The Issue Whether one or more grounds exist for suspending, or imposing other discipline against, Respondent’s license, where Petitioner charges that Respondent engaged in fraudulent or dishonest practices in the conduct of business as a licensed health insurance agent.
Findings Of Fact The evidence presented at final hearing established the facts that follow. The Big Picture 1. Gonzalez is, and at all times material was, a Florida- licensed health insurance agent whose conduct qua licensee is subject to the regulatory jurisdiction of the Department. 2. From April 1997 until January 25, 1999, Gonzalez worked as a sales representative for Foundation Health, a Florida Health Plan, Inc. (“Foundation”) at its offices in Dade County, Florida. Foundation paid Gonzalez a base salary and car allowance plus commissions and bonuses tied to production. 3. As an agent of Foundation, Gonzalez’s job was to solicit applications from Medicare recipients for membership in Foundation’s Senior Value Medicare Plan, a health maintenance organization (“HMO”) that, through managed care, provided a broader spectrum of benefits than otherwise was available under traditional Medicare coverage. For each Medicare recipient enrolled in the Senior Value Medicare Plan, Foundation received a monthly payment from the federal Health Care Financing Administration (“HCFA”). 4. On January 14, 1999, Gonzalez, as Foundation’s representative, signed an application for enrollment in the Senior Value Medicare Plan that had been filled out for an applicant named “Doris Simpson.” Included in the application were numerous identifying data such as Ms. Simpson’s address, phone number, date of birth, social security number, and Medicare number. Gonzalez submitted Ms. Simpson’s January 14, 1999, application to Foundation, initiating the enrollment process. 5. The Doris Simpson who fit the application’s description had died on or around July 1, 1998. The fact of her death was discovered in short order by HCFA during the ordinary course of the enrollment process. HCFA naturally rejected the bogus application and notified Foundation of the problem on or around January 20, 1999. 6. On January 22, 1999, Foundation suspended Gonzalez for three days, effective immediately, pending the outcome of its investigation into the Doris Simpson matter. 7. Gonzalez resigned his employment with Foundation on January 25, 1999. Thereafter, on February 1, 1999, Gonzalez began working for Physicians Healthcare Plans, Inc. as a sales representative, a job he has held ever since. Mistake or Misconduct? 8. The foregoing facts are largely undisputed; those that follow mostly are, hotly. Getting to the bottom of whether Gonzalez made an honest mistake, as he maintains, or submitted a fraudulent application, as the Department has charged, is facilitated by a careful scrutiny of Gonzalez’s conflicting explanations of what happened. 9. Gonzalez’s most contemporaneous account of the Simpson affair appears to be contained in an undated handwritten document, entitled simply “Statement,” that Gonzalez himself indisputably prepared and signed. The full text of this paper follows: STATEMENT Prospect: Doris Simpson Ss# 075-22-6675 Agent: George J. Gonzalez Ss# 263-92-7916 To whom it may concern: To the best of my recollection I arrived at 20879 N.W. 9th Ct #107 (Walden Ponds Community) during the morning of (on or about) 11 a.m. 14th Jan.—through the gate system. Ms. Simpson agreed to my visit & let me in. Ms. Simpson opened [the] door and throughout my presentation produced a Medicare card and then proceeded to verification. Verification person was “DAWN.” Throughout the whole process everything proceeded to a normal sit down “application-to-verification” prospect call. P.S. She is blind, African-American. {Signed] George J. Gonzalez 10. Gonzalez’s manager at Foundation, Sergio Rumie, testified that sometime between January 20 and January 22, 1999, Gonzalez personally had handed him this Statement, which, according to Mr. Rumie, constituted Gonzalez’s written explanation of what had occurred with the Simpson application. Mr. Rumie recalled that in a discussion between the two of them, Gonzalez had told him that he (Gonzalez) had met with someone (obviously not Doris Simpson) in the Simpson household on January 14, 1999, who had held herself out as Ms. Simpson and signed the application. Mr. Rumie believed Gonzalez. 11. Although the Statement is not dated, two details in Gonzalez’s handwritten memorandum strongly suggest that the events of January 14, 1999, were its intended subject. The first of these telltale details is the date itself. The controversial Simpson application is dated January 14, 1999. The Statement refers to a meeting between Gonzalez and Doris Simpson on January 14. No imagination is required to connect one to the other. 12. The second common denominator linking the Statement to the phony Simpson application is the verifier’s name, Dawn. Before going on, however, some additional background must be provided, so that the significance of this datum may be understood. 13. At all times material, an independent contractor located in Utah performed application verification services for Foundation. The name of this contractor is not in evidence. For convenience’s sake, following the witnesses’ lead, the contractor will be referred to simply as “Utah.” 14. As part of the approved sales process, Foundation required its agents to place a telephone call to Utah, in the presence of the prospective enrollee, whenever an application had been completed. Once connected, the agent was supposed to introduce the applicant to the verifier, and then turn the phone over to the applicant. Using a script, the verifier would ask the applicant a series of questions, to confirm that he or she understood the transaction at hand. If the interview went well, the verifier would give the agent a verification number along with his or her name, both of which the agent would record on the face of the application. Foundation would not accept an _application unless it contained a verification number. 15. On the controversial Simpson application of January 14, 1999, Gonzalez wrote, by hand, a verification number and the verifier’s name, which happens to have been Dawn—the very name, recall, of the verifier who was so prominently identified (as “DAWN”) in the Statement. 16. If the story ended here, it would be difficult to find that Gonzalez had willfully submitted a false application. Rather, to this point, Gonzalez seems to have been the victim of a strange hoax, fooled by an imposter pretending (for reasons that admittedly are not readily apparent) to be the late Doris Simpson. Mr. Rumie, after all, who knew Gonzalez and was ina position to assess his character and credibility at the time of the incident, had believed this to be the case. 17. But there is more to the story. The exculpatory scenario just mentioned holds water only if Gonzalez were unacquainted with the real Doris Simpson, for if Gonzalez had known the decedent personally, then common sense would counsel that he could not have fallen for a poseur’s deceit. 18. Gonzalez testified that he had been to Ms. Simpson's home on three occasions before January 1999, and that he knew her well. Twice, he said, he had taken an application from Ms. Simpson in person, had submitted the application, which was accepted, and thereby had succeeded in enrolling her in Foundation’s HMO. Each time, however, Ms. Simpson had dis- enrolled before long. Corroborating Gonzalez’s account are two completed applications, dated March 31, 1997, and June 4, 1998, and the fact that Ms. Simpson had been a member of the Senior Value Medical Plan for brief periods following these dates. 19. Gonzalez claimed also to have taken an application from Ms. Simpson in January 1998 that was rejected. In contrast to the other two, however, no application from January 1998 was produced at hearing—indeed, no persuasive corroborating evidence of any kind was adduced in support of this supposed January 1998 application. 20. The reliability of Gonzalez's testimony that he knew Ms. Simpson personally from dealings between them that had occurred before January 1999 is high because the fact is against his interests; this much of Gonzalez's testimony, therefore, is accepted as true and adopted as a fact finding. 21. On the other hand, Gonzalez's testimony that he met with Ms. Simpson in January 1998 and took an application from her at that time is suspiciously self-serving (as will be seen) and, ultimately, not believable. Initially, Gonzalez’s failure to produce the purported application raises a skeptical eyebrow. But what sinks Gonzalez's story about meeting Ms. Simpson in January 1998 is that the tale was told in an incredible attempt to explain away the Statement (which, if intended to refer to events of January 14, 1999, cannot be squared with Gonzalez’s admission that he had by then known Ms. Simpson personally from prior dealings) as a memorandum regarding this purported January 1998 visit. Gonzalez maintained that, by coincidence, he had happened to meet with Ms. Simpson on January 14, 1998, and again on January 14, 1999, and that both times the verifier, as chance would have it, was Dawn. This contention is contrived and forced. 