Visio, ~ a Te atl STATE OF FLORIDA mus DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, ) ! ) OIF ASUS PC PETITIONER, ) ) v. ) CASE NO. 1998-13148 ) JOEL K. SHUGAR, M.D, ) ) RESPONDENT. _ HO ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, Department of Health, hereinafter referred to as “Petitioner,” and files this Administrative Complaint before the Board of Medicine against Joel K. Shugar, M.D., hereinafter referred to as “Respondent,” and alleges: 1. Effective July 1, 1997, Petitioner is the state agency charged with regulating the Practice of medicine Pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes, and Chapter 458, Florida Statutes. Pursuant to the provisions of Section 20.43(3), Florida Statutes, the Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial services required by the Division of Medical Quality Assurance, councils, or boards, as appropriate. ! 2. Respondent is and has been at all times material hereto a licensed Physician in the state of Florida, having been issued license number ME 0053263. Respondent's last known address is 1211 North Center Street, Perry, FL 32347. 3. Respondent specializes in ophthalmology, but at all time relevant hereto, he practiced general medicine aS a significant portion of his Practice. 4. On or about February 23, 1995, Patient B.O., a forty-nine year old female, presented to Respondent for primary care. 5. On or about July 27, 1996, Patient B.O. presented to Respondent with a concern regarding a small bump on her nose. Because Patient B.O. had a history of possible skin cancer, the patient and the Respondent agreed that the bump should be excised, 6. On or about July 27, 1996, Respondent removed the small bump using loupe magnification and plastic surgical technique. Respondent closed the resulting tissue defect by creating and advancing flaps and inserting a couple of stitches. The tissue removed measured 0.5 x 0.3 x 0.2 cm. 7. On or about August 5, 1996, Patient B.O. returned to Respondent for removal of the sutures. At that time, nine days post surgery, the patient's nose was well healed and the sutures were removed. The patient was advised that, since the pathology report was not back, the Respondent could not state what the charges would emai vent eae be for the surgery. The patient Paid $100.00 and was told that Respondent would bill “her insurance and would advise the patient if she owed more than that $100.00, 8. On or about August 14, 1996, the Respondent submitted a claim for this Surgery to the patient’s insurance company. The claim was for a Rhinoplasty, CPT Code 30400, in the amount of $1,600, and for a Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet, 1.1 to 2.5 cm., CPT Code 13131, in the amount of $625.00, for a total claim of $2,225,00. 9. On or about August 27, 1996, the Patient's insurance carrier wrote to the Patient and the Respondent and requested additional information before they could complete the claim. The insurance carrier specifically asked the following: Please submit a letter documenting the medical necessity of the procedure including: 1) Degree of functional impairment, 2) Date of injury, 3) X-ray report of the injury, 4) Pre-operative photographs, and 5) Patient's history and physical examination report. ° 10. On or about September 23, 1996, Respondent signed and sent a letter to the patient’s insurance Carrier in response to that inquiry. Respondent. referred specifically to the reconstructive surgery performed on Patient B.O. and stated “This - reconstruction was necessary following excision of a large, white, enlarging, elevated, Suspicious lesion from [the patient's] nose. The lesion was excised with wide Margins as it appeared Suspicious for a malignancy and your company was billed for the subsequent reconstructive surgery.” 11. When Patient B.0. received the inquiry letter from her insurance carrier, she was astounded to learn that Respondent had filed a claim for $2,225.00 for the relatively minor procedure. Thinking that it Surely was a mistake, the Patient called Respondent's office and was told that the claim was correct. 12. On or about September 23, 1996, Respondent's insurance carrier again wrote to Respondent and indicated that it had not received any response to its previous letter. It again requested the same information as that requested in its August 27, 1996 letter. 13. Respondent’s billing records indicate that the claim was denied on or about October 29, 1996, because the CPT code was for a cosmetic procedure. Respondent refiled the claim under the same CPT codes on December 5, 1996. 14. On or about January 15, 1997, the Patient's insurance carrier again acknowledged the claim that had been filed for repair of a lesion removal, and asked for additional information, specifically “the operative report for the above surgery and the date of the previous surgery for which the lesion was removed.” 15. On or about February 5, 1997, the patient's insurance carrier denied the Claim because the insurance carrier had not received the requested information, but subsequently the claim was reopened. 16. On or about March 10, 1997, Patient B.O's insurance carrier again wrote to Respondent indicating that it had never received a response to its earlier request for the operative notes and additional information. POT ee eI rae Fr oer 17. Respondent again billed the patient's insurance carrier for these services cn March 31, 1997. 18. Respondent sent a letter to the patient's insurance carrier on or about May 30, 1997, along with copies of prior correspondence and the office notes for July 27, 1996. 19. Patient B.O.'s insurance carrier denied the claim for Payment on CPT Codes 30400 and 13131 on or about August 28, 1997, because the procedure was not medically necessary. 20. On or about September 8, 1997, after having the claim finally denied as not medically necessary, Respondent refiled the claim for $2,225.00 using CPT Codes 11441 and 13150. CPT Code 11441 iS for Excision, other benign lesions, on the face, nose, etc., lesion diameter 0.6-1.0 cm. CPT Code 13150 is for a reconstructive procedure, complicated wound closure, repair, complex of the nose 1.0 cm. or less. 21. On or about October 28, 1997, Respondent again rebilled the patient's insurance carrier for $2,225.00 under CPT Codes 11441 and 13150 and Respondent edited his billing records to remove the Rhinoplasty, 22. Onor about December 15, 1997, B.O.'s insurance carrier paid $600 on this claim. In doing so, the insurance carrier excluded $1,475 from the total bill of $2,225, and paid 80% of the remainder. 23. Respondent knew or should have known the CPT Codes under which these services were billed beginning in July 1996. Further, Respondent knew or should have known that the CPT Codes 30400 and 13131 used for billing for these services TEE er EE TEE Meer OR eRe Fer from July 27, 1996 to September 8, 1997, were incorrect and were for procedures that were not performed, Finally, Respondent krlew or should have known that the amount 24." A Physician under similar conditions and circumstances is the person 25. Based on the foregoing, Respondent violated Section 458.331(1)(h), Florida Statutes, by making or filing a report which the licensee knows to be false. UNT TWO 26. Based upon the foregoing, Respondent violated Section 458.331(1)(n), Florida Statutes, by exercising influence on the patient in such a manner as to exploit the patient for financial gain of the licensee or of a third party. imposition of an administrative fine, issuance of a reprimand, Placement of the Respondent on Probation, the assessment of costs related to the investigation and Prosecution of this Case, other than costs associated with an attorney’s time, as Provided for in Section 456.072(4), Florida! Statutes, and/or any other relief that the Board deems appropriate, SIGNED this_Qath day of Cen p , 2001. Robert G. Brooks, M.D., Secretary Nancy M. Snurkowski : Chief Attorney, Practitioner Regulation COUNSEL FOR DEPARTMENT: Diane Kiesling FILED Senioe Attorney DEPARTMEN® OF HEALTH Agency for Health Care Administration DEPUTY CLE P. O. Box 14229 . K Pa Tallahassee, Florida 32317-4229 CLER [ab Florida Bar # 233285 DATE PCP: April 13, 2001 PCP Members: Ashkar, Zachariah, Cherney

Docket for Case No: 01-004549PL

Orders for Case No: 01-004549PL