The Issue Whether Respondent engaged in sanctionable conduct in violation of Medicaid laws, as alleged in the April 9, 2012, sanction letters the Agency for Health Care Administration (ACHA) sent to Respondent in the above-styled cases, and, if so, what sanction(s) should be imposed.
Findings Of Fact AHCA is the state agency charged with administering and overseeing the Medicaid program in Florida. Housed within AHCA is the Bureau of Medicaid Program Integrity (MPI). Among MPI's responsibilities is to conduct audits and investigations to ensure that the state's Medicaid providers are in compliance with programmatic requirements. At all times material to the instant cases, Respondent was enrolled in the Florida Medicaid program under two separate provider numbers (Provider No. 679849796, as a provider of Developmental Disabilities Home and Community-Based Medicaid Waiver services, and Provider No. 142150600, as a provider of assistive care services) and subject to the terms of Medicaid Provider Agreements,3/ which contained the following provisions, among others: (5) Provider Responsibilities: The Medicaid provider shall: * * * (b) Keep, maintain, and make available in a systematic and orderly manner all medical and Medicaid-related records as AHCA requires for a period of at least five (5) years. * * * (d) Send, at the provider's expense, legible copies of all Medicaid-related information to authorized state and federal employees, including their agents. The provider shall give state and federal employees access to all Medicaid patient records and to other information that cannot be separated from Medicaid-related records; and, in connection with Provider No. 679849796, it was also subject to the terms of a Medicaid Waiver Services Agreement with the Florida Agency for Persons with Disabilities (APD),4/ in which it had agreed, among other things, to do the following: To permit persons duly authorized by APD, the Agency for Health Care Administration (AHCA), or representatives of either, to monitor, audit, inspect, and investigate any recipient records, payroll and expenditure records, (including electronic storage media), papers, documents, facilities, goods and services of the Provider, which are relevant to this Agreement . . . . * * * Upon demand, and at no additional cost to the APD, AHCA, or their authorized representatives, the Provider will facilitate the duplication and transfer of any records or documents (including electronic storage media), during the required retention period . . . . At all times material to DOAH Case No. 12-1664MPI Respondent, as an enrolled Medicaid provider of Developmental Disabilities Home and Community-Based Medicaid Waiver services, was bound by the following provisions of the Developmental Disabilities Waiver Services Coverage and Limitations Handbook dealing with employee training and recordkeeping requirements, which handbook provisions were incorporated by reference (along with the other provisions of the handbook) in Florida Administrative Code 59G-13.083: Companion Provider Requirements * * * Training Requirements Proof of training in the areas of Cardiopulmonary Resuscitation (CPR), HIV/AIDS and infection control is required within 30 days of initially providing companion services. Proof of annual or required updated training shall be maintained on file for review. The provider is responsible for all training requirements outlined in the Core Assurances. Note: Refer to the Core Assurances in Appendix A for the provider training requirements. . . . * * * Appendix A: Core Assurances for Providers of Developmental Disabilities Home and Community-Based Waiver Services Program * * * 2.1 Required Training The provider and its employees will ensure they receive the specific training required to successfully serve each recipient including the following topics: * * * H. All direct service providers hired after 90 days from the effective date of this rule are required to complete the Agency for Persons with Disabilities developed Zero Tolerance Training course prior to rendering direct care services (as a pre-service training activity). Said training may only be completed via APD's web-based instruction or classroom-led instruction (using APD's approved classroom curriculum presented either by APD staff or an individual who has been trained and approved by APD to conduct such classroom trainings). In addition, all direct service providers shall be required to complete the APD developed Zero Tolerance training course at least once every three years. The provider shall maintain on file for review, adequate and complete documentation to verify its participation, and the participation of its employees, in the required training sessions. The documentation for the above listed training shall, at a minimum, include the training topic(s), length of training session, date and location of training, name and signature of trainer, name and signature of person(s) in attendance. Proof of training shall be on file and available for monitoring and review. At all times material to DOAH Case No. 12-1841MPI, Respondent, as an enrolled Medicaid provider of assistive care services, was bound by the following provisions of the Assistive Care Services Coverage and Limitations Handbook dealing with health assessments, which handbook provisions were incorporated by reference (along with the other provisions of the handbook) in Florida Administrative Code Rule 59G-4.025: Recipients receiving Assistive Care Services must have a complete assessment at least annually by a physician or other licensed practitioner of the healing arts (Physician Assistant, Advanced Registered Nurse Practitioner, Registered Nurse) or sooner if a significant change in the recipient's condition occurs (see below for a definition of a significant change). An annual assessment must be completed no more than one year plus fifteen days after the last assessment. An assessment triggered by a significant change must be completed no more than fifteen days after the significant change. -The assessment for a resident of a ALF or AFCH must be completed by a physician or other licensed practitioner of the healing arts (Physician Assistant, Advanced Registered Nurse Practitioner, Registered Nurse) acting within the scope of practice under state law, physician assistant or advanced registered practitioner. -The assessment for a resident of a RTF must be completed by a physician or licensed mental health professional. The assessment must document the need for at least two of the four ACS components. The assessment for ALF residents must be recorded on the Resident Health Assessment for Assisted Living Facilities, AHCA Form 1823. At all times material to both DOAH Case No. 12-1664MPI and DOAH Case No. 12-1841MPI, Respondent was also bound by the following provisions of the Florida Medicaid Provider General Handbook, which were incorporated by reference in Florida Administrative Code Rule 59G-5.020 and applied to all enrolled Medicaid providers, including providers of Developmental Disabilities Home and Community-Based Medicaid Waiver services and providers of assistive care services: Record Keeping Requirement Medicaid requires that the provider retain all business records as defined in 59G- 1.010(30) F.A.C., medical-related records as defined in 59G-1.010(154) F.A.C., and medical records as defined in 59G-1.010(160) F.A.C. on all services provided to a Medicaid recipient.[5/] Records can be kept on paper, magnetic material, film, or other media including electronic storage, except as otherwise required by law or Medicaid requirements. In order to qualify as a basis for reimbursement, the records must be signed and dated at the time of service, or otherwise attested to as appropriate to the media. Rubber stamped signatures must be initialed. The records must be accessible, legible and comprehensible. * * * Record Retention Records must be retained for a period of at least five years from the date of service. * * * Right to Review Records Authorized state and federal agencies and their authorized representatives may audit or examine a provider's or facility's records. This examination includes all records that the agency finds necessary to determine whether Medicaid payment amounts were or are due. This requirement applies to the provider's records and records for which the provider is the custodian. The provider must give authorized state and federal agencies and their authorized representatives access to all Medicaid patient records and to other information that cannot be separated from Medicaid- related records. The provider must send, at his expense, legible copies of all Medicaid-related information to the authorized state and federal agencies and their authorized representatives upon request of AHCA. At the time of the request, all records must be provided regardless of the media format on which the original records are retained by the provider. All medical records must be reproduced onto paper copies. * * * Incomplete Records Providers who are not in compliance with the Medicaid documentation and record retention policies described in this chapter may be subject to administrative sanctions and recoupment of Medicaid payments. Medicaid payments for services that lack required documentation or appropriate signatures will be recouped. Note: See Chapter 5 in this handbook for information on administrative sanctions and Medicaid payment recoupment The foregoing contractual and handbook provisions supplemented section 409.913(9), Florida Statutes, which then provided (as it still does) as follows: A Medicaid provider shall retain medical, professional, financial, and business records pertaining to services and goods furnished to a Medicaid recipient and billed to Medicaid for a period of 5 years after the date of furnishing such services or goods. The agency may investigate, review, or analyze such records, which must be made available during normal business hours. However, 24-hour notice must be provided if patient treatment would be disrupted. The provider is responsible for furnishing to the agency, and keeping the agency informed of the location of, the provider's Medicaid- related records. The authority of the agency to obtain Medicaid-related records from a provider is neither curtailed nor limited during a period of litigation between the agency and the provider. On or about December 6, 2011, MPI investigators visited Respondent's facility to review Respondent's Medicaid-related records, but left before completing their review. Approximately a month later, MPI sent Respondent a letter, dated January 5, 2012, concerning claims that Respondent had filed under its Provider No. 679849796 as a provider of Developmental Disabilities Home and Community-Based Medicaid Waiver services (January 5 Letter). The letter read as follows: The Agency for Health Care Administration (Agency), Office of Inspector General, Bureau of Medicaid Program Integrity is in the process of completing a review of claims billed to Medicaid during the period June 01, 2011, through December 01, 2011, to determine whether the claims were billed and paid in accordance with Medicaid policy. Pursuant to Section 409.913, Florida Statutes (F.S.), this is official notice that the Agency requests the documentation for services paid by the Florida Medicaid provider to the above provider number [679849796]. The Medicaid-related records to substantiate billing for the [four] recipients identified on the enclosed printout are due within fifteen (15) calendar days of your receipt of this notification. Please submit the documentation and the attached Certification of Completeness of Records to the Agency within this timeframe, or other mutually agreed upon