The Issue Whether the petitions for formal administrative hearing filed by Petitioner in these consolidated cases should be dismissed as contended by Respondent? If not, whether Petitioner should be granted the relief sought in these petitions?
Findings Of Fact Based upon the record evidence and the factual stipulations entered into by the parties, the following Findings of Fact are made: Petitioner is a Florida Medicaid provider. Its provider number is 027856400. Paragraph 8 of the provider agreement that it entered into with the Department provides that it 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 Department is the state agency that administers the Florida Medicaid program. The Department's Medicaid Program Integrity Unit audits and investigates claims for reimbursement submitted by Florida Medicaid providers. John M. Whiddon is Chief of the Unit. Ellen Williams is one of his subordinates. In November, 1991, Whiddon received a letter from the Director of the Auditor General's Fraud Control Unit. The body of the letter read as follows: The Florida Medicaid Fraud Control Unit is currently in the process of conducting a criminal investigation of [Petitioner]. Our investigation has established that there is a basis for criminal prosecution for the billing of services not rendered and for providing treatment that was not prescribed (there were no treatment plans). As of today's date the provider's YTD earnings are in excess of $444,000. I believe that a review of the claims submitted the last 90-120 days will indicate a high volume of the claims being false and that you may want to proceed administratively to stop the improper claims. Shortly after receiving this letter, Whiddon ordered that each of Petitioner's claims be subjected to prepayment review. On February 17, 1992, Petitioner filed with the Department his petition requesting an award of "damages in excess of $10,000.00." The petition contains four counts. Count I of the petition alleges that "[i]n refusing to reimburse [Petitioner] for services rendered, [the Department] has violated Section 409.266, et seq., Fla. Stat." Count II of the petition alleges that "[i]n refusing to reimburse [Petitioner] for services rendered and failing to notify [Petitioner] of [the Department's] intent to withhold any payment due [Petitioner], [the Department] has violated Rule 10C-7.060, et seq., Fla. [Admin. Code]." Count III of the petition alleges that "[b]y withholding monies due and owing to [Petitioner] for services rendered without prior notice to [Petitioner], in violation of its own rules and regulations, and failing to provide for any procedure for a post-deprivation hearing, [the Department] violated [Petitioner's] due process rights." Count IV of the petition alleges that "[the Department] has breached its agreement to reimburse [Petitioner] for services rendered." Each of the foregoing counts contained the following prayer for relief: WHEREFORE, Our Lady requests this Court enter judgment against HRS for compensatory damages, attorneys' fees, costs and interest and such other relief as the Court deems just and proper. On March 7, 1992, Petitioner received a letter from Whiddon, dated January 28, 1992. The body of the letter read in part as follows: In accordance with 42 CFR 455.23, the Department of Health and Rehabilitative Services is withholding payments for Medicaid claims submitted by Our Lady Health Care Services. Based on our review of a sample of your home health records for the period February 1, 1991-November 30, 1991, we find evidence of willful misrepresentation on your part. Your home health records revealed that: You billed for services for which there was not a valid treatment plan, and You billed for nursing and aide services that were not documented as having been provided. As stated in 42 CFR 455.23, this action is temporary and will not continue after: the department determines that there is insufficient evidence of willful misrepresentation by the provider; or legal proceedings related to the provider's alleged willful misrepresentation are completed. In accordance with 42 CFR 455.23, you have the right to submit written evidence for consideration by the department. If you have such evidence, please send it to Ms. Ellen D. Williams, 2002 Old St. Augustine Road, Suite B-10, Tallahassee, Florida 32301. Pursuant to Section 120.57, Florida Statutes (F.S.) and Rule Section 10- 2.056, Florida Administrative Code (F.A.C.) you may request either a formal or informal hearing on the department's action. Your request for such hearing must be received by the department within 30 days of the date you received this letter. A request for informal hearing must be in writing and a request for formal hearing must be in the form of a petition in compliance with Rule Section 28-5.201, F.A.C. Either request must be substantive and state clearly the specific actions to which you object and why you object to them. . . . The purpose of either a formal or informal hearing is to determine whether the action taken in this letter is within the authority of the Department of Health and Rehabilitative Services and in accordance with the department's applicable rules and policies. . . . If a hearing request is not received within 30 days from the date of receipt of this letter, the right to such hearing is waived. On March 19, 1992, Petitioner filed a petition with the Department requesting a formal hearing on the matter. On June 4, 1992, Whiddon sent Petitioner a letter. The body of the letter read as follows: Please be advised that this office has concluded its investigation of Our Lady Health Services, pursuant to 42 CFR 455.23. Based upon this investigation, your claims are now pended for medical review pursuant to Section 409.913(2), Florida Statutes. Please forward copies of all supporting documentation for those claims which are now in pend status. Attached hereto are the claims which are the subject of this review. The supporting documentation must be received by this office within 30 days of receipt of this letter. If you have any questions, please contact Ms. Ellen Williams at (904) 488- 3588. As of June 8, 1992, the date of the final hearing in these cases, the Department had not made any official determination regarding overpayments made to Petitioner, nor had it decided to pay or deny the pended claims. These matters were still under review and investigation.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Department of Health and Rehabilitative Services enter a final order dismissing the petitions filed by Petitioner in these consolidated cases. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 4 day of August, 1992. 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 4 day August, 1992.
