The Issue The issues in this case are set forth in 11 separate counts within the four consolidated cases: Case No. 09-5360 Count I--Whether Respondent failed to properly monitor and care for a patient in restraints. Count II--Whether Respondent failed to ensure the physician's plan of care for patient was implemented. Case No. 09-5363 Count I--Whether Respondent failed to properly implement the physician's plan of care for patient. Case No. 09-5364 Count I--Whether Respondent failed to ensure a patients' right to privacy. Count II--Whether Respondent failed to ensure that food was served in the prescribed safe temperature zone. Count III--Whether Respondent failed to ensure that only authorized personnel had access to locked areas where medications were stored. Count IV--Whether Respondent failed to perform proper nursing assessments of a patient. Count V--Dismissed. Count VI--Whether Respondent failed to maintain patient care equipment in a safe operating condition. Case No. 09-5365 Count I--Whether Respondent failed to triage a patient with stroke-like symptoms in a timely fashion. Count II--Whether Respondent's nursing staff failed to assess and intervene for patients or ensure implementation of the physician's plan of care.
Findings Of Fact Petitioner is the state agency responsible for, inter alia, monitoring health care facilities in the state to ensure compliance with all governing statutes, rules and regulations. It is the responsibility of AHCA to regularly inspect facilities upon unannounced visits. Often AHCA will inspect facilities for the purpose of licensure renewal, certification, or in conjunction with federal surveys. AHCA will also inspect facilities on the basis of complaints filed by members of the general public. Respondent, Gulf Coast Medical Center ("Gulf Coast" or "GCH") is a hospital within the Lee Memorial Health System. South West Florida Regional Medical Center ("SWF") was another hospital within the Lee Memorial Health System. SWF closed in March 2009, when it was consolidated with Gulf Coast. On October 15, 2008, the Agency conducted a complaint investigation at SWF; a follow-up complaint investigation was done on November 13, 2008. SWF filed and implemented a plan of correction for the issues raised in each of the investigations. The November investigation resulted in an Administrative Complaint containing two counts. On December 16, 2008, AHCA performed another complaint investigation at Gulf Coast. Gulf Coast filed and implemented a plan of correction for the issues raised in the investigation. The investigation resulted in an Administrative Complaint containing one count. On January 5 through 9, 2009, AHCA conducted a routine licensure survey at Gulf Coast. The hospital filed and implemented a plan of correction for the issues raised in the survey. The survey resulted in an Administrative Complaint containing six counts (although Count V was dismissed during the course of the final hearing). On February 18, 2009, AHCA did its follow-up survey to the previous licensure survey. Gulf Coast filed and implemented a plan of correction for the issues raised in the survey. The survey resulted in an Administrative Complaint containing two counts. Case 09-5360 The complaint investigation at SWF on November 13, 2008, was conducted under the supervision of Charlene Fisher. Count I in this case addresses findings by the Agency concerning a patient who was placed in restraints at the hospital on August 28, 2008. The patient, A.D., came into the hospital emergency department under the Baker Act seeking medical clearance to a facility. The patient presented at approximately 4:00 p.m., with back pain. He had a history of drug abuse, so there was concern by the hospital regarding the use of narcotics or certain other medications to treat the patient. The patient engaged in some scuffling with police. A physician signed and dated a four-point restraint (one on each limb) order, resulting in the patient being physically restrained. The restraint was deemed a medical/surgical restraint, rather than a behavioral restraint. AHCA had concerns about the restraint, specifically whether there was a notation for Q 15 (or every 15 minutes) monitoring of the restrained patient. However, medical/surgical restraints only require monitoring every two hours. The restraint worksheet for the patient confirms monitoring every two hours. The patient was ultimately admitted to the hospital at 9:37 p.m., and, thereafter, began complaining of left shoulder pain. The hospital responded to the patient's complaints about back pain and began treating the pain with analgesics. However, the patient continued to complain about the pain. An X-ray of the patient's shoulder was finally done the next morning. Shoulder dislocation was confirmed by the X-ray, and the hospital (four hours later) began a more substantive regimen of treatment for pain. Surgery occurred the following morning, and the shoulder problem was resolved. It is clear the patient had a shoulder injury, but it is unclear as to when that injury became more painful than the back injury with which the patient had initially presented. The evidence is unclear whether or when the shoulder injury became obvious to hospital staff. During its course of treating this patient, the hospital provided Motrin, Tylenol, Morphine, Percocet and other medications to treat the patient's pain. Count II in this case also involved a restrained patient, M.D., who had presented to the emergency department under the Baker Act. The patient was released from handcuffs upon arrival at the hospital. After subsequently fighting with a deputy, this patient was also placed in a medical/surgical restraint pursuant to a physician's order. The doctor signed and dated, but did not put a time on, the restraint order. A time is important because there are monitoring requirements for patients in restraints. However, the time of 0050 (12:50 a.m.) appears on the patient's chart and is the approximate time the restraints were initiated. The proper procedure is to monitor a restrained patient every two hours. This patient, however, was removed from his restraints prior to the end of the first two-hour period. Thus, there are no records of monitoring for the patient (nor would any be necessary). The evidence presented by AHCA was insufficient to establish definitively whether the hospital nursing staff failed to properly respond to the aforementioned patients' needs. It is clear the patients could have received more care, but there is not enough evidence to prove the care provided was inadequate. Case No. 09-5363 On December 16, 2008, AHCA conducted a complaint investigation at SWF. The Agency had received a complaint that the hospital did not properly implement a physician's plan of care. Count I in this complaint addresses alleged errors relating to two of four patients reviewed by the surveyors. Both of the patients came to the hospital from a nursing home. One patient, I.A., had presented to the emergency department complaining of chest pains. The medication list sent to the hospital by the nursing home for I.A. actually belonged to someone other than I.A. I.A.'s name was not on the medication list. The drugs listed on the patient chart were different than the drugs I.A. had been taking at the skilled nursing facility from which she came. The skilled nursing facility actually sent I.A.'s roommate's medication list. The erroneous medications were then ordered by the admitting physician and administered to the patient. The hospital is supposed to review the medication list it receives and then enter the medications into the hospital system. The person reviewing the medication list does not necessarily have to be a nurse, and there is no evidence that the person making the error in this case was a nurse or was some other employee. It is clear, however, that the person reviewing the medication list did not properly ascertain that the list belonged to patient I.A. The other patient from the nursing home had been admitted for surgery at SWF. Again, the nursing home from whence she came sent a medication list that was incorrect. The medications on the incorrect list were entered into the system by a SWF employee. The erroneous medications were ultimately ordered by the attending physician for the patient, but there is no evidence the patient was ever administered those medications. Neither of the residents was harmed by the incorrect medications as far as could be determined. Case 09-5364 From January 5 through 8, 2009, AHCA conducted a licensure survey at Gulf Coast and SWF in conjunction with a federal certification survey. Count I of the complaint resulting from this survey addressed the right of privacy for two residents. In one instance, a patient was observed in her bed with her breasts exposed to plain view. In the other instance, a patient's personal records were found in a "public" place, i.e., hanging on the rail of a hallway in the hospital. AHCA's surveyor, Nancy Furdell, saw a female patient who was apparently asleep lying in her