timeframe. Correspondence and requested records should be sent to the following address: Victor Rivera, Investigator Agency for Health Care Administration Medicaid Program Integrity 400 West Robinson Street, Suite S309 South Tower, Hurston Building Orlando, Florida 32801 In accordance with Section 409.913, F.S., and Rule 59G-9.070, Florida Administrative Code (F.A.C.), the Agency shall apply sanctions for violations of federal and state laws, including Medicaid policy. Pursuant to the aforementioned provisions, failure to provide all Medicaid-related records in compliance with this request will result in the application of sanctions, which include, but are not limited to, fines, suspension and termination. The Medicaid-related records associated with this review should be retained until [the review is] completed. If you have any questions, please contact Victor Rivera, Investigator, at (407)420- 2524. The Certification of Completeness of Records form enclosed with the letter was to be completed by the provider's "official custodian of records," and it contained the following verification and certification: I hereby verify that I have searched the Medicaid-related records maintained by the Provider and have determined that the attached records consisting of (# of pages) are true and correct copies of the Medicaid- related records requested by the Agency for Health Care Administration, Office of the Inspector General, Bureau of Medicaid Program Integrity. I further certify that these are all of the Medicaid-related records that were made at or near the time that the services were rendered by, or from information transmitted by, the Provider; are kept in the course of the regularly conducted business of the Provider; and that it is the regular practice of the Provider to keep such records. Also accompanying the letter was a printout providing information concerning "documentation organization." Among other things, it advised that the "employee documentation" that needed to be submitted included "[c]opies of all required AHCA training certificates," and it contained the further advisement that "[f]ailure to follow the aforementioned guidelines and/or failure to provide the [sic] ALL of the requested documentation for ALL staff members who provided services to Medicaid Recipients during the predetermined audit period w[ould] result in the [a]application of sanctions," including "fines." The January 5 Letter and accompanying documents were received by Respondent on January 9, 2012. Ten days later, MPI sent Respondent a second letter, dated January 19, 2012 (January 19 Letter). This letter concerned claims that Respondent had filed under its Provider No. 142150600 as a provider of assistive care services, and it provided as follows: The Agency for Health Care Administration (Agency), Office of Inspector General, Bureau of Medicaid Program Integrity is in the process of completing a review of claims billed to Medicaid during the period January 1, 2011, through November 30, 2011, to determine whether the claims were billed and paid in accordance with Medicaid policy. Pursuant to Section 409.913, Florida Statutes (F.S.), this is official notice that the Agency requests the documentation for services paid by the Florida Medicaid provider to the above provider number [143150600]. The Medicaid-related records to substantiate billing for the [four] recipients identified on the enclosed printout are due within fifteen (15) calendar days of your receipt of this notification. Please submit copies of the Medicaid-related records and the attached Certification of Completeness of Records to the Agency within this timeframe, or other mutually agreed upon timeframe. Correspondence and requested records should be sent to the following address: Victor Rivera, Investigator Agency for Health Care Administration Medicaid Program Integrity 400 West Robinson Street, Suite 309 South Tower, Hurston Building Orlando, Florida 32801 In accordance with Section 409.913, F.S., and Rule 59G-9.070, Florida Administrative Code (F.A.C.), the Agency shall apply sanctions for violations of federal and state laws, including Medicaid policy. Pursuant to the aforementioned provisions, failure to provide all Medicaid-related records in compliance with this request will result in the application of sanctions, which include, but are not limited to, fines, suspension and termination. The Medicaid-related records associated with this review should be retained until [the review is] completed. If you have any questions, please contact Victor Rivera, Investigator, at (407)420- 2524. At the bottom of the "enclosed printout" referenced in the letter was the following cautionary advisement: Please refer to your Assistive Care Services handbook, July 2009, for information on the required documentation for recipient files. The Certification of Completeness of Records form enclosed with the letter was identical to the Certification of Completeness of Records form that had accompanied the January 5 Letter. The January 19 Letter and accompanying documents were received by Respondent on January 21, 2012. Respondent, through its owner/administrator Angel Cox, responded to the records requests made in the January 5 and January 19 Letters by providing MPI with copies of numerous documents, along with two completed, signed, and dated Certifications of Completeness of Records (one for each records request), on January 24, 2012.6/ Ms. Cox supplemented this response by faxing additional copies to MPI on February 7, 2012. Victor Rivera, the MPI investigator to whom Respondent had been directed to send its responses to MPI's January 5, 2012, and January 19, 2012, records requests, reviewed the documentation that Ms. Cox had submitted and determined that the following Medicaid-related records that Respondent had been requested to produce in the January 5 and January 19 Letters were missing (hereinafter referred to collectively as the "Further Required Documentation"): written proof that D. S., an employee of Respondent's who had helped deliver services for which Respondent had billed the Florida Medicaid program from June 1, 2011, through December 1, 2011, under its Developmental Disabilities Home and Community-Based Medicaid Waiver services provider number, had completed the infection control and zero tolerance training required by the Developmental Disabilities Waiver Services Coverage and Limitations Handbook; and the annual health assessments required by the Assistive Care Services Coverage and Limitations Handbook for the four recipients of the services for which Respondent had billed the Florida Medicaid program from January 1, 2011, through November 30, 2011, under its assistive care services provider number. At all times material to the instant cases, Respondent had the Further Required Documentation in its possession,7/ however, Ms. Cox had inadvertently failed to include these documents in the submissions she made (on behalf of Respondent) in response to MPI's January 5 and January 19 Letters. Ms. Cox first learned that the Further Required Documentation was missing during a telephone conversation she had with Mr. Rivera at the end of March 2012, when he advised her of the omission and told her that she needed to get these documents to him "as soon as possible."8/ On April 1 or 2, 2012, no more than three or four days after this telephone conversation, Ms. Cox provided Mr. Rivera, by fax, with copies of the following: a certificate of completion issued by APD to employee D. S. on April 28, 2010, for "Zero Tolerance Training"; a certificate of completion issued by All Metro Health Care to employee D. S. for "Infection Control Guidelines" training completed on February 12, 2011; and a completed March 2011 annual health assessment recorded on AHCA Form 1823 (2011 Health Assessment Form) for each of the four recipients identified in the printout accompanying the January 19 Letter. Respondent also had in its possession the previous year's completed AHCA Form 1823 (2010 Health Assessment Form) for each of these recipients, but Ms. Cox did not fax copies of these forms9/ to Mr. Rivera because she reasonably believed that Mr. Rivera had asked only for the 2011 Health Assessment Forms.10/ MPI tries to "work with the [Medicaid] providers." If a provider is asked by MPI to provide, "as soon as possible," a specified document or documents previously requested but not produced and the provider, in response to such a follow-up request, produces the document(s) in question within a matter of days, it is MPI's practice to not impose any sanctions on the provider and, instead, to "move on to the next case."11/ In the instant cases, however, in an unexplained departure from that practice, MPI chose to issue the April 9, 2012, sanction letters set out above. It is these sanction letters that frame the issues to be resolved in these cases.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration dismiss the allegations made against Respondent in the April 9, 2012, sanction letters issued in these cases and it not impose any sanctions against Respondent for the conduct alleged in these letters. DONE AND ENTERED this 21st day of February, 2013, in Tallahassee, Leon County, Florida. S STUART M. LERNER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 21st day of February, 2013.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant facts are found: At all times pertinent to this proceeding, respondent was a licensed practical nurse holding license number 11005-1. On April 8th and 9th 1975, respondent was employed at St. Vincent's Medical Center in Jacksonville, Florida. As required by federal law and the normal course of the business of pharmacy, the pharmacist of the Center maintains and retains narcotic control records which chart the withdrawal and disposition, of controlled substances. The narcotic control records introduced into evidence as Exhibit 2 record the disposition of various dosages of meperidine ampuls. Demerol is the trademark name of the generic drug meperidine, which is a controlled substance under Ch. 893 of the Florida Statutes. St. Vincent's Medical Center has specific procedures to be followed when withdrawing and administering narcotic drugs. When a nurse withdraws a narcotic drug for a patient, it is her duty to fill out the narcotic control record showing the date, the time, the dosage, the patient to whom the drug is to be administered, the treating physician and the signature of the person withdrawing and administering the substance. The substance should then be administered to the patient within minutes of the withdrawal time, and the time of administration and dosage should immediately be noted or charted on that portion of the patient's medical record entitled "Nurses Notes." From the testimony adduced at the hearing, and by comparing the narcotic control records with the "Nurses Notes" on several patients; it is clear that on April 8th and 9th, 1975, respondent did not chart or note as having administered a substantial quantity of the drugs withdrawn by her. Furthermore, many that she did chart were not specific as to the time administered or the time charted was a half hour or more from the time listed on the narcotic control record. There was no evidence that respondent was using these drugs for her own purposes or that the patients, in fact, did not receive their medication after it was withdrawn by respondent. It was respondent's testimony that the discrepancies existing between the narcotic control sheets and the "Nurse's Notes" resulted from either errors in charting on another patient's chart or mistakenly forgetting to chart the administration due to being so busy or short-staffed. Respondent denied taking any of the narcotic drugs herself.