22. Taken as a whole, the evidence is convincing that Gonzalez wrote the Statement in January 1999 for his former employer and delivered it to Mr. Rumie between January 20 and January 22, 1999, with the intent that the Statement be understood as a description of the circumstances surrounding Gonzalez’s solicitation of the January 14, 1999, application from the putative Ms. Simpson. The contents of the Statement, 10 however, are false and misleading, as was Gonzalez's testimony at hearing about the Statement. 23. Gonzalez gave a different account of the Simpson application to the Department of Insurance in response to the Administrative Complaint in this matter. In an undated letter to the Department which the Department received on September 6, 2000, Gonzalez wrote: By recollection I believe this case involves a mail-in situation. I recall that I sent maybe two/three such invitation packages in the Spring of 1998 and one could have been for Mrs. Simpson. That practice is no longer tolerated after a new Vice-president of marketing (Medicare) was installed in the Sawgrass Headquarters late May of that same year. As 1998 was ending in December (late) I believe I received an application signed and (I believe) it was the Simpson one. I completed the data in those days that followed early in January 1999, before starting my new job did a phone verification (3 way) or gave this information to a verifying person (Utah) and the person was thus verified (I cannot be clear on this). Hearing no problems from Utah I recorded the authorization # on a call back from Utah or after the verification; if done by 3-way. I did not know of her death and in fact only found out when receiving your package of counts and allegations on August 21, 2000. I would only add that Mrs. Simpson had a family member there, perhaps her sister. During my first application for the plan with Mrs. Simpson in late 1997 I believe she helped in the signing and subsequent verification of her sister. Mrs. Simpson 11 could not sign any proper way the petitions. I believe she was blind in my recollections. 24. Ironically, one of the few unqualified representations in this letter of Gonzalez's to the Department—that he “in fact” had first learned of Ms. Simpson’s death upon receipt of the Administrative Complaint—was clearly untrue. In fact, Gonzalez undeniably had known of Ms. Simpson's death at the time of his resignation from Foundation on January 25, 1999, if not sooner, and certainly long before August 21, 2000, in any event. 25. As for the rest of this explanation, Gonzalez essentially stuck with it at hearing, although his memory apparently had improved by then, for he seemed far more confident of the details than he had as author of the above- quoted letter. 26. In a nutshell, Gonzalez claimed that, on his own initiative, he had mailed a partially filled-out application to Ms. Simpson in June or July 1998 with note asking her to sign and return the document if she wanted to re-enroll in Foundation's Medicare HMO. He claimed to have had no further contact with Ms. Simpson until, in late December 1998 or early January 1999, he received through the mail Ms. Simpson's signed- but-undated application. According to Gonzalez, despite the delay of some five months, Gonzalez failed to call Ms. Simpson to confirm her continued interest and instead signed the 12 application on January 14, 1999, inscribing the same date next to the purported signature of Ms. Simpson. He claimed to have contacted Utah, provided the necessary information to the verifier, and in due course to have received a verification number from Dawn, which signified to him that all was in order. 27. This story is facially unbelievable and is rejected as a fabrication. Moreover, there is an out-of-place detail on the January 14, 1999, application that exposes the chicanery; namely, the designated primary care physician, a Dr. Nidal Radwan, who is specifically identified therein as Ms. Simpson's current physician. When Gonzalez was asked at hearing to point out the parts of the application that he had filled out, Gonzalez replied, making reference to the top quarter of the first page where the primary care physician information appears, that [t]he part that's my handwriting is the name, the address, the phone number, and the date of birth, and doctor selected, which was her last doctor. I put it there, I said does she [sic] want this doctor again. Transcript of Final Hearing at 193 (emphasis added). 28. At the time Gonzalez supposedly prepared this application, in June or July 1998, he had not spoken with Ms. Simpson specifically about doing so; indeed, she may well already have passed away. He certainly did not speak with her about doctors after July 1, 1998. Yet on the previous 13 application that Gonzalez had taken from Ms. Simpson just a few weeks before her death, dated June 4, 1998 (Respondent's Exhibit 4), Ms. Simpson had chosen a Dr. [Illegible] -Nunez as her primary care physician—not Dr. Radwan. 29. It is commonly known that for a genuine insurance application, the sales representative or agent will endeavor to elicit truthful, complete, and current information from the applicant and rely upon the applicant's representations in preparing the paperwork. The fact that Gonzalez's selection of Dr. Radwan as Ms. Simpson's "current" primary care physician was not based on information obtained from Ms. Simpson—aindeed, his election deviated from her last (known) written expression of intent in this regard—-exposes the act as an arbitrary choice of Gonzalez's, which in turn underscores the counterfeit nature of the January 14, 1999, application. The Charges 30. In Count I of its Administrative Complaint, based on allegations that Gonzalez had signed and presented an application for insurance in the name Doris Simpson, who was at the time deceased, the Department accused Gonzalez of having submitted an enrollment form that he "knew or should have known" contained false or fraudulent information, in violation of Sections 626.611 and 626.621, Florida Statutes. Specifically, the Department alleged the following grounds for discipline: 14 (a) Willful misrepresentation of any insurance policy or annuity contract or willful deception with regard to any such policy or contract, done either in person or by any form of dissemination of information or advertising. [Section 626.611(5), Florida Statutes] ; (b) Demonstrated lack of fitness or trustworthiness to engage in the business of insurance. [Section 626.611(7}, Florida Statutes] ; (c) Fraudulent or dishonest practices in the conduct of business under the license or appointment. [Section 626.611(9), Florida Statutes] ; (d) Willful failure to comply with, or willful violation of, any proper order or rule of the department or willful violation of any provision of this code. [Section 626.611(13), Florida Statutes] ; (e) Violation of any provision of this code or of any other law applicable to the business of insurance in the course of dealing under the license or appointment. [Section 626.621(2), Florida Statutes] ; (£) In the conduct of business under the license or appointment, engaging in unfair methods of competition or in unfair or deceptive acts or practices, as prohibited under part X of this chapter, or having otherwise shown himself or herself to be a source of injury or loss to the public or detrimental to the public interest. [Section 626.621(6), Florida Statutes] ; [and] (g} UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE ACTS.- The following are defined as unfair methods of competition and unfair or deceptive acts or practices: Misrepresentation in insurance applications.- Knowingly making a false or 15 fraudulent written or oral statement or representation on, or relative to, an application or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual. [Section 626.9541(1) (k), Florida Statutes] [.] Ultimate Factual Determinations 31. Because the evidence does not illuminate all the particulars of Gonzalez’s scheme, it is impossible to reconstruct completely the precise course of his misconduct. The evidence is sufficient, however, to establish, clearly and convincingly, that on or around January 14, 1999, Gonzalez: (a) signed an insurance application for Ms. Doris Simpson knowing that she had neither requested the sought-after coverage, nor supplied information for that application, nor executed the application herself; (b) placed a date next to the purported signature of Ms. Simpson (which he knew was not hers) intentionally to represent, falsely, that “she” and he had signed the instrument contemporaneously (and hence, implicitly, in one another’s presence); and (c) with intent to deceive, submitted this bogus application to his employer, Foundation, for the purpose of obtaining a commission or other benefit. 16
Conclusions For Petitioner: Anoush A. Arakalian, Esquire Department of Insurance Division of Legal Services 200 East Gaines Street Tallahassee, Florida 32399-0333 For Respondent: Ignacio Siberio, Esquire 525 Northwest 27th Avenue, Suite 100 Miami, Florida 33125
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department enter a final order suspending Gonzalez’s health insurance agent license for a period of one year. 21 DONE AND ENTERED this 10 day of July, 2001, in Tallahassee, Leon Count 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 lot day of July, 2001.
