitioner is entitled to be reimbursed at the limited level of service, if not as an EPSDT screen.
Based upon the findings of fact and the conclusions of law reached, it is, RECOMMENDED:
That a final order be entered confirming the alleged overpayments described, subject to the adjustments.
DONE and ENTERED this 26th day of July, 1996, in Tallahassee, Florida.
CHARLES C. ADAMS, 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 26th day of July, 1996.
ENDNOTE
1/ There remains to be decided whether the Medicaid reimbursement program used a valid statistical formula and methodology to determine the total amount of Medicaid overpayment based upon a statistical sampling from Petitioner's provider records associated with Medicaid recipients who received Petitioner's physician's services. That issue is bifurcated from the issues examined in this Recommended Order. The bifurcation was made in response to the Amended Joint Motion to Bifurcate through the August 25, 1995 Order granting the motion.
Dependent upon the recommendation and agency disposition by Final Order concerning the appropriateness of the billings for the statistical sampling, it may be necessary for Petitioner to recalculate the overall amount of overpayment for all recipients by employing the statistical formula and methodology previously used. Following the opportunity to recalculate, Petitioner will be provided notice of the final overpayment calculation. Upon notification, Petitioner shall advise Respondent concerning the desire to contest the statistical formula and methodology used to determine the total amount of Medicaid overpayment to the provider. Should Petitioner wish to continue the contest to examine the statistical formula and methodology, the case shall be returned to the Hearing Officer to consider that issue. The hearing record remains open before the Division of Administrative Hearings to that extent. The agency shall notify the Hearing Officer concerning Petitioner's election to proceed to hearing to consider the remaining issue or the decision to decline that opportunity. Following notification to the Hearing Officer, the case will be reconvened or closed before the Division of Administrative Hearings dependent upon Petitioner's election.
APPENDIX CASE NO. 95-2419
The following discussion is given concerning the proposed findings of fact:
Petitioner's Facts:
Paragraphs 1 through 10 are subordinate to facts found. Paragraph 11 is not necessary to the resolution of the dispute. Paragraph 12 is subordinate to facts found.
Paragraphs 13 and 14 are not necessary to the resolution of the dispute.
The first sentence to Paragraph 15 is subordinate to facts found. The second sentence is not necessary to the resolution of the dispute nor is Paragraph 16.
Paragraphs 17 through 20 are subordinate to facts found.
Paragraphs 21 and 22 in the suggestion that it was necessary for forms to be provided to Petitioner related to the EPSDT examinations in order to record information concerning assessments is rejected.
Paragraphs 23 to 233 are subordinate to facts found with the exception of those facts which do not originate with the records maintained. The suggestion that the EPSDT screenings should be reimbursed and the assertions concerning levels of service are rejected, other than the two claims for Recipients No. 13 and No. 15 related to EPSDT screening.
Paragraphs 234 through 238 are not necessary to the resolution of the dispute.
Paragraph 239 is subordinate to facts found.
Paragraphs 240 through 242 are rejected in the suggestion that Respondent has failed to sustain its burden concerning overpayments other than described above.
Paragraph 243 constitutes a conclusion of law.
Respondent's Facts:
Paragraphs 1 through 16 are subordinate to facts found. Paragraph 17 is not necessary to the resolution of the dispute.
Paragraphs 18 through 72 are subordinate to facts found, other than the aforementioned claims for Recipients No. 13 and No. 15 for EPSDT screening.
COPIES FURNISHED:
W. David Watkins, Esquire Post Office Box 6507 Tallahassee, FL 32314-6507
Wayne Mitchell, Esquire
Agency for Health Care Administration Building 1 Fort Knox Center
2727 Mahan Drive
Tallahassee, FL 32308
Marm Harris, Executive Director Agency for Health Care Administration 1940 North Monroe Street
Tallahassee, FL 32399-0792
Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, FL 32308-4131
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 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.