The Issue Whether the Petitioner should be required to reimburse the Respondent for Medicaid overpayments as set forth in the Final Agency Audit Report dated October 29, 2001.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made: AHCA is, and was at the times material to this proceeding, the state agency responsible for administering the Medicaid program for the State of Florida. Section 409.901(2), Florida Statutes (1997 & 1998).2 AHCA is, and was at the times material to this proceeding, authorized to make payments on behalf of persons eligible for the Medicaid program for goods and services covered by the program to providers who are qualified under state and federal law to receive such payments. Section 409.902, Florida Statutes (1997 & 1998). AHCA is, and was at the times material to this proceeding, authorized to make payments for goods and services provided to persons eligible for Medicaid benefits only to persons who have in effect a provider agreement with AHCA. Section 409.907, Florida Statutes (1997 & 1998). At the times pertinent to this proceeding, IV Concepts operated under a Florida community/special pharmacy license, and its place of business was a suite of offices located in Broward County, Florida. IV Concepts was in the business of compounding medications and delivering them to patients to be administered in their homes. IV Concepts received prescriptions for medications submitted by physicians either by telephone or by facsimile transmittal, and the pharmacy was not open to the public. Many of the patients to whom IV Concepts dispensed medications were HIV-infected, and IV Concepts dispensed medications to these patients for administration orally or by injection. Other patients served by IV Concepts were not HIV- infected, and IV Concepts dispensed medications to these patients for the treatment of ordinary health problems. A provider agreement executed by AHCA and IV Concepts was in effect at the times material to this proceeding, and IV Concepts received payments from the Medicaid program under Medicaid Provider Number 102900200. IV Concepts executed the Non-Institutional Professional Technical Medicaid Provider Agreement on December 26, 1994. In the agreement, IV Concepts agreed, among other things: 2. . . . [T]o keep for 5 years complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billings 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. . . . * * * . . . [T]o abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. AHCA is, and was at the times material to this proceeding, required "to operate a program to oversee the activities of Florida Medicaid recipients, and providers and their representatives, to ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum extent possible, and to recover overpayments and impose sanctions as appropriate." Section 409.913, Florida Statutes (1997 & 1998). As part of this program, AHCA is, and was at the times material to this proceeding, required to "conduct, or cause to be conducted by contract or otherwise, reviews, investigations, analyses, audits, or any combination thereof, to determine possible fraud, abuse, overpayment, or recipient neglect in the Medicaid program and shall report the findings of any overpayments in audit reports as appropriate." Section 409.913(2), Florida Statutes (1997 & 1998). Pursuant to this responsibility, AHCA's fiscal agent instituted a desk audit of Medicaid payments made to IV Concepts between February 1, 1997, and January 31, 1998. Twenty-five drugs were flagged in the desk audit because it appeared that the inventory of the drugs was not sufficient to match the claims submitted to Medicaid. After the results of the desk audit were received in AHCA's Medicaid Program Integrity office ("MPI office"), an audit of IV Concepts was begun by Susan Williams, a senior pharmacist employed in the MPI office. In a letter to IV Concepts dated June 25, 1998, Ms. Williams notified IV Concepts that AHCA's MPI office was conducting an audit of its pharmacy department and requested that IV Concepts provide, within 30 days: Documentation that identifies all purchases/acquisitions by IV Concepts, Inc., for the products listed on "Attachment A" for the period from January 1, 1997, through June 15, 1998. Documentation that identifies all credits/returns for the period stated above for the products listed on "Attachment A". "Attachment A" was a list of 18 different drugs for which IV Concepts was to provide documentation. Ms. Williams chose to limit her audit to the drugs listed in "Attachment A" because they were expensive drugs and because IV Concepts had claimed Medicaid reimbursement during the audit period for large quantities of these drugs. Ms. Williams requested the documentation so she could compare the quantities of drugs for which IV Concepts had claimed Medicaid reimbursement during the audit period and the quantities of drugs IV Concepts had available to dispense to Medicaid recipients during the audit period. Ms. Williams was advised in a letter from IV Concepts' attorney dated July 30, 1998, and in a letter from Juan Gallinal dated August 26, 1998, that IV Concepts was having difficulties compiling all of the requested documentation. In a separate letter dated July 30, 1998, IV Concepts' attorney requested an additional 30 days, or until September 1, 1998, to produce the documentation. Ms. Williams granted the requested extension. Ms. Williams was aware from telephone conversations during July and August 1998 that IV Concepts was considering a sale of its assets to another entity. She was advised by letter in September 1998 that IV Concepts had sold its assets to Flagship Health Care, Inc., and Flagship Pharmacy ("Flagship"). IV Concepts and Ms. Williams worked together cordially, and IV Concepts provided some documentation to Ms. Williams pursuant to her request in the June 25, 1998, letter. Ms. Williams proceeded with her audit, and AHCA's Provisional Agency Audit Report ("PAAR"), which was prepared by Ms. Williams, was issued on April 17, 2000. In the PAAR, IV Concepts was advised that AHCA had determined that IV Concepts had received an overpayment for Medicaid claims with service dates during the audit period in the amount of $3,105,471.66. In calculating this amount, AHCA had considered the Medicaid claims paid to IV Concepts with service dates during the audit period and the purchase/acquisition documentation provided by IV Concepts on August 12, 13, and 27, 1998; September 10, 1998; and October 5, 1998. According to the PAAR, IV Concepts had "failed to provide adequate documentation to the effect that the available quantity of certain drugs of given strength was as great as the quantity of those drugs billed to and reimbursed by Medicaid." In addition, IV Concepts was not given credit for "purported purchases from suppliers that were not a licensed drug wholesaler [sic] in accordance with Chapter 499, F.S." IV Concepts was advised in the PAAR that the overpayment determination was a provisional finding, and IV Concepts was encouraged to provide AHCA with any additional documentation that might change the overpayment determination. During the time she was working on the IV Concepts audit, Ms. Williams was also working on a Medicaid provider fraud and abuse investigation of a company named ImmuneCare. During the course of this audit, Ms. Williams received from AHCA's legal department copies of invoices provided to AHCA's legal department by ImmuneCare that purported to show that IV Concepts had transferred quantities of drugs during the audit period to ImmuneCare and/or to Dr. Mark Sachs, a physician affiliated with