The Issue The issue is whether Petitioner, Utopia Home Care, Inc. (Utopia or Petitioner), is entitled to payment of $38,432.71 for the services it provided to Medicaid recipients during the period of January 1, 2000, through December 31, 2000.
Findings Of Fact At all times relevant to this proceeding, Utopia was an authorized Medicaid provider in the State of Florida. Pursuant to a valid Medicaid provider agreement, Utopia was authorized to provide home and community-based services to Medicaid recipients. The Agency is charged with the administration and oversight of the Medicaid Program and funds throughout the State of Florida. One of the Agency's responsibilities is to monitor the provision of Medicaid services and make payments to providers for services which have been appropriately provided and for which claims have been correctly processed. During the period of January 1, 2000, through December 31, 2000 (the audit period), Utopia rendered services to Medicaid recipients who receive home care services through the Medicaid Program. The cost of these services, for which Utopia has not received payment, is $38,432.71. There is no dispute that these services were authorized and provided by Utopia. Robert Fritz is vice president of Utopia and works in Utopia's St. Petersburg, Florida, office. In or about February 2002, while Mr. Fritz was participating in an accounts receivable project, he discovered that Utopia had not been paid for some of the services it had provided to Medicaid recipients during the audit period. Mr. Fritz contacted the Agency soon after he discovered that Utopia had not received payment for the services it rendered during the audit period. Over a period of several months, Utopia, through Mr. Fritz, provided the Agency with documentation that the services were authorized and had been invoiced at or near the time the services were provided. Additionally, at the request of the Agency, Utopia completed numerous 081 Forms, Request for Payment Forms for the Florida Medicaid Program, to establish a baseline as to what claims were unpaid. Utopia completed the 081 Forms for the services which were provided during the audit period and for which it had not received payment in or about February 2002. In addition to the completed 081 Forms, dated February 2002, Utopia also provided to the Agency documentation generated from Utopia's computer system in Florida. The documents, created by the computer system on a weekly basis, included payroll checks for employees and invoices for services rendered. As part of Utopia's contractual requirements with the lead agency, which oversees the Medicaid Program at the local level, a monthly Medicaid Expenditure Tracking Report (Expenditure Tracking Report) is created by Utopia's St. Petersburg, Florida, office. The Expenditure Tracking Report lists anticipated expenditures from the Medicaid system to Utopia for services rendered in a particular month. Many of these documents were provided to the Agency in seeking to establish that the services had been provided during the audit period and to obtain payment for the services. The documents created by Utopia's computer system and discussed in paragraph 6 above were created at or near the time services were rendered. Due to the documentation provided by Utopia, the Agency stipulated that Utopia provided authorized services to Medicaid recipients and that the cost of these services was $38,432.71. Nonetheless, the Agency has refused to pay Utopia for the services because the claims were not filed in accordance with Medicaid procedures, as established in the Medicaid Provider Reimbursement Handbook, Non-Institutional 081 (Reimbursement Handbook). Based on the Agency's review of its records, it determined that Utopia had not filed the claims within 12 months of the services being rendered. The procedures for filing claims for Medicaid payments are outlined in the Reimbursement Handbook, which is referenced and incorporated by reference in Florida Administrative Code Rule 59G-8.200(6). Also, for purposes of this case, the Reimbursement Handbook sets forth the applicable Medicaid requirements for processing claims. The Reimbursement Handbook, pages 6-2 and 6-3, provides in relevant part the following: Medicaid providers should submit claims timely so that any problems with a claim can be corrected and the claim resubmitted before the filing deadline. * * * A clean claim for services rendered must be received by the agency or its fiscal agent no later than 12 months from the date of service. * * * The date electronically coded on the provider's electronic transmission by the Medicaid fiscal agent is the recorded date of receipt for an electronic claim. At all times relevant to this proceeding, Consultec was the company responsible for receiving claims from and paying those claims to Medicaid providers in the State of Florida. The Reimbursement Handbook indicates that the processing time for claims "under normal circumstances" is within 10 to 30 days after the claim is filed. The Reimbursement Handbook also provides that a "remittance voucher" is mailed each week if Consultec processed any claims or put any claims in "Suspend" status. With regard to the remittance voucher, the Reimbursement Handbook, page 8-4, states in relevant part the following: The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment--whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted. The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received. Utopia filed all its claims electronically. Therefore, to determine whether Utopia was entitled to payment for services rendered during the audit period, the Agency searched its data warehouse. The data warehouse allows the Agency to review claims that have been electronically filed and the status of those claims. Based on the Agency's review, which compared claims filed by Utopia in February 2002 for services rendered during the audit period, the Agency found that 36 claims had been submitted by Utopia and paid and 108 claims had not been paid. With regard to the 108 claims that were not paid, the Agency found no evidence that the claims had ever been filed. Utopia's St. Petersburg, Florida, office provided the services in question. Staff members in that office generate and enter data into the computer system that creates the documents described in paragraph 6 above and provide billing information to the local lead agency. Utopia provides this information to the local lead agency, Neighborly Senior Services (Neighborly), pursuant to a contractual arrangement which authorizes Utopia to provide services to Medicaid recipients. Utopia's staff at the St. Petersburg, Florida, office prepares and compiles billing information regarding the services it has provided and electronically transmits the information to Utopia's corporate office in Kingsburg, New York. The practice of Utopia is that the corporate office in New York then finalizes the billing information and transmits the claims to the entity designated by the Agency to process and pay claims. At all times relevant to this proceeding, that entity was Consultec. Once the St. Petersburg, Florida, office transmits the billing information to the corporate headquarters in New York, it has no further responsibility or control over the billing information sent to Medicaid. Utopia's St. Petersburg, Florida, office also has no responsibility to reconcile the services actually billed to Medicaid by the corporate office with the services provided in Florida. At this proceeding, no evidence was presented to establish that Utopia's corporate office in New York ever filed claims for the services during the audit period for which no payment has been made. Likewise, Utopia never provided the Agency with documentation or evidence that claims for the services provided during the audit period were ever filed within 12 months of the services being provided. Similarly, no such evidence was ever produced at this proceeding. The Reimbursement Handbook provides for exceptions to the 12-month time limit if the claim meets one or more of the following conditions: (1) original payment voided, (2) court or hearing decision, (3) delay in recipient eligibility determination, (4) agency delay in updating eligibility file, (5) court ordered or statutory action, and (6) system error on a claim that was originally filed within 12 months from the date of service. Upon consideration of the applicable provisions of the Reimbursement Handbook, the Agency properly determined that Utopia did not file the claims within 12 months from the date of the service and that none of the conditions were present which warranted granting an exception.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency enter a final order finding that the disputed claims were not filed within the required 12-month period and denying reimbursement of those services. DONE AND ENTERED this 29th day of December, 2003, in Tallahassee, Leon County, Florida. S CAROLYN S. HOLIFIELD 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 29th day of December, 2003. COPIES FURNISHED: Jeffries H. Duvall, Esquire Agency for Health Care Administration Fort Knox Building III, Mail Station 3 2727 Mahan Drive, Suite 3431 Tallahassee, Florida 32308-5403 Robert C. Fritz Utopia Home Care, Inc. 215 Second Avenue, North St. Petersburg, Florida 33701 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308
The Issue Whether Petitioner, Agency for Health Care Administration (AHCA or Petitioner), is entitled to a recoupment for a Medicaid overpayment to Respondent, Humane Minority, Inc. (Humane or Respondent), in the amount of $177,581.26.