Findings Of Fact Fred Hoeful Mercer is licensed and qualified for licensure as an insurance agent in the State of Florida. At the times relevant to this case, Mercer was licensed with Old Southern Life Insurance Company and American Integrity Insurance Company. On April 9, 1985, Mercer was placed on probation for a period of two years pursuant to a Consent Order (Case No. 84-L-3I7SF). In October, 1985, and again on or about August 10, 1987, Mercer went to the home shared by Evelyn Lawry and Eleanor Mack, sisters. Mercer went to their home to sell a Medicare Supplement policy. At the time of each sales visit, Ms. Mack was covered by Medicare. Ms. Lawry was not covered by Medicare. During each visit, both women told Mercer several times that Ms. Lawry did not have Medicare coverage. Mercer told both women that a Medicare Supplement policy would pay benefits even if Ms. Lawry was not covered by Medicare. As a result of the October 1985, sales visit, Ms. Lawry bought the Medicare Supplement policy from American Integrity Insurance Company. A person not on Medicare is not eligible for benefits under a Medicare Supplement policy. In fact, when Ms. Lawry submitted a claim to American Integrity in 1987, the claim was denied because she was unable to submit the required Medicare Explanation of Benefits form. On August 10, 1987, Mercer returned to the sisters' home and tried to sell them new Medicare Supplement policies with Old Southern Life Insurance Company. The women signed up for the new policies but refused them when they came because they had found out that the Medicare Supplement policy would cover only if Medicare coverage already existed. On both sales visits, Mercer made the primary sales presentations, but was accompanied by Horace LeGrave. Mr. LeGrave actually wrote the policies. The sales commission paid by the insurance companies is 60% of the first year's premium. Mercer and LeGrave split the commission for both of these sales. Ms. Lawry ultimately was refunded the premiums paid on both policies by the insurance companies. At the time of the first solicitation visit in October, 1985, Mercer's license was on probation with the Department. That probation arose from an Administrative Complaint that involved multiple counts alleging misrepresentations in the sale of Medicare Supplement policies. Those sales were allegedly also with LeGrave as the writing agent.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Insurance Commissioner enter a Final Order revoking the insurance license of Fred Hoeful Mercer. DONE and ENTERED this 11th day of August, 1989, in Tallahassee, Florida. DIANE K. KIESLING 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 11th day of August, 1989. APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 89-1877 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case. Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Department of Insurance and Treasurer 1. Each of the following proposed findings of fact are adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1-7(1-12). COPIES FURNISHED: Stephen C. Fredrickson Attorney at Law Department of Insurance Office of Legal Services 412 Larson Building Tallahassee, FL 32399-0300 Fred Hoeful Mercer 555 Cassadaga Road Lake Helen, FL 32744 Hon. Tom Gallagher State Treasurer and Insurance Commissioner The Capitol, Plaza Level Tallahassee, FL 32399-0300 Don Dowdell General Counsel Department of Insurance The Capitol, Plaza Level Tallahassee, FL 32399-0300
The Issue Whether Respondent's medical license should be disciplined because he filed false insurance claims.
Findings Of Fact Petitioner is the state agency charged with regulating the practice of medicine pursuant to Section 20.43 and Chapters 456 and 458, Florida Statutes. Pursuant to Section 20.43(3)(g) Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial services required by the Division of Medical Quality Assurance, councils or boards, as appropriate, including the issuance of emergency orders of suspension or restriction. Dr. Shugar is a physician holding Florida license ME 0053263, which was issued to him by Petitioner. Dr. Shugar, during all times pertinent, practiced medicine in Perry, Florida. Dr. Shugar began practicing in Perry in 1991. Although Respondent is currently known to be primarily an ophthalmologist during all times pertinent, he was engaged in the general practice of medicine. Patient B.O. B.O., a 49-year-old female, became a patient of Dr. Shugar in February 1995. On June 8, 1996, Patient B.O. was seen by Dr. Shugar. He observed a lesion on her nose. Patient B.O. and Dr. Shugar were concerned that the lesion might be malignant. On or about July 27, 1996, Patient B.O. presented to Dr. Shugar for the purpose of having the lesion removed. Using local anesthesia, Dr. Shugar surgically removed the lesion and some surrounding tissue. This material was sent to a pathologist in Tallahassee, Florida, who upon examination, opined that the growth was a benign nevus rather than a carcinoma. On August 5, 1996, the sutures were removed and Patient B.O.'s medical records indicated that the area was, "well healed." Patient B.O. had no complaints with regard to the outcome of the surgery. When Patient B.O. subsequently received a bill in the amount of $2,225, she was shocked at the amount. She called Respondent's office and her insurance company. She personally paid only $100. Sheila Hilson was the person who assigned Physicians' Current Procedural Terminology (CPT) codes for Dr. Shugar. CPT codes are numbers assigned to actions taken during patient evaluation and management and to procedures performed. CPT codes are widely used by government agencies and insurance companies. CPT codes translate into dollar amounts used for billing patients and provide the basis for reimbursement by insurers and governmental agencies. A CPT code for a simple procedure will translate into a certain number of dollars. A CPT code for a more complex procedure will translate into a larger number of dollars. Dr. Shugar utilized a superbill, which is a list of CPT codes provided in the written word and in a bar code. The superbill contained only the most common ailments. In the usual case, Dr. Shugar, subsequent to treating a patient, would circle the appropriate CPT code on the superbill. The superbill with the circled item would then be forwarded to his administrative office and the appropriate charge would be billed to the patient or third party payer in accordance with Dr. Shugar's direction. If the superbill did not contain an item for a particular procedure, Dr. Shugar would make a note on a patient and evaluation management form and his clerical staff would divine the correct CPT code from his note. Dr. Shugar did not regularly supervise the billing process. He would only become involved when a problem was encountered. As noted above, Dr. Shugar, during times pertinent, had a general or family type practice which meant that he treated a wide variety of ailments. Because of this, it was impossible for his superbill to reflect all of the work that he accomplished. The procedure performed on Patient B.O. was not reflected on the superbill. This being so, Ms. Hilson reviewed Respondent's notes on the patient management and evaluation record and determined a CPT code. This was her usual practice when the procedure was not listed on the superbill. Ms. Hilson, when reviewing the patient evaluation and management form, noted that Respondent had performed work on Patient B.O.'s nose and observed the word "plasty." She began her code determination exercise by turning to the section under "nose" and thereafter went to the section under "repair." Following this trail resulted in the conclusion that the procedure was a rhinoplasty. As will be noted hereinafter, determining correct CPT codes is fraught with difficulty and often experts on CPT codes will disagree as to the proper code to be assigned when presented with identical descriptions of a procedure. That having been said, Ms. Hilson's determination, nevertheless, was far off the mark. A rhinoplasty, CPT Code 30400, is what is colloquially called a "nose job." A rhinoplasty is a substantially more involved procedure than the excision of a lesion. Moreover, it is usually, but not always, considered a cosmetic procedure of a type not usually reimbursed by insurance. Ms. Hilson also filed for this procedure under CPT Code 13152, "Repair, complex, scalp, arms, and/or legs; . . . 2.6 cm to 7.5 cm." It was this error that resulted in Patient B.O.'s being shocked when she received her bill. The bill, in the form of a claim, was also sent to B.O.'s medical insurance carrier. Patient B.O.'s insurance carrier responded to the claim with a letter dated August 27, 1996, which was date stamped by Respondent's office on September 5, 1996. This letter requested documentation as follows: (1) Degree of functional impairment; (2) date of injury; (3) X-ray report of the injury; (4) pre-operative photographs; and (5) patient's history and physical examination report. Neither the coding of the procedure nor the word rhinoplasty was mentioned in the letter. On September 10, 1996, Ms. Hilson discussed the matter with Dr. Shugar for the first time. Dr. Shugar answered the carrier's letter on September 23, 1996. Neither the coding of the procedure nor the word rhinoplasty was mentioned in this letter. The response was factually correct. The claim, despite the additional information supplied by Dr. Shugar, was denied by the carrier. In the ensuing months Ms. Hilson and the carrier exchanged letters. Eventually Dr. Shugar discovered that Ms. Hilson had filed a claim for a rhinoplasty. Subsequently, on September 8, 1997, the claim was re-filed under CPT Codes 11441 and 13150-51. This was incorrect also and resulted in codes which caused Dr. Shugar to be inadequately reimbursed for the procedure performed. Subsequent to this filing, Patient B.O.'s insurance carrier paid $600 to Dr. Shugar. This amount, along with the $100 paid to him by Patient B.O., resulted in Respondent's receiving a total of $700 for treating the lesion on Patient B.O.'s nose. Patient V.A.A. V.A.A. became a patient of Dr. Shugar in 1995. On February 14, 1996, Patient V.A.A. presented to Dr. Shugar with a lesion on her cheek and a crusted place on her nose. Both areas caused concern for malignancy which Dr. Shugar desired to rule out. Dr. Shugar made a referral to a Dr. Grate in Tallahassee, Florida, an ear, nose, and throat physician, because of Respondent's concern that the area on her nose was a basal cell carcinoma. On March 23, 1996, Dr. Shugar removed the lesion on Patient V.A.A.'s cheek. Dr. Shugar noted that the lesion was 1.1 centimeters in diameter. He documented in V.A.A.'s medical record that he "excised under loupe mag., 3.0 cm length, complex closure." A pathology report was generated by