ImmuneCare. It was the practice of IV Concepts during 1997 and 1998 to provide drugs to ImmuneCare and/or Dr. Sachs for infusion into Dr. Sachs' patients. Each day, IV Concepts received a list of prescriptions to be filled for those of Dr. Sachs' patients scheduled for infusions on the next day; IV Concepts was also provided with a prescription for each patient. A pharmacist or a pharmacy technician employed by IV Concepts compounded and assembled the medications in accordance with the prescriptions provided by Dr. Sachs, and the drugs were delivered to Dr. Sachs each morning. Dr. Bebell worked as a pharmacist at IV Concepts, and he also, at the request of IV Concepts management, worked part-time at ImmuneCare, compounding and dispensing medications from ImmuneCare's small pharmacy. IV Concepts' usual business practice was to fill prescriptions for individual patients and to deliver the medications to the patients' homes, together with delivery slips the patients would sign indicating that they had received the medications. The medications shown on the invoices that came into Ms. Williams' possession were, however, all delivered to ImmuneCare and/or Dr. Sachs, rather then directly to the patients' homes. According to Mr. Gallinal, who supervised IV Concepts' billing department, invoices for the medications delivered to ImmuneCare and/or Dr. Sachs were sent along with the medications for payment by ImmuneCare or Dr. Sachs as a third party. Mr. Gallinal identified Invoice #1934 in Agency Exhibit 32 as an example of an invoice for the medications delivered by IV Concepts to ImmuneCare and/or Dr. Sachs. The invoice shows Dr. Sachs as the "insured," and the total amount billed on Invoice #1934 was $17,526.88 for medications transferred from IV Concepts to ImmuneCare on November 3, 5, 6, and 7, 1997. According to Mr. Gallinal, ImmuneCare paid IV Concepts for the medications delivered to ImmuneCare and/or Dr. Sachs. Ms. Williams left AHCA's MPI office in May 2000 to take another job with AHCA. Joann Jackson, a senior pharmacist with AHCA's MPI office, took over both the IV Concepts audit and the ImmuneCare fraud investigation after Ms. Williams' departure. Among the documents in the audit file for IV Concepts were the invoices showing that IV Concepts delivered quantities of drugs to ImmuneCare and/or Dr. Sachs. Because the PAAR had been recently issued when Ms. Jackson took over the IV Concepts audit, she was awaiting a response to the PAAR from IV Concepts. Ms. Jackson received a response dated May 16, 2000, from Mr. Green, who continued to act as IV Concepts' attorney for purposes of the audit. Mr. Green advised Ms. Jackson that IV Concepts disputed the overpayment assessed in the PAAR, and he stated that IV Concepts needed a copy of all of the invoices that it had provided to AHCA during the audit. Mr. Green also requested copies of the documents supporting the implication in the PAAR that IV Concepts had purchased drugs from unlicensed wholesalers. Finally, Mr. Green advised that IV Concepts would again be attempting to obtain additional documentation of its drug purchases during the audit period either from Flagship or from its wholesale pharmaceutical vendors. Mr. Green asked for, and was granted, an additional 90 days in which to provide the additional documentation. In letters dated August 23, 2000; September 12, 2000; October 16, 2000; November 17, 2000; and December 6, 2000, Mr. Green kept the MPI office apprised of the efforts IV Concepts was making to obtain additional documentation from Flagship and/or the wholesale drug distributors from which it purchased drugs during the audit period. Mr. Green also requested in the September 12, 2000, letter that the MPI office send him a list of the reimbursements made by Medicaid to IV Concepts during the audit period. Ms. Jackson provided Mr. Green with copies of the documents and with the information he requested. On January 16, 2001, Mr. Green sent the MPI office IV Concepts' formal response to the PAAR issued April 17, 2000. The response consisted of a letter and of a loose-leaf binder containing a worksheet presenting information on additional invoices located by IV Concepts and information relating to particular medications. In the letter, Mr. Green provided an explanation of the materials contained in the response as follows: IV Concepts had, during times of shortages, transferred to other pharmacies drugs which were not covered by the audit in exchange for an equal value of Abelcet, Proleukin, and Neupogen, drugs that were included in the audit, which transfers were addressed in affidavits submitted by Jose Gallinal, a pharmacy technician employed by IV Concepts, and by Dr. Bebell; IV Concepts had found it necessary, during times of shortages, to obtain Sandoglobulin and Gammar, two of the drugs included in the audit, from A.D. Allen, a wholesale pharmaceutical company operating in the United Kingdom, and it was providing in its response additional documentation for the purchase of these drugs, including invoices from A.D. Allen and documentation from the federal Food and Drug Administration releasing the medications for delivery to IV Concepts. Mr. Green also requested that IV Concepts receive credit in the audit for units of drugs that IV Concepts purchased in strengths that were not specified in the list of drugs attached to the PAAR. Mr. Green reported in the January 16, 2001, letter to the MPI office that he had re-calculated the amount of the overpayment based on the additional documentation and information provided in the response and that the overpayment should be reduced from $3,105,471.66 to $842,605.97. Ms. Jackson reviewed the materials submitted by IV Concepts on January 16, 2001, and gave IV Concepts credit for a number of drug purchases based on the documentation IV Concepts had provided in its response to the PAAR. The FAAR that is the subject of this proceeding was issued on October 29, 2001. IV Concepts was notified in the FAAR that the MPI office had determined that IV Concepts had received overpayments from Medicaid in the amount of $2,841,045.40 during the audit period. This overpayment related only to Medicaid claims paid IV Concepts during the audit period for nine specified drugs. IV Concepts was advised in the FAAR that it had "failed to provide adequate documentation to the effect that the available quantity of certain drugs of given strength was as great as the quantity of those drugs billed to and reimbursed by Medicaid." The FAAR also contained the following statement: The overpayment calculation is based upon the assumption that all stock, with the exception of stock purportedly acquired from unlicensed drug wholesalers, that you have demonstrated as available during the period was exclusively dispensed to Medicaid recipients; this is undoubtedly not the case and the assumption serves to reduce the amount of the calculated overpayment. Medicaid payments that have been substantiated by documented inventory are assumed to be valid; and payments in excess of that amount are regarded to be invalid. The FAAR included four attachments to support the overpayment calculation: A compilation of the claims paid by Medicaid to IV Concepts for the nine drugs that were the subject of the audit report; A summary of the basis for the calculation of the total overpayment amount, including the amount of the Medicaid payments to IV Concepts during the audit period for each of the nine drugs, the number of units of each drug for which Medicaid paid IV Concepts, the number of units of the nine drugs that IV Concepts had documented it purchased during the