Findings Of Fact Petitioner is the state agency responsible for administering the Florida Medicaid Program. As part of its duties, Petitioner attempts to recover Medicaid overpayments from Medicaid providers. At all times material to this case, Humane was licensed to provide various health care services to Medicaid recipients under a contract to AHCA as a Medicaid provider. As provider number 255724000, Humane participated in the Medicaid program from January 1, 2005, to February 8, 2006 (audit period). As a Medicaid provider, Respondent was subject to audit. This case arose when the Discovery Unit of Medicaid Program Integrity (MPI) identified that during the audit period Humane billed 1.5 times as much for one week as compared to ten other weeks, which is an indicator of billing irregularities. As a result, the Discovery Unit of MPI recommended a comprehensive audit of Humane. Gary Mosier, a Registered Nursing Consultant employed by AHCA in the bureau of MPI, initiated the audit of Humane after receiving the Discovery Unit’s File #47650 Recommendation memo dated May 19, 2006, referring Humane for a comprehensive audit. On or about June 13, 2006, MPI requested 30 random Medicaid patients' records from Humane’s entire Medicaid patient group for the audit period. Humane complied with the request and supplied records. The submitted medical records included a Certificate of Completeness of Records from Humane stating the documents supplied constituted all of the Medicaid-related records for the 30 patients during the Audit period. After Humane provided the requested medical records to Mosier, he forwarded the records to three physician consultants: Machado, a general practitioner; Edgar, a psychiatrist; and Reisman, an urologist. Each physician consultant reviewed Humane’s records relevant to his area of expertise and filled out agency worksheets detailing why claims should be disallowed. MPI reviewed Humane’s records provided and the worksheets filled out by the three physician consultants and determined that overpayments were made to Humane due to numerous services in whole or in part not being covered by Medicaid, which violated various Medicaid policy guidelines set forth in both the Florida Medicaid Provider General Handbook (General Handbook)1 and the Florida Medicaid Physician Services Coverage and Limitations Handbook (Physician Services Handbook).2 Humane violated policy by providing documentation that supported a lower level of office visit than the one for which Humane billed and received payment. Humane violated policy by billing and receiving payments for some services that were not documented. Humane violated policy by billing and receiving payment for services rendered by a practitioner who was not a member of Humane’s group. Humane violated policy by billing for procedure codes that have time requirements but not documenting the time spent providing the service. Humane violated policy by billing and receiving payment for services performed by another practitioner who was not enrolled in Medicaid at the time the services were rendered. Humane violated policy by billing and receiving payment for services for which the medical records, when reviewed by a Medicaid physician consultant, indicated that the services provided did not meet the Medicaid criteria for medical necessity. Humane violated policy by billing for radiology services when the reading and interpretation was done by a radiologist outside of the physician’s group. Humane violated policy and was paid for billing and received payment for portable x-ray services where Humane performed only the technical component and an independent interpreter performed the professional component. Humane violated policy and received payment when Humane did not bill according to the current procedural terminology guidelines in certain instances. On March 13, 2007, MPI issued its Preliminary Audit Report (PAR). The report detailed the Medicaid policy violations, overpayment amounts, and provided Humane the opportunity to submit an explanation or additional documentation demonstrating that some or all of the claims were properly paid. The report also notified Humane that a Final Audit Report (FAR) would be issued identifying the amount of overpayment due. Humane did not respond to the PAR. Consequently, on April 27, 2007, MPI issued a FAR, that included the amount of $177,581.26 that Humane received from Medicaid that was not authorized to be paid. This grand total of $177,581.26 constitutes an overpayment that Humane must return to the agency. A Final Audit Report-Corrected Copy was issued on May 22, 2007, correcting the total amount due.3 In addition to the overpayment amount, Petitioner also seeks a fine in the amount of $3,000.00. The fine is a calculated amount as authorized by rule.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency enter a final order requiring Humane to repay the Agency for the principal amount of $177,581.26 together with an administrative fine of $3000.00. DONE AND ENTERED this 22nd day of June, 2009, in Tallahassee, Leon County, Florida. S JUNE C. McKINNEY 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 June, 2009.
The Issue The issue is whether Respondent failed to maintain a service plan for each of four residents, in violation of the Florida Medicaid Assistive Care Services Coverage and Limitations Handbook. If so, an additional issue is the sanctions that should be imposed.
Findings Of Fact Respondent owns and operates an assisted living facility known as Izquierdo Home Care I. At all material times, Respondent was enrolled in the Medicaid program as a provider authorized to supply assistive living services to Medicaid recipients at Izquierdo Home Care I. At all material times, Respondent was subject to the Florida Medicaid Assistive Care Services Coverage and Limitations Handbook. The handbook imposed upon Respondent the duty to develop a service plan for each Medicaid recipient not less often than annually. On March 27, 2012, Petitioner's inspector conducted a site visit of Izquierdo Home Care I. At the time of the site visit, the facility had six beds, but only four residents. According to a letter from Petitioner dated March 27, 2012, and delivered to Respondent's representative at the time of the inspection, the following four residents were Medicaid recipients: E. C., R. R., J. H., and A. R. However, according to the questionnaire completed by Respondent's representative at the time of the inspection, only two of the four current residents were Medicaid recipients, although the questionnaire does not identify these residents. In fact, A. R. had been discharged from Izquierdo Home Care I in September 2011. At the hearing, Petitioner's inspector confirmed that Respondent had not billed Medicaid for services for A. R. after the date of discharge. The second resident whose Medicaid status is in question was identified, in Respondent's proposed recommended order, as E. C. Respondent contends in its proposed recommended order that E. C. was not receiving Medicaid at the time of the inspection. If the Proposed Recommended Order were the only notice to Petitioner of Respondent's claim that a second resident was not a Medicaid recipient, the Administrative Law Judge would ignore this assertion because it is not evidence, and, as a defense, it was raised too late. However, the questionnaire, which was admitted as one of Petitioner's exhibits, is evidence that two of the four residents were not receiving Medicaid at the time of the inspection. In assessing the evidentiary record in terms of whether it establishes a third Medicaid recipient, the Administrative Law Judge notes: a) Petitioner has alleged a violation concerning A. R., even though A. R. was no longer a Medicaid recipient at the time of the inspection; b) at hearing, Petitioner's inspector was readily able to read the "query" to confirm that Respondent had not submitted a Medicaid billing on account of A. R. after September 2011 (Transcript 49); and c) as discussed in the Conclusions of Law, Petitioner bears the burden of proof by clear and convincing evidence. Under these circumstances, Petitioner has proved only that two residents of the facility were Medicaid recipients at the time of the inspection. There is no dispute that current service plans for two Medicaid recipients did not exist at the time of the March 2012 inspection.
Recommendation It is RECOMMENDED that the Agency for Health Care Administration enter a final order imposing a fine of $2000 against Respondent. DONE AND ENTERED this 26th day of October, 2012, in Tallahassee, Leon County, Florida. S ROBERT E. MEALE 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 26th day of October, 2012. COPIES FURNISHED: Jeffries H. Duvall, Esquire Office of the General Counsel Agency for Health Care Administration Fort Knox Executive Center, Building 3 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308-5403 Julia Arrendell, Qualified Representative 13899 Biscayne Boulevard North Miami Beach, Florida 33181 Elizabeth Dudek, Secretary Office of the General Counsel Agency for Health Care Administration Fort Knox Executive Center, Building 3 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308-5403 Stuart Williams, General Counsel Office of the General Counsel Agency for Health Care Administration Fort Knox Executive Center, Building 3 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308-5403 Richard J. Shoop, Agency Clerk Office of the General Counsel Agency for Health Care Administration Fort Knox Executive Center, Building 3 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308-5403
The Issue Whether the subject supplemental Medicaid payments to Petitioner for services to patients with acquired immunodeficiency syndrome (AIDS) during the audit period January 1, 1999 through June 20, 2001, constitute overpayments. Whether Respondent has the authority to recoup such overpayments. If such authority is found, whether the doctrine of unjust enrichment should be applied to prevent Respondent's recouping any overpayment under the facts of this proceeding.
