STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

ROOSEVELT T. JACKSON, JR., M.D. )

)

Petitioner, )

)

vs. )

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

Case No. 01-3812MPI

)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was held in this case by video teleconference on January 30, 2002, with the parties appearing from Fort Lauderdale, Florida, before J. D. Parrish, a designated Administrative Law Judge of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Roosevelt T. Jackson, Jr., M.D., pro se

3740 West Broward Boulevard Plantation, Florida 33312

For Respondent: Kim A. Kellum, Esquire

Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building 3, Suite 3431

Tallahassee, Florida 32308-5403 STATEMENT OF THE ISSUE

Whether the Petitioner should reimburse the Respondent for alleged Medicaid overpayments in the amount of $44,581.50.

PRELIMINARY STATEMENT

On June 27, 2001, the Respondent, Agency for Health Care Administration (Agency), issued a Final Agency Audit Report that advised the Petitioner of an alleged Medicaid overpayment. The basis for the claim was an alleged failure on the Petitioner's part to follow the guidelines set forth in the applicable rules and Medicaid fee schedules as required by his provider agreement. More specifically, the Respondent has alleged that the Petitioner must reimburse the Agency for services that were billed at a higher level than actually performed, for services that were medically unnecessary, and for services not properly documented. The calculated amount for such overpayments is

$44,581.50.

For his part, the Petitioner disputed the amount claimed and requested a formal hearing by letter dated July 13, 2001. Thereafter the matter was forwarded to the Division of Administrative Hearings for formal proceedings on September 28, 2001.

At the hearing, the Agency offered Respondent's Exhibits 1-3 and 5-11 that were admitted into evidence. Vicki Stiles,

Margerite Johnson, Robert V. Peirce (by deposition), and Joel H. Kramer, M.D. (by deposition) testified on behalf of the Agency. The Petitioner participated in the hearing but offered no exhibits or testimony.

The transcript of these proceedings was filed on March 18, 2002. A Motion for Extension of Time to File Proposed Recommended Orders was granted and the parties were given leave until April 8, 2002, to file such proposals. All proposed orders have been considered in the preparation of this order.

FINDINGS OF FACT

1. At all times material to the allegations of this case, the Petitioner, Roosevelt T. Jackson, Jr., M.D., has been a Medicaid provider authorized to receive reimbursement for Medicaid services provided to Medicaid recipients. Dr. Jackson is an ophthalmologist. All services in this cause related to Medicaid claims for procedures performed between January 1, 1998, and December 31, 1999.

2. The Respondent is the state agency responsible for the administration of the Medicaid program within the State of Florida. Medicaid Program Integrity is the arm of the Agency that oversees the activity of the Florida Medicaid providers and recipients to ensure that they are in compliance with the Medicaid program.

3. As part of its duties, the Agency audits the records of providers to verify compliance with all Medicaid rules. In this case the audit of Petitioner's records was triggered by a computer program that reviews data from similar Medicaid providers.

4. The Surveillance Utilization Review Section (SURS) of the Medicaid Program Integrity office found that the Petitioner had exceeded the norm in Medicaid billings when compared to his peers. When the SURS kicked back the Petitioner's name, it represented that the Petitioner had exceeded his peers in the total number of Medicaid recipients serviced, total number of evaluation and management procedures, average number of evaluation and management procedures per recipient, number of office visits, average number of office visits per recipient, and average number of services per recipient.

5. Based upon the SURS responses, the Agency elected to conduct a sample audit of the Petitioner's records. Records for

   30 Medicaid recipients were requested and obtained from the Petitioner.

6. The results of that sample audit were then extended to calculate the overpayment for which the Respondent currently seeks reimbursement.

7. The Respondent's audit established that the Petitioner had failed to comply with Medicaid provisions in three specific areas. First, based upon the records submitted to the Agency, the Petitioner billed for services at a higher level than actually performed.

8. Second, the audit established that the Petitioner billed for services that were "medically unnecessary" as that term is utilized by Medicaid.

9. And third, the audit found that the Petitioner billed for services that were not properly documented by the records maintained. Such records were created, maintained and produced to the Agency by the Petitioner.

10. The results of the audit were set forth in the Final Agency Audit Report and were provided to the Petitioner. The report requested reimbursement from the Petitioner in the amount of $44,581.50. The report was completed on or about June 27, 2001.