| Issue Date | Proceedings |
|---|---|
| Oct. 28, 1996 | Amended Final Order filed. |
| Sep. 27, 1996 | Final Order filed. |
| Jul. 26, 1996 | Recommended Order sent out. CASE CLOSED. Hearing held 01/25-26/96. |
| May 13, 1996 | Petitioners Memorandum of Law; Petitioner`s Proposed Recommended Order filed. |
| May 13, 1996 | Respondent Agency`s Proposed Recommended Order filed. |
| Apr. 30, 1996 | Letter to Hearing Officer from W. Watkins Re: Requesting brief extension of time to file Proposed Recommended Orders filed. |
| Mar. 07, 1996 | Order sent out. (Proposed Recommended Order`s are due 5/1/96) |
| Mar. 04, 1996 | Joint Motion for Extension of Time filed. |
| Mar. 01, 1996 | Notice of Filing; DOAH Court Reporter Hearing Transcript (Volumes 1 -4 TAGGED) filed. |
| Feb. 29, 1996 | Letter to Hearing Officer from W. Watkins Re: Toma Exhibits No. 3, 4, 6, and 7 Enclosed filed. |
| Feb. 08, 1996 | (W. David Watkins) Stipulation for Substitution of Counsel filed. |
| Feb. 05, 1996 | (W. David Watkins) Notice of Appearance filed. |
| Jan. 25, 1996 | CASE STATUS: Hearing Held. |
| Jan. 22, 1996 | (Petitioner) Response to Request for Official Recognition filed. |
| Jan. 22, 1996 | (Respondent) Amended Request for Taking Official Recognition filed. |
| Jan. 12, 1996 | (Petitioner) Prehearing Stipulation filed. |
| Jan. 10, 1996 | (Respondent) Notice of Taking Deposition; (Petitioner) Notice of Taking Deposition Duces Tecum filed. |
| Jan. 10, 1996 | (Respondent) Request for Taking Official Recognition filed. |
| Sep. 05, 1995 | Order of Prehearing Instructions sent out. |
| Sep. 01, 1995 | (Petitioner) Amended Motion to Establish Prehearing Deadlines filed. |
| Sep. 01, 1995 | Order Rescheduling Hearing sent out. (hearing rescheduled for Jan. 24-26, 1996; 9:00am; Tallahassee) |
| Aug. 28, 1995 | (Petitioner) Unopposed Motion for Continuance filed. |
| Aug. 28, 1995 | Amended Joint Motion to Bifurcate Final Hearing and Memorandum of Law In Support Thereof filed. |
| Aug. 25, 1995 | Order sent out. (joint motion to bifurcate final hearing is granted) |
| Aug. 24, 1995 | (Petitioner) Motion to Establish Prehearing Deadlines filed. |
| Aug. 23, 1995 | Joint Motion to Bifurcate Final Hearing and Memorandum of Law In Support Thereof filed. |
| Aug. 03, 1995 | (Respondent) Notice of Serving Answers to Interrogatories; Agency Response to Request for Production filed. |
| Aug. 01, 1995 | Petitioner`s Response to Request for Production; Petitioner, Siham K.Toma`s, Response to Requests for Admission; Notice of Service of Answers to Interrogatories filed. |
| Jun. 30, 1995 | Petitioner`s Request for Production; (Petitioner) Notice of Service of Interrogatories filed. |
| Jun. 28, 1995 | (Respondent) Notice of Request for Production; Agency`s Request for Admissions; Notice of Propounding Interrogatories filed. |
| Jun. 01, 1995 | Notice of Hearing sent out. (hearing set for September 6, 7 and 8, 1995; 9:00am; Tallahassee) |
| May 25, 1995 | (Petitioner) Response to Initial Order filed. |
| May 16, 1995 | Initial Order issued. |
| May 09, 1995 | Notice; Petition for Formal Administrative Proceeding; Agency Action letter filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Sep. 24, 1996 | Agency Final Order | |
| Jul. 26, 1996 | Recommended Order | Provider was overpaid for services provided under Medicaid. |
ARTHUR HENSON, D.O. vs AGENCY FOR HEALTH CARE ADMINISTRATION, 95-002419 (1995)
MILTON M. APONTE, M. D. vs AGENCY FOR HEALTH CARE ADMINISTRATION, 95-002419 (1995)
OKAN, INC., D/B/A CHOICE PHARMACY vs AGENCY FOR HEALTH CARE ADMINISTRATION, 95-002419 (1995)
HAL COWEN vs AGENCY FOR HEALTH CARE ADMINISTRATION, 95-002419 (1995)