Findings Of Fact Petitioner operates a duly-licensed nursing home located in Broward County, Florida. At all times pertinent to this proceeding, Respondent was a Medicaid provider with the following Medicaid provider number: 020695400. As a Medicaid provider, Petitioner agreed to comply with all pertinent state and federal laws and regulations. At the times pertinent to this proceeding Petitioner had a valid Medicaid Provider Agreement with Respondent. Respondent is the agency of the State of Florida responsible for oversight of the integrity of the Medicaid program in Florida. The unnumbered opening sentence of Section 409.913, Florida Statutes, provides as follows: The agency shall 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. During the audit period, Petitioner was subject to all of the duly enacted statutes, laws, rules, and policy guidelines that generally govern Medicaid providers. Petitioner was required to follow all the Medicaid Coverage and Limitation Handbooks and all Medicaid Reimbursement Handbooks in effect, including, the Florida Medicaid Provider Reimbursement Handbook, Institutional 021 (the Institutional Provider Handbook), which is incorporated by reference by Respondent's Rule 59G-4.200, Florida Administrative Code. During the audit period, the applicable statutes, laws, rules, and policy guidelines in effect required Petitioner to maintain all "Medicaid-related Records" and information that supported any and all Medicaid invoices or claims that Petitioner made during the audit period.1 During the audit period, the applicable statutes, laws, rules, and policy guidelines in effect required Petitioner at Respondent's request to provide Respondent or Respondent's authorized representatives all Medicaid-related Records and other information that supported all the Medicaid-related invoices or claims that Petitioner made during the audit period.2 Section 409.913(7), Florida Statutes, provides, in pertinent part, as follows: (7) When presenting a claim for payment under the Medicaid program, a provider has an affirmative duty . . . to supervise and be responsible for preparation and submission of the claim, and to present a claim that is true and accurate and that is for goods and services that: * * * Are provided in accord with applicable provisions of all Medicaid rules, regulations, handbooks, and policies and in accordance with federal, state, and local law. Are documented by records made at the time the goods or services were provided, demonstrating the medical necessity for the goods or services rendered. Medicaid 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 record. Section 409.913(1), Florida Statutes, defines the terms "medical necessity" and "medically necessary" as follows: "Medical necessity" or "medically necessary" means any goods or services necessary to palliate the effects of a terminal condition, or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity, which goods or services are provided in accordance with generally accepted standards of medical practice. For purposes of determining Medicaid reimbursement, the agency is the final arbiter of medical necessity. Determinations of medical necessity must be made by a licensed physician employed by or under contract with the agency and must be based upon information available at the time the goods or services are provided. Section 409.913(10), Florida Statutes, provides as follows: (10) The agency may require repayment for inappropriate, medically unnecessary, or excessive goods or services from the person furnishing them, the person under whose supervision they were furnished, or the person causing them to be furnished. Section 409.913(1)(d), Florida Statutes, defines the term "overpayment" as follows: "Overpayment" includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake. On March 28, 2001, Respondent sent Petitioner the audit letter for the audit period. The audit letter provided, in pertinent part, as follows: The Agency for Health Care Administration, Medicaid Program Integrity office has completed a review of your Medicaid claims for dates of service during the period January 1, 1999, through June 30, 2000. A provisional letter was sent to you indicating you were overpaid $49,965.30 for claims that in whole or in part are not covered by Medicaid. We have received no response from you regarding the provisional letter. This review and the determination of overpayment were made in accordance with the provisions of Section 409.913, Florida Statutes (F.S.). In determining payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies and the limitations and exclusions found in the Medicaid provider handbooks. In applying for Medicaid reimbursement, providers are required to follow the guidelines set forth in the applicable rules and Medicaid fee schedules, as promulgated in the Medicaid policy handbooks and billing bulletins. Medicaid cannot pay for services that do not meet these guidelines. The audit letter thereafter cited the following from Chapter 7 of the Institutional Provider Handbook (Chapter 7) in asserting there had been an overpayment: Nursing facilities may receive a supplemental payment for a recipient with AIDS. The supplemental payment must be prior authorized by the Medicaid office before the facility will be reimbursed for it. The facility where the recipient resides must request the prior authorization. The Medicaid office notifies the provider with a letter of approval or denial. An approved authorization is not a guarantee that Medicaid will reimburse the supplemental payment. The provider must be enrolled in Medicaid, and the recipient must be eligible on the date of service for a Medicaid program that reimburses for institutional care.3 Chapter 7 provides as follows for the effective date of the supplement: If the recipient is approved for the increased supplemental payment, the approval letter will state the effective date of the supplemental payment. The effective date of the supplemental payment is determined by the following criteria: If the recipient was ICP eligible when admitted to the facility and met the AIDS criteria on the admission date, the effective date will be the same as the admission date. If an ICP recipient becomes HIV positive while in the facility and meets the AIDS criteria, the effective date will be the date that the Medicaid office determines the clinical criterion was evidenced. For recipients registered through SFAN, the effective date will be the effective date of the SFAN registration or ICP eligibility, whichever is later. Chapter 7 provides that a nursing home may receive "H" Supplement payments for a recipient who has been diagnosed as being positive for the human immunodeficiency virus (HIV), has laboratory confirmation of a reactive screening test for HIV antibodies, and is receiving active treatment for a condition that meets the Center for Disease Control definition of AIDS. A nursing home may also receive "H" Supplement payments for a recipient who is registered with the South Florida AIDS Network (SFAN). Chapter 7 requires that a request for prior authorization contain a letter from the facility requesting the "H" Supplement payment; a copy of the admission cover sheet; a confirming HIV test (Western Blot or IFA)4; and a signed physician letter or statement documenting current treatment for an opportunistic AIDS-related disease, or if the recipient is registered with SFAN, a letter from the facility stating that the recipient was admitted to the registry, the date admitted, and the SFAN registry number. During the audit period, Petitioner billed Respondent for "H" Supplement Payments in the total amount of $49,965.30 for eight separate recipients. Prior to the issuance of the audit letter, Petitioner did not submit, make, or deliver any "H" Supplement prior request for any of the eight recipients at issue. Despite the fact that the "H" Supplement payments were not prior authorized, Respondent made those payments to Petitioner.5 The parties stipulated that the eight recipients at issue were patients of Petitioner, suffered from AIDS, and received treatment from Petitioner for AIDS. The parties further stipulated that six of the eight recipients suffered from AIDS opportunistic diseases. There is no dispute as to whether the other two recipients suffered from disease, but there was no stipulation that the diseases were AIDS opportunistic diseases.6 There is no issue as to the quality of care rendered the eight recipients. Fraud is not at issue in this proceeding. Subsequent to the issuance of the audit letter, the only recipient for which Petitioner has presented a Western Blot confirmatory test is for the recipient identified with the initials J.F. and further identified in Petitioner's Exhibit G. Petitioner has not submit a Western Blot or IFA test for the seven other recipients at issue in this proceeding. Petitioner's medical records do not establish that, but for its failure to obtain prior authorization for each recipient, the subject "H" Supplements would have been paid by Respondent. Section 409.913(10), Florida Statutes, provides as follows: (10) The agency may require repayment for inappropriate, medically unnecessary, or excessive goods or services from the person furnishing them, the person under whose supervision they were furnished, or the person causing them to be furnished. Section 409.913(14), Florida Statutes, provides, in pertinent part, as follows: (14) The agency may seek any remedy provided by law, including, but not limited to, the remedies provided in subsections (12) and (15) and s. 812.035, if: * * * The provider has failed to maintain medical records made at the time of service, or prior to service if prior authorization is required, demonstrating the necessity and appropriateness of the goods or services rendered; The provider is not in compliance with provisions of Medicaid provider publications that have been adopted by reference as rules in the Florida Administrative Code; with provisions of state or federal laws, rules, or regulations; with provisions of the provider agreement between the agency and the provider; or with certifications found on claim forms or on transmittal forms for electronically submitted claims that are submitted by the provider or authorized representative, as such provisions apply to the Medicaid program . . .
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent enter a final order finding Petitioner received overpayments from the Medicaid Program for "H" Supplement payments during the audit period in the amount of $49,965.30. It is further recommended that Petitioner be required to repay those overpayments. DONE AND ENTERED this 14th day of November, 2001, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON 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 14th day of November, 2001.