Recommendation Based upon the findings of fact and conclusions of law recited above, it is recommended that the Board of Nursing find respondent guilty as charged in the administrative complaint and suspend respondent's license for a period of six (6) months. Respectfully submitted and entered this 9th day of August, 1976, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Ms. Geraldine Johnson Florida State Board of Nursing 6501 Arlington Expressway Jacksonville, Florida 32211 Mr. Juluis Finegold 1130 American Heritage Life Building Jacksonville, Florida 32202 Ms. Dorothy M. Hall Cobb 1720 West 13th Street Jacksonville, Florida 32209
The Issue The central issue in this case is whether the provider, Medilab, was overpaid for medicaid claims as alleged in the letter dated November 3, 1993.
Findings Of Fact The Agency is the state agency responsible for administering the Florida Medicaid program. At all times material to this case, Medilab was a medicaid provider. Medilab enrolled as a physician group provider on or about October 2, 1991. Medilab was not enrolled with the Florida Medicaid program as a diagnostic lab. At all times material to this case, Medilab was owned and operated by Roberto Rodriguez and Jorge Nunez. Mr. Rodriguez handled the administrative duties for Medilab while Mr. Nunez operated the diagnostic portion of the business. Medilab operated several machines for diagnostic evaluations as ordered by a physician. Such machines produced documentation which was then evaluated by another physician. Dr. Carmouze did not perform the service nor interpret the diagnostic results. When Medilab applied for a provider number to enroll in the Medicaid program it represented that services were to be provided by Dr. Arnoldo Carmouze. It was further represented that Dr. Carmouze would treat or supervise treatment of patients on behalf of the Medilab "group." On or about January 11, 1992, Medilab received its group provider number along with a copy of the Medicaid Physician Provider Handbook. Medilab was notified that it could begin billing for services beginning October 2, 1991. Subsequently, the Agency performed an audit of Medilab for the period October 2, 1991 through August 31, 1992. Li-Hsiang Wu, a computer systems project analyst employed by the Agency, generated a random sample of Medicaid recipients by using a computer program to calculate the total number of Medicaid recipients for which claims were submitted during the audit period. Then Medilab's provider number and the dates of the audit were used to generate the total number of Medicaid recipients for whom claims were submitted by Medilab for the audit period. Once the total number of recipients was identified, Ms. Wu generated a list of forty-three recipient numbers which were selected by the computer from the total number claimed by Medilab for the period searched. Mr. Allen then requested and obtained from Medilab the medical records for the same forty-three randomly selected Medicaid recipients. The medical records were first reviewed by Phyllis Stiver, the Agency's registered nurse consultant. Once Ms. Stiver completed her initial review, Mr. Allen requested additional records from Medilab. Specifically, documentation for the office visit and records that established the necessity for the tests performed by Medilab were requested for each of the forty-three recipients. Medilab subsequently submitted additional records to the Agency which were also reviewed by Ms. Stiver. Ms. Stiver determined that based upon her review of the forty-three records, Medilab had violated Medicaid rules and policy as follows: Medilab failed to have all of the medical records signed by a physician and dated; and Medilab failed to document in the medical records to show that certain diagnostic tests were performed. After Ms. Stiver completed her review of the records, Dr. Sullenberger reviewed each of Medilab's medical records for the forty-three patients. Dr. Sullenberger determined, and it is found, that the majority of the tests performed by Medilab were not medically necessary based upon the symptoms documented for each patient, the prior patient histories established by the records, and the absence of other, less expensive testing that would normally be utilized to determine a medical condition. Virtually all of the patient records reviewed recited the same medical complaints: chest pain, shortness of breath, palpitation, numbness or tingling in extremities, and dizziness. Only five of the forty-three patients were over 49 years of age. The ages of the majority of the forty-three were under 50. That age group is rarely afflicted by the types of medical conditions which the Medilab equipment was used to detect. The symptoms and medical histories recited in the medical records did not justify the tests performed by Medilab for the following patients (recipients identified in this record as numbers 1 through 43): 1, 2, 17, 18, 21, 22, 24, 25, 32, 34, 35, 37, 38, and 41. With the exception of the electrocardiogram, the symptoms and medical histories recited in the medical records did not justify the tests performed by Medilab for the following patients (recipients identified in this record as numbers 1 through 43): 3, 4, 5, 6, 7, 9, 11, 12, 13, 15, 16, 19, 20, 23, 26, 27, 29, 30, 31, 33, 36, 39, 40, 42, and 43. With regard to recipient 8, except for the electrocardiogram and the abdominal ultrasound, the tests performed by Medilab were medically unnecessary. With regard to recipient 10, except for the electrocardiogram and the Doppler echocardiogram, the tests performed by Medilab were medically unnecessary. With regard to recipient 14, except for the electrocardiogram and the echocardiogram, the tests performed by Medilab were medically unnecessary. With regard to recipient 28, except for the mammogram, the tests performed by Medilab were medically unnecessary. None of the services or testing performed by Medilab were supervised by a physician. Two physicians, Dr. Pozo and Dr. Pereira, radiologists, read the diagnostic results but were not on site to perform or supervise the tests on a daily basis. Dr. Pozo did not supervise the services that were provided at Medilab. Dr. Pereira, who is deceased and whose testimony was not available, did not supervise the services that were provided at Medilab. According to Mr. Nunez, Dr. Pereira had someone from his office courier the tests results and his interpretations to and from the Medilab facility. Dr. Pereira may have visited the facility on occasion but was not there during its full hours of operation. Dr. Carmouze, the treating physician and representative for Medilab's physician group, did not supervise the services at Medilab. Dr. Carmouze treated over 95 percent of the total patients referred to Medilab yet Dr. Carmouze never billed the Medicaid program for the patients' office visits. For the audit period, of the 493 different patients Medilab billed Medicaid for, Dr. Carmouze is the only treating physician identified by the records. The Medicaid Physician's Handbook, supplied to Medilab at the time of its enrollment, specified that to be reimbursable the services performed by a physician group provider had to be medically necessary and supervised by a physician. The Medicaid Provider Agreement required Medilab to keep complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered for five years. All tests performed by Medilab were documented with a physician's order for same. Medilab submitted for review all medical and fiscal records it maintained in its attempt to fully justify and disclose the extent of the services it rendered.