bed. The patient's breasts were exposed as she slept. Furdell observed this fact at approximately 1:15 p.m., on January 7, 2009. Furdell did not see a Posey vest on the patient. She did not know if anyone else saw the exposed breasts. Furdell continued with her survey duties, and at approximately 5:00 p.m., notified a staff member as to what she had seen. Furdell did not attempt to cover the patient or wake the patient to tell her to cover up. The female patient with exposed breasts was in the intensive care unit (ICU) of the hospital. Visiting hours in ICU at that time were 10:00 to 10:30 a.m., and again from 2:00 till 2:30 p.m. Thus, at the time Furdell was present, no outside visitors would have been in the ICU. ICU patients are checked on by nursing staff every half-hour to an hour, depending on their needs. This particular patient would be visited more frequently due to her medical condition. On the day in question, the patient was supposed to be wearing a Posey vest in an effort to stop the patient from removing her tubing. The patient had been agitated and very restless earlier, necessitating the Posey vest. Also on January 7, 2009, a surveyor observed some "papers" rolled up and stuffed inside a hand-rail in the hospital corridor. This occurred at 1:15 p.m., on the fourth floor of the south wing of the hospital. A review of the papers revealed them to be patient records for a patient on that floor. The surveyor could not state at final hearing whether there were hospital personnel in the vicinity of the handrail where she found the patient records, nor could she say how long the patient records had been in the handrail. Rather, the evidence is simply that the records were seen in the handrail and were not in anyone's possession at that moment in time. Count II of the complaint was concerned with the temperature of certain foods being prepared for distribution to patients. Foods for patients are supposed to be kept at certain required temperatures. There is a "danger zone" for foods which starts at 40 degrees Fahrenheit and ends at 141 degrees Fahrenheit. Temperature, along with time, food and environment, is an important factor in preventing contamination of food and the development of bacteria. Surveyor Mary Ruth Pinto took part in the survey. As part of her duties, she asked hospital staff to measure the temperature of foods on the serving line. She found some peaches at 44 degrees, yogurt at 50 degrees, and cranberry juice at 66 degrees Fahrenheit. According to Pinto, the hospital's refrigerator temperatures were appropriate, so it was only food out on the line that was at issue. Pinto remembers talking to the hospital dietary manager and remembers the dietary manager agreeing to destroy the aforementioned food items. The hospital policies and procedures in place on the date of the survey were consistent with the U.S. Food and Drug Administration Food Code concerning the storage, handling and serving of food. The policies acknowledge the danger zone for foods, but allow foods to stay within the danger zone for up to four hours. In the case of the peaches and yogurt, neither had been in the danger zone for very long (not more than two hours). The cranberry juice was "shelf stable," meaning that it could be stored at room temperature. The food services director for the hospital remembers the peaches and yogurt being re-chilled in a chill blaster. She does not believe any of the food was destroyed. Count III of the complaint addressed whether an unauthorized person had access to a room where medications were being stored. A state surveyor, Gary Furdell, was part of the survey team on January 5, 2009. Furdell was touring the second floor of the hospital when he noticed a locked door. Furdell asked a hospital medical technician who was standing nearby about the door. The medical technician gave Furdell the code to unlock the door. Furdell peeked inside and noticed bottles that he presumed were medications. It would be a violation for a medical technician to have access to medications, because medical technicians cannot distribute drugs. The room Furdell looked into is a "mixed use" room located behind a nursing station. A mixed use room is used to store medical supplies, including medications, as long as there is a locked cabinet in the room for that purpose. This particular mixed use room had a locked cabinet. The room is used for the preparation of medications and for other purposes. No narcotics were stored in this particular mixed use room. The room contained locked cabinets used to store other medications. The evidence presented was insufficient to determine what "medications" Furdell may have seen in the room. Count IV of the complaint concerned the nursing assessment of a patient, and whether the assessment was properly and timely performed. A patient, M.S., had been admitted to the hospital on June 18, 2008, for lung surgery. Following the surgery, Amiodarone (a very toxic drug which can cause clots and other complications) was administered to treat M.S. for heart arrhythmia. The Amiodarone was administered intravenously and M.S. developed blisters and irritation at the intravenous site. That is not an uncommon complication with Amiodarone. M.S.'s attending physician was notified about the irritation and prescribed a treatment. He also ordered a consult with an infectious disease specialist who ultimately changed M.S.'s antibiotics. Although M.S. was seen daily by her physicians, the nursing notes do not reflect the assessment and treatment of her blisters. It appears that proper care was rendered, but the care was not documented properly. Another patient was admitted to the hospital on December 15, 2008, with End Stage Renal Disease and diabetes mellitus for which she began dialysis treatment. The patient was not weighed before and after a particular dialysis treatment on January 5, 2009. However, the patient had been moved to an air mattress bed on that date for comfort. The air mattress bed did not allow for a weight to be taken as it could be on a regular bed. There is an allegation in the Administrative Complaint concerning the discontinuation of the calorie count for a patient. This issue was not discussed in AHCA's Proposed Recommended Order, nor was sufficient evidence of any wrong- doing concerning this matter presented at final hearing. During the survey, the hospital was found to be storing the medication Mannitol in blanket warmers, rather than in warmers specifically designed for the drug. The blanket warmers maintained the Mannitol at 100-to-110 degrees Fahrenheit. The manufacturer's label on the drug calls for it to be dispensed (injected) at between 86 and 98.5 degrees Fahrenheit. In order to meet this requirement, the hospital takes the drug out of the blanket warmer in time for it to cool sufficiently before it is injected. There is nothing inherently wrong with using a blanket warmer to store Mannitol. On January 5, 2009, a surveyor found two vials of Thrombin, one vial of half-percent Lidocaine and Epi, and one vial of Bacitracin in operating room No. 4. The operating room is within the secured and locked suite of surgical rooms on the second floor. Two of the vials had syringes stuck in them and one of them was spiked. Whoever had mixed the medications was not attending to them at the time the surveyor made her observation. There were two unlicensed technicians in the room preparing for the next surgery. A registered nurse anesthetist was present as well. There was no identifying patient information on the medications. The hospital's policies and procedures do not require the patient's name to be on the label of medications prepared for impending surgery. That is because the procedures for the operating room include a process for ensuring that only the correct patient can be in the designated operating room. There is a fail-safe process for ensuring that only the proper patient can receive the medications that are set out. At around 2:45 p.m. on January 5, 2009, there were patient records in the emergency department showing that several drugs had been administered to a patient. The surveyor did not see a written order signed by a physician authorizing the drugs. When the surveyor returned the next morning, the order had been signed by the physician. The hospital policy is that such orders may be carried out in the emergency department without a doctor's signature, but that a physician must sign the order before the end of their shift. AHCA cannot say whether the physician signed the order at the end of his shift or early the next day. Count V of the complaint was voluntarily dismissed by the Agency. Count VI of the complaint concerned the status of certain patient care equipment, and whether such equipment was being maintained in a safe operating condition. A patient was weighed at the hospital upon admission on December 27, 2008, and found to weigh 130 pounds using a bed scale. Six days later, on January 2, 2009, the patient's weight was recorded as 134 pounds. Two days later, in the same unit, the patient weighed 