Conclusions THE PARTIES resolved all disputed issues and executed a Settlement Agreement. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. ah DONE and ORDERED on this the QRH day of (eles , 2014, in Tallahassee, Florida. U- Pp IZABETH D Le fo Agency for Health Care Administration 1 AHCA vs. Boca Delray Renal Associates, Inc., C.1. 12-2163-000 Final Order Filed February 26, 2014 1:28 PM Division of Administrative Hearings A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Katharine B. Heyward Assistant General Counsel Agency for Health Care Administration Office of the General Counsel (Interoffice Mail) Vanessa A. Reynolds, Esquire Broad and Cassel One Financial Plaza, Suite 2700 Post Office Box 14010 Fort Lauderdale, FL 33394 (U.S. Mail) Richard Zenuch, Bureau Chief, Medicaid Program Integrity Finance and Accounting Health Quality Assurance Florida Department of Health 2 AHCA vs. Boca Delray Renal Associates, Inc., C.I. 12-2163-000 Final Order CERTIFICATE OF SERVICE I HEREBY CERTIFY that a truc and correct copy of the foregoing has been furnished to the above named addressees by U.S. Mail or other designated method on this the / day of 7 ruery , 2014. 010) Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308-5403 (850) 412-3630/FAX (850) 921-0158 3 AHCA vs. Boca Delray Renal Associates, Inc., C.I. 12-2163-000 Final Order STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, CASE NO.: 12-002585MPI PROVIDER NO.: 212210300 vs. C.J. NO.: 12-2163-000 NPI NO.: 1528047909 LICENSE NO.: ME39337 BOCA DELRAY RENAL ASSOCIATES, INC., Respondent. / oo SETTLEMENT AGREEMENT Petitioner, the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, (*AHCA” or “Agency”), and Respondent, BOCA DELRAY RENAL ASSOCIATES, INC., (“PROVIDER”), by and through the undersigned, hereby stipulate and agree as follows: 1. The parties enter into this agreement for the purpose of memorializing the resolution of this matter. 2. PROVIDER is a Medicaid provider in the State of Florida, provider number 212210300, and was a provider during the audit period. 3. In its Final Audit Report, dated June 18, 2012, the Agency notified PROVIDER that a review of Medicaid claims performed by the Agency’s Office of the Inspector General, Bureau of Medicaid Program Integrity (“MPI”), indicated that certain claims, in whole or in part, were inappropriately paid by Medicaid. The Agency sought repayment of this overpayment, in the amount of forty-six thousand, two hundred dollars and eighty-eight cents ($46,200.88). Additionally, the Agency applied sanctions in accordance with Sections 409.913(15), (16), and Agency for Health Care Adina v Ooce Delay Renal Associates, Inc. Settlement Agreement Page 1 of 6 (17), Florida Statutes, and Rule 59G-9.070(7), Florida Administrative Code. Specifically, the Agency assessed the following sanctions against PROVIDER: a fine in the amount of nine thousand, two hundred forty dollars and eighteen cents ($9,240.18) for violation(s) of Rule 59G- 9,070(7)(e), Florida Administrative Code; and costs in the amount of forty-seven dollars and sixteen cents ($47.16). The total amount due was fifty-five thousand, four hundred eighty-eight dollars and twenty-two cents ($55,488.22). 4, In response to the Final Audit Report dated June 18, 2012, PROVIDER filed a Petition for Formal Administrative Hearing. Subsequently, the PROVIDER submitted information which was reviewed but did not reduce the overpayment. 5. In order to resolve this matter without further administrative proceedings, PROVIDER and AHCA agree as follows: (1.) | AHCA agrees to accept the payment set forth herein in settlement of the overpayment, fine, and costs arising from the above-referenced audit. (2.) PROVIDER agrees to pay AHCA the sum of fifty-five thousand, four hundred eighty-eight dollars and twenty-two cents ($55,488.22). 3.) Asof October 23, 2013, AHCA has recouped a total of forty-six thousand, two hundred dollars and eighty-eight cents ($46,200.88). The remaining balance is nine thousand, two hundred eighty-seven dollars and thirty-four cents ($9,287.34). The outstanding balance accrues at 10% interest per year. Within thirty (30) days of entry of the Final Order, PROVIDER will make a lump sum payment of the remaining balance in the amount of nine thousand, two hundred eighty-seven dollars and thirty-four cents ($9,287.34). Should the provider’s Agency for Health Care Administration v. Boca Delray Renal Associates, Inc. (C. | No.: 12-2163-000) Settlement Agreement Page 2 of 6 enrollment with Medicaid be terminated, the full amount owed will be due within 30 days of termination. (4.) PROVIDER and AHCA agree that full payment, as set forth above, resolves and settles this case completely and releases both parties from any administrative or civil liabilities arising from the findings relating to the claims determined to have been overpaid as referenced in audit C.I. 12-2163-000. (5.) PROVIDER agrees that it shall not re-bill the Medicaid Program in any manner for claims that were not covered by Medicaid, which are the subject of the review in this case. 6. Payment shall be made to: AGENCY FOR HEALTH CARE ADMINISTRATION Medicaid Accounts Receivable 27277 Mahan Drive, Mail Station #14 Tallahassee, Florida 32308 7. PROVIDER agrees that failure to pay any monies due and owing under the terms of this Agreement shall constitute PROVIDER’S authorization for the Agency, without further notice, to withhold the total remaining amount due under the terms of this agreement from any monies due and owing to PROVIDER for any Medicaid claims. 8. AHCA reserves the right to enforce this Agreement under the laws of the State of Florida, the Rules of the Medicaid Program, and all other applicable rules and regulations. 9. This settlement does not constitute an admission of wrongdoing or error by either party with respect to this case or any other matter. 10. The signatories to this Agreement, acting in a representative capacity, represent that they are duly authorized to enter into this Agreement on behalf of the respective parties. Agency for Heatth Care Administration v. Boca Delray Renal Associates, inc. {C. |. No.: 12-2163-000} Settlement Agreement Page 3 of 6 11. This Agreement shall be construed in accordance with the provisions of the laws of Florida. Venue for any action arising from this Agreement shall be in Leon County, Florida. 12. This Agreement constitutes the entire agreement between PROVIDER and AHCA, including anyone acting for, associated with or employed by them, concerning all matters and supersedes any prior discussions, agreements or understandings; there are no promises, representations or agreements between PROVIDER and AHCA other than as set forth herein. No modification or waiver of any provision shall be valid unless a written amendment to the Agreement is completed and properly executed by the parties. 13. This is an Agreement of Settlement and Compromise, made in recognition that the parties may have different or incorrect understandings, information and contentions as to facts and law, and with each party compromising and settling any potential correctness or incorrectness of its understandings, information and contentions as to facts and law, so that no misunderstanding or misinformation shall be a ground for rescission hereof. 14. PROVIDER expressly waives in this matter its right to any hearing pursuant to sections 120.569 or 120.57, Florida Statutes, the making of findings of fact and conclusions of law by the Agency, and all further and other proceedings to which it may be entitled by law or rules of the Agency regarding this proceeding and any and all issues raised herein. PROVIDER further agrees that it shall not challenge or contest any Final Order entered in this matter which is consistent with the terms of this settlement agreement in any forum now or in the future available to it, including the right to any administrative proceeding, circuit or federal court action or any appeal. 