11. Thereafter, the Petitioner timely challenged the results of the audit, and requested a formal administrative hearing to dispute the amounts set forth in the report.

12. As to all amounts claimed in the report, the evidence presented in this cause supports the Agency's conclusions as to the overpayment.

13. Prior to January of 1999, the Petitioner was not authorized to bill for a level 4 visit. Thus all services billed at that rate prior to January 1999 should be reduced.

14. Secondly, none of the records supplied by the Petitioner supported the complexity required for a level 4

    billing. Therefore, services billed at the level 4 rate should be reduced to the appropriate level.

15. The Petitioner also billed for services that were not medically necessary. A normal examination (with no retinal problem identified in the record) would not warrant additional retinal examinations. Therefore, billings for additional procedures would not be warranted in such cases.

16. Finally, Medicaid rules require that a physician maintain records in compliance with documentation guidelines. The Petitioner's records did not comply with such guidelines. Accordingly, Medicaid payments for services that lack the required documentation may be recouped.

17. After a full review of the records submitted, the Agency used a standard formula to extend the sample data throughout the population from which the sample was taken. That is, from the 30 patient records reviewed, the results were applied by statistical formula to the entire Medicaid patient population served by the Petitioner. This computation resulted in the amount of the overpayment currently sought.

18. The statistical formula used by the Agency to compute the overpayment was reasonable and within the guidelines of the law.

    CONCLUSIONS OF LAW

    
    

19. The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of these proceedings. Section 120.57, Florida Statutes.

20. The Respondent is required by law to ensure that Medicaid providers are correctly reimbursed for Medicaid services provided to Medicaid recipients. See Section 409.913, Florida Statutes.

21. In this case, the Respondent bears the burden of proof to establish the overpayment it claims the Petitioner received.

22. Section 409.913, Florida Statutes, provides in pertinent part:

    1. In making a determination of overpayment to a provider, the agency must use accepted and valid auditing, accounting, analytical, statistical, or peer-review methods, or combinations thereof. Appropriate statistical methods may include, but are not limited to, sampling and extension to the population, parametric and nonparametric statistics, tests of hypotheses, and other generally accepted statistical methods. Appropriate analytical methods may include, but are not limited to, reviews to determine variances between the quantities of products that a provider had on hand and available to be purveyed to Medicaid recipients during the review period and the quantities of the same products paid for by the Medicaid program for the same period, taking into appropriate consideration sales of the same products to non-Medicaid customers during the same period. In meeting its burden of proof in any administrative or court proceeding, the

       agency may introduce the results of such statistical methods as evidence of overpayment.

    2. When making a determination that an overpayment has occurred, the agency shall prepare and issue an audit report to the provider showing the calculation of overpayments.

    3. The audit report, supported by agency work papers, showing an overpayment to a provider constitutes evidence of the overpayment.

       
       

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23. In this case, the Respondent has met its burden to establish that the Petitioner is liable for an overpayment. The audit results support the conclusion that the Petitioner billed an inappropriate level 4 procedure code, performed services for which the level 4 code were not authorized, failed to maintain documentation to support the procedure billed, and billed for procedures that were not medically necessary.

24. It is further concluded that the Agency applied statistically sound methodology to apply the results of the sample audit to the Medicaid population served by the Petitioner.

25. Consequently, as the Petitioner presented no evidence to rebut the conclusions of the audit, such results must stand as presumptively valid.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a Final Order confirming the Medicaid overpayment in the amount of $44,581.50.

DONE AND ENTERED this 21st day of May, 2002, in Tallahassee, Leon County, Florida.

J. D. PARRISH Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 21st day of May, 2002.

COPIES FURNISHED:

Virginia A. Daire, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building, Suite 3431 Tallahassee, Florida 32308

William Roberts, Acting General Counsel Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building, Suite 3431 Tallahassee, Florida 32308

Roosevelt T. Jackson, Jr., M.D. 3740 West Broward Boulevard Plantation, Florida 33312

Kim A. Kellum, Esquire

Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building 3, Suite 3431

Tallahassee, Florida 32308-5403

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.

Docket for Case No: 01-003812MPI

Orders for Case No: 01-003812MPI