147 pounds and the next day was recorded as weighing 166 pounds. During the survey process, the patient was weighed and recorded at 123 pounds on a chair scale. The hospital does not dispute the weights which were recorded, but suggests there are many factors other than calibration of the equipment that could explain the discrepant weights. For example, the AHCA surveyor could not say whether the patient sometimes had necessary medical equipment on his bed while being weighed, whether different beds were involved, or whether any other factors existed. AHCA relies solely on the weight records of this single patient to conclude that the hospital scales were inaccurate. Case No. 09-5365 On February 18, 2009, AHCA conducted a licensure survey at Gulf Coast. Count I of the complaint from this survey concerned the timeliness of triage for a patient who presented at the hospital emergency department with stroke-like symptoms. AHCA surveyors witnessed two patients on stretchers in the ambulance entrance hallway leading to the emergency department. Each of the two patients had been brought in by a separate emergency medical service (EMS) team and was awaiting triage. One patient was taken to an emergency department room (ER room) 50 minutes after his/her arrival at the hospital. The other patient waited 45 minutes after arrival before being admitted to an ER room. Meanwhile, a third patient arrived at 2:20 p.m., and was awaiting triage 25 minutes later. During their observation, the surveyors saw several nursing staff in the desk area of the emergency department, i.e., they did not appear to be performing triage duties. The emergency department on that date was quite busy. That is not unusual during February, as census tends to rise during the winter months due to the influx of seasonal residents. A summary of the action within the emergency department from 1:00 p.m. to 3:00 p.m., on the day of the survey shows the following: Patient L.G., 74 years old with stable vital signs, was radioed in by her EMS team at 1:08; L.G. was processed into the ER at 1:21 (which is not an unreasonable time; EMS teams call in when they arrive at or near the hospital. By the time they gain access, wait their turn if multiple ambulances are present, and get the patient inside, several minutes may lapse). L.G. was stabilized and quickly reviewed by ER staff, then officially triaged at 2:04. Patient H.M., an 89-year-old male residing in a nursing home, arrived at 1:20 and was processed in at 1:59. He was triaged at 2:01, but ultimately signed out of the hospital against medical advice. Patient E.M. arrived at 2:18 and was processed at 2:25. Triage occurred one minute later. This patient presented as a stroke alert, and hospital protocol for that type patient was followed. Patient C.J. arrived at 1:08 and was processed at 2:38. Triage occurred immediately after C.J. was processed. This patient was not stroke alert, but had some stroke-like symptoms.1 C.J. had not been transported to the hospital as emergent, because the symptoms had been going on for 24 hours. Patient W.M., an auto accident victim, arrived at 1:40 and was processed at 1:49. Triage occurred within six minutes. Patient M.M., W.M.'s wife (who had been with M.M. in the automobile accident, but was placed in a separate ambulance), arrived at 2:06 and was triaged at 2:34. There is no record of when M.M. was processed. Patient L.M. came to the hospital from a nursing home. She arrived at 1:43 and was processed at 2:35. L.M. was triaged at 2:37. Patient K.M. arrived at 2:45 and was processed within three minutes. Triage occurred at 2:52. Her triage was done very quickly due to the condition in which she arrived, i.e., shortness of breath and low oxygen saturation. Patient R.S. arrived at 1:00 and was triaged at 1:15. The aforementioned patients represent the patients presenting to the emergency department by ambulance during a two-hour period on a very busy day. It is the customary procedure for ER staff to make a quick visual review (rapid triage) of patients as they come into the hospital. Those with obvious distress or life-threatening conditions are officially triaged first. Others, as long as they are stable, are allowed to wait until staff is available for them. As part of their duties, nurses necessarily have to be in the desk area (nursing station) in order to field phone calls from physicians concerning treatment of the patients who present. It is not unusual or improper for nurses to be in the nursing station while residents are waiting in the processing area. It is clear that some patients waited a much longer time for triage than others. However, without a complete record of all patients who presented that day and a complete review of each of their conditions, it is impossible to say whether the hospital was dilatory in triaging any of them. Count II of the complaint addressed the nursing staff and whether it failed to assess and intervene in the care of a patient or failed to implement a physician's plan of care for the patient. Patient D.W. was a 67-year-old female who was morbidly obese, diabetic, debilitated, had end stage renal disease, and was receiving dialysis. Upon admission, D.W. had a Stage 3 pressure ulcer to her sacrum and a Stage 4 ulcer on her left calf. A wound care protocol was initiated immediately, and a Clinitron bed was obtained for her on the day of admission. Due to the seriousness of her condition, the wound care physician declined to accept her case at first. He later ordered Panafil, and it became part of the protocol for treating the patient. The nursing documentation for D.W. was only minimally sufficient, but it does indicate that care was provided. Patient R.H. was an 83-year-old male who presented on February 10, 2009, in critical condition. R.H. was suffering from congestive heart failure, pneumonia, and respiratory failure. Due to the critical nature of his respiratory problems, R.H. was placed on a ventilator. As a ventilator patient, he did not fit the profile for obtaining wound care. Nonetheless, the hospital implemented various other measures to deal with R.H.'s pressure wounds.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by Petitioner, Agency for Health Care Administration, imposing a fine in the amount of $500.00 in DOAH Case No. 09-5363 and a fine in the amount of $500.00 in DOAH Case No. 09-5364, Count VI. DONE AND ENTERED this 30th day of April, 2010, in Tallahassee, Leon County, Florida. R. BRUCE MCKIBBEN 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 30th day of April, 2010.
The Issue Whether Medicaid overpayments were made to Petitioner and, if so, what is the total amount of those overpayments.
Findings Of Fact Petitioner Petitioner is a Florida-licensed osteopathic physician specializing in internal medicine. He has board certifications in internal medicine and nuclear medicine. In addition, he is certified in the sub-specialty of cardiology. Petitioner graduated from the Kirksville College of Osteopathic Medicine in Kirksville, Missouri in 1962. He has been practicing as an osteopathic internist in Florida since 1966, the year he came to the state after completing his residency at Brentwood Hospital in Cleveland, Ohio. Petitioner's Practice Petitioner's practice is now, and has been at all times material to instant case, located in Miami-Dade County, Florida. Petitioner currently practices at 9765 Southwest 184th Street in Miami Florida. Among Petitioner's current patients are Ira Hershman, D.O., a retired osteopathic physician who, as noted above, testified as a medical expert on Petitioner's behalf in this case, and Dr. Hershman's wife. Dr. Hershman's "career as an active doctor ended in 1997." Dr. Hershman was, and still is, board-certified in family practice medicine. Unlike Petitioner, at no time has he been board-certified in internal medicine. When he was in active practice and needed to consult with an internist, he "utilized [Petitioner's] services."12 From the "mid '60s through the '90s," Dr. Hershman and Petitioner were "on the staff of hospitals" together. They are, and have been over the years, "friends." Furthermore, their "families know each other" and socialize. During the period from March 1, 1996, through March 17, 1998 (Audit Period), Petitioner rendered "primary care" services at 17615 Southwest 97th Avenue, Miami, Florida, in a 30,000 square foot facility known as the Suburban Medical Center (Facility), which he owned and operated. A significant number of Medicaid patients were served at the Facility. Other physicians, hired by Petitioner, saw and otherwise provided services to Petitioner's patients at the Facility. Petitioner considered these physicians, who included Drs. Katzeff and Lubin, to be "independent contractors." On the premises of the Facility, Petitioner had "sophisticated equipment," not typically found in a "primary care" setting, available to perform various diagnostic tests,13 as well as a room equipped with items for urgent care that "very few" primary care physicians have. Petitioner used Dr. Key as a "consultant in radiology" to provide him with the "official reading" of x-rays, CAT scans, mammographies, and other imaging tests done at the Facility. The Provider Agreements During the Audit Period, Petitioner was authorized to provide physician services to eligible Medicaid patients. Petitioner provided such services pursuant to two provider agreements. The first agreement was a Non-Institutional Professional and Technical Medicaid Provider Agreement (First Provider Agreement) that Petitioner had entered into with the Department of Health and Rehabilitative Services, AHCA's predecessor, in 1983.14 The First Provider Agreement contained the following provisions, among others: * * * The provider agrees to keep such records as are necessary to fully disclose the extent of services provided to individuals receiving assistance under the State Plan and agrees to furnish the State Agency upon request such information regarding any payments claimed for providing these services. Access to these pertinent records and facilities by authorized Medicaid Program representatives will be permitted upon a reasonable request. The provider agrees that claims submitted must be for services rendered to eligible recipients of the Florida Medicaid Program and that payment by the program for services rendered will be based on the payment methodology in the applicable Administrative Rule. The Provider also agrees to submit requests for payment in accordance with program policies. * * * Payment by the State agency shall constitute full payment for services rendered to recipients under the Medicaid program except in specific programs when co- insurance is required from the recipient. The provider and the Department agree to abide by the provisions of the Florida Administrative Rules, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. * * * The second agreement was a Medicaid Provider Agreement (Second Provider Agreement) that Petitioner had entered into with AHCA in October of 1996. The Second Provider Agreement contained the following provisions, among others: The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions: * * * Quality of Services. The provider agrees to provide medically necessary services or goods of not less than the scope and quality it provides to the general public. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, of a quality comparable to those furnished by the provider's peers, and within the parameters permitted by the provider's license or certification. The provider further agrees to bill only for the services performed within the specialty or specialties designated in the provider application on file with the Agency. The services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting the claim. Compliance. The provider agrees to comply with all local, state and federal laws, rules, regulations, licensure laws, Medicaid bulletins, manuals, handbooks and Statements of Policy as they my be amended from time to time. Term and signatures. The parties agree that this is a voluntary agreement between the Agency and the provider, in which the provider agrees to furnish services or goods to Medicaid recipients. This provider agreement shall become effective the date the provider's Florida Medicaid Enrollment Application is received by the state or its fiscal agent. It shall remain in effect until July 1, 1999, unless otherwise terminated. This agreement shall be renewable only by mutual consent. The provider understands and agrees that no Agency signature is required to make this Agreement valid and enforceable. Provider Responsibilities. The Medicaid provider shall: * * * (b) Keep and maintain in a systematic and orderly manner all medical and Medicaid related records as the Agency may require and as it determines necessary; make available for state and federal audits for five years, complete and accurate medical, business, and fiscal records that fully justify and disclose the extent of the goods and services rendered and billings made under the Medicaid. The provider agrees that only records made at the time the goods and services were provided will be admissible in evidence in any proceeding relating to the Medicaid program. * * * (d) Except as otherwise provided by law, the provider agrees to provide immediate access to authorized persons (including but not limited to state and federal employees, auditors and investigators) to all Medicaid- related information, which may be in the form of records, logs, documents, or computer files, and all other information pertaining to services or goods billed to the Medicaid program. This shall include access to all patient records and other provider information if the provider cannot easily separate records for Medicaid patients from other records. * * * (f) Within 90 days of receipt, refund any moneys received in error or in excess of the amount to which the provider is entitled from the Medicaid program. * * * Accept Medicaid payment as payment in full . . . . . . . . The provider shall be liable for all overpayments for any reason and pay to the Agency any fine or overpayment imposed by the Agency or a court of competent jurisdiction. Provider agrees to pay interest at 12% per annum on any fine or repayment amount that remains unpaid 30 days from the date of any final order requiring payment to the Agency. * * * Agency Responsibilities. The Agency: (a) Unless claims have been pended for medical review or investigation of suspected fraud or abuse, will make payment within 60 days at the established rate for medically necessary services or goods furnished to an eligible recipient by the provider upon receipt of a properly completed claim. . . . Termination and Equitable Relief. This agreement may be terminated, with or without cause, upon thirty (30) days written notice by either party. . . . * * * (19) Assignability. The provider number is the property of the Agency and the provider may not assign its rights or obligation under this number or this Agreement without the express written consent of the Agency. * * * THE PROVIDER AGREES THAT THIS AGREEMENT SHALL MERGE AND BECOME A PART OF THE PROVIDER APPLICATION . . . . The Provider Reenrollment Request form that Petitioner submitted (with which the Second Provider Agreement "merge[d]") reflected that the "provider['s] name" was "Minkes, Jules G." At no time did Petitioner enroll in the Medicaid program as part of a group practice (consisting of two or more physicians).15 He was enrolled only as an individual provider, and he used his individual provider number (0466301-00) to bill the Medicaid program. All of the Medicaid claims that are the subject of the instant controversy were billed by Petitioner under his individual provider number. Manual and Handbook Provisions Among the "manuals" and "handbooks" Petitioner was required to "abide by" and "comply with" during the Audit Period pursuant to the First and Second Provider Agreements were the Medicaid Provider Reimbursement Handbook, HCFA-1500 (MPR Handbook) and the Physician Coverage and Limitations Handbook (PCL Handbook). Medical Necessity The PCL Handbook provided that the Medicaid program would reimburse for services "determined [to be] medically necessary" and not duplicative of another provider's service, and it went on to state as follows: In addition, the services must meet the following criteria: the services must be individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient's needs; the services cannot be experimental or investigational; the services must reflect the level of services that can be safely furnished and for which no equally effective and more conservative or less costly treatment is available statewide; and the service must be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a covered services. Note See Appendix D, Glossary, in the Medicaid Provider Reimbursement Handbook, HCFA-1500 and EPSDT 224, for the definition of medically necessary The term "medically necessary" was defined in Appendix D of the MPR Handbook as follows: Medically Necessary or Medical Necessity Means that the medical or allied care, goods, or services furnished or ordered must: Meet the following conditions: Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; Be individualized specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient's needs; Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider. "Medically necessary" or "medical necessity" for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service. Documentation Requirements The MPR Handbook required that: "medical records . . . state the necessity for and the extent of services provided"16; and the provider "retain all medical, fiscal, professional, and business records on all services provided to a Medicaid recipient" for "at least five years from the date of service." The handbook further provided that "payments for services that lack[ed] required documentation" would be recouped. Physician Supervision The PCL Handbook provided: Delivery of all services must be done by or under the personal supervision of the physician. Personal