15. | PROVIDER does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, Agency for Health Cara Administration v. Boca Delray Renal Associates, inc. {C. |. No.: 12-2163-000) Settlement Agreement Page 4 of 6 actions, causes of action, suits, damages, losses and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter, AHCA’s actions herein, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement. 16. The parties agree to bear their own attorney’s fees and costs, if any. This does not include the above listed costs of the investigation and audit which PROVIDER agrees to pay. 17. This Agreement is and shall be deemed jointly drafted and written by all parties to it and shall not be construed or interpreted against the party originating or preparing it. 18. To the extent that any provision of this Agreement is prohibited by law for any reason, such provision shall be effective to the extent not so prohibited, and such prohibition shall not affect any other provision of this Agreement. 19. This Agreement shall inure to the benefit of and be binding on each party’s successors, assigns, heirs, administrators, representatives and trustees. 20. All times stated herein are of the essence of this Agreement. 21. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. BOCA DELRAY RENAL ASSOCIATES, INC., , ce Dated: /) /Y , 2013 (Signed) av: Faau ces Kenusé VP (Print Name and Title) Agency for Health Care Administration v. Boca Delray Renal Associates, Inc. {C. 1. No.: 12-2163-000) Settlement Agraement Page 5 of 6 AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Bldg. 3, Mail Stop #3 Tallahassee, FL 32308-5403 Dated: U : 2046 Stuaé F. Williams, Esquire General Counsel af 7 44 rads (li ated: | A2—. 2017 im Kellum, Esquire Chief Medicaid Counsel oo ~ j cof NMA 4 wre Yow Dated: A | H org! Katharine B. Heyward, Esquire Assistant General Counsel Agency for Health Care Administration v. Boca Delray Renal Associates, Inc. (C. L.No.; 12-2163-000) Settlement Agreement Page 6 of 6 proad and Cassel /19/2012 4:18 PAGE 7/11 RightFax Juli@1212;90a © KRAUSE 5610940872 p2 RICK SCOTT ea ELIZABETH OUDEK GOVERNOR Setter Health Cure far alt Ploridiens SECRETARY MAIL 4 1 June 18, 2012 Provider No: 212210300 NPINo: 1528047909 License No.: MB39337 BOCA DELRAY RENAL ASSOC 1905 CLINT MOORE RD, SUITE 306 BOCA RATON, FL 33496 tu Reply Refer to FINAL AUDIT REPORT C.L: No, 12-2163-000 Dear Provider: The Agency for Hesith Care Administration (Agetioy), Office of Inspector General, Bureau of Medicaid Program Integrity, has comploted a review of claims for Medicald reimbursement for dates of service during the perlod April 1, 2609 through March 31, 2010, A preliminary audit repost dated May 24, 2022 waa sent to you indicating that we had determined you. were overpaid $46,200.88. Since no. documentation was produced to refute these billings, wll the claims are considered overpayments, We have determined that you were overpaid $46,200.88 for services that in whole or in part are not covered by Medicaid, A fine of $9,240.18 has been applied, The cost assessed for this audit is $47.16. The total amount duc is $55,488.22, Be advised of the following: (1) In accordance with Sections 409.913(15), (16), and (17), Florida Statutes (F.S.), end Rule $9G-9.070, Florida Administeative Code (F.A.C.), the Agency shall apply sanctions for violations of federal and state laws, including Medicaid policy. ‘This letter shall setve as _ hotles of the following sanction(s): A fine of $9,240.18 for violation(s) of Rule Section 59G-9,076(7) (e), F.A.C. (2) Pursuant to Section 409,913(23) (a), F.S., the Agency is entitled to recover all investigative, legal, and expert witness costs. This review and the determination of overpayment were made in aovordance with the provisions of Section 409.913, F.S. In determining the appropriateness of Medicaid payment pursuant to Medicaid policy, the Medicaid program utilizes progerure codes, despriptions, policies, limitations end re ew 6, a slusti Lo. 2727 Muten Drive, M88 6 vat ee - Visit ARCA online at Tallohasseo, Florida $2308 ns Dttp;/fence.myfinride.com broad and Cassel 7/19/2012 4:18 PAGE 8/11 RightFax Jul 19 12.12:302 KRAUSE §619940872 p.3 Page 2 requirements found in the Medicaid provider handbooks and Section 409.913, F.S, In applying for Medicaid reimbursement, providers are required to follow the guidelines set forth in the applicable rules and Medicaid fes achedules, as prommuigated in the Medicaid policy handbooks, billing bulletins, and the Medicaid provider agreement. Medicaid cannot pay for services that do not meet these guidelines. Below is a discuasion of the particular guidelines related to the review of your claims, and an explanation of why these claims do not meet Medicaid requirements, The audit claims detail Is included, listing the claims that are affected by this determination. REVIEW DETERMINATIONS) 1, Florida Medicaid Provider General Handbook, dated October 2003, page 1-22 and January 2007, pago 1-26, both state: . HMO Caverage When a provider verifies 8 reciplent’s sligibilty for Medicald, he must also varity, ‘whethar the recipient ig emoited in an HMO. if a recipiant is an HMO member, the provider must esak authorization from the HMO in whioh tha recipient ie currently entotied priar ta providing services, unless ft is an emergency. W the raniplent le In an HMO, Medicald will not pay @ provider for any HiiC- covered services. Providers rust seek authorization and reimbursement from the HMC for services the HMO covers for its members. Note: See Chepler 3 in this handbook for information on verliying réciplent | eligibility and HMO enroliment. 2. Plorida Medicaid Provider General Handbook, dated July 2008, page 1-28. states: HMO Coverage When a provider varios 4 recipient's eligibility for Medicaid, he must also veuty whether the recipient ls enrolled in an HMO. Hf a recipient ip a HMO member, the provider must auak authorization from the HMO in which the recipients currently enrolled prier to providing services covered by the HMO, untess q fe an emergency. the recent in enHino, Medicaid will not pay a provider for any HMO» covered services. Providers must seek sulhorization and reimbursement the HIMG for ecrvices the HMO covers for ts members. Note: See Chapter 3.In thie handbook for information on ns verifying faciplent eligibility and HMO srvoliment Broad and Cassel dul 19 12 12:30a KRAUSE Page 3 7/19/2012 4:18 PAGE 9/11 RightFax 6619840672 pa 3. Florida Medicaid Provider General Handbook, dated July 2004, page 1-23 states: HMO Covered Services ‘The services provided under contrac! with each HMO ere negotiated with ant HMO conitecior, However, every HMO pian mvat include the following tuasle serviced up bo the limits reguirad by fae-for-sorvica iedlicaid: © Chg Hoatth Check-lip thentel health services (only in Areas 4 and 6) Dintysis trasiment in freestanding centers Durehla medical equipment and medical suppiles Family planring services Ing sarvioas Horne health services Hosplel vervoee (inpatient oisipatisnt and emergency services) ‘Laborstery satviogn, Including independent laboratory warvioes Prescribed drag servings Physlolun services (as desartbad below! Nena rect tpetadonte mentoemet {onty ih Arnas 1 and 8) 4, Fioride Modionid Provider Genoral Handbook, dated January 2007, page 1-27 and July 2008, page 1-29 