audit period, the unit difference, the unit price, and the amount of the overpayment for each of the nine drugs; An Invoice Review listing purchases for which IV Concepts provided documentation, including the date of the invoice, the supplier, the drug and strength, the package size, the number of packages, and the number of units purchased, together with the total number of documented unit purchases made by IV Concepts; and A packet containing the invoices from IV Concepts to ImmuneCare and/or Dr. Sachs provided to Ms. Williams in the course of the fraud investigation of ImmuneCare, which do not constitute part of AHCA's audit work papers. Ms. Jackson prepared the October 29, 2001, FAAR. The focus of the audit was to establish that the drugs for which IV Concepts received payment from Medicaid during the audit period were actually available to IV Concepts to dispense to Medicaid recipients. In preparing the FAAR, Ms. Jackson first compiled a list of each payment made by Medicaid to IV Concepts during the audit period for each of the nine drugs included in the audit; these payments necessarily included payments for drugs dispensed prior to the first day of the audit period. This data included the numbers of units of each of these drugs for which payment was made to IV Concepts during the audit period. Ms. Jackson then computed the number of units of the specified drugs that IV Concepts had documented were available for dispensing to Medicaid recipients during the audit period.3 Ms. Jackson did not give IV Concepts credit for the units of drugs shown by the invoices provided by IV Concepts to have been purchased before January 1, 1997, or after June 15, 1998.4 These exclusions are consistent with AHCA's standard practice of assuming that a pharmacy's inventory remains relatively constant during the audit period and that the shelf inventory on the first day of the audit period is equal to the shelf inventory on the last day of the audit period. Ms. Jackson did not give IV Concepts credit for the units of drugs shown by the invoices provided by IV Concepts to have been shipped and billed to pharmacies other than IV Concepts.5 IV Concepts did not provide any supplementary documentation showing that it had subsequently purchased the drugs, and, therefore, it failed to provide documentation establishing that the units of drugs identified in this group of invoices were available to be dispensed to Medicaid recipients during the audit period. Ms. Jackson did not give IV Concepts credit for the units of drugs shown by invoices provided by IV Concepts to have been shipped to a pharmacy other than IV Concepts, even though the invoices show that IV Concepts was billed for the drugs.6 IV Concepts did not provide any supplementary documentation showing that it took possession of the drugs, and it, therefore, failed to provide documentation establishing that the units of drugs identified in this group of invoices were available to be dispensed to Medicaid recipients during the audit period. Ms. Jackson did not give IV Concepts credit for the units of the nine specified drugs that were purportedly obtained by IV Concepts through the barter of other drugs of equal value. IV Concepts provided AHCA with affidavits of Dr. Bebell and Jose Gallinal, which included averments that, during the audit period, IV Concepts acquired through barter approximately 1,000 of the units of Neupogen that was paid by Medicaid, approximately 5% of the units of Abelcet that was paid by Medicaid, and approximately 5% of the units of Proleukin that was paid by Medicaid.7 Dr. Bebell and Jose Gallinal further averred that no invoices or other documentation was typically received to evidence these barter transactions. The information contained in these affidavits is not sufficient, however, to establish that IV Concepts acquired through barter the amounts of the three drugs as specified in the affidavits and had these quantities of the drugs available for dispensing to Medicaid recipients during the audit period as a result of barter. The affidavits are imprecise and are not the types of documents that are acceptable to establish that quantities of drugs were available to IV Concepts for dispensing to Medicaid recipients because the affidavits were not prepared in the normal course of IV Concepts' business. Ms. Jackson did not give IV Concepts credit for the units of drugs shown on invoices provided by IV Concepts that showed the purchase of drugs from entities that Ms. Jackson determined were not licensed in Florida as wholesale drug distributors.8 "The purchase or receipt of a legend drug from a person that is not authorized under the law of the state in which the person resides to distribute legend drugs" is unlawful. Section 499.005(14), Florida Statutes (1997 & 1998). Even though IV Concepts provided documentation to establish that the units of drugs specified in these invoices were available for dispensing to Medicaid recipients during the audit period, IV Concepts should not be permitted to receive Medicaid payments for the unlawfully acquired units of drugs that it dispensed to Medicaid recipients during the audit period. Ms. Jackson did not give IV Concepts credit for the units of drugs shown on invoices provided by IV Concepts that showed purchases of drugs from A.D. Allen, a foreign drug wholesaler, that were not accompanied by a notice indicating that the federal Food and Drug Agency ("FDA") had either approved the shipment prior to entry into the United States or had appended a signed notice allowing the importation of the drugs without FDA examination.9 In the absence of FDA approval for these drugs to enter the United States, the drugs were not legally acquired by IV Concepts, and, even though IV Concepts provided documentation to establish that the units of drugs specified in these invoices were available for dispensing to Medicaid recipients during the audit period, IV Concepts should not be entitled to receive Medicaid payments for the units of drugs it imported into the United States without FDA approval. Finally, Ms. Jackson subtracted from the number of units of the nine specified drugs for which she had given IV Concepts credit the units of drugs delivered to ImmuneCare and/or Dr. Sachs, as shown by the invoices provided to AHCA by ImmuneCare.10 These units were not available to IV Concepts to dispense to Medicaid recipients, and, in addition, ImmuneCare and/or Dr. Sachs paid IV Concepts for the units of drugs delivered for infusion into Dr. Sachs' patients. After the FAAR was issued, Ms. Jackson re-calculated the amount of overpayment charged against IV Concepts, and reduced the amount to $2,815,847.32. The reduction was the result of Ms. Jackson's giving IV Concepts credit for invoices showing the purchase of drugs from wholesale drug distributors who were not licensed in Florida but were licensed in their home states. The unrefuted evidence presented by AHCA is sufficient to establish that IV Concepts received overpayments from Medicaid during the period extending from January 1, 1997, through June 15, 1998, in the amount of $2,815,847.32, which amount is subject to recoupment by AHCA.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order finding that IV Concepts received overpayments from the Medicaid program in the amount of $2,815,847.32 during the period extending from January 1, 1997, through June 15, 1998, and requiring IV Concepts to repay the overpayment amount. DONE AND ENTERED this 30th day of June, 2003, in Tallahassee, Leon County, Florida. PATRICIA HART MALONO Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of June, 2003.