supervision means the physician: is in the building when the services are rendered, and signs and dates the medical record within 24 hours of providing the service. Enrollment Requirements The PCL Handbook and the MPR Handbook both mandated that two or more physicians practicing together as a group enroll in the Medicaid program as a "provider group" and that each member of the group enroll in the program as an individual provider. Under the provisions of the MPR Handbook, an "individual provider" was required to "report when the provider bec[ame] a member of a provider group or [was] no longer a member of a provider group." Coding Chapter 3 of the PCL Handbook "describe[d] the procedure codes for the services reimbursable by Medicaid that [had to be] used by physicians providing services to eligible recipients." As explained on the first page of this chapter of the handbook: The procedure codes listed in this chapter [were] Health Care Financing Administration Common Procedure Coding System (HCPCS) Levels 1, 2 and 3. These [were] based on the Physician[]s['] Current Procedural Terminology (CPT) book. The CPT include[d] HCPCS descriptive terms and numeric identifying codes and modifiers for reporting services and procedures. . . . The Physicians' Current Procedural Terminology At all times material to the instant case, the American Medical Association's Physicians' Current Procedural Terminology (or the "CPT") referred to in Chapter 3 of the PCL Handbook contained an "[i]ntroduction," which read, in pertinent part, as follows: Physicians' Current Procedural Terminology (CPT) is a systematic listing and coding of procedures and services performed by physicians. Each procedure is identified by a five digit code. . . . Inclusion of a descriptor and its associated specific five-digit identifying code number in CPT is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. . . . * * * Section Numbers and Their Sequences Evaluation and Management 99201 to 99499 * * * Surgery 10040 to 69979 Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) 70010 to 79999 * * * At all times material to the instant case, the CPT referred to in Chapter 3 of the PCL Handbook had "[e]valuation and [m]anagement (E/M) [s]ervice [g]uidelines" (E/M Guidelines). It was noted on the first page of the E/M Guidelines that: The E/M section is divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). The subcategories of the E/M services are further classified into levels of E/M services that are identified by specific codes. . . . "New and [e]stablished patient[s]" were described in the E/M Guidelines as follows: A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. The concept of "[l]evels of E/M [s]ervices" was described, in pertinent part, as follows in the E/M Guidelines: Within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. . . . The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventative pediatric and adult health supervision, and similar medical services, such as the determination of the need and/or location for appropriate care. Medical screening includes the history, examination, and medical decision-making required to determine the need and/or location for appropriate care and treatment of the patient . . . . The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E/M services may be used by all physicians. The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. The first three or these components (history, examination and medical decision making) are considered the key components in selecting a level of E/M services. . . . The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors in the majority of encounters. . . . * * * Time . . . . The inclusion of time as an explicit factor beginning in CPT 1992 is done to assist physicians in selecting the most appropriate level of E/M services. It should be recognized that the specific times expressed in the visit code descriptors are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances. * * * According to the E/M Guidelines, "[l]isted services [could] be modified under certain circumstances," with the "modifying circumstances" being "identified by the addition of [an] appropriate modifier code . . . ." Among the available "modifier codes" was one for "[p]rolonged [e]valuation and [m]anagement [s]ervices," which was explained in the E/M Guidelines as follows: When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of E/M service within a given category, it may be identified by adding the modifier "-21" to the E/M code number or by use of the separate five digit modifier code 09921. A report may also be appropriate. The E/M Guidelines contained "[i]nstructions for [s]electing a [l]evel of E/M [s]ervice," which read, in pertinent part, as follows: * * * Review of Level of E/M Service Descriptors and Examples in the Selected Category or Subcategory The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. The first three or these components (i.e., history, examination and medical decision making) are considered the key components in selecting a level of E/M services. An exception to this rule is in the case of visits which consist predominantly of counseling or coordination of care. . . . The nature of the presenting problem and time are provided in some levels to assist the physician in determining the appropriate level of E/M service. Determine the Extent of History Obtained The extent of history is dependent upon critical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of history that are defined as followed: Problem Focused: chief complaint; brief history of present illness or problem. Expanded Problem Focused: chief complaint; brief history of present illness; problem pertinent system review. Detailed: chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family and/or social history directly related to the patient's problems. Comprehensive: chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family and social history. * * * Determine the Extent of Examination Performed The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of examinations that are defined as follows: Problem Focused: a limited examination of the affected body area or organ system. Expanded Problem Focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive: a general multi-system examination or a complete examination of a single organ system. . . . For the purposes of these CPT definitions, the following body areas are recognized Head, including the face Neck Chest, including breasts and axilla Abdomen Genitalia, groin, buttocks Back Each extremity For the purposes of these CPT definitions, the following organ systems are recognized Eyes Ears, Nose, Mouth and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic Determine the Complexity of Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: the number of possible diagnoses and/or the number of management options that must be considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and -The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. Four types of medical decision making are recognized: straightforward; low complexity; moderate complexity; and high complexity. To qualify for a given type of decision making, two of the three elements [shown] below must be met or exceeded. Type of Decision Making: straightforward; Number of Diagnoses or Management Options: minimal; Amount and/or Complexity of Data to be Reviewed: minimal or none; Risk of Complications and/or Morbidity or Mortality: minimal Type of Decision Making: low complexity; Number of Diagnoses or Management Options: limited; Amount and/or Complexity of Data to be Reviewed: limited; Risk of Complications and/or Morbidity or Mortality: low Type of Decision making: moderate complexity; Number of Diagnoses or Management Options: multiple; Amount and/or Complexity of Data to be Reviewed: moderate; Risk of Complications and/or Morbidity or Mortality: moderate Type of Decision Making: High complexity; Number of Diagnoses or Management Options: extensive; Amount and/or Complexity of Data to be Reviewed: extensive; Risk of Complications and/or Morbidity or Mortality: high Select the Appropriate Level of E/M Services Based on the Following For the following categories/ subcategories, all of the key components, i.e., history, examination, and medical decision making, must meet or exceed the stated requirements to qualify for a particular level of E/M service: office, new patient; . . . For the following categories/ subcategories, two of the three key components, (i.e., history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service: office, established patient; . . . In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office . . . ), then time is considered the key or controlling factor to qualify for a particular level of E/M services. The extent of counseling and/or coordination of care must be documented in the medical record. At all times material to the instant case, the CPT referred to in Chapter 3 of the PCL Handbook contained the following codes and code descriptions for "E/M" office and other outpatient