both state: HMO Covered Services ‘The servicas provided.under contract wa each HMO are negotiated with each HMO contractor. Howaver, waved by ‘eeloramrvee must Inchide the folowing basic services up to the linits require s Medicald: Pr a ee Child Health Checked ot Conny nae eth sandoas : | Dialyeis treatment in feestanding centers Durable medical equipment and medica! euppitas Farnlly ptarming s services Hearing services Home health services - Hospital services (Inpatient, outpatient and emergency services) Laboratory services, Inckiding independent jaboratory services earvices Presatbed drug Physician services (as doseitbed below) . Manta! health targeted case management H broad and Vassel U/19/Z012Z 4:18 PAGE 10/11 RightFax Jul 19 42 12:31 KRAUSE 6819940672 pb Page 4 5. Florida Medicaid Provider Reimbursement Handbook , CMS-1500, dated Ootober 2003, page 1- 8, February 2006, page 1-8, and July 2008, page 1-10 all state: Bafore Completing Before Ming out the clan form, answer the following questions: Was the raciplant eligibie for Medicald on the date of service? Has tha recipient's eligiolity been vortied? Vive edPane or iM autharzation obtained, t applicable? ike service covered by Medicaid’? Was service authorization on caeee F in tue and a response received for aii tha reaivlent’s other « =Was the procedure within the service limitations’ J Ooeg thie oiaim require any f medical “ioouentaon or attachment? { Hall of he shove intenmetion is no} avakatte, review the Instruotions tn th handbaok. Hite repens tre sor, eis auwiae Yu fi out the claim form following the step-by-step {natructions for each item Medicaid fee-for-service payments have been identified for recipients thar were currently enrolled in Medicaid managed care at the time of the service. These services were covered by the managed care plan. Medicaid providers must verify recipient eligibility, including enrollment in managed care, prior 4 providing services to 8 reciplent unless it is an emergency. This Medicatd provider requirement can be referenced in the Florida Medicaid Provider Genoral Handbook. The resulting Medicaid fee-for- service reimbursements are considered overpayments, If you are eurrently involved in a bankruptey, you should notify your attorney immediatly ond provide acopy of this letter for them, Please advise your athorney thet we need the following information. immediately:. (1) the date of filing of the bankruptcy petition; (2) the case number; (3) the court nams and the division in which the potition was filed (e.g., Northern District of Florida, Tallahassee Division); and, (4) the name, address, and telephone number ‘your attorney. If you are not in bankruptcy and you concur with our findings, remit by certiiied check the total amount reflected on page one, paragraph one, of this lefter which inolndes the overpayment amount es well as any fines imposed and assessed costs. The check must be payabis to the Florida Agency for Health Care Adminbtration. Questions regarding procedures for submitting payment should be directed to Medicaid Accounts Receivable, (850) 412-3901, To ensure proper credit, be certain you legibly record on your check your Medicaid provider mnsner and the C1 summer listed on the first page of this audit report, Please mail paymentto: Medicaid Accounts Receivable - MS # 14 Agenoy for Health Care Administration 2727 Mahan Drive Bldg. 2, 0 Tallahassee, FL, S50” Siea0t Pursuant to section 409. 913(25)(d), F.S., the s Agency may collect money owed by ail means allowable . by law, including, but not limited to, exercising the option to collect money from Medicare that is broaq and Vassel 7/19/Z012 4:18 PAGE 11/11 RightFax dul 19 12 12:31a KRAUSE 6619840672 pé Page 5 payable to the provider. Pursuant to section 409,913(27), F.S., if within 30 days following this notice you have not either repaid the alleged overpayment amount or ‘entered into a satisfactory repayment agreement with the Agency, your Medicaid rolmbursoments will be withheld; they will continue to be withheld, even during the pendency of an administrative hearing, untl! such time as ths overpayment amount is satisfied. Pursuant to section 409,913(30), F.S., the Agency shall terminate your participation in the Medicaid program if you fail to repay an overpayment ot enter into a satisfactory repayment agreement with the Agency, within 35 days after the date of'a final order which is no longer subject to durther appeal. Pursuant to sections 409.913(15)(q) and 409.913(25)(c), F.S., a provider that does not adhere to the terms of'a repayment agreement is subject to tennination from the Medicaid program. Finally, failure to comply with all sanctions applied or due dates may result in additional sanctions being, imposed, Yow have the right to request a formal or informal hearing pursuant to Section 120,569, F.S. Ifa request for a formal hearing is made, the petition must be made in compliance with Section 28-106.201, F.A.C. and mediation may be available, Lf a request for an informal hearing is made, the petition must be raade in compliance with mule Ssotion 28-106,301, P.A.C. Additionally, you-are hereby informed that if request for a heating is made, the petition must be received by the Agency within twenty-one (21) days of receipt of this letter, For more information regarding your hearing and mediation rights, Pleane see the attached Notice of Administrative Hearing and Mediation Rights. Any questions you may have about this matter should be directed to: Shert Creel, Auditor, Agency far Health Care Adwlnistration, Office of Inspector General, Medicaid Program Integrity, 2727 Mahan Drive, Mail Stop ¥6, Tallahassee, Florida 32308-5403, telephone (680) 412- 4008, favalmlle (850) 410-1972, or by email at Shor’.Cract@ahea.myBorids.com : bbe ee Program Administrator Office of Inspector General Medicaid Program Integrity PRISC() Enolosure(s) Copies furnished to: Finanos & Accounting (lnteroffice mail} Department of Health (DOH) (E-mail) ode sgt rs se ee APNE OE BOW Se same Pediix. us arbi S AbI2 4bOb 344) we od Sender's Copy {oi mememene ea me WaT io eet, VSOA ~|AGOn le Cpeeinnmoempe 19 psmaas omen ay 5 Shor; ~~ Sepeetee Ota” OB al ine? Sheri Cree! row $0 YO 4b eon Berson ain BATU seaiereacty er ; oe . elEx Envelope cae nat evable,Marivum cig Ose tend te _ STometfoeatyas. any __ AC et uy Tox > Health Care Admin ab own! Prokane on 5s aa Sa Mahan“. 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Detailed Results _ i Tracking no.! 889246063441 Select time format: 42H 6 Delivered Delivered Signed-for by: LAURA ‘Shipment Dates Dastination Ship date “Gui'z?; Boig ren Signature Peet af Datway™ Delivery date Jin * Shipment Options "Hold at Fedx Location a Hold at FedEx Lopation service ig not avaliable for this shipment. -Shinmen Facts _ Service type FedEx 2Day Envelo Oelivered to ReceptionisvFront Desk Reference 68103010000 Shipment Travel History” Select time zdne: Local Stan Tinie All shipment travel aotivity Is displayed in tocel time for the location cDetetine——SSCAVy SSC Dt Jun, 212 740AM____‘AlWoeal Fedixtadity __BOGARATONFL——— “Jun 28, 2012 631 AM___Aldeatinalon aoriTedily ____-FORTLAUDERDALE, FL “Sin 28,2012 300AM ‘Departed Fedextocation ___WEMPHIS,INSSSS dun 28, 2012 2:27PM tint transit iMEMPHIS, TN ¢ dun 28, 2012 6:50 AM. “Amtived at FedEx location “MEMPHIS, TN | TALLAHASSEE, FL fun 27, 2012 615 PM ‘Left FedEx origin facility : . 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The Issue Whether five employees meet the required criteria to be eligible to provide behavior analysis services; and, if not, what is the Medicaid overpayment amount Respondent owes to Petitioner.