Recommendation Based on the foregoing, it is, hereby, RECOMMENDED: That the Agency for Health Care Administration, Medicaid Program Integrity Office, issue a final order charging Medilab for the full amounts paid for the audit period as the services rendered were not supervised by a physician and were, therefore, not "physician services." Additionally, the Agency should impose an administrative fine in an amount not to exceed $5,000.00. DONE AND RECOMMENDED this 1st day of March, 1995, in Tallahassee, Leon County, Florida. JOYOUS D. PARRISH 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 1st day of March 1995. APPENDIX TO RECOMMENDED ORDER, CASE NO. 94-0096 Rulings on the proposed findings of fact submitted by the Petitioner: Paragraphs 1, 2, 4, 6, and 12 are accepted. Paragraph 3 is rejected as not supported by the weight of credible evidence. Paragraph 5 is rejected as irrelevant. Paragraph 7 is accepted as to the general statement but is rejected as to the amount claimed. Paragraph 8 is rejected as a mischaracterization of testimony; it is accepted Dr. Sullenberger, on further reflection and in an effort to be consistent, gave Medilab the benefit of doubt and modified disallowed items. Paragraph 9 is rejected as irrelevant. Paragraph 10 is rejected as irrelevant. Paragraph 11 is rejected as contrary to weight of credible evidence. Paragraph 13 is rejected as irrelevant or argument. Paragraph 14 is rejected as irrelevant. That Dr. Carmouze never charged for the alleged office visits that generated the referral for tests was the relevant fact. Paragraph 15 is accurate but is irrelevant in light of the stipulation. Rulings on the proposed findings of fact submitted by the Respondent: 1. Paragraphs 1 through 36, 39, 41, 43, 46, 48, 49, 50, 52, and 53 are accepted. Paragraphs 37, 38, 40, 42, and 47 are rejected as argument. Paragraph 44 is rejected as hearsay not supported by direct evidence. Paragraph 45 is rejected as not supported by the weight of credible evidence. With regard to paragraph 51, the first sentence is accepted; the remainder rejected as not supported by the weight of credible evidence. COPIES FURNISHED: Heidi E. Garwood Agency for Health Care Administration 1317 Winewood Boulevard Building B, Room 271 Tallahassee, Florida 32399-0700 Monte K. Rassner Rassner, Rassner, Kramer & Gold, P.A. 7000 Southwest 62nd Avenue, Suite PH-B South Miami, Florida 33143 Sam Power, Agency Clerk Agency for Health Care Administration The Atrium, Suite 301 325 John Knox Road Tallahassee, Florida 32303 Tom Wallace, Assistant Director Agency for Health Care Administration The Atrium, Suite 301 325 John Knox Road Tallahassee, Florida 32303
The Issue Whether Petitioner was overpaid for those Medicaid claims which, according to the post-hearing submissions of the parties, remain in dispute.
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Jay's Medical Center Jay's Medical Center (hereinafter referred to as "JMC") is a medical clinic located in a low income area in Miami. It is staffed by three physicians, including Shelley Wolland, D.O., the clinic's Medical Director, 6/ and several support staff. In general, the community JMC serves is poorly educated and has a relatively high incidence of medical problems. Approximately 7,000 members of the community receive medical services at JMC, with anywhere from 40 to 80 patients receiving services in a single day. Many of the clinic's patients are Medicaid recipients. The Provider Agreement JMC is now, and has been since May of 1990, when it entered into a Non- Institutional Professional and Technical Medicaid Provider Agreement with the Department, authorized to provide physician services, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) services, and family planning services to its Medicaid patients eligible to receive such services. The provider agreement between JMC and the Department provided as follows: The provider agrees that services will be provided to recipients of the Florida Medicaid Program without regard to race, color, religion, national origin, or handicap. The provider agrees to keep for 5 years complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billing made under the Medicaid program and agrees to furnish the State Agency and Medicaid Fraud Control unit upon request such information regarding any payments claimed for providing these services. Access to the pertinent patient records and facilities by authorized Medicaid program representatives will be permitted upon reasonable request. All records relating to Medicaid recipients are to be held confidential as provided under 42 CFR 431.305 and 306. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, Medicaid compensable and of quality comparable to those furnished by the provider's peers, and the services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting a claim. The provider agrees to submit Medicaid claims in accordance with program policies and that payment by the program for services rendered will be based on the payment methodology in the applicable Florida Administrative Rule. The provider in executing this agreement acknowledges that he understands that payment of Florida Medicaid claims is made from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. The providers of Independent Laboratory, Portable X-Ray Services, Home Health Services, Hospice and Rural Health Clinic Services agree to furnish the Office of Licensure and Certifi- cation a completed copy of Form HCFA-1513 (Ownership and Control Interest Disclosure Statement) in accordance with 42 CFR 455.104. The providers of Prescribed Drug Services agree to bill the Medicaid program no more than usual and customary charges and on request, to provide access to usual and customary pricing information. The Department agrees to notify the provider of any major changes in Federal or State rules and regulations relating to Medicaid. Payment made by the State Agency shall constitute full payment for services rendered to recipients under the Medicaid program. This includes situations when no payment is made to physicians when Medicare coinsurance claims are adjudicated due to Medicaid's payment methodology. The only exception is in specific programs when Medicaid coinsurance is required from the recipient. The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. The agreement may be terminated upon thirty days written notice by either party. The Department may terminate this agreement in accordance with Chapter 120, F.S. This agreement becomes effective the date the signature of the authorized agent of the Office of Medicaid is affixed. The provider eligibility will be established at the latter of the date of licensure of the provider, if applicable, or ninety (90) days prior to receipt of the application. The provider shall be responsible for assuring that the signature on the claim form is appropriate for authorization. Persons authorized to submit Medicaid claims on behalf of the provider shall be limited to the provider, the provider's employees or authorized agent. Handbook Provisions Among the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement was the Medicaid Physician Provider Handbook (hereinafter referred to as the "MPP Handbook"). Chapter 10 of the MPP Handbook addressed the subject of "provider participation." Section 10.9 of this chapter provided as follows: RECORD KEEPING You must retain physician records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, treatment plans, prior authorization information, any third party claim information, x-rays, fiscal records, and copies of sterilization and hysterectomy consents. Medical records must contain the extent of services provided. The following is a list of minimum requirements: history, physical examination, chief complaint on each visit, diagnostic tests and results, diagnosis, a dated, signed physician order for each service rendered, treatment plan, including prescriptions for medications, supplies, scheduling frequency for follow-up or other services, signature of physician on each visit, date of service, anesthesia records, surgery records, copies of hospital and/or emergency records that fully disclose services, and referrals to other services. If time is a part of the procedure code prescription being billed, then duration of visit shown by begin time and end time must be included in the record. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the MPP Handbook addressed the subject of "covered services and limitations." Section 11.1 of this chapter provided as follows: INTRODUCTION The physician services program pays for services performed by a licensed physician or osteopath within the scope of the practice of medicine or osteopathy as defined by state law. The services of this program must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient. Delivery of the services in this manual must be done by or under the personal supervision of a physician or osteopath at any place of service. Personal supervision is defined as the physician being in the building when the service was rendered. The physician must sign and date the medical record either on the date of service or within 24 hours. Each service type listed has special policy requirements that apply specifically to it. These must be adhered to for payment. HCPCS CODES and ICD-9-CM CODES Procedure codes listed in Chapter 12 are HCPCS (Health Care Financing Administration Common Procedure Coding System) codes. These are based on the Physician's Current Procedural Terminology, Fourth Edition. Determine which procedure describes the service rendered and enter that code and description on your claim form. HCPCS codes described as "unlisted" are used when there is no procedure among those listed that describes the service rendered. Physician's Current Procedural Terminology, Fourth Edition, Copyright 1977, 1980, 1981, 1982, 1983, 1984, 1985, 1986, 1987 by the American Medical Association (CPT-4) is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. The Health Care Financing Administration Common Procedure Coding System (HCPCS) includes CPT-4 descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials contained in CPT-4 which are copyrighted by the American Medical Association. The Diagnosis Codes to be used are found in the International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM). A diagnosis code is required on all physician claims. Use the most specific code available. Fourth and fifth digits are required when available. There are six levels of service associated with the visit procedure codes. They require varying skills, effort, responsibility, and medical knowledge to complete the examination, evaluation, diagnosis, treatment and conference with the recipient about his illness or promotion of optimal health. These levels are: . Minimal is a level of service supervised by a physician. . Brief is a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and exam. . Limited is a level of service used to evaluate a circumscribed acute illness or to periodically reevaluate a problem including a history and examination, review of effectiveness of past medical management, the ordering and evaluation of appropriate diagnostic tests, the adjustments of therapeutic management as indicated and discus- sion of findings. . Intermediate level of service pertains to the evaluation of a new or existing condition compli- cated with a new diagnostic or management problem, not necessarily related to the primary diagnosis, that necessitates the obtaining of pertinent history and physical or mental status findings, diagnostic tests and procedures, and ordering appropriate therapeutic management; or a formal patient, family or a hospital staff conference regarding the patient's medical management and progress. . Extended level of service requires an unusual amount of effort or judgment including a detailed history, review of medical records, examination, and a formal conference with the patient, family, or staff; or a comparable medical diagnostic and/or therapeutic service. . Comprehensive level of service provides for an in-depth evaluation of a patient with a new or existing problem requiring the development or complete reevaluation of medical data. This service includes the recording of a chief complaint, present illness, family history, past medical history, personal review, system review, complete physical examination, and ordering appropriate tests and procedures. 