services: New Patient 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problems are self- limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. * * * 99202 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. * * * 99203 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. * * * 99204 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. * * * 99205 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problems are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. * * * Established Patient 99211 Office or other outpatient visit for the evaluation and management of an established patient that may or may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. * * * 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self- limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. * * * 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. * * * 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. * * * 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. It is a rarity for an osteopathic internist to provide office services at the 99205 or 99215 "E/M" code level. Generally speaking, office services at the 99203 and 99213 "E/M" code levels are the most common types of office services that osteopathic internists provide. Typically, osteopathic internists provide a "higher percentage" of office services at the 99204 and 99214 "E/M" code levels than at the 99202 and 99212 "E/M" code levels.17 The experience or expertise of the provider is not a factor to be taken into consideration in determining the appropriate "E/M" code level. The Audit and Aftermath Commencing in 1998, AHCA conducted an audit of paid Medicaid claims submitted by Petitioner for services assertedly rendered from March 1, 1996, through March 17, 1998. The audit was undertaken because it had been determined, from a review of the Medicaid provider database maintained by AHCA, that Petitioner had billed for more "chest x-rays and various radiology [tests]" than the "average provider."18 Petitioner had submitted 2,571 Medicaid claims for services assertedly rendered during the Audit Period to 314 patients, for which he had received payments totaling $134,597.58. From the 314 Medicaid patients to whom Petitioner had assertedly provided services during the Audit Period, AHCA randomly selected, by computer, a "cluster sample" of 42, and asked Petitioner to produce the medical records he had on file for these 42 patients. Petitioner had submitted a total of 386 claims for services assertedly rendered to the 42 patients in the "cluster sample" during the Audit Period and had received a total of $20,823.33 in Medicaid payments for these services. Each of these claims was reviewed by AHCA to determine whether it was supported by information contained in the medical records produced by Petitioner in response to AHCA's medical records request. Based on a preliminary review conducted by AHCA staff and a physician consultant (John Sullenberger, M.D.), AHCA determined that Petitioner had been overpaid a total $98,545.98 for the Medicaid claims he had submitted for services assertedly rendered during the Audit Period. After having been advised of this preliminary determination, Petitioner sent additional documentation to AHCA. The additional documentation was reviewed by AHCA staff and Dr. Sullenberger. Following this review, the overpayment was recalculated by AHCA and determined to be $94,208.27. As noted above, by letter dated June 29, 1999, Petitioner was notified of this recalculation and advised of his right to request an administrative hearing on the matter. After Petitioner requested such a hearing, in or around March of 2000, as a result of the Legislature's enactment of the "peer review" provisions of Section 409.9131, Florida Statutes, which became effective July 1, 1999, AHCA retained the services of Richard Thacker, D.O., an osteopathic physician, like Petitioner, Board-certified in internal medicine. Dr. Thacker received his medical education at Nova Southeastern University, College of Osteopathic Medicine, from which he graduated in 1992. After graduation, he obtained "internal medicine training" for three years in the internship and residency program at Delaware Valley Medical Center in Langhorne, Pennsylvania. In 1995, he returned to Florida, and has been in "active practice" as an osteopathic physician in the state since his return. His experience includes "working in Medicaid clinics." He currently practices with the Medical Group of North Florida, a Tallahassee "multi-specialty group with primary emphasis on general internal medicine." Aside from his practice, among other things, he serves as: the chairman of the Tallahassee Community Hospital's Department of Medicine; the Medical Director of Outpatient Services at Health South Rehabilitation Hospital of Tallahassee; the Medical Director of Long Term Care at Capital Health Care Center; the Medical Director of American Home Patient Home Health; and an Associate Professor for Clinical Instruction at Florida State University College of Medicine. At AHCA's request, Dr. Thacker reviewed all of the records that Petitioner had provided regarding the 42 patients in the "cluster sample" (including those records that had been furnished after June 29, 1999)19 to determine whether there was documentation to support the Medicaid claims relating to these patients that Petitioner had submitted for services assertedly rendered during the Audit Period.20 On or about May 15, 2000, after Dr. Thacker completed his review, the overpayment was again recalculated by AHCA and determined to be $84,486.25. On or about June 12, 2003, following a meeting between Dr. Thacker and Petitioner held the afternoon of the first day of hearing in this case, AHCA made another downward revision in its overpayment calculation, this time to $70,629.68.21 AHCA has made no additional revisions to its overpayment calculation in the instant case. It maintains that Petitioner received $70,629.68 in Medicaid overpayments for services claimed to have been provided during the Audit Period. Respondent's Exhibit 25 contains spreadsheets prepared by AHCA which identify all of the alleged overpaid claims (of the 386 reviewed) and, for each such claim, specify the amount of the alleged overpayment and AHCA's reason(s) for determining that an overpayment was made. Where AHCA alleges "upcoding" (that is, billing for a higher (and more costly) "level of E/M service" than Petitioner's documentation reveals was actually provided) or "inappropriate cod[ing]" of a surgical or radiological procedure, and no other billing deficiency is asserted, the procedure code deemed appropriate by AHCA, based on the documentation furnished by Petitioner, is also specified. The spreadsheets that comprise Respondent's Exhibit 25 accurately identify (as "not documented") those claims (of the 386 reviewed) that were for services not shown, by the documentation Petitioner has furnished AHCA, to have been actually provided (by anyone). The monies Petitioner received for these claimed, but undocumented, services constitute overpayments. The spreadsheets that comprise Respondent's Exhibit 25 accurately identify (through entries made in the "not group member" columns thereof) those claims (of the 386 reviewed) that were for services not shown, by the documentation Petitioner has furnished AHCA, to have been provided by Petitioner or under his "personal supervision," as that term was described in the materials Petitioner was required to "abide by" and "comply with" during the Audit Period pursuant to the First and Second Provider Agreements. The monies Petitioner received for these claimed services not documented as having been provided by him or under his "personal supervision" as required by the First and Second Provider Agreements constitute overpayments. The spreadsheets that comprise Respondent's Exhibit 25 accurately identify those claims (of the 386 reviewed) that were for services not shown, by the documentation Petitioner has furnished AHCA, to have been "medically necessary," as that term was used in the materials Petitioner was required to "abide by" and "comply with" during the Audit Period pursuant to the First and Second Provider Agreements. The monies Petitioner received for these claimed services not documented as having been "medically necessary" as required by the First and Second Provider Agreements constitute overpayments. The spreadsheets that comprise Respondent's Exhibit 25 accurately identify (through entries made in the "levels of care" columns thereof) those claims (of the 386 reviewed) that were "upcoded."22 The documentation Petitioner has furnished AHCA supports "adjust[ed]" "levels of E/M service" no higher than those indicated in the "adjust" columns of the spreadsheets. For each "upcoded" claim, Petitioner was overpaid in an amount equal to what he received minus what he would have received had he billed at the "adjust[ed]" level specified on Respondent's Exhibit 25. The spreadsheets that comprise Respondent's Exhibit 25 accurately identify those claims for radiological