Ketchum Wood and Burgert Pathology Associates which diagnosed an absence of malignancy. On April 4, 1996, it was noted that the incision was "well healed." Ms. Hilson reviewed the Patient Evaluation and Management Record and filed a claim with Patient V.A.A.'s insurance carrier for the cheek surgery using CPT Codes 11403 and 13131. CPT Code 11403 addresses, "Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; . . . lesion diameter 2.1 to 3.0." CPT Code 13131 addresses, "Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm." Ms. Hilson's use of CPT Code 11403 was improper because that code does not address procedures involving the cheek and because the lesion, as noted in the Patient Evaluation and Management Record, was 1.1 centimeters. It was the length of the closure which was three centimeters. Upon consideration of all the available evidence, it appears that Ms. Hilson simply made a coding error because of a transposition of the length of the lesion and the length of the closure. Because of the coding error, Dr. Shugar obtained less compensation than he was entitled to. When Patient V.A.A. came to Dr. Shugar on April 4, 1996, for follow-up on her cheek incision, Dr. Shugar was concerned because Patient V.A.A. had not visited Dr. Grate as she had been advised. Patient V.A.A. had decided to forgo treatment by Dr. Grate because her medical insurance would not pay for treatment by him. Dr. Shugar had previously made a differential diagnosis on the suspicious area on V.A.A.'s nose of basal cell and squamous cell carcinoma. The passage of time since February 14, 1996, when he first observed the area, and a closer examination of the area, enabled Dr. Shugar to make a diagnosis of basal cell carcinoma during the April 4, 1996, visit. After considering the desires of Patient V.A.A. and the treatment regimens available in the local area, Respondent decided on that date to prescribe Efudex. Efudex is a chemical, which when applied to a growth on the skin, will destroy the growth and, for that matter, skin not having a growth upon it. Dr. Shugar referred to this procedure as, "Chemical treatment of malignancy." This was billed by Ms. Hilson under CPT Code 17283. This code is under the general heading of, "Destruction, Malignant Lesions, Any Method," and specifically, "Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane,: . . . lesion diameter 2.1 to 3.0 cm." Patient V.A.A. obtained the Efudex and applied it to the lesion herself, having been instructed by Dr. Shugar as to its proper use. On April 25, 1996, Dr. Shugar saw Patient V.A.A. and instructed Patient V.A.A. to discontinue the use of the Efudex. On May 29, 1996, V.A.A.'s last visit with him, Dr. Shugar noted that the carcinoma on her nose was "well-treated." After receiving the superbill for the April 4, 1996, treatment provided to Patient V.A.A., Ms. Hilson selected CPT Code 17283. She selected this code based upon Dr. Shugar's note that he had used "chemical treatment." This selection was not discussed with Dr. Shugar. When Patient V.A.A. received her explanation of benefits she believed it to be in error because it indicated a surgical procedure had been performed on April 4, 1996. She contacted Dr. Shugar's office on September 5, 1996, and pointed out that she did not have a surgical procedure on April 4, 1996. Dr. Shugar called her and explained that the chemical treatment, according to the CPT manual, was the same as a surgical procedure. In the 1996 CPT Code Manual, the narrative description for CPT Code 17283 states, "Destruction, malignant lesion, any method, . . . nose." Destruction is further defined to include chemical treatment. The CPT Code Manual language is amended from year to year to resolve ambiguities and confusion over code selection. In 1999, the CPT Code Manual was amended to clarify that initiation of treatment with Efudex should no longer be billed under the series of codes for chemical treatment of benign lesions. Dr. Shugar was correct in his use of the 1996 manual. Patient V.A.A. was insured under a cancer policy issued by American Family Life Assurance Company. In October of 1996, Patient V.A.A. was provided a claims form by her insurance representative. She called Dr. Shugar to inquire again about the nature of the procedure he provided. Patient V.A.A.'s insurance representative suggested that she complete it and send it to the insurance company. She either faxed or personally delivered it to Dr. Shugar's office. Subsequently, she received the claims form from Dr. Shugar's office. The claims form has what appears to be Dr. Shugar's initials on it. Dr. Shugar denied that he initialed the form. Broward Taff, who was accepted as a handwriting expert, testified that the initials on the claim form were inconsistent with the more than one hundred known signatures and initials provided by Dr. Shugar. The claim to the insurance company would have resulted in a payment directly to Patient V.A.A. The record contains no evidence that Dr. Shugar was aware that the claim form was submitted to his office or that he participated in its completion. Petitioner's experts Jean Acevedo conducts coding and billing compliance audits for health care practices. She is a licensed health care risk manager and a certified professional coder. She was accepted as an expert in the area of CPT coding. In conducting an audit she reviews between ten and 15 patients per provider. Physicians make mistakes when determining CPT codes upon which billing amounts are determined. She is of the opinion that a physician who is in a general practice treating a wide variety of maladies is apt to make more billing errors than a physician who is a specialist. When performing a compliance audit on providers who have been previously determined to have submitted false bills, Ms. Acevedo will audit between 20 to 50 patient charts. She considers a provider to be in compliance so long as the errors do not exceed five percent of the total dollar amount of the charges billed. The testimony of Ms. Acevedo was credible. Thomas Breza, M.D., is a dermatologist. He was accepted as an expert witness in the area of CPT coding. He never performs services which are not on his superbill. It is his opinion that physicians are responsible for every billing error which results in an incorrect claim being filed. He believes he would be committing fraud if he allowed an incorrect bill to leave his office. However, Dr. Breza admitted that he has mailed incorrect bills from his office. Dr. Breza's testimony indicated that his personal definition of fraud is different from the legal definition of fraud. His opinion, with regard to the requirements of accuracy, are based on his experience as a specialist and failed to take into account the variety of diagnoses and procedures experienced in a general practice. Diana Calderone, M.D., was accepted as an expert witness in the area of CPT coding. Like Dr. Breza, Dr. Calderone takes a Draconian approach when addressing coding errors. While opining that coding and resultant billing errors were unacceptable, she conceded that total accuracy is unrealistic and acknowledged that she had made mistakes in this area. Dr. Calderone, is also a dermatologists with little or no experience with the coding problems inherent in a general practice. Margie Vaught is an independent health care consultant. She is a certified professional coder, and sits as a board member of the National Advisory Board of the American Academy of Professional Coders. She performs compliance audits for health care practices. She was accepted as an expert witness in the area of CPT coding. She reviews between ten to 30 patient charts per practitioner when doing a compliance audit. She has never made an audit that did not reveal coding errors. Ms. Vaught reviewed all of the information provided in this case regarding the bills prepared by Dr. Shugar. It is her opinion that there is insufficient information for one to determine whether there is any pattern to Dr. Shugar's billing procedures. Ms. Vaught noted that the HCFA Form 1500 was a form developed for billing in the case of federal medical programs. A HCFA Form 1500 will be accepted by federally funded programs with the signature of a physician's agent rather that the actual signature of the physician. She explained that many private carriers use the HCFA Form 1500 for billing purposes and some of them require no signature. Ms. Vaught's testimony was credible. Mitchell King, M.D., is a board-certified family practice physician. He is an assistant professor and director of the Department of Family Medicine at Northwestern University Medical School in Chicago. Dr. King was accepted as an expert in the area of CPT coding. Dr. King has published three studies related to CPT coding by family practice physicians. One of the studies demonstrated that 38 percent of family practice physicians delegate all or a portion of CPT coding to a staff member. Another found that physicians selected the wrong code 48 percent of the time. Another found that certified coders disagreed as to the appropriate code 43 percent of the time. Dr. King agreed with Ms. Acevedo to the effect that a family practice physician would have more coding errors because of the broad nature of the services rendered. He believes that the CPT code manual is difficult to use. Dr. King's testimony was accepted as credible.
Recommendation Based upon the Findings of Fact and Conclusions of Law, RECOMMENDED: That a final order be entered which dismisses the allegations of the complaints. DONE AND ENTERED this 11th day of June, 2002, in Tallahassee, Leon County, Florida. HARRY L. HOOPER 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 11th day of June, 2002. COPIES FURNISHED: Diane K. Kiesling, Esquire Agency for Health Care Administration 2727 Mahan Drive, Building 3 Room 3226, Mail Stop 39 Tallahassee, Florida 32308 Gary A. Shipman, Esquire Brian Newman, Esquire Pennington, Moore, Wilkinson, Bell & Dunbar, P.A. Post Office Box 10095 Tallahassee, Florida 32302-2095 Tanya Williams, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
The Issue Whether Octavio J. Carreno, M.D. ("Respondent" or "Dr. Carreno"), is liable to the Agency for Health Care Administration ("AHCA," "Agency," or "Petitioner") for an overpayment in the amount of $121,641.42 for certain claims for services during the audit period of January 1, 2012, through December 31, 2014, that in whole or in part were not covered by Medicaid. Whether Respondent is liable to Petitioner for a sanction in the amount of $24,328.28 pursuant to Florida Administrative Code Rule 59G-9.070(7)(e). Whether Respondent is liable to Petitioner for Petitioner's incurred investigative, legal, and expert witness costs, which Petitioner contends it is entitled to recover pursuant to section 409.913(23)(a), Florida Statutes (2014).