The Issue The issues to be resolved in this proceeding concern whether the Respondent Agency must be reimbursed by the Petition for purported overpayments regarding Medicaid claims, as delineated in the Respondent's Final Agency Audit Report of December 12, 2003, related to the audit period of July 1, 2000 through July 31, 2002.
Findings Of Fact The Agency is responsible for administering the Florida Medicaid program. The Agency is thus charged with a duty to recover overpayments to medical service providers enrolled in that program. The term "overpayment" means any amount not authorized to be paid by the Medicaid program, whether paid as a result of inaccurate reporting or improper reporting of costs, improper claims, unacceptable practices, fraud, abuse, or by mistake. See § 409.913.(1).(d), Fla. Stat. The Petitioner, Maria Lourdes Burgos, M.D., is a pediatrician duly licensed in the State of Florida, practicing as an authorized Medicaid provider for purposes of the relevant portions of Chapter 409, Florida Statutes, at times pertinent hereto. During the period July 1, 2000 through July 31, 2002, (the audit period) the Petitioner had a valid Medicaid provider agreement with the Respondent Agency. During the period of the audit the Petitioner provided services to Medicaid recipients or patients and submitted claims for those services and was compensated for those services. This case is a result of the Agency's attempt to recover purported overpayments from Dr. Burgos. In choosing to become a Medicaid provider, a physician such as Dr. Burgos must assume the responsibilities enumerated in Section 409.913(7), Florida Statutes (2004), which provided generally that such a provider had an affirmative duty to supervise the provision of such services and be responsible for the preparation and submission of claims. The claims are required to be true and accurate, the services are required to actually have been furnished to the recipient by the provider submitting the claim; the services are required to be medically necessary, of a comparable quality to those furnished to the general public by the provider's peers; and to have been provided in accordance with all applicable provisions of Medicaid rules, regulations, handbooks, and policies. They must be in accordance with federal, state, and local law. Additionally, the provision of medical services are required to be documented by records made contemporaneously with the provision of the services, demonstrating the medical necessity for them and the medical basis and specific need for them must be properly documented in the recipient's medical record. The "audit period" involved in this proceeding is July 1, 2000 through July 31, 2002. The Medicaid program reimbursed Dr. Burgos in excess of $43,238.57 in payments pursuant to the Medicaid program during that audit period. The Final Agency Audit Report is in evidence as Respondent's Exhibit One and the calculations pertaining to the overpayment amount are included in that report as part of Respondent's Exhibit One in evidence. The Agency contends that $43,238.57 is an overpayment and subject to recoupment because of Medicaid policy, as alleged in the Final Agency Audit Report (FAAR). Medical records reveal that some services billed, and for which payment was received, were not documented and that documentation provided supported a lower level of office visits than the one for which the Medicaid program was billed and for which payment was received by the Petitioner; and, because payments can be made only for those services listed in the provider handbook, that the Petitioner billed and received payments for services not covered by Medicaid as overpayments. The Agency furnishes all authorized Medicaid providers a manual entitled The Physician Coverage and Limitations Handbook (Handbook). The Handbook contains the requirements demanded of Medicaid providers and it and the procedure code manual (CPT) manual that was in effect during the audit period is in evidence in this proceeding. The handbook has been incorporated by reference in Florida Administrative Code Rule 59G-4.230. This handbook sets forth Florida Administrative Code Rule 59G-4.230 and sets forth pertinent applicable Medicaid policies and claims processing requirements applicable to this proceeding. Upon convening of the audit procedure, the Agency requested certain records from the Petitioner and the Petitioner fully complied with the relevant requirements of Chapter 409, Florida Statutes, submitting copies of all records dealing with the recipients who where the subject of the audit. See Exhibit Eight in evidence. The Petitioner, in effect, does not dispute the statistical methodology employed by the agency, but does dispute the manner in which it was applied to certain procedure codes (CPT codes) and the result of the overpayment calculations. Additionally, for every office visit that the Petitioner had with Medicaid patients, she personally made an individual judgment about the level of service that she provided and accordingly billed for that level of care and treatment provided. She was consistent in this in her billing practices as to both Medicaid and non-Medicaid patients. In some instances, regarding the audited Medicaid patient/recipient records, it was demonstrated by the Petitioner that the patient presented with somewhat more complexity as to medical condition that the CPT code, postulated by the Agency as applicable, represented that thus she billed for the higher code (as for instance a "99215" instead of a "99213) or "99214"). Some of these medical judgment calls made by the Petitioner were shown to be appropriate and justified and some where shown by the Respondent's evidence, chiefly the testimony of Dr. Larry Deeb, the Respondent's expert, to be not really appropriate and that they should have been coded and therefore billed at a lower level. In any event, based upon the testimony of Dr. Larry Deeb, as well as the Petitioner's testimony, the submission of both a "well child" checkup billing and a "sick office visit" billing was appropriate and consistent with good medical practice under the circumstances demonstrated by the Petitioner's testimony and her records. Thus it was