Findings Of Fact AHCA 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, otherwise known as the Medicaid program. See § 409.902(1), Fla. Stat. As part of its duties, AHCA oversees and administers the Florida Medicaid Program and attempts to recover Medicaid overpayments from Medicaid providers. At all times material to this case, ABA was licensed to provide healthcare services to Medicaid recipients under a contract with AHCA as a Medicaid provider. As provider number 019514000, ABA participated in the Medicaid program from November 1, 2017, through July 31, 2018 ("audit period"). AHCA's Bureau of Medicaid Program Integrity ("MPI") is the unit within AHCA that oversees the activities of Florida Medicaid providers and recipients. MPI ensures that providers abide by Medicaid laws, policies, and rules. MPI is responsible for conducting audits, investigations, and reviews to determine possible fraud, abuse, overpayment, or neglect in the Medicaid program. See § 409.913, Fla. Stat. ABA signed a provider agreement and agreed to abide by the handbook and policies. As a Medicaid provider, ABA was subject to the enacted federal and state statutes, regulations, rules, policy guidelines, and Medicaid handbooks incorporated by reference into the rule, which were in effect during the audit period. Behavior analysis is a treatment that improves the lives of those individuals with mental health conditions such as developmental and intellectual disabilities. Up until approximately 2014, behavior analysis services had been covered under the developmental disabilities waiver program. In October 2017, the Florida Medicaid Behavior Analysis Services Coverage Policy ("Handbook") was promulgated, which placed the services under the state plan, expanded the population, and detailed the eligibility categories and criteria to provide behavior analysis services. This case arose when MPI decided to audit all the Medicaid behavior analysis service providers. AHCA reviewed the employee qualifications for every enrolled behavior analysis provider. After the review, approximately 600 audit cases were opened. The Preliminary Audit and Final Audit ABA was one of the providers MPI reviewed. On December 6, 2017, MPI issued ABA a request for records seeking supporting documentation about the qualifications of employees providing behavior analysis services. ABA submitted the first set of employees' records in response to AHCA's request the same month. Karen Kinzer ("Kinzer"), investigative analyst, was assigned to oversee and conduct ABA's employee eligibility determination audit. On or about September 14, 2018, Kinzer reviewed the billing logs and requested additional employee records, which ABA then submitted. Kinzer reviewed each ABA employee and their behavior assistant qualifications based on the requirements of the Handbook. Rules applicable to the claims reviewed in this case are enumerated in the Handbook and include the following requirements in policy 3.2: Behavior assistants working under the supervision of a lead analyst and who meet one of the following: -Have a bachelor's degree from an accredited university or college in a related human services field; are employed by or under contract with a group, billing provider, or agency that provides Behavior Analysis; and, agree to become a Registered Behavior Technician credentialed by the Behavior Analyst Certification Board by January 1, 2019. -Are 18 years or older with a high school diploma or equivalent; have at least two years of experience providing direct services to recipients with mental health disorder, developmental or intellectual disabilities; and, complete 20 hours of documented in- service trainings in the treatment of mental health, developmental or intellectual disabilities, recipient rights, crisis management strategies and confidentiality. Kinzer determined that overpayments were made to ABA because numerous behavior analysis services had been performed by ineligible employees, which were not covered by Medicaid. Kinzer prepared the Preliminary Audit Report ("PAR") after reviewing ABA's employee records and conducting an audit of paid Medicaid claims for behavior analysis services to Medicaid recipients. MPI issued the PAR dated November 26, 2018. The report detailed the Medicaid policy violations, overpayment amounts, and provided ABA the opportunity to submit additional documentation for consideration. The overpayment amount totaled $1,215,281.09, and the report also notified ABA that an FAR would be issued identifying the amount of overpayment due. Each time ABA supplied additional records, MPI reviewed the supporting documentation provided from the employment files to evaluate if the employees met the minimum qualifications to perform behavior analysis services pursuant to policy 3.2. On February 11, 2019, MPI issued an Amended Preliminary Audit Report ("APAR") that reduced ABA's overpayment amount to $977,539.52. Attached to the APAR was a list of specific employees who were ineligible to perform behavioral analysis services. The list also detailed how much billing was credited to each of the ineligible employees. The APAR allowed ABA the opportunity to submit additional documentation for consideration. On April 18, 2019, AHCA concluded the audit and issued an FAR on or about April 30, 2019, alleging that Respondent was overpaid $852,043.63 for behavior analysis services that were not covered by Medicaid. The overpayment was calculated based on the determination that 20 ABA employees were ineligible according to policy 3.2 of the Handbook. The FAR included employee overpayment and claim reports as well as claim bills by ABA for the 20 ineligible employees. Also listed was the total amount for the audit period. AHCA informed ABA by the FAR that it was seeking to impose a fine of $172,908.73 and costs in the amount of $461.50 for a total amount of $1,025,413.86. An additional fine of $2,500.00 as a sanction was also included. Additionally, the FAR detailed ABA's violations in Finding 1, which stated, in pertinent part: The Florida Medicaid Provider General Handbook, page 1-2, states that only health care providers that meet the conditions of participation and eligibility requirements and are enrolled in Medicaid Behavior Analysis Services Coverage Policy, Rule 59G- 4.125, F.A.C., Section 3.0, states that providers must meet the qualifications specified in this policy in order to be reimbursed for Florida Medicaid BA [behavior analysis] services. Payments for Florida Medicaid Behavior Analysis Services rendered by an individual determined not to meet the qualifications or for whom documentation was insufficient to determine eligibility are considered an overpayment. After the April 18, 2019, FAR was issued, 15 of ABA's employees obtained their registered behavior technician ("RBT") certifications, which made them eligible under policy 3.2. AHCA reduced the number of ineligible ABA employees from 20. After the reduction, MPI concluded that five ABA employees still did not meet the minimum legal requirements to perform behavior assistant services during the audit period under policy 3.2. Employee No. 1 MPI discovered ABA violated policy by billing Medicaid $3,803.28 for behavior analysis services conducted by Erica del Sodorro Lebron Diaz ("Lebron Diaz"). Lebron Diaz's computer engineering degree failed to be in the required human services field. Additionally, she neither had an RBT certificate nor had two years' experience providing direct services to recipients with mental health disorders, developmental or intellectual disabilities ("target population"). Instead, Lebron Diaz only had one month direct service experience in 2019 as a home health aide that could be verified. Employee No. 2 MPI discovered ABA violated policy by billing Medicaid $44,737.30 for behavior analysis services conducted by Herman Chavez ("Chavez"). Chavez lacks a bachelor's degree, does not have an RBT certificate, and his work history only had nine months' work experience with the required target population, which is 15 months short of the minimum requirements of the Handbook. Employee No. 3 MPI discovered ABA violated policy by billing Medicaid $79,551.14 for behavior analysis services conducted by Mairelis Gonzalez Rodriguez ("Rodriguez"). Rodriguez lacks a bachelor's degree and has a high school diploma, but does not have an RBT certificate and does not have the two years' work experience with the required target population. Employee No. 4 MPI discovered ABA violated policy by billing Medicaid $44,737.30 for behavior analysis services conducted by Nury Grela Dominguez ("Dominguez"). Dominguez lacks a bachelor's degree and has a high school diploma, but does not have an RBT certificate. She also does not have two years of work experience with the target population. Employee No. 5 MPI found ABA violated policy by billing Medicaid $48,272.40 for behavior analysis services conducted by Yoiset Orive ("Orive"). Orive neither has a bachelor's degree nor the RBT certificate that is required with a high school diploma. Additionally, she only has 19 months' direct work experience with the target population instead of the required 24 months. Hearing At the final hearing, the parties announced and stipulated that only five ABA employees', Lebron Diaz, Chavez, Rodriguez, Dominguez, and Orive's ("disputed employees"), eligibility is contested for the determination of Medicaid overpayment in this matter. AHCA is seeking an overpayment of $207,082.92 and sanctions and costs in the amount of $2,500.00 for the disputed employees. At hearing, Jennifer Ellingsen ("Ellingsen"), AHCA's Medicaid health program analyst, testified that she was assigned ABA's case after Kinzer retired. Ellingsen worked for AHCA as an analyst on audits of Medicaid providers for 12 years. Ellingsen reevaluated the eligibility of the disputed employees. During her review, Ellingsen assessed all the records supplied by ABA. She looked at the complete employment files of the disputed employees including applications, resumes, and references. She also attempted to verify credentials by calling references when the employee files did not contain the required information. During the review, Ellingsen researched previous employers listed on the resumes to confirm periods of employment and whether work duties were with the required target population. Some letters of reference were character references, which she was not able to use toward eligibility because the letters did not relate to work history. Ellingsen also faced challenges verifying backgrounds for the disputed employees when some phone numbers were not in service, she could not find current numbers or locations for the entity listed, or people did not return her calls. Several of the employee reference letters also failed to have any notation that Respondent attempted to verify the letters. Ellingsen made numerous attempts to verify that each of the disputed employees had previously worked with the target population, but was unable to confirm the two years' direct care service for all of the disputed employees. Ellingsen credibly summarized the verification process, background research results, and concluded that each of the disputed employees were ineligible to perform behavior analysis services because they did not meet the criteria in policy 3.2. She testified that the disputed employees' ineligibility was because all five lacked college degrees in a human services- related field, none had RBT certifications, and each lacked the verifiable two years of direct care services experience with the target population, which the Handbook required. Ellingsen added up ABA's Medicaid overpayments owed from the disputed employees for a total of $207,082.92. At hearing, Robi Olmstead ("Olmstead") explained that section 409.913, Florida Statutes, and Florida Administrative Code Rule 59G-9.070(7) require that sanctions be applied in the amount of $1,000.00 per claim, which would have been over approximately $3,000,000.00 in this case. However, Olmstead testified that, in this case, AHCA implemented the cap that reduced ABA's sanctions and costs to $2,500.00. Respondent, Varinia Cabrera ("Cabrera"), ABA owner, testified that she interviewed and checked the references of all of the disputed employees. Cabrera believed that each of the disputed employees met the requirements of policy 3.2 before she hired them to perform behavior analysis services at ABA. Cabrera also maintained that since AHCA provided each of the disputed employees in question with a Medicaid Provider ID number, she believed AHCA had also validated and approved the disputed employees to work for her performing behavior analysis services. A Medicaid Provider ID number is a number assigned to employees and contractors of Medicaid providers to track and bill for claims. The provision of a Medicaid Provider ID number does not substitute for any Medicaid provider ensuring that its employees or subcontractors have the required credentials to perform the services to which they are billing.