Findings Of Fact Based on the evidence presented at the hearing, and the record as a whole, the undersigned makes the following findings of material and relevant facts: Agreed Facts in Parties' Amended Joint Prehearing Stipulation Petitioner is designated as the single state agency authorized to make payments for medical assistance and related services under Title XIX of the Social Security Act. This program of medical assistance is referred to as the "Medicaid program." See § 409.902, Fla. Stat.; JPS ¶ E12. Petitioner has the responsibility for overseeing and administering the Medicaid program for the state of Florida, pursuant to section 409.913. JPS ¶ E13. The Medicaid provider agreement is a voluntary contract between AHCA and Respondent. An enrolled Medicaid provider must comply fully with all state and federal laws pertaining to the Medicaid program, including Medicaid provider handbooks incorporated by reference into rule, as well as all federal, state, and local laws pertaining to licensure to receive payment from the Medicaid program. JPS ¶ E14. During the audit period, Respondent was an enrolled Medicaid provider and had a valid Medicaid provider agreement with AHCA, Medicaid Provider No. 002993600. JPS ¶ E2; Pet. Ex. 1. AHCA's Bureau of Medicaid Program Integrity ("MPI"), pursuant to its statutory authority, conducted an audit of Respondent for Medicaid claims it paid to him for medical services he provided to Medicaid recipients, occurring during the time period from January 1, 2012, through December 31, 2014. JPS ¶¶ E1 and E4. AHCA issued a FAR dated March 15, 2016, MPI Case ID No. 2015-0003243, alleging that Respondent was overpaid $139,250.66 for certain services that are not covered by Medicaid. In addition, the FAR informed Respondent that AHCA was seeking to impose a fine of $27,850.13 as a sanction for violation of rule 59G-9.070(7)(e) and seeking costs pursuant to section 409.913(23). The amounts of the overpayment and the sanction were revised, after the FAR was issued, to $121,641.42 and $24,328.28, respectively. JPS ¶ E5. The FAR, supported by the Agency work papers, constitutes evidence of the overpayment to Respondent pursuant to section 409.913(22). JPS ¶ E15. In the FAR section entitled "Findings," AHCA set forth the bases for the overpayment determinations. JPS ¶ E6. The claims which make up the overpayment alleged by AHCA were filed by and paid to Respondent prior to the initiation of this action. JPS ¶ E7. There is no dispute from Respondent as to the process of the statistical sampling or the statistical methods utilized to establish the validity of the overpayment calculation utilized by AHCA. JPS ¶ E16. Additional Facts Adduced at the Hearing Ms. Robi Olmstead, an administrator of the Practitioner Unit at AHCA, under the Offices of the Inspector General, MPI, testified regarding her experience and role in the audit of Respondent. MPI is required by federal and Florida law to investigate medical providers for fraud, abuse, or overpayments. Olmstead cited section 409.913 as the authority to investigate Medicaid providers, including Respondent. The instant case against Respondent was opened based on a referral from one of the investigators who noticed "a significant portion of Dr. Carreno's office visits" (evaluation and management or "E&M" codes) were billed at high levels. Olmstead also independently confirmed this in her review of the data. Olmstead opened the audit, set the coverage dates of the audit period, and assigned the matter to an AHCA investigator. The investigator obtained a list of claims for 40 random recipients from the Agency's cluster sample program. After the sample was obtained, Petitioner then requested the medical records of the sample recipients from Respondent. Pet. Ex. 2. Petitioner utilized the services of a peer consultant, Ellen D. Silkes, M.D. Dr. Silkes meets the requirements and qualifications of a "peer" as defined in section 409.9131. JPS ¶ E17. Dr. Silkes practices the same specialty or sub-specialty as Respondent and is licensed under the same chapter. Pet. Ex. 6, p. 147. Both Dr. Silkes and Dr. Carreno are otolaryngologists, commonly referred to as ear, nose, and throat ("ENT") doctors. The medical records received from Respondent were reviewed by the AHCA investigator and by an AHCA registered nurse consultant and then sent to the peer reviewer, Dr. Silkes, along with other relevant documents, including the worksheets generated by the claims sample process. When the medical records were returned to the Agency with the peer's comments, the Agency calculated the amount of the overpayments. The peer reviewer's role is to make determinations of medical necessity and levels of service. Decisions as to the lack of documentation are made by a combination of the peer reviewer and the Agency nurse consultant. After the agency and peer review were completed, a Preliminary Audit Report ("PAR")(Pet. Ex. 4) was sent to Respondent on December 14, 2015. After the receipt of the PAR, Respondent had the opportunity to submit additional medical records to the Agency for consideration. This was done by Respondent. The FAR (Pet. Ex. 5) was then issued on March 15, 2016. The FAR made multiple findings delineating the reasons for the overpayments, including improper "consult" claims, reductions for levels of service, insufficient or no documentation to support claims, improper claims for global procedures, errors in coding, and lack of medical necessity for certain procedures. Pet. Ex. 5, pp. 88-90. Subsequent to the FAR and prior to the final hearing, the review of additional information provided to the Agency by Respondent resulted in a reduction of the alleged overpayment to $121,641.42. JPS ¶ A; Pet. Ex. 19. Rule 59G-9.070(7)(e) addresses sanctions for failure to comply with the provisions of the Medicaid laws. For a first offense, there is a $1,000.00 fine per claim found to be in violation. AHCA initially found 86 violations. Pet. Ex. 6. After the state mandated cap of 20 percent was applied, the initial fine was set by the Agency at $27,850.13. Subsequently, based on the allowance of some claims submitted by Respondent with additional documents or clarification, the fine amount was reduced to $24,328.28. Pet. Ex. 19. The Agency considered all of the statutory factors when assessing the sanction. Olmstead considered the violations in this case to be "typical" and "nothing extraordinary" and did not enhance or reduce the sanctions. The Agency incurred costs in its investigation of this matter. However, costs have not yet been fully determined. Pet. Ex. 5, p. 150B. Based on Olmstead's experience, the audit was conducted in a routine and acceptable manner. Identification of the Disputed Claims Notably, in the JPS and again at hearing, the parties agreed that only the following "Disputed Claims" required factual findings and conclusions of law by the undersigned: Recipient #2 Claims 1, 2 and 3 Recipient #3 Claims 5, 11, 12, 13, 17, 18, 20, 21, 22, 24, 26, 28, 35 Recipient #25 Claim 11 Recipient #29 Claim 6 Recipient #30 Claims 1, 2, 4 None of the other audit determinations made by AHCA were challenged by Respondent at the hearing.1/ The parties agreed at the start of the hearing that the downward adjustments made by AHCA to Recipient #2, Claims 1 and 2, were agreed to and would not be disputed. The worksheets, as revised, now showed the peer's determination of those claims as properly payable at Current Procedural Terminology ("CPT") Code 99213. Pet. Ex. 19. Evaluation and Management Claims Many of the "Disputed Claims" are for E&M services, which are office visits, and specifically in this audit, office visits for established patients of Respondent. In order to properly code and bill the appropriate level of E&M services for an encounter with an established patient, the medical records must establish that two of the three key components (i.e., history, examination, and medical decision- making) meet or exceed the stated requirements of that level of service. In some cases, time spent with the patient is considered a key factor as well. Pet. Ex. 13, p. 271. For encounters with established patients, the CPT Code (2012) provides in pertinent part, as follows: 99212 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these three key components: A problem focused history;A problem focused examination;A problem focused examination. 99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these three key components: An expanded problem focused history;An expanded problem focused examination;Medical decision making of low complexity. 