inappropriate for the Agency to automatically claim an overpayment due for those billings, based upon only its policy interpretation. Additionally, based upon Ms. Mocks testimony, it is apparently an Agency policy or practice in conducting audits, and in recouping overpayments, that when errors are discovered in the audit or in the billing records which happen to be in favor of the practitioner (the Petitioner) that the Agency does not provide a credit applied to any alleged overpayment. It would seem that fundamental fairness dictates that both credits and overpayments be weighed against each other in calculating the ultimate amount of any overpayment, if one exists. In any event, based upon Dr. Deeb's testimony and the Petitioner's testimony, with regard to the random sample of patients and their medical records submitted, reviewed and involved in this dispute, the evidence demonstrates that the Petitioner was not overpaid as to the following amounts and patients/recipients: Recipient Date of CPT Disallowed/ Number Service Billed and Paid Adjusted Amount 1 12/05/00 99215 $37.59 09/05/01 99215 $60.95 2 03/05/01 99214 $15.11 3 09/19/00 99215 $13.01 4 04/04/01 99215 $60.95 5 09/15/00 99214 $15.11 05/10/01 W9881 $22.70 6 01/14/02 99215 $14.52 8 11/08/01 99214 $15.11 9 05/03/01 99205 $87.24 10 05/03/01 99205 $87.241/ 11 04/04/02 90669 $ 0.002/ 04/04/01 W9881 $37.81 04/04/01 99214 $46.42 12 10/18/01 99214 $15.11 01/18/02 99215 $29.63 01/30/02 99215 $14.52 05/20/02 99214 $15.11 13 08/14/00 99215 $13.01 14 01/31/01 99214 $15.11 08/27/01 99214 $15.11 05/13/02 99214 $24.58 15 10/17/00 99356 $50.94 Recipient Date of CPT Disallowed/ Number Service Billed and Paid Adjusted Amount 10/19/00 99233 $12.53 16 10/13/00 99215 $57.14 17 05/10/01 99215 $60.95 12/11/01 W9881 $37.81 12/11/01 99214 $46.42 20 12/22/00 99205 $17.02 22 11/19/01 99223 $42.04 11/20/00 99239 $11.53 23 03/27/02 W1998 $ 0.003/ 04/03/02 99356 $49.72 04/22/02 99215 $ 0.004/ 04/29/02 99214 $13.86 05/10/02 99215 $ 0.005/ 24 08/12/01 99356 $ 0.006/ 08/15/01 99239 $12.06 25 09/30/01 99223 $22.71 10/01/01 99233 $12.66 26 12/03/01 99356 $49.257/ 12/06/01 99239 $12.06 12/14/01 99205 $18.12 01/16/02 99215 $29.63 01/23/02 99215 $29.638/ 28 10/13/01 99431 $ 0.009/ Recipient Number Date of Service CPT Disallowed/ Billed and Paid Adjusted Amount 10/14/02 99233 $12.66 10/15/01 99239 $12.06 29 02/28/02 99356 $ 5.4210/ 03/01/02 99233 $13.80 03/02/02 99239 $13.66 03/06/02 99205 $18.67 29 03/13/02 99215 $14.52 11. The Petitioner in its Proposed Recommended Order has agreed that other than the above (Proposed Recommended Order paragraph 10 patients and amounts) that the Petitioner agrees with the Agency's review and the overpayment calculations on a per office visit basis. Additionally, however, as referenced above, there were additional health insurance claim forms which were, or should have been, submitted to the Agency, representing claims for payment for dates of service that clearly fall within the relevant audit period, that were never compensated by the Agency's contracted agent. The alternative is that the claim forms for some reason were not actually submitted. Unfortunately, neither the Petitioner's records and testimony nor the Agency records can clearly show whether the claim forms were actually submitted or not. It is apparently not possible to retrieve that information from the Agency's claim filling and payment-related computer programming system, for reasons not understood by either party or the judge. There is thus no clear explanation of record concerning why these claims were not paid earlier, even though they fall within the audited period. It is clear, however, that the additional claims referenced in the Petitioner's Exhibit Seven, admitted as a late exhibit herein, do relate to that audit period and represent medical services provided by the Petitioner within that audit period. Since that audit period and the claims referenced in evidence are the subject of a "proceeding" and are pending a "court or hearing decision . . ." or, alternatively and admittedly somewhat speculatively, could be subject of a "system error on claim that was originally filed within (12) months from date of service," it appears patently apparent that fundamental fairness dictates that these health insurance claim forms related to the same audit period should be considered and a determination made as to whether and how much of those claims should be reimbursed to the Petitioner for the medical services they represent. Thus, especially as to exception (2) to the twelve- month filing requirement listed in the above-reference handbook, Exhibit Seven has been admitted into evidence and the claim forms represented therein should be considered and the amounts payable to the Petitioner should be credited against the resultant overpayment amounts calculated as a result of these Findings of Fact.
Recommendation Based on the foregoing Findings of Fact, Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties, it is, therefore, RECOMMENDED that the Respondent, Agency for Health Care Administration, re-calculate the amount of overpayment in a manner consistent with the above Findings of Fact and Conclusions of Law, excluding from the amount of overpayment those amounts determined above to have not constituted overpayments. It is further RECOMMENDED that the Respondent calculate the amount of reimbursement not provided pursuant to the recently submitted or re-submitted (but never paid) Exhibit Seven health insurance claim forms, and as for the reasons indicted in the above Findings of Fact and Conclusions of Law, and credit that additional amount of reimbursement against the overpayment calculation amount in arriving at the new overpayment due from the Petitioner to the Respondent. The Petitioner shall repay the Respondent the re-calculated monetary amount of overpayment within a reasonable period of time and by reasonable installment payments, agreed to by both parties, but shall not be obligated to pay other costs or fees related to this matter. DONE AND ENTERED this 4th day of November, 2005, in Tallahassee, Leon County, Florida. S P. MICHAEL RUFF Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 4th day of November, 2005.