services that, following the meeting between Dr. Thacker and Petitioner, it was agreed were "inappropriate[ly] cod[ed]," and they further reflect the correct codes and reimbursement amounts for these "inappropriate[ly] cod[ed]" services. The difference between the amount Petitioner was reimbursed for each such "inappropriate[ly] cod[ed]" service and the correct reimbursement amount set forth on Respondent's Exhibit 25 represents an overpayment. As Respondent's Exhibit 25 indicates, the office services Petitioner claimed he provided Patient #79 on October 20, 1997, for which he billed Medicaid at the 99214 "E/M" code level, as well as the office services he claimed he provided Patient #203 on February 16, 1998, for which he billed Medicaid at the 99215 "E/M" code level, were wholly non- reimbursable inasmuch as the documentation concerning these office visits does not reveal that, in either case, the patient received services justifying reimbursement at even the lowest "E/M" code level (99211) for an established patient. As Respondent's Exhibit 25 also indicates, Petitioner's claim for the January 7, 1998, excision of a benign lesion from Patient #264's left ankle was "inappropriate[ly] coded." Given what the documentation Petitioner has furnished AHCA reveals about the size of the lesion and what needed to be done to remove it and close the resulting wound, in billing Medicaid for this service, Petitioner should have used the 11401 procedure code, instead of the 11404 procedure code, which has a higher reimbursement rate. In making its final overpayment calculation, AHCA determined, correctly, that Petitioner was overpaid a total of $11,913.23, or $30.86329051 per claim, for the 386 claims he had submitted seeking reimbursement from Medicaid for services assertedly rendered during the Audit Period to the 42 patients in the "cluster sample." Using a statistical formula that Petitioner has admitted is valid, AHCA extended these results to the total "population" of 2,571 Medicaid claims that Petitioner had submitted for services assertedly rendered during the Audit Period, and it correctly calculated that Petitioner had been overpaid a total of $70,629.68. Simple Mistake or Fraud? There has been no allegation made, nor proof submitted, that any of the overbillings referenced above were the product of anything other than simple mistake or inadvertence on Petitioner's part.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that AHCA enter a final order finding that Petitioner received $70,629.68 in Medicaid overpayments for paid claims covering the period from March 1, 1996, through March 17, 1998, and requiring Petitioner to repay this amount to AHCA. DONE AND ENTERED this 28th day of January, 2004, in Tallahassee, Leon County, Florida. S STUART M. LERNER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 28th day of January, 2004.
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, including the parties' Joint Prehearing Stipulation, the following findings s of fact are made: Petitioner and his Practice Petitioner is a general practice physician. He has been licensed to practice medicine in Florida for the past ten years. He is now, and has been at all times material to the instant case, in private practice in Miami-Dade County, Florida Petitioner's Participation in the Medicaid Program During the Audit Period, Petitioner was authorized to provide physician services to eligible Medicaid patients. Petitioner provided such services pursuant to a valid provider agreement with AHCA.4 Petitioner's Medicaid provider number was, and remains, 3759873 00 Petitioner billed all of the Medicaid claims that are the subject of the instant controversy under this (individual) provider number. Handbook Provisions As a prerequisite to his entitlement to Medicaid payment for services rendered during the Audit Period, Petitioner was required to comply with, among other things, the provisions of the Physician Coverage and Limitations Handbook (PCL Handbook) then in effect. Medical Necessity Chapter 2 of the PCL Handbook provided that the Medicaid program would reimburse physician providers for services "determined [to be] medically necessary" and not duplicative of another provider's service, and it went on to state as follows: In addition, the services must meet the following criteria: the services must be individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient's needs; the services cannot be experimental or investigational; the services must reflect the level of services that can be safely furnished and for which no equally effective and more conservative or less costly treatment is available statewide; and the service must be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a covered services. Radiology Services Chapter 2 of the PCL Handbook further provided that, "[t]o be reimbursed the maximum fee [or 'global fee'] for a radiology service, the physician must provide both the technical and professional components." A physician provider billing the "global fee" was not authorized, pursuant Chapter 2 of the PCL Handbook, to also seek additional payment for the "professional component" of that fee. Doing so amounted to impermissible "double-billing." Coding Chapter 3 of the PCL Handbook "describe[d] the procedure codes for the services reimbursable by Medicaid that [had to be] used by physicians providing services to eligible recipients." As explained on the first page of this chapter of the handbook: The procedure codes listed in this chapter [were] Health Care Financing Administration Common Procedure Coding System (HCPCS) Levels 1, 2 and 3. These [were] based on the Physician[]s['] Current Procedural Terminology (CPT) book. The CPT include[d] HCPCS descriptive terms and numeric identifying codes and modifiers for reporting services and procedures. . . . The Physicians' Current Procedural Terminology At all times material to the instant case, the American Medical Association's Physicians' Current Procedural Terminology (or the "CPT") referred to in Chapter 3 of the PCL Handbook contained an "[i]ntroduction," which read, in pertinent part, as follows: Current Procedural Terminology, Fourth Edition (CPT) is a systematic listing and coding of procedures and services performed by physicians. Each procedure or service is identified by a five digit code. . . . Inclusion of a descriptor and its associated specific five-digit identifying code number in CPT is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. . . . * * * Section Numbers and Their Sequences Evaluation and Management 99201 to 99499 * * * Surgery 10040 to 69979 Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) 70010 to 79999 Pathology and Laboratory 80002 to 89399 Medicine (except Anesthesiology) 90701 to 99199 * * * The CPT had "[e]valuation and [m]anagement (E/M) [s]ervice [g]uidelines" (E/M Guidelines). It was noted on the first page of the E/M Guidelines that: The E/M section is divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). The subcategories of the E/M services are further classified into levels of E/M services that are identified by specific codes. . . . "New and [e]stablished patient[s]" were described in the E/M Guidelines as follows: A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. The concept of "[l]evels of E/M [s]ervices" was described, in pertinent part, as follows in the E/M Guidelines: Within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. Levels of E/M services are not interchangeable among the different categories of service. For example, the first level of E/M services in the subcategory of office visit, new patient, does not have the same definition as the first level of E/M services in the subcategory of office visit, established patient. The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventative pediatric and adult health supervision, and similar medical services, such as the determination of the need and/or location for appropriate care. Medical screening includes the history, examination, and medical decision-making required to determine the need and/or location for appropriate care and treatment of the patient (e.g., office and other outpatient setting, emergency department, nursing facility, etc.). The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E/M services may be used by all physicians. The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. The first three of these components (history, examination and medical decision making) are considered the key components in selecting a level of E/M services. . . . The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors in the majority of encounters. . . . * * * The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician's interpretation of the results or diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with the modifier -26 appended. * * * Time . . . . The inclusion of time as an explicit factor beginning in CPT 1992 is done to assist physicians in selecting the most appropriate level of E/M services. It should be recognized that the specific times expressed in the