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these three key components: A detailed history;A detailed examination;Medical decision making of moderate complexity. Pet. Ex. 13, p. 273. There was no evidence to suggest that the CPT codes for these procedures changed at any time during the audit period between 2012 and 2014. As a result, the CPT codes admitted were properly relied upon by the parties. Pet. Ex. 13. As mentioned, the key components of coding an E&M encounter are the examination, the history, and the medical decision-making required of the physician. Pet. Ex. 13. The CPT codes from 99211 to 99215 are also referenced as Levels 1 through 5 with the main difference being the complexity and extent of the visit and examination. Counseling and/or coordination of care with the patient and/or family can be a controlling factor in coding the proper level. However, the CPT code notes provide that the "extent of counseling and/or coordination of care must be documented in the medical record." Pet. Ex. 13, p. 271. The Florida Medicaid Provider General Handbook provides that "[m]edical goods or services are excessive or not medically necessary unless both the medical basis and the specific need for them are fully and properly documented in the recipient's medical records." Pet. Ex. 9, pp. 169-173.2/ The undersigned undertook a careful and meticulous review of the record. This included reading Transcript testimony, reviewing manuals and handbooks provided, and comparing and cross-referencing the hearing testimony to the worksheets and handwritten medical notes and other records prepared by Respondent. Findings of Fact on Disputed Claims Recipient #2, Claim 3. Respondent submitted this claim using CPT Code 69200. Pet. Ex. 15-2, p. 376-A. Dr. Silkes testified that there was a myringotomy tube that was placed in the ear by Respondent. The tube is not considered a foreign body, and Medicaid does not pay for its removal when inserted by the original doctor. She concluded that removal of the tubes is not properly billed as CPT Code 69200. This conclusion is also supported by provisions of the Physicians Services Handbook (Pet. Ex. 13, p. 199), which does not permit additional billing under global surgery packages for the removal of "items such as tubes, drains . . . ." (see bullet point 6 entitled "Miscellaneous Services and Supplies). This restriction does not place any time limit when the non-reimbursable "miscellaneous service" is performed, even outside the normal 90- or ten-day time period. The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and AHCA. The removal of the tubes fell under the exclusion of miscellaneous services or did not otherwise qualify for reimbursement (Pet. Ex. 13, p. 199). The claim was properly denied. Recipient #3, Claim 5. Respondent submitted a claim using CPT Code 31237 for services on January 30, 2012, Nasal/Sinus Endoscopy Surgery. Pet. Ex. 15, pp. 376 (worksheet) and 387 (medical record). Dr. Silkes denied this claim because she could not find documentation to support the procedure. However, there is documentation at Petitioner's Exhibit 15, page 387, included in a contemporaneous office note for January 30, 2012. It indicates on the fifth line that Respondent performed a nasal endoscopy ("nasal endo") and that he did bilateral debridement of the sinuses. He found crusting on the right, and the right sphenoid sinus was narrow. Dr. Silkes testified that she may have misread the nasal endo reference and that Dr. Carreno may be correct on that point. The undersigned credits and finds more persuasive Respondent's evidence and finds that the claim should have been paid as requested and coded. Recipient #3, Claim 11. Respondent submitted a claim using CPT Code 31231 for services on June 13, 2012, nasal endo. Pet. Ex. 15, pp. 377 (worksheet) and 388 (medical record). Dr. Silkes denied this claim because she did not find anything in the medical record to support billing for this service. The supporting medical note documents a nasal endo in the middle of the notes. Respondent wrote in the assessment and plan ("A/P") "looks good but mucocele of right sphenoid." Also, he testified that if he did not do the endoscopy, he could not have seen the right sphenoid. The undersigned credits and finds more persuasive Respondent's evidence and finds that the claim should have been paid as requested and coded. Recipient #3, Claim 12. This claim was adjusted from CPT Code 99214 to 99212 by Dr. Silkes. She concluded that the medical records failed to properly document an examination and the medical decision-making was straightforward. Pet. Ex. 15-3, p. 377. The undersigned credits and finds more persuasive AHCA's evidence and finds that the code should be reduced to CPT Code 99212. Recipient #3, Claim 13. This claim was denied by AHCA on the basis that the examination of July 30, 2012, was included within a global surgical fee package. The surgery was performed on August 13, 2012, after the decision to perform the surgery was made on July 16, 2012. Pet. Ex. 15-3, pp. 378 and 389. The Physicians Services Coverage and Limitations Handbook (Pet. Ex. 11, p. 199) provides as follows: Evaluation and management services, subsequent to a decision for surgery visit, that are limited and focused to determine the health of the individual prior to surgery are included in the global surgery package and may not be billed separately. The primary purpose of the visit on July 30, 2012, was an examination to determine the health of the individual. The patient visit was limited in scope and should be included in the global surgical package. The surgical decision was made prior to this encounter, and the surgery occurred after it. The undersigned credits and finds more persuasive ACHA's evidence and finds that the claim was properly denied. Recipient #3, Claim 17. Respondent submitted a claim for services performed on January 14, 2013, office outpatient visit. Pet. Ex. 15, pp. 378 (worksheet) and 392 (medical record). Dr. Silkes down-coded this from CPT Code 99214 to 99212, because "only nasal examination was performed with cultures and he [the patient] was told to return for a full examination." She said the history was problem focused, the exam was problem focused, and the decision-making was straight forward. Both Dr. Carreno and his coding witness, Lorraine Molinari, pointed out that the record says that the visit lasted "30 minutes." This factor justifies a claim under CPT Code 99214. Also, the visit involved a more detailed and extensive examination of the nasal areas by Respondent. The undersigned credits and finds more persuasive the evidence presented by Respondent, particularly due to the amount of time devoted to this visit. It was properly coded as CPT Code 99214. Recipient #3, Claim 18. Respondent submitted a claim using CPT Code 99214 for an office outpatient visit on February 13, 2013. Pet. Ex. 15, pp. 378 (worksheet) and 392 (medical record). Dr. Silkes down-coded this to CPT Code 99213, opining that Dr. Carreno only performed an expanded problem focused history, expanded problem focused examination, and the decision- making was of low complexity. Dr. Carreno characterized this patient as one of the most complicated medical cases he has handled. The patient had a myriad of medical problems related to his ENT systems. Dr. Carreno and Molinari stated that the visit included an extensive conversation with the patient and his mother, and he also had to review and consider information from Dr. Ramos (immunologist's) notes. Dr. Carreno documented a left maxillary sinus suctioned under endoscopy. The extent of his note and documentation is reflective of a more extensive and complex examination and visit. Molinari opined that it should be CPT Code 99214. The undersigned credits and finds more persuasive the evidence presented by Respondent, particularly due to the complexity of the examination. It was properly coded as CPT Code 99214. Recipient #3, Claim 20. This claim was adjusted from CPT Code 99214 to 99213 by Dr. Silkes. She opined that the examination was only problem focused ("nasal exam only") and that there were no other records that would support the higher level of services claimed. Pet. Ex. 15-3, pp. 379 and 393. Additionally, there was no documentation to support a higher level claim under CPT Code 99214, nor was the use of an endoscope documented. The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and ACHA. The claim was properly reduced to CPT Code 99213. Recipient #3, Claim 21. Respondent submitted this claim using CPT Code 31231, a nasal endo code. Pet. Ex. 15-3, pp. 379 and 393. Dr. Silkes testified she did not find any documentation in the record that would show that an endoscopy was performed on that date, but did allow an office visit for the same date where a nasal exam was performed (Claim 20, adjusted from CPT Code 99214 to 99213). The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and AHCA. The claim was properly reduced to CPT Code 99213 primarily for failure to properly document that an endoscopy was performed. Recipient #3, Claim 22. Respondent submitted a claim using CPT Code 99214 for services on June 17, 2013, office outpatient visit. Pet. Ex. 15, pp. 379 (worksheet) and 393 (medical record). Dr. Silkes testified that she reduced this to CPT Code 99213 because only a nasal examination was done which is a problem focused examination. She concluded that the ear, nose, and throat were not examined. Dr. Carreno testified that it was not only a nasal exam. His contemporaneous notes reference an "endoscopic debridement" on the third line, which means he used an endoscope to see in the nose and clean fungal content out with suction and graspers. Molinari opined that the visit should remain CPT Code 99214 because the medical decision-making reflected in the note was at least moderate complexity. The undersigned credits and finds more persuasive the evidence presented by Respondent. The use