Findings Of Fact The Respondent, Jack P. Randall, is a chiropractic physician licensed to practice in the State of Florida. He holds license number 2770. On August 8, 1978, a federal grand jury filed an indictment in the United States District Court for the Northern District of Alabama, charging the Respondent with 29 counts of willfully making a false, fictitious and fraudulent statement and representation as to material facts in a matter within the jurisdiction of the United States Department of Health, Education and Welfare, Health Care Financing Administration (formerly Social Security Administration) in violation of 18 U.S.C. 1001 which states: "Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and wilfully falsifies, conceals or covers up by any trick, scheme of device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both." This indictment asserts that on 29 occasions between December, 1976, and January, 1978, the Respondent requested payment from the United States for chiropractic services performed on patients when such services were not actually performed. On October 25, 1978, in the United States District Court for the Northern District of Alabama, the Respondent was convicted of 24 of the 29 counts in the indictment, and sentenced to imprisonment for a period of one year, and fined the sum of $5,000, to be followed by a suspended sentence of four years during which time the Respondent would be placed on probation. Each of the 24 counts upon which the Respondent was convicted directly relates to the practice of chiropractic. Thereafter, the Respondent appealed his conviction to the United States Court of Appeals for the Fifth Circuit. By its opinion filed on April 19, 1979, the verdict and judgment against the Respondent was affirmed. Certified copies of the indictment, the verdict and judgment, and the appellate opinion were received in evidence in support of the Administrative Complaint. In his defense, the Respondent asserted that the representation he received from his attorney was ineffective, and that the trial court would not let him employ another attorney. However, these matters are collateral to the issues presented in this proceeding. If they consist of a remedy, the Respondent must pursue it in court and not here.
Recommendation Based upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that license number 2770 held by the Respondent, Jack P. Randall, be revoked. THIS RECOMMENDED ORDER entered on this 15th day of May, 1981. COPIES FURNISHED: Tina Hipple, Esquire Assistant General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Jack P. Randall 3244 Seminole Avenue Macon, Georgia 31204 WILLIAM B. THOMAS Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 15th day of May,1981
The Issue The issue is whether Respondent has been convicted of a crime directly related to the practice of nursing, in violation of Section 464.018(1)(c), Florida Statutes, and, if so, what penalty should be imposed.
Findings Of Fact Respondent was born on September 27, 1963, in Havana, Cuba. She is now a United States citizen and is married with three children. Since 1985, Respondent has been a licensed registered nurse, holding license number RN 1643122. She has not previously been disciplined. In 1991, Respondent separated from, and later divorced, her then-husband. She was under considerable financial pressure, caring as a single parent for her children, who were then newborn, 18 months old, and four and one-half years old. Respondent was then employed by St. Johns Home Health Agency, Inc. Respondent served as a nurse who performed admissions and follow-up care. Pressured for money, Respondent agreed to participate in a scheme in which she prepared false notes concerning patient care. Specifically, Respondent would see her patients and appropriately record accurate vital signs once weekly. For her more involved patients, such as diabetics or patients undergoing wound care, Respondent would see them as often as indicated and duly record their vital signs. However, for less involved patients, Respondent would document other visits during the week that did not take place and record fictitious vital signs. Respondent understood that the purpose of this fraudulent activity was to induce the federal government to pay her employer unearned Medicare monies, part of which the employer then paid Respondent. Although no patients were harmed by Respondent's fraud, she continued this practice for over one year and perhaps as long three and one-half years. Some days, Respondent falsified over 20 patient visits. On December 17, 1998, the grand jury returned an indictment against 26 defendants, including Respondent, for Medicare fraud and various related crimes. By Judgment entered March 23, 1999, Respondent pleaded guilty of one count of conspiracy to submit false claims to the United States, in violation of 18 United States Code Section 286. Respondent played a minor role in a massive case of Medicare fraud pursued with diligence and careful, coordinated planning by several entities, not just Respondent's employer. The indictment alleges a total of $25 million in fraudulent Medicare claims arising from unperformed home visits and extensive money laundering and racketeering by the principal perpetrators of this fraud. The prosecutors credit Respondent with early cooperation, even at the grand-jury stage, that was instrumental in obtaining guilty pleas from over 20 defendants. Respondent's testimony at trial was "extremely valuable" against two of the three defendants who went to trial--and received "significant prison terms." As the prosecutors describe the assistance of Respondent and one other defendant, they "did all that they could do from the earliest time to help undo the wrongdoing in which they had been involved." The judge initially sentenced Respondent to 18 months' imprisonment and ordered her to pay the United States Department of Health and Human Services $20,000 as partial restitution for the estimated $300,000 of loss attributable to Respondent's fraud. Later, due to Respondent's cooperation and at the request of the prosecutors, the judge reduced the sentence from 18 months' imprisonment to five years' probation. Respondent has since paid the $20,000 in restitution. The United States Department of Health and Human Services excluded Respondent from Medicare for ten years. After an administrative hearing and pursuant to the recommendations of the Administrative Law Judge, the agency reduced this penalty to five years. At present, Respondent serves as a recovery room nurse at two South Florida cosmetic surgery centers. Respondent expresses heartfelt remorse and displays deep shame for her past criminal behavior. She recognizes that her financial circumstances did not justify her fraudulent acts. However, revocation or a long suspension would cause considerable financial hardship upon Respondent and the three children, who are now 11, 13, and 15 1/2 years old and, as much as is possible for children of these ages, planning on attending college. Petitioner has consistently sought revocation in this case. In past cases, Petitioner has not always sought revocation for licensees convicted of Medicare fraud, but it appears that Petitioner has altered its policy in this regard.
Recommendation It is RECOMMENDED that the Board of Nursing enter a final order finding Respondent guilty of violating Section 464.018(1)(c), Florida Statutes, and reprimanding her license, placing her license on probation for five years, imposing an administrative fine of $10,000, and assessing costs. DONE AND ENTERED this 15th day of August, 2002, in Tallahassee, Leon County, Florida. ROBERT E. MEALE Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 15th day of August, 2002. COPIES FURNISHED: Ruth R. Stiehl, Ph.D., R.N. Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701 Reginald D. Dixon Senior Attorney Department of Health Bureau of Health Care Practitioner Regulation--Legal Division of Medical Quality Assurance 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Lawrence R. Metsch Metsch & Metsch, P.A 1455 Northwest 14th Street Miami, Florida 33125
The Issue The issue to be determined is the amount payable to the Agency for Health Care Administration (AHCA or Respondent) in satisfaction of its $157,983.63 Medicaid lien asserted against medical malpractice settlement proceeds received by Hunter Lamendola (Hunter), a minor, by and through his mother and natural guardian, Ashley Lamendola (Petitioner).