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 directing Advanced Behavioral Association, LLC, to repay $207,082.92 for the claims found to be overpayments and $2,500.00 in sanctions and costs. DONE AND ENTERED this 20th day of November, 2019, in Tallahassee, Leon County, Florida. S JUNE C. MCKINNEY 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 20th day of November, 2019. COPIES FURNISHED: Varinia F. Cabrera, Psy.D. Advanced Behavioral Association, LLC 7925 Northwest 12th Street, Suite 118 Doral, Florida 33216-1820 (eServed) Kimberly Murray, Esquire Ryan McNeill, Esquire Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 (eServed) Richard J. Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 (eServed) Stefan Grow, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 (eServed) Mary C. Mayhew, Secretary Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 1 Tallahassee, Florida 32308 (eServed) Shena L. Grantham, Esquire Agency for Health Care Administration Building 3, Room 3407B 2727 Mahan Drive Tallahassee, Florida 32308 (eServed) Thomas M. Hoeler, Esquire Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 (eServed)
The Issue Whether the Agency for Health Care Administration (Petitioner) is entitled to recover certain Medicaid payments made to Cape Memorial Hospital, Inc., d/b/a Cape Coral Hospital (Respondent).
Findings Of Fact Title XIX of the Social Security Act establishes Medicaid as a collaborative federal-state program in which the state receives federal funding (also known as “federal financial participation” or “FFP") for services provided to Medicaid- eligible recipients in accordance with federal law. The Florida statutes and rules relevant to this proceeding essentially incorporate federal Medicaid standards. The Petitioner is the state agency charged with administering the Medicaid provisions relevant to this proceeding. Section 409.902, Florida Statutes (2015)1/, states that the Petitioner is the “single state agency authorized to make payments” under the Medicaid program. The referenced statute limits such payments to “services included in the program” and only on “behalf of eligible individuals.” The Respondent is enrolled in the Florida Medicaid Program as a Medicaid Hospital Provider. The Respondent's participation in the Florida Medicaid Program is subject to the terms of a Medicaid Provider Agreement. The Respondent's Medicaid Provider Agreement requires compliance with all state and federal laws governing the Medicaid program, including the state and federal laws limiting Medicaid payments for services provided to undocumented aliens. Eligibility for Medicaid services is restricted to United States citizens, and to specified non-citizens who have been lawfully admitted into the United States. Pursuant to section 409.902(2)(b), Medicaid funds cannot be used to provide medical services to individuals who do not meet the statutory eligibility criteria "unless the services are necessary to treat an emergency medical condition" or are for pregnant women. The cited statute further provides that such services are “authorized only to the extent provided under federal law.” The relevant federal law (42 U.S.C. section 1396b(v)(3)) defines an "emergency medical condition" as: medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in-(A) placing the patient's health in serious jeopardy, (B) serious impairment to bodily functions, or (C) serious dysfunction of any bodily organ or part. The Florida definition of “emergency medical condition” set forth at section 409.901(10)(a) mirrors the federal definition. Pursuant to section 409.904(4), the Petitioner can make payments to a Medicaid provider on behalf of "a low-income person who meets all other requirements for Medicaid eligibility except citizenship and who is in need of emergency medical services" for “the period of the emergency, in accordance with federal regulations." The Florida Medicaid program requirements relevant to this proceeding were identified in the Florida Hospital Services Coverage and Limitations Handbook (incorporated by reference in Florida Administrative Code Rule 59G-4.160(2),), and in the Florida Medicaid Provider General Handbook (incorporated by reference in Florida Administrative Code Rule 59G-5.020.) The applicable Florida Hospital Services Coverage and Limitations Handbook provided as follows: The Medicaid Hospital Services Program reimburses for emergency services provided to aliens who meet all Medicaid eligibility requirements except for citizenship or alien status. Eligibility can be authorized only for the duration of the emergency. Medicaid will not pay for continuous or episodic services after the emergency has been alleviated. Similar provisions were contained in the Florida Medicaid Provider General Handbook. Section 409.913 requires that the Petitioner monitor the activities of Medicaid providers and to “recover overpayments.” The Petitioner’s Bureau of Medicaid Program Integrity (BMPI) routinely conducts audits to monitor Medicaid providers. Section 409.913(1)(e) defines “overpayment” to include “any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.” The BMPI conducted a review of the Respondent's claims for services rendered to undocumented aliens during the period January 1 through December 31, 2006. The Respondent provided all documentation requested by the Petitioner necessary to review the claims addressed herein. As to each claim, the designated reviewing physician made a determination, based on the medical records, as to whether the claim was related to an emergency medical condition, and, if so, when the emergency medical condition was alleviated. Based on the evidence, and on the testimony of the physicians identified herein, the determinations of the physicians are fully credited as to the existence of emergency medical conditions and as to when such conditions were alleviated. CLAIM #1 Dr. Thomas Wells reviewed Claim #1, which involved a length of stay from March 31 through April 10, 2006. Based upon his review of the medical records, Dr. Wells determined that an emergency medical condition existed on March 31, 2006, and that it had been alleviated as of April 6, 2006. CLAIM #3 Dr. Michael Phillips reviewed Claim #3, which involved a length of stay from May 27 through June 12, 2006. Based upon his review of the medical records, Dr. Phillips determined that an emergency medical condition existed on May 27, 2006, and that it had been alleviated as of May 28, 2006. CLAIM #4 Dr. Michael Phillips reviewed Claim #4, which involved a length of stay from January 15 through January 20, 2006. Based upon his review of the medical records, Dr. Phillips determined that an emergency medical condition existed on January 15, 2006, and that it had been alleviated as of January 17, 2006. CLAIM #5 Dr. Michael Phillips reviewed Claim #5, which involved a length of stay from March 4 through April 10, 2006. Based upon his review of the medical records, Dr. Phillips determined that an emergency medical condition existed on March 4, 2006, and that it had been alleviated as of March 7, 2006. CLAIM #6 Dr. Steve Beiser reviewed Claim #6, which involved a length of stay from June 15 through June 18, 2006. Based upon his review of the medical records, Dr. Beiser determined that an emergency medical condition existed on June 15, 2006, and that it had been alleviated as of June 16, 2006. CLAIM #7 Dr. Thomas Wells reviewed Claim #7, which involved a length of stay from June 15 through July 6, 2006. Based upon his review of the medical records, Dr. Wells determined that the emergency medical condition existed on June 15, 2006, and that it had been alleviated as of June 28, 2006.
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 a Medicaid overpayment of $57,350.67 related to the six claims identified herein. Pursuant to section 409.913(23), Florida Statutes, the Petitioner is entitled to recover certain investigative, legal, and expert witness costs. Jurisdiction is retained to determine the amount of appropriate costs if the parties are unable to agree. Within 30 days after entry of the final order, either party may file a request for a hearing on the amount. Failure to request a hearing within 30 days after entry of the final order shall be deemed to indicate that the issue of costs has been resolved. DONE AND ENTERED this 27th day of July, 2016, in Tallahassee, Leon County, Florida. S WILLIAM F. QUATTLEBAUM 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 27th day of July, 2016.