of an endoscope and performing the debridement procedure were sufficiently documented. The services performed supported coding as CPT Code 99214. Recipient #3, Claim 24. This claim by Respondent was adjusted from CPT Code 99214 to 99213 by Dr. Silkes. She opined that "only a nasal examination was done" and that the examination and history were both either problem focused or expanded problem focused. Pet. Ex. 15-3, pp. 379 and 394. Respondent's witness, Molinari, agreed with Dr. Silkes' adjustment. The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and AHCA. The claim was properly reduced to CPT Code 99213 primarily because the visit only involved a less complicated nasal examination. Recipient #3, Claim 26. Respondent submitted a claim using CPT Code 99214 for services on January 8, 2014, office outpatient visit. Pet. Ex. 15, pp. 380 (worksheet) and 395 (medical record). Dr. Silkes down-coded it to CPT Code 99213 because "only the nose was examined." However, Dr. Carreno testified that he performed a fiberoptic laryngoscopy, using an endoscope, to inspect for any fungal debris. This was sufficiently documented in his contemporaneous office notes. He also used the scope to view the nasopharynx. His notes also reflect that a physical exam (PE) was performed. Molinari felt the claim should remain CPT Code 99214 because the medical decision-making was of moderate complexity. The undersigned credits and finds more persuasive the evidence presented by Respondent. The use of a scope to inspect the nasal passages and nasopharynx were sufficiently documented. The services performed supported his coding as CPT Code 99214. Recipient #3, Claim 28. The claim submitted was adjusted from CPT Code 99214 to 99213 by Dr. Silkes. She opined that "only the nose was examined" and that there were no other records that would support the higher level. Pet. Ex. 15-3, pp. 380 and 395. Further, there was no documentation that an endoscope was used. The undersigned credits and finds more persuasive the evidence from Dr. Silkes and AHCA. The claim was properly reduced to CPT Code 99213, primarily because the visit involved a less complicated nasal examination. Recipient #3, Claim 35. Respondent submitted a claim under CPT Code 31237 for services on April 30, 2014, Nasal/Sinus Endoscopy Surgery. Pet. Ex. 15, pp. 381 (worksheet) and 395 (medical record). Dr. Silkes denied this claim because she felt that this was included in the global surgery package for the septoplasty that was performed on April 21, 2014. A "septoplasty" is where you move the septum in the nose if it is causing problems with sinuses or breathing. In her view, Claim 35 was a normal post- operative visit, namely, to remove the splint. Dr. Carreno testified and conceded that "yes, I did remove the splints, but I also needed to place the endoscope to assess the sinus surgical site. And not only did I assess it, but I cleaned it and debrided it, and it clearly said cleaned, debrided, endo shows." Dr. Carreno acknowledged that a septoplasty procedure has a 90-day global period, but testified that a global surgery package does not apply to a sinus endoscopy and debridement following the sinus surgery. The undersigned credits and finds more persuasive the evidence presented by Respondent. It was medically prudent and necessary to use an endoscope post-operatively for inspection and debridement, and this was sufficiently documented. The services performed supported coding as CPT Code 31237. Recipient #25, Claim 11. Respondent submitted this claim using CPT Code 69200. Pet. Ex. 15-25, p. 782. Dr. Silkes testified that there was a myringotomy tube that was placed in the ear by Respondent. The tube is not considered a "foreign body," and Medicaid does not pay for its removal when inserted by the original doctor. She concluded that removal of the tubes is not properly billed as CPT Code 69200. This conclusion is supported by provisions of the Physicians Services Handbook (Pet. Ex. 13, p. 199), which does not permit additional billing under global surgery packages for the removal of "items such as tubes, drains . . . ." This is found under bullet point 6 entitled "Miscellaneous Services and Supplies." This restriction does not place any time limit on when the non-reimbursable "miscellaneous service" is performed, even outside the normal 90-day time period. The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and AHCA. The removal of the tubes fell under the exclusion for miscellaneous services or did not otherwise qualify for reimbursement. Pet. Ex. 13, p. 199. The claim was properly denied. Recipient #29, Claim 6. Respondent submitted this claim using CPT Code 69200. Pet. Ex. 15-29, p. 830. Dr. Silkes testified that there was a myringotomy tube that was placed in the ear by Respondent. The tube is not considered a "foreign body," and Medicaid does not pay for its removal when inserted by the original doctor. She concluded that removal of the tubes is not properly billed as CPT Code 69200. This conclusion is supported by provisions of the Physicians Services Handbook (Pet. Ex. 13, p. 199), which does not permit additional billing under global surgery packages for the removal of "items such as tubes, drains. . . ." (see bullet point 6 entitled "Miscellaneous Services and Supplies"). This restriction does not place any time limit on when the non-reimbursable "miscellaneous service" is performed, even outside the normal 90-day time period. The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and AHCA. The removal of the tubes fell under the exclusion for miscellaneous services or did not otherwise qualify for reimbursement. Pet. Ex. 13, p. 199. The claim was properly denied. Recipient #30, Claim 1. This claim was adjusted down from CPT Code 99214 to 99213 by Dr. Silkes. She opined that both the history and examination were problem focused and that the decision-making was straightforward. Pet. Ex. 15-30, pp. 856 and 861. The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and AHCA. The claim was properly adjusted to CPT Code 99213. Recipient #30, Claim 2. This was submitted under CPT Code 69210. Dr. Silkes denied the claim citing a lack of documentation to show that any cerumen or ear wax was actually removed. The undersigned credits and finds more persuasive the evidence and conclusions from Dr. Silkes and AHCA. The removal of cerumen was not properly documented, and the claim should be denied. Recipient #30, Claim 4. Respondent submitted a claim for services using CPT Code 99214 for services on May 16, 2012, Office/Outpatient Visit. Pet. Ex. 19 (no Bates stamp numbers, as this was a late submission). After reviewing several late-filed documents from Respondent, Dr. Silkes down-coded this to CPT Code 99213 because there was an expanded problem focused history, there was a problem focused examination, and medical decision- making was of low complexity. Dr. Carreno explained that the claim should be allowed as CPT Code 99214 because he examined four separate body systems or areas. He examined the throat due to enlarged tonsils and enlarged adenoids, he examined the ear for infection, he took the patient's temperature and weight in connection with sleep apnea, and he examined the nose. He also rescheduled the patient for surgery and discussed the risks and benefits of surgery with the parents. Molinari testified that it should be allowed as a CPT Code 99214 because the decision-making was, at least, of moderate complexity, including a detailed examination of pallet, tonsils, and sinuses, as well as explaining the risk and benefits of surgery to the parents. The undersigned credits and finds more persuasive the evidence presented by Respondent. This visit involved a more detailed and extensive examination of the patient and justified a claim using CPT Code 99214.
Recommendation Based on the evidence covering the Disputed Claims during the audit period of January 1, 2012, through December 31, 2014, it has been established by a preponderance of the evidence that Respondent was overpaid for certain services not covered by Medicaid. Those overpayments are listed in paragraph 123 in the Conclusions of Law section. The undersigned recommends that the Agency for Health Care Administration enter a final order ordering Respondent to repay the recalculated amount. Considering the facts proven at the hearing, the Agency has established by clear and convincing evidence that Respondent failed to comply with the provisions of the Medicaid law for certain claims. Those overpayments are also listed in paragraph 123 in the Conclusions of Law section. It is recommended that the Agency recalculate and impose a sanction commensurately lower than the previous sanction, pursuant to rule 59G-9.070(7)(e). Pursuant to section 409.913(23)(a), the Agency's request of an award of reasonable investigative, legal, and expert witness costs as the prevailing party is granted, in part, based on a limited number of violations outlined in paragraph 123. If the amount of the costs cannot be agreed to, then the Agency may request a hearing for the establishment of the costs. DONE AND ENTERED this 22nd day of May, 2017, in Tallahassee, Leon County, Florida. S ROBERT L. KILBRIDE 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 22nd day of May, 2017.