Findings Of Fact On June 26, 2012, Petitioner presented to the hospital with a history of contractions for six hours prior to her arrival at the hospital. She had been placed on bed rest for gestational hypertension five days prior to arriving at the hospital. When she arrived, she had hypertension. Petitioner was admitted to the labor and delivery unit at 8:33 p.m. Petitioner was placed on a fetal monitor and progressed through her course of labor. Her initial fetal monitoring showed the baby was healthy and well-oxygenated, however, throughout the course of labor, the fetal monitor exhibited signs that the baby was in significant distress. At 4:01 a.m. on June 27, 2012, Petitioner was given an epidural, and after a course of labor, Hunter was delivered at 3:47 p.m. through an operative vaginal delivery. Hunter suffered permanent and catastrophic brain damage during his birth. As a result, Hunter is unable to eat, speak, toilet, ambulate, or care for himself in any manner. Hunter’s medical care related to the delivery was paid by Medicaid. The Medicaid program through AHCA provided $157,983.63 in benefits. The Medicaid program through the Department of Health Children’s Medical Services Title XIX MMA – Pedicare (DOH), provided $26,189.66 in benefits; the Medicaid program through a Medicaid-managed care organization, known as Amerigroup Community Care (Amerigroup), provided $51,696.99 in benefits; and the Medicaid program through a Medicaid-managed care organization, known as WellCare of Florida (WellCare), provided $13,239.19 in benefits. Accordingly, the sum of these Medicaid benefits, $249,109.47, constituted Hunter’s entire claim for past medical expenses. Petitioner brought a medical malpractice action against the medical providers and staff responsible for Hunter’s care (Defendant medical providers) to recover all of Hunter’s damages, as well as her own individual damages associated with Hunter’s injuries. The medical malpractice lawsuit was settled through a series of confidential settlements totaling $10,000,000 and this settlement was approved by the Court. During the pendency of Hunter’s medical malpractice action, AHCA was notified of the action, and AHCA asserted a $157,983.63 Medicaid lien against Hunter’s cause of action and settlement of that action. AHCA, through the Medicaid program, spent $157,983.63 on behalf of Hunter, all of which represents expenditures paid for Hunter’s past medical expenses. No portion of the $157,983.63 paid through the Medicaid program on behalf of Hunter represent expenditures for future medical expenses, and Medicaid did not make payments in advance for medical care. Application of the formula set forth in section 409.910(11)(f), Florida Statutes, to Hunter’s settlement requires payment to AHCA of the full $157,983.63 Medicaid lien. Petitioner has deposited the full Medicaid lien amount in an interest-bearing account for the benefit of AHCA pending an administrative determination of AHCA’s rights, and this constitutes “final agency action” for purposes of chapter 120, Florida Statutes, pursuant to section 409.910(17). At the final hearing, Mr. Harwin, who represented Hunter and his family in the underlying medical malpractice action, testified, and was accepted, without objection, as an expert in the valuation of damages suffered by injured parties. Mr. Harwin is a member of several trial attorney associations, stays abreast of jury verdicts relative to birth injuries, and ascertains the value of damages suffered by injured parties as a routine part of his practice. Mr. Harwin was familiar with and explained Hunter’s catastrophic brain injury giving rise to Petitioner’s claim. He also explained that, as a result of Hunter’s injury, Hunter is blind, fed through a feeding tube, unable to control his arms, legs or head, and suffers between six to eight seizures per day. Mr. Harwin testified that Hunter’s injury has also had a devastating impact on Hunter’s mother, Ashley Lamendola. According Mr. Harwin, considering Hunter’s past medical expenses, a life care plan for Hunter’s care prepared by an economist, and the extent of non-economic damages, and in light of determinations of mock juries and a jury consultant in this case, as well as Mr. Harwin’s familiarity with jury verdicts reached in similar cases, Hunter and his mother’s damages have a value in excess of $35,000,000. Mr. Harwin’s testimony as to the value of Petitioner’s claim was credible and is accepted. Petitioner also presented the testimony of Mr. Barrett, who was accepted as an expert in the valuation of damages. Mr. Barrett has been accepted as an expert in valuation of damages in a number of other Medicaid lien cases before DOAH. Mr. Barrett has been a trial attorney for 41 years, with a primary focus on plaintiff personal injury cases, including medical malpractice, medical products liability, and pharmaceutical products liability. Mr. Barrett stays abreast of jury verdicts and often makes assessments concerning the value of damages suffered by injured parties. After familiarizing himself with Hunter’s injuries through review of pertinent medical records and Petitioner’s exhibits, Mr. Barrett offered his opinion, based upon his professional training and experience, as well as review of comparable jury verdicts, that a conservative value of the damages suffered would be “$35,000,000 to $50,000,000.” Mr. Barrett’s testimony as to the value of Petitioner’s claim was credible and is accepted. AHCA did not call any witnesses, present any evidence as to the value of Petitioner’s claim, or propose a differing valuation of the damages. Based upon the unrebutted evidence presented by Petitioner’s experts, it is found that a conservative value of Petitioner’s claim is $35,000,000. Attorney’s fees for the underlying medical malpractice case leading to Petitioner’s $10,000,000.00 settlement totaled $4,500,000.00, with costs of $490,486.33. While the formula under section 409.910(11)(f) determines amounts distributable to Medicaid after attorney’s fees and taxable costs, there is no language in section 409.910(17)(b) suggesting that attorney’s fees or costs should be subtracted from settlement proceeds in determining whether a lesser portion of the total recovery should be allocated to reimburse Medicaid. Costs and attorney’s fees are not an element of Petitioner’s damages and were not subtracted from the settlement proceeds in determining whether a lesser portion of the total recovery should be allocated to AHCA’s Medicaid lien. Considering the valuation of Petitioner’s claim at $35,000,000.00, Petitioner’s $10,000,000.00 settlement represents only a 10/35ths recovery of Petitioner’s damages. Multiplying that same 10/35 fraction to the $157,983.63 paid by AHCA through the Medicaid program for past medical expenses results in the proportional sum of $45,138.18 from the settlement proceeds available to satisfy AHCA’s Medicaid lien.