7/ Section 11.2 of Chapter 11 of the MPP Handbook provided in part, that "[t]reatment of an illness found by a physician during an EPSDT screening that requires considerable office time (30 minutes or more) to treat, may also be billed as an office visit on the appropriate claim form." Another of the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement between JMC and the Department was the Medicaid EPSDT Provider Handbook (hereinafter referred to as the "EPSDT Handbook"). Chapter 10 of the EPSDT Handbook addressed the subject of "provider participation." Section 10.8 of this chapter provided as follows: RECORD KEEPING You must retain EPSDT records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, Treatment plans, Prior authorization information, Any third party claim information, X-rays, Fiscal records, and Copies of sterilization and hysterectomy consents. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the EPSDT Handbook addressed the subject of "covered services and limitations." Sections 11.3 and 11.5 of this chapter provided that the components of an EPSDT preventive health screening examination were: a health and developmental history; unclothed physical assessment or examination; nutritional assessment; updating of routine immunizations, "as indicated by the recipient's age, health history, or population group;" laboratory tests, "as indicated by the recipient's age, health history, or population group;" development assessment, vision, hearing and dental screening; and health education. Section 11.7 of Chapter 11 provided, in part, as follows: Under federal regulations the state must provide for medically necessary treatment services diagnosed as a result of screening. Once the EPSDT recipient is screened and referred for treatment, any further diagnosis and/or treatment is then provided through the individual treatment service program. For example, if an EPSDT recipient is found to have an abnormal laboratory test result, such as tuber- culin (TB) skin test, any further referral, diagnosis and treatment is considered diagnostic treatment under physician services. Billing for a treatment visit at the time of a screening visit is only allowed when the illness is discovered during the screening examination. This treatment visit must be at least 30 minutes or more. Treatment visits completed in conjunction with a screening visit must be billed on the HFCA-1500 and the fact that the visit is screening related must be noted on the claim form. Treatment procedure codes should be related to screening results as noted on the EPSDT 221 claim form. An EPSDT screening should not routinely be completed on an obviously ill child, as the illness may distort the screening results. Sound professional judgment should be exercised in determining the appropriate- ness of screening an ill child. If screening results are questionable, treatment should be provided and the screening appointment rescheduled. If, however, an illness is detected during a screening examination, the screening may be completed and treatment provided on the same date, billing the treatment on the appropriate Medicaid claim form. Billing for treat- ment on the same day as the screening evaluation should be done only when a detected illness or condition requires significant time and procedures in addition to the time usually spent for a screening evaluation. The Audit Commencing in 1992, the Department conducted an audit of Medicaid claims submitted by JMC for services rendered from July 1, 1990, through December 31, 1991. During the course of the audit, the Department examined the files of 40 patients (Patients 1 through 19 and 21 through 41, hereinafter also referred to by their initials) who had received services during the audit period. Patient 1 (S.M.) January 16, 1991, Visit On January 16, 1991, S.M. presented at the clinic complaining of a sore throat and fever. The attending physician determined that S.M. had an upper respiratory tract infection, as well as vaginitis. Treatment was provided. JMC billed this as a "comprehensive" visit (procedure code 90020) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one (procedure code 90060), as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 29, 1991, Visit S.M. next visited the clinic on January 29, 1991. JMC billed this visit as a "limited" one (procedure code 90050) and payment was made accordingly. Respondent does not dispute the appropriateness of such billing and payment. 8/ April 23, 1991, Visit On April 23, 1991, S.M. presented at the clinic complaining of blood in her urine. She further indicated that she had recently had a Pap smear test, the results of which reflected a possible precancerous condition. A pregnancy test revealed that S.M. was pregnant. She was also diagnosed as having an upper respiratory tract infection, for which she was treated. A gynecological referral was made. JMC billed this visit as a "extended" one (procedure code 90070) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 9, 1991, Visit and Streptococcal Test S.M. visited the clinic again on October 9, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. It also sought and obtained separate payment for a streptococcal (hereinafter referred to as "strep") test (procedure code 86317) given during the visit. Both parties are now in agreement that the billing and payment for the strep test was appropriate 9/ and that the office visit should have been billed and paid, not as an "extended" visit, but as an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. November 6, 1991, Visit Cerumen Removal and Strep Test On November 6, 1991, S.M. presented at the clinic complaining of sinus problems and pustules on her nose. She was diagnosed as having folliculitis, pharyngitis and sinusitis. Treatment was provided. JMC billed this visit as a "extended" one and payment was made accordingly. It also sought and obtained separate payment for impacted cerumen removal (procedure code 69210) and a strep test. The parties are in agreement that the billings and payments for the impacted cerumen removal and strep test were appropriate. 10/ A dispute still exists, however, as to the appropriateness of JMC billing and receiving payment for an "extended" visit. JMC's medical records pertaining to the visit, to the extent that they are legible, document that the visit was not an "extended" visit, but was merely an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. Moreover, these records were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. 11/ Accordingly, JMC should not have received any payment for this office visit. Patient 2 (O.R.) October 7, 1991, Billings JMC billed and was paid for a "comprehensive" visit and other services (procedure codes 86317, 94010 and 94664) it claimed it rendered Patient 2, O.R., on October 7, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that, on that date, O.R. was seen at the clinic by a physician or that she received the other billed for services. Accordingly, payment should not have been made to Petitioner for an office visit of any type or for any of the other services Petitioner claimed it rendered O.R. on October 7, 1991. October 22, 1991, Visit On October 22, 1991, O.R. presented at the clinic with a fever, sore throat and high blood pressure. In addition, she complained that she was wheezing, suffering from headaches and had a runny nose. At the time of the visit, O.R. was five feet, two inches tall and weighed 206 pounds. The attending physician determined that O.R. was suffering from asthma. Using a nebulizer, he treated her with Ventolin. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit, Routine Venipuncture and Therapeutic Injection O.R. returned to the clinic two days later, on October 24, 1991, with respiratory problems. She was coughing and wheezing severely. Her throat was red. The attending physician determined that O.R. had pharyngitis, pneumonia and severe asthma. Treatment was provided. Medications were prescribed and oral instructions regarding medication administration and compliance were given. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC also sought and obtained separate payment for a routine venipuncture (procedure code 36415) and a therapeutic injection for asthma (procedure code 90782). The parties are in agreement that the routine venipuncture was appropriately billed and paid. The appropriateness of the billing and payment for a therapeutic injection, however, is still in dispute. JMC's medical records, to the extent that they are legible, do not document that O.R. was given the billed and paid-for therapeutic injection on October 24, 1991. Accordingly, it should not have been paid for this service. Patient 3 (T.F.) January 31, 1991, Visit On January 31, 1991, Patient 3, T.F., a ten-year old girl who had already begun menstruating, presented at the clinic with complaints of vomiting for the past two days, as well as cramps and abdominal pain. She further indicated that she had had her last menstrual period two weeks previous. A physical examination, which included the genital and rectal areas, was conducted, a history was taken and a strep test was given. The results of the strep test were positive. The attending physician determined that T.F. had strep throat, for which she received treatment. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 19, 1991, Visit On September 19, 1991, T.F. presented at the clinic complaining of a high fever and a sore throat. She further indicated that she had vomited earlier in the morning. A physical examination, which did not include the genital area, was conducted, an updated history was taken and a strep test was given. The attending physician determined that T.F. had tonsillitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 4 (K.W.) October 3, 1991, Visit On October 3, 1991, Patient 4, K.W., presented at the clinic. He had lower back pain, an upper respiratory tract infection, trauma to his right ankle and folliculitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 4, 1991, Billings JMC billed and was paid for an "extended" visit and another service (procedure code 86317) it claimed it rendered K.W. on November 4, 1991, but the medical records maintained by JMC do not contain legible, physician-signed and dated documentation substantiating that, on that date, K.W. was seen at the clinic by a physician or that he received the other billed-for service. Accordingly, payment should not have been made to Petitioner for any type of office visit or for the other service Petitioner claimed it rendered K.W. on November 4, 1991. Patient 5 (S.W.) October 19, 1990, Visit JMC billed and was paid for a "comprehensive" office visit, in addition to an EPSDT screen (procedure code W9881), for services rendered to Patient 5, S.W., on October 19, 1990. The parties are in agreement that the EPSDT screen was appropriately billed and paid. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. The medical records maintained by JMC do not contain legible, physician-signed and dated documentation justifying JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. October 29, 1990, Visit S.W. again visited the clinic on October 29, 1990. This was a follow- up visit. She had been to the clinic four days previous with a high fever and complaining of a headache, stuffiness and a cough. JMC billed S.W.'s October 29, 1990, visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 14, 1991, Visit On May 14, 1991, S.W. presented at the clinic complaining of a cough. She was diagnosed as having an upper respiratory tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit Two weeks later, on May 29, 1991, S.W. returned to the clinic for a follow-up visit. She was still coughing. Tests taken before the visit revealed that, in addition to her respiratory problems, S.W. was suffering from iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 12, 1991, Visit On June 12, 1991, S.W. paid another follow-up visit to the clinic. During the visit, she admitted that she had not taken her medication "properly." A spirometry test taken before the visit revealed "severe obstruction." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 6 (B.F.) July 12, 1990, Visit On July 12, 1990, Patient 6, B.F., a 32-year old woman, presented at the clinic complaining of chest palpitations and abdominal pain. A physical examination, which included an examination of the vaginal and pelvic areas, was conducted, a history was taken, tests were ordered and treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, a "comprehensive" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. January 14, 1991, Visit B.F. visited the clinic on January 14, 1991, complaining of lower abdominal discomfort, which, she claimed, she had been experiencing for the past two weeks. The attending physician determined that, in addition to the abdominal discomfort B.F. was experiencing, she also had vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 28, 1991, Visit On January 28, 1991, B.F. presented at the clinic complaining of general malaise and a cough that she claimed she had had for four or five days. The attending physician determined that B.F. was suffering from acute bronchitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 24, 1991, Visit On April 24, 1991, B.F. presented at the clinic complaining of chest pain, headaches and dizziness she had been experiencing for several days. She also had shortness of breath. A physical examination, which included an examination of the genital and rectal areas, was conducted, an updated history was taken and tests were ordered. The chest pain was determined to be non-cardiac in nature. It was thought to be caused by a tender rib. Medication was prescribed to combat B.F.'s headaches and dizziness. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, B.F. paid a followup visit to the clinic. She reported that she was still experiencing dizziness, but no longer had any chest pain or headaches. She further advised that she was unable to tolerate the medication that had been prescribed on the previous visit. A rhythm strip test was administered. A new medication was prescribed to combat B.F.'s dizziness. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 7 (C.C.) July 23, 1991, Visit On July 23, 1991, Patient 7, C.C., visited the clinic for the removal of a lesion from her nose by electrodesiccation. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 8 (L.F.) October 21, 1991, Visit On October 21, 1991, Patient 8, L.F., presented at the clinic complaining of a skin rash. The attending physician determined that L.F. was suffering from impetigo, as well as bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 9 (L.A.) November 26, 1990, Visit On November 26, 1990, Patient 9, L.A., presented at the clinic complaining of chest pain. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that such billing and payment was appropriate and thus JMC was not overpaid for this visit. March 28, 1991, Visit On March 28, 1991, L.A. presented at the clinic complaining of chest and abdominal pain. 152. The attending physician determined that the chest pain was non- cardiac in nature and that L.A. was suffering from gastritis. 153. Medication was prescribed. 154. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 6, 1991, Visit On May 6, 1991, L.A. visited the clinic to obtain birth control pills. JMC billed this visit as an "extended" one. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 17, 1991, Visit On June 17, 1991, L.A. presented to the clinic complaining of a sore throat and back pain. The latter ailment was the result of her having been hit in the back with a chair that was thrown at her at work. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 8, 1991, Debridement On August 8, 1991, L.A. presented to the clinic complaining of a gash on her left leg that she had received the night before, as well as a headache and continuing back pain. The leg wound was cleaned. Necrotic tissue around the edge of the wound was removed. JMC billed for a debridement (procedure code 11042) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC. JMC was therefore appropriately paid for this procedure. September 27, 1991, Visit On September 27, 1991, L.A. presented at the clinic complaining of diarrhea, a cold and postnasal drip. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 28, 1991, Visit On October 28, 1991, L.A. presented to the clinic complaining of a sore throat. She further indicated that she had been exposed to the flu. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 10 (B.W.) February 26, 1991, Visit and EPSDT Screen On February 26, 1991, Patient 10, B.W., who was then twelve years old, presented at the clinic for an EPSDT screen. complaining of an abscess behind her ear and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 12/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. March 1, 1991, Billing JMC billed and was paid for services rendered B.W. during an "intermediate" office visit it claimed took place on March 1, 1991, but the physician signed-medical records maintained by JMC, to the extent that they are legible, do not document that B.W. was seen that day at the clinic by a physician. Payment for such an office visit therefore should not have been made. March 13, 1991, Visit On March 13, 1991, B.W. presented at the clinic with multiple, yet relatively uncomplicated, medical problems, including iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. June 24, 1991, Visit On June 24, 1991, B.W. presented at the clinic complaining of a skin rash. She also had a slightly elevated temperature. The attending physician determined that B.W had dermatitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 27, 1991 Visit Three days later, on June 27, 1991, B.W. again visited the clinic. This time she had an abscess in the area of her left armpit. The abscess was drained. JMC billed this visit as an "extended" one and payment was made accordingly. 13/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit and EPSDT Screen On October 18, 1991, B.W. presented at the clinic for an EPSDT screen complaining of an abscess in the area of her right armpit and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 14/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 11 (T.M.) October 30, 1990, Visit On October 30, 1990, Patient 11, T.M., who was then six years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, a wart was discovered on T.M.'s left wrist. The wart was removed. The procedure took approximately 15 minutes. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 15/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. May 9, 1991, Visit T.M. presented at the clinic on May 9, 1991, with an elevated temperature. The attending physician determined that he had an upper respiratory tract infection. Medication was prescribed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 12 (D.W.) November 30, 1990, Visit On November 30, 1990, Patient 11, D.W., who was then three months old, presented at the clinic for an EPSDT screen. He had a stuffy nose. The screen was performed. The physician performing the screen determined that D.W. was suffering from an upper respiratory tract infection and otitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 14, 1990, Visit On December 14, 1990, D.W. presented at the clinic. His mother reported that D.W. had a persistent cough. D.W. was given a strep test, the results of which were negative. The attending physician determined that D.W. still had an upper respiratory tract infection and otitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 17 and 27, 1990, Visits D.W. visited the clinic on December 17, 1990, and again on December 27, 1990. JMC billed these visits as "intermediate" ones and payments were made accordingly. The parties agree that these billings and payments were appropriate. January 21, 1991, Visit On January 21, 1991, D.W. returned to the clinic with his mother. He had a fever of 102 degrees Fahrenheit, which, his mother reported, he had had for the past four days. Following an examination and a strep test, the attending physician determined that D.W. had a strep throat and an ear infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 7, 1991, Visit On June 7, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was discovered that D.W had an ear problem, for which he received treatment. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office on this date. June 21, 1991, Visit 254. D.W. returned to the clinic on June 21, 1991, with an ear infection and a rash behind his right ear. 255. Treatment was provided. 256. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. July 23, 1991, Visit On July 23, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that D.W. was suffering from diaper rash. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 13 (J.H.) December 29, 1990, Visit and EPSDT Screen On December 29, 1990, J.H., who was then three years of age, presented at the clinic for an EPSDT screen. She was suffering from constipation. During the screen, the attending physician determined that J.H. also had vaginitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, there is no indication that J.H.'s teeth and gums were examined during the visit. Accordingly, JMC was not entitled to receive any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 4, 1991, Visit On January 4, 1991, J.H. presented at the clinic. She looked ill and had glassy eyes. It was reported that her temperature (taken with a rectal thermometer) had reached 104 degrees Fahrenheit at home. When her temperature was taken (again rectally) at the clinic, however, it was only 99.2 degrees Fahrenheit. The attending physician determined that J.H. had a urinary tract infection and pharyngitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 14 (J.Y.) April 20, 1991, Visit On April 20, 1991, Patient 14, J.Y., a 25-year old woman suffering from obesity and hypertension, presented at the clinic to obtain a refill of medication that she had been given on a previous visit. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 15 (K.C.) September 20, 1991, Visit On September 20, 1991, Patient 15, K.C., who was then four years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that K.C. was suffering from an upper respiratory ailment. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "intermediate" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "intermediate" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 16 (D.W.) December 17, 1991, Visit On December 17, 1991, Patient 16, D.W., who was then eight years of age, presented to the clinic for an EPSDT screen. During the screen, the attending physician determined that D.W. was suffering from dermatitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks adequate supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 17 (R.G.) There are no issues in dispute concerning any billings and payments made in connection with services JMC rendered to Patient 17, R.G. Patient 18 (C.F.) February 12, 1991, Visit On February 12, 1991, C.F., a 25-year old woman, presented at the clinic complaining of profuse menstrual bleeding. The attending physician determined that C.F. was simply having irregular menstrual periods and that medical intervention was not warranted. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 18, 1991, Visit On November 18, 1991, C.F. returned to the clinic. She still had irregular menstrual periods and, in addition, she complained of a heavy discharge of breast milk from both of her breasts. Tests were ordered. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991, Visit On December 9, 1991, C.F. again visited the clinic. This time she had an upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 19 (J.R.) September 17, 1990, Visit On September 17, 1990, Patient 19, J.R., who was then six months old, visited the clinic. 16/ He had, what his mother described as, a "bad cold." The attending physician determined that J.R. had an upper respiratory tract infection and bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 31, 1991, Visit On January 31, 1991, J.R. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that J.R. was suffering from a rash, a mild upper respiratory ailment, and a sore throat. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "extended" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. February 26, 1991, Visit On February 26, 1991, J.R. again visited the clinic. He had an ear infection and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, J.R. paid another visit to the clinic. Diaper rash was still a problem. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit J.R. returned to the clinic on May 29, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that any of JMC's staff physicians provided medically necessary services to J.R. on this date. While these records do reflect that J.R. received an abbreviated physical examination during his visit to the clinic, they do not reveal why the examination was conducted or what conclusions the attending physician reached as a result of the examination. Accordingly, JMC should not have received any payment for an office visit on this date. Patient 21 (T.M.) April 26, 1991, Visit On April 26, 1991, Patient 21, T.M., who was then five years of age, presented at the clinic for an EPSDT screen. He had sickle cell anemia, but was doing well. The screen was performed. Following the screen, the attending physician recommended that T.R. continue taking folic acid and vitamins. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 22 ( K.C.) August 28, 1990, Visit On August 28, 1990, Patient 22, K.C., who was then six months old and had recently been exposed to hepatitis B, presented at the clinic for an EPSDT screen. The screen was performed. The attending physician did not believe that K.C. had contracted hepatitis B. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 23 ( K.G.) July 10, 1990, Visit On July 10, 1990, Patient 23, K.G., presented at the clinic complaining of a vaginal discharge. The attending physician determined that K.G. was suffering from vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 15, 1990, Visit On October 15, 1990, K.G. presented at the clinic complaining of a rash in the area of her groin. The attending physician determined that K.G. had folliculitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. February 15, 1991, Visit On February 15, 1991, K.G. presented at the clinic complaining of swelling in her legs. 17/ The attending physician determined that she had pinworms. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. March 8, 1991, Visit On March 8, 1991, K.G. presented at the clinic complaining of rectal pain and a persistent cough. The attending physician determined that K.G. had pharyngitis, pneumonia and an anal fissure. Treatment, which included the use of an aerosol spray, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 18/ 372. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. June 6, 1991, Visit On June 6, 1991, K.G. visited the clinic complaining of weight gain and pain in her left side. The attending physician determined that the pain was caused by gas and prescribed medication to combat the problem. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 28, 1991, Visit On June 28, 1991, K.G. presented at the clinic complaining of a sore throat and a cough producing yellowish sputum. She claimed that she had had the sore throat for three to four days. A strep test was given, the results of which were negative. The attending physician determined that K.G. had bronchitis and pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 1, 1991, Visit On August 1, 1991, K.G. presented at the clinic. 19/ She had a pararectal abscess and a urinary tract infection. The abscess was drained. In addition, treatment was provided for the urinary tract infection. JMC billed this visit as an "extended" one and payment was made accordingly. 20/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 5, 1991, Visit On September 5, 1991, K.G. presented at the clinic. She had a cough and sore throat. A strep test was given, the results of which were negative. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 24 (L.W.) December 10, 1990, Visit On December 10, 1990, Patient 24, L.W., who was then five years of age, presented at the clinic for an EPSDT screen. The screen was performed. As part of the screen, her weight was taken. She weighed only 30 pounds. 401. Because she had a persistent cough and a runny nose, a strep test was given, the results of which were positive. 402. JMC billed for an EPSDT screen and a "comprehensive" visit. 403. The parties agree that the billing and payment for an EPSDT screen was appropriate. The billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. July 2, 1991, Visit On July 2, 1991, L.W. presented at the clinic. 21/ Her right breast was enlarged. In addition, she had pharyngitis and impacted cerumen in her ears. A strep test was given, the results of which were negative. Treatment, which included the removal of the impacted cerumen, was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 22/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 25 (R.W.) October 3, 1991, Visit On October 3, 1991, Patient 25, R.W., who was then four months old, presented at the clinic for an EPSDT screen. 23/ He had an asthmatic condition and bronchitis. The screen was performed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 24/ JMC therefore should not have received any payment for an office visit on this date. October 10, 1991, Visit On October 10, 1991, R.W. presented at the clinic for another EPSDT screen. His asthma and bronchitis were much improved. The screen was performed. No new problems were discovered. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 25/ JMC therefore should not have received any payment for an office visit on this date. October 16, 1991, Visit On October 16, 1991, R.W. returned to the clinic. His condition had worsened and he was crying in his mother's arms. In addition to the problems he had had previously, he now also had an ear infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit R.W. paid a follow-up visit to the clinic on October 24, 1991. His condition had improved since his last visit to the clinic on October 16, 1991. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that this visit, like R.W.'s prior visit to the clinic, was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 26 (E.W.) September 16, 1991, Visit On September 16, 1991, Patient 26, E.W., who was then four months old, presented at the clinic with a cold and cough. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks sufficient supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 27 (C.S.) 26/ November 4, 1991, Visit and EPSDT Screen On November 4, 1991, Patient 27, C.S., who was then seven months old, presented at the clinic. She was suffering from a cold. Treatment was provided. JMC billed for an EPSDT screen and an "extended" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, these records contain no nutritional or developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not an "extended" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 28 (S.S.) 27/ May 15, 1991, Visit On May 15, 1991, Patient 28, S.S., presented at the clinic complaining of keloid skin masses on both of her ears which, she indicated, she wanted removed. JMC billed this visit as a "comprehensive" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as an "intermediate" one and that therefore JMC was overpaid for this visit. May 29, 1991, Visit On May 29, 1991, S.S. returned to the clinic for evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on May 29, 1991. June 12, 1991, Visit On June 12, 1991, S.S. paid another visit to the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on June 12, 1991. July 10, 1991, Visit On July 10, 1991, S.S. again visited the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on July 10, 1991. August 7, 1991, Visit S.S. went back to the clinic on August 7, 1991, for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 12, 1991, Visit On September 12, 1991, S.S. presented at the clinic for additional evaluation and treatment of her keloids, which were scheduled to be removed the following day. She also had a sore throat. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 19, 1991, Visit Only one of the keloids, the one on her left ear, was removed on September 13, 1991. Six days later, on September 19, 1991, S.S. visited the clinic for a postsurgical examination and to discuss the removal of the keloid on her right ear. She presented at the clinic with a sore throat and earache. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 26, 1991, Visit S.S. returned to the clinic on September 26, 1991. She had an abscess on her ear. The abscess was incised and drained. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 28/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Debridement On October 7, 1991, S.S. presented at the clinic complaining of continuing skin problems on and behind her ears. An abscess and "raggedy" skin were discovered. The abscess was incised and drained and the "raggedy" skin was removed. JMC billed and was paid for a debridement. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC, and that therefore JMC was entitled to the payment it received for the debridement. Patient 29 (T.J.) January 28, 1991, Visit On January 28, 1991, Patient 29, T.J., who was then one month old, was seen at the clinic. She had congenitally deformed ("toe[d] in") feet, multiple insect bites and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 30, 1991, Visit T.J. returned to the clinic two days later. She had been vomiting for the past two days. In addition, she had a sore throat and an earache. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 22, 1991, Visit On April 22, 1991, T.J. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was determined that T.J. had dermatitis caused by insect bites. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 24, 1991, Visit On April 24, 1991, T.J. again visited the clinic. Her dermatitis was still causing her some discomfort. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 30 (G.D.) March 11, 1991, Visit On March 11, 1991, Patient 30, G.D., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed that G.D. had upper respiratory problems, as well as an umbilical hernia. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 22, 1991, Visit G.D. was next seen at the clinic on April 22, 1991. He had pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 3, 1991, Visit G.D. next visited the clinic on June 3, 1991. He had a mild upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 31 (H.C.) October 15, 1990, Visit On October 15, 1990, H.C., who was then 18 years old, presented at the clinic complaining of delayed menstruation. She was given a pregnancy test, the results of which revealed that she was pregnant. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 32 (R.M.) February 12, 1991, Visit On February 12, 1991, Patient 32, R.M., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in R.M.'s ears. The impacted cerumen was removed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 29/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 33 (C.W.) December 3, 1990, Visit On December 3, 1990, Patient 33, C.W., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in C.W.'s ears and that R.M. had pharyngitis. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 30/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. August 22, 1991, Visit 534. On August 22, 1991, C.W. presented at the clinic complaining of a headache. 535. The attending physician determined that C.W. had pharyngitis. 536. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Visit On October 7, 1991, C.W. again visited the clinic. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed and paid for as a "limited" one, as described in Chapter 11 of the MPP Handbook. October 10, 1991, Visit Three days later, on October 10, 1991, C.W. returned to the clinic. She had tonsillitis, pharyngitis and an upper respiratory infection. Her temperature was 103.4 degrees Fahrenheit. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 34 (K.K.) September 19, 1990, Visit On September 19, 1990, Patient 34, K.K., who was then three years old, presented at the clinic for an EPSDT screen. He had a runny nose and a cough. His mother also complained that he was hyperactive. 549. The screen was performed. 550. The screen revealed that K.K. had impacted cerumen in his ears. 551. provided. Treatment, including the removal of the impacted cerumen, was 552. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 31/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 17, 1990, Visit On or about December 17, 1990, K.K. returned to the clinic. He had dermatitis, as well as impacted cerumen in his ears. In addition, his mother was concerned about his behavior. Treatment, including the removal of the impacted cerumen, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 32/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 3, 1991, Visit On January 3, 1991, K.K. returned to the clinic for a physical examination for school. During the visit, his mother complained that K.K.'s appetite for food had decreased. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 35 (T.B.) November 15, 1990, Visit On November 15, 1990, Patient 35, T.B., presented at the clinic for a physical examination for work. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 20, 1990, Visit T.B. returned to the clinic on December 20, 1990, complaining that she was not feeling well. During the visit, impacted cerumen was removed from her ears. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 33/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. July 18, 1991, Visit On July 18, 1991, T.B. went to the clinic to obtain "medical certificates." A routine physical examination was performed, but no history was taken. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 4, 1991, Visit On December 4, 1991, T.B. presented at the clinic with "pink eye." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 36 (D.W.) January 2, 1991, Visit On January 2, 1991, Patient 36, D.W., who was then 19 years of age, visited the clinic for a checkup. The attending physician determined that D.W. had an iron deficiency and anemia, for which treatment was provided. During the visit, family planning issues were also addressed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit On April 17, 1991, D.W. presented at the clinic complaining that she had been feeling ill for two days. 34/ 592. A strep test was given, the results of which were negative. The attending physician determined that D.W had tonsillitis and was still suffering from anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 16, 1991, Visit On September 16, 1991, D.W. presented at the clinic. She had a sore throat and vaginitis. 35/ In addition, she was now pregnant and still anemic. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. 601. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 17, 1991, Visit On October 17, 1991, D.W., who was still pregnant at the time, made a follow-up visit to the clinic. She complained of shortness of breath and tightness in her chest, as well as a sore throat. A fetal examination was conducted. A strep test was given, the results of which were negative. The attending physician determined that D.W. had a urinary tract infection, sinusitis, pharyngitis and anemia. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 14, 1991, Visit and Echography D.W. returned to the clinic on November 14, 1991. She was in approximately the thirty-second week of her pregnancy and she was still suffering from a urinary tract infection and anemia. Her sinus condition was improving. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. It also sought and received separate payment for an echography (procedure code 76855). The parties now agree that JMC should not have been paid for an echography. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 3, 1991, Visit A still-pregnant D.W. visited the clinic again on December 3, 1991, complaining of shortness of breath. The attending physician determined that she was still suffering from a urinary tract infection and anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 10, 1991, Visit A week later, on December 10, 1991, with her anticipated date of delivery approaching, D.W. returned to the clinic complaining of vaginal irritation and pain in her left wrist. Her urinary tract infection was improving. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 37 (E.A.) September 27, 1991, Visit On September 27, 1991, Patient 37, E.A., who was then seven weeks old, presented at the clinic with an upper respiratory infection, pharyngitis and thrush. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit E.A. returned to the clinic on October 18, 1991, for an EPSDT screen. 633. The screen was performed. The screen revealed that he still had an upper respiratory infection and thrush. Treatment was provided. JMC billed for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. November 20, 1991, Visit E.A. visited the clinic again on November 20, 1991. He had a bad cough and a green discharge from his eyes and nose. The attending physician determined that E.A. had an upper respiratory infection and pharyngitis, as well as a "foreign body" in his nose. Treatment, including the removal of the "foreign body," was provided. 36/ JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore entitled to the payment it received for this visit. November 21, 1991, Incision and Removal JMC billed and was paid for an incision and removal of a "foreign body" (procedure code 10120) it claimed had been performed on E.A. at the clinic on November 21, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that E.A. received an incision and removal at the clinic on this date. Accordingly, payment should not have been made to JMC for this billed-for service. Patient 38 (O.S.) December 2, 1991, Visit and EPSDT Screen On December 2, 1991, Patient 38, O.S., who was then three months old, presented at the clinic for an EPSDT screen. She had a cold and blotches all over her body and her hair was falling out. The screen revealed that O.S. had tinea capitis, otodynia, and pharyngitis, as well as impacted cerumen in her ears. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 37/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete EPSDT screen was performed. For example, these records contain no developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991 O.S. returned to the clinic a week later on December 9, 1991. She had a new rash on her left arm. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 39 (T.G.) September 5, 1991, Visit On September 5, 1991, Patient 39, T.G., who was then three months old, presented at the clinic for an EPSDT screen. She had a stuffy nose and was crying. According to his mother, he had been crying for the past 12 hours. The screen was performed. A strep test was given, the results of which were negative. The attending physician determined that T.G. had an ear infection, an upper respiratory tract infection and phayrngitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, justify JMC billing and receiving payment for, in addition to an EPSDT screen, only an "intermediate" office visit and not a "comprehensive" one. JMC was therefore overpaid for this visit. September 19, 1991, Visit T.G. returned to the clinic for a follow-up visit on September 19, 1991. He had diaper rash. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 40 (T.B.) November 26, 1991, Visit On November 26, 1991, T.B., a 62-year old man with a history of heart disease, hypertension and stroke, presented at the clinic with a periorbital abscess. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. 38/ JMC was therefore overpaid for this visit. November 29, 1991, Visit Three days later, on November 29, 1991, T.B. returned to the clinic again complaining about the abscess. The attending physician reevaluated the problem and referred T.B. to Jackson Memorial Hospital for treatment. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 41 (L.B.) January 25, 1991, Visit On January 25, 1991, Patient 41, L.B., who was then 19 years of age and had history of mental illness, presented at the clinic stating that she was pregnant and complaining, among other things, of abdominal pain. She appeared to be confused and it was difficult to obtain an accurate history from her. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit L.B. returned to the clinic on April 17, 1991, complaining of continuing abdominal pain, vaginal discharge, breast tenderness and nausea. The attending physician determined that L.B. had vaginitis and a urinary tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 25, 1991, Visit L.B. visited the clinic again on November 25, 1991. On this visit she complained of a rash. The attending physician determined that L.B. had dermatitis. 694. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 6, 1991, Visit On December 6, 1991, L.B. presented at the clinic claiming that there were things crawling on her scalp. The attending physician determined that L.B. was demented. He filled out a Social Security Administration form indicating that it was his opinion that L.B. was "not medically competent." JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. Simple Mistake or Fraud? There has been no allegation made, nor proof submitted, that any of the overbillings referenced above were the product of anything other than simple mistake or inadvertence.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration adopt the findings made by the Hearing Officer regarding the sampled claims remaining in dispute in the instant case and use these findings to redetermine the total amount of Medicaid overpayments made to Petitioner during the audit period and the amount of the fine Petitioner should be required to pay for its erroneous billings during this period of time. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd of May, 1995. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of May, 1995.