Findings Of Fact Petitioner is the state agency charged with regulating the practice of medicine pursuant to Section 20.30 and Chapters 455 and 458, F.S. Respondent is and has been at all times material hereto a licensed medical physician in the State of Florida, having been issued license number ME 0029506. Medicare is a health insurance program for beneficiaries 65 or older or disabled. It is a Federal program under Title 18, USCA, the Social Security Act. By contract, Blue Cross/Blue Shield administers the Medicare Program in Florida, and is hereafter also referred to as "Medicare" throughout this Recommended Order. On or about August 23, 1986, Respondent rendered care and treatment to patient G.C. by assisting one Dr. Kluger with patient G.C.'s surgery. On or about September 1, 1986, patient G.C. expired. He was survived by his widow, J.C. An assignment is an agreement between the physician and the patient/beneficiary whereby the patient/beneficiary transfers to the physician his rights to benefits based on covered services specified on the assigned claim. When the physician accepts said assignment, he agrees that the allowed charges determined by Medicare is the full amount he expects to receive, and his charges to the patient/beneficiary should be no more than 20% of the allowed charges. It is clear on the record that on January 9, 1987, Respondent advised J.C. that he would not accept a Medicare assignment for his services, and that he required full payment from her. On that date, she paid him in full by personal check the undiscounted amount of $731.75 which he had billed her on October 24, 1986. It is not certain whether Respondent ever specifically told J.C. before January 9, 1987 that he would not accept assignment, but it is clear that he never told her that he would accept assignment and that he billed her for the full amount on October 26, 1986, before anybody made any claim to Medicare. Prior to Respondent's January 9, 1987 conversation with J.C., Respondent's wife and office manager had, on November 28, 1986, submitted a claim to Medicare for Respondent's services to G.C. This claim was submitted over Respondent's (apparently stamped) signature, making him responsible for its contents. Despite her denials on the record, Mrs. Castro clearly has difficulty understanding others and expressing herself orally in the English language. Her recollection was that she had submitted the Medicare claim form dated November 28, 1986 without checking either the box on the form by which a physician signifies agreement to accept assignment or the box on the form whereby the physician declines to accept assignment. The reason she gave at formal hearing for not checking the assignment box is that she knew that Dr. Kluger had not accepted assignment for treatment of G.C. and that it also had been Respondent's oral instruction to her not to accept assignment of his associate fees. However, Mrs. Castro's only explanation as to why she had left both boxes blank instead of checking the one signifying "no assignment" was that she understood that forms without any election were usually processed as non-assigned claims. This November 28, 1986 claim form, as produced by Medicare authorities, shows the "yes assignment" box marked. The widow, J.C., had some memory retrieval problems in the course of her testimony. She testified that on January 10, 1987 she personally went to the Jacksonville, Florida, offices of Medicare and, using a receipt given her by Respondent for her check presented to him the day previously, she made a Medicare claim in her own name. (TR-20) However, she also testified that she received "no satisfaction" from her claim because the Respondent had already submitted a claim. (TR-21-23) Medicare has no record that such a claim was ever made by J.C. A physician can file claims with Medicare by applying for a provider number and using it on his claims for reimbursement. At all times material, Respondent had such a Medicare provider number. However, acceptance of such a provider number by a physician does not automatically make a physician a "participating physician," nor does it obligate him to accept assignments to Medicare. "Participating physicians" have also signed a contract agreeing to accept assignment on every claim they submit. For "non-participating physicians," assignments or non-assignments are done on a claim by claim basis. At all times material, Respondent was a "non-participating physician." If the physician submitting a claim is a "non-participating physician" and the assignment block is left blank on his claim form, Medicare's standard operating procedure is to process his claim form as a "non-assignment." If a physician discovers he has made an error in checking the wrong block on his claim form, it is also Medicare's standard operating procedure to correct that error provided both the physician and the patient/beneficiary notify Medicare prior to the time Medicare applies a reasonable charge to the claim. As a practical matter, the window for this type of notification covers only the period of time required for Medicare to receive the original erroneous claim form, microfilm it, and feed it into the Medicare computer; in total, perhaps less than one workday. After the computer applies a reasonable charge to the claim, Medicare will not permit mistaken assignments to be rescinded. On or about March 2, 1987, Medicare sent Respondent a check for $174.64, which is 80% of the amount Medicare approved for his services. There is no adequate explanation in the record why it took Medicare from December 3, 1986 when it received the November 28, 1986 claim form until March 2, 1987 to process the initial claim. Respondent's office deposited the $174.64 Medicare check in the normal course of business. On or about March 3, 1987, J.C. received an "Explanation of Medical Benefits" letter (EMOB) from Medicare advising her that Respondent had accepted assignment on G.C.'s claim, that Medicare had allowed Respondent $220.00 for his services, that Medicare had paid Respondent $174.64, and that J.C. owed Respondent $44.10. Quite naturally, J.C. was incensed by this notification from Medicare because she had already paid Respondent in full on January 9, 1987. Sometime after March 2, 1987, but prior to April 1, 1987, Respondent sent his own check for $174.64 to Medicare, stating that the money should have been sent by Medicare directly to J.C. In March of 1987, J.C. requested a refund from Respondent. Respondent refused to give her the refund, stating that Medicare should pay her directly. Therefore, J.C. contacted Medicare for a refund. Thereafter, various employees of Medicare contacted Respondent telling him repeatedly that because the "yes assignment" box had been checked on the November 28, 1986 claim form, he must take the discounted amount allowed by Medicare and refund an amount to J.C. sufficient so that she would not have paid more than 20% of the allowed charges. Apparently, Respondent was given to colorful language in his telephone conversations both with Respondent and with Medicare personnel, and no meeting of the minds ever was reached between Respondent and J.C. or between Respondent and Medicare. The situation was further complicated when Medicare sent Respondent a letter on May 5, 1987 acknowledging his return of the $174.64 to Medicare and advising Respondent that, We have received your $174.64 payment dated March 16, 1987. We have applied this money to your account. Thank you for returning the payment issued to you in error. Our records are being corrected accordingly. . . Therefore, when, on or about August 24, 1987, Medicare sent Respondent a new check for $165.45 for the same claimed services to G.C. because Medicare had unilaterally made a correction to its "Procedure Code," Respondent assumed that Medicare had made another mistake. His office again cashed this Medicare check, and only after Medicare fraud and abuse investigators contacted him, did Respondent send Medicare his own check, dated November 30, 1987, for the $165.45. With Respondent's check, Mrs. Castro enclosed a note, dated December 1, 1987, requesting that Medicare send payment directly to J.C. Respondent has no record of submitting a third check to Medicare, but Medicare records show that at some point Medicare issued yet another check to Respondent for $165.45, and that Respondent again returned the money through his own check. Mrs. Castro testified that she re-submitted the health insurance claim form to Medicare on or about April 20, 1987 with the "no assignment" box checked and that she did so in an attempt to get Medicare to pay J.C. directly and to straighten out the problem with G.C.'s bill. At that time, she did not indicate "signature on file" as she had on the initial November 28, 1986 claim form. Instead, she made a big "X" and signed the deceased patient's name beside the "X." Mrs. Castro asserted that she never attempted to emulate G.C.'s handwriting, and examination of the form does not suggest that she did. Medicare has no record of receiving this form contemporaneously with the April 20, 1987 date on it, but Medicare received it either from the Respondent with his November 30, 1987 check and Mrs. Castro's December 1, 1987 note requesting that Medicare pay J.C. direct or they received it at about the same time from Respondent's attorney. Medicare personnel interpreted the April 20 claim form to constitute a forgery of G.C.'s signature since it had not been received by Medicare in April 1987 and because G.C. had died in September, 1986. Medicare never processed the April 20, 1987 claim form as either a substitute for, or as an amendment to, the original November 28, 1986 claim form. Mrs. Castro was unable to explain at formal hearing why the April 20, 1987 claim form was not received by Medicare until December, 1987, and her explanation that she thought Medicare would interpret the "X" as an indication that someone else had signed for the decedent is illogical. However, upon Mrs. Castro's candor and demeanor while testifying, it is plausible that she genuinely believed that coupled with the repeated return of all monies to Medicare hers was an acceptable way to explain to Medicare the Respondent's consistent intent to refuse assignment and to defuse the escalating acrimony of the claim situation. Upon this basis, Medicare's interpretation of Mrs. Castro's meretricious motivation with regard to the April 20 claim form, which motivation Medicare also attributed to the Respondent, is rejected. The burden to prove fraud by clear and convincing evidence is upon Petitioner, and there is no affirmative proof of meretricious motive here. Throughout this dispute, Medicare continued to tell J.C. that after all adjustments, Respondent should pay her $689.97 (the balance of the full payment amount she had paid Respondent above the 20% of the charge allowed by Medicare). Respondent has never refunded any monies to J.C.
Recommendation Based upon the foregoing findings of fact and conclusions of law, it is: RECOMMENDED that the Board of Medicine enter a Final Order dismissing all charges against Respondent. DONE and ENTERED this 21st day of September, 1989, at Tallahassee, Florida. ELLA JANE P. DAVIS 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 21st day of September, 1989.
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
Recommendation Based upon the findings of fact and conclusions of law recited above, it is recommended that the information filed against respondent be dismissed. Respectfully submitted and entered this 18th day of December, 1975, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Mr. Louis B. Guttman, III Staff Counsel Florida Real Estate Commission 2699 Lee Road Winter Park, Florida 32789 Mr. Robert J. O'Toole Buckeye Building 208 Southeast Sixth Street Ft. Lauderdale, Florida 33301