visit code descriptors are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances. * * * The E/M Guidelines contained "[i]nstructions for [s]electing a [l]evel of E/M [s]ervice," which read, in pertinent part, as follows: * * * Review of Level of E/M Service Descriptors and Examples in the Selected Category or Subcategory The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. The first three or these components (i.e., history, examination and medical decision making) are considered the key components in selecting a level of E/M services. An exception to this rule is in the case of visits which consist predominantly of counseling or coordination of care. . . . The nature of the presenting problem and time are provided in some levels to assist the physician in determining the appropriate level of E/M service. Determine the Extent of History Obtained The extent of history is dependent upon clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of history that are defined as followed: Problem Focused: chief complaint; brief history of present illness or problem. Expanded Problem Focused: chief complaint; brief history of present illness; problem pertinent system review. Detailed: chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family and/or social history directly related to the patient's problems. Comprehensive: chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family and social history. * * * Determine the Extent of Examination Performed The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of examinations that are defined as follows: Problem Focused: a limited examination of the affected body area or organ system. Expanded Problem Focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive: a general multi-system examination or a complete examination of a single organ system. . . . For the purposes of these CPT definitions, the following body areas are recognized Head, including the face Neck Chest, including breasts and axilla Abdomen Genitalia, groin, buttocks Back Each extremity For the purposes of these CPT definitions, the following organ systems are recognized Eyes Ears, Nose, Mouth and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic Determine the Complexity of Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: the number of possible diagnoses and/or the number of management options that must be considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and -The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. Four types of medical decision making are recognized: straightforward; low complexity; moderate complexity; and high complexity. To qualify for a given type of decision making, two of the three elements [shown below] must be met or exceeded. Type of Decision Making: straightforward; Number of Diagnoses or Management Options: minimal; Amount and/or Complexity of Data to be Reviewed: minimal or none; Risk of Complications and/or Morbidity or Mortality: minimal Type of Decision Making: low complexity; Number of Diagnoses or Management Options: limited; Amount and/or Complexity of Data to be Reviewed: limited; Risk of Complications and/or Morbidity or Mortality: low Type of Decision making: moderate complexity; Number of Diagnoses or Management Options: multiple; Amount and/or Complexity of Data to be Reviewed: moderate; Risk of Complications and/or Morbidity or Mortality: moderate Type of Decision Making: High complexity; Number of Diagnoses or Management Options: extensive; Amount and/or Complexity of Data to be Reviewed: extensive; Risk of Complications and/or Morbidity or Mortality: high Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making. Select the Appropriate Level of E/M Services Based on the Following For the following categories/ subcategories, all of the key components, i.e., history, examination, and medical decision making, must meet or exceed the stated requirements to qualify for a particular level of E/M service: office, new patient; hospital observation services; initial hospital care; office consultations; initial inpatient consultations; confirmatory consultations; emergency department services; comprehensive nursing facility assessments; domiciliary care, new patient; and home, new patient. . . For the following categories/ subcategories, two of the three key components, (i.e., history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service: office, established patient; subsequent hospital care; follow-up inpatient consultations; subsequent nursing facility care; domiciliary care, established patient; and home, established patient. In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility) then time is considered the key or controlling factor to qualify for a particular level of E/M services. The extent of counseling and/or coordination of care must be documented in the medical record.[5] The CPT contained the following codes and code descriptions for "E/M" office and other outpatient services: New Patient 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problems are self- limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. * * * 99202 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. * * * 99203 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. * * * 99204 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. * * * 99205 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problems are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. * * * Established Patient 99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. * * * 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self- limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. * * * 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. * * * 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. * * * 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. The CPT provided separate codes for "prolonged physician service with direct (face-to-face) patient contact" and contained the following explanation as to when these codes were to be used: Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to other physician service, including evaluation and management service at any level. Appropriate codes should be selected for supplies or procedures performed in the care of the patient during this period. Codes 99354-99357 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service. Either code also may be used to report a total duration of prolonged service of 30-60 minutes on a given date. Either code should be used only once per date, even if the time spent by the physician is not continuous on that date. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes. Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Either code may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. * * * The Audit and Aftermath Commencing in or around August 2000, AHCA conducted an audit of paid Medicaid claims submitted by Petitioner for services assertedly rendered from May 22, 1998, through May 22, 2000.6 Petitioner had submitted 4,574 Medicaid claims for services assertedly rendered during the Audit Period to 492 patients, for which he had received payments totaling $156,903.14. From the 492 Medicaid patients to whom Petitioner had assertedly provided services during the Audit Period, AHCA randomly selected a "cluster sample" of 41, and obtained from Petitioner medical records he had on file for these 41 patients. Petitioner had submitted a total of 325 claims for services assertedly rendered to the 41 patients in the "cluster sample" during the Audit Period and had received a total of $11,562.14 in Medicaid payments for these services.7 Each of these claims was reviewed to determine whether it was supported by information contained in the medical records obtained from Petitioner. Based on a preliminary review, AHCA determined that Petitioner had been overpaid a total $58,157.96 for the Medicaid claims he had submitted for services assertedly rendered during the Audit Period. By letter dated September 10, 2002, AHCA advised Petitioner of this preliminary determination and "encourage[d] [him] to submit any additional information or documentation" in his possession that he believed would "serve to reduce the overpayment." The antepenultimate and penultimate paragraphs of the letter read as follows: Since you have a choice of accepting the above overpayment or submitting additional information, this is not a final action by the Agency for Health Care Administration. If you have not made payment within thirty (30) days, we will prepare and send to you the final agency determination, taking into consideration any information or documentation that you submit within that time period. Petitioner did not "ma[k]e payment within thirty (30) days" of AHCA's September 10, 2002, letter. As promised, following another review conducted after the expiration of this 30-day period, AHCA "prepare[d] and sen[t] to [Petitioner]" its Final Agency Audit Report showing the calculation of overpayments made to Petitioner during the Audit Period.8 AHCA's Final Agency Audit Report was dated January 28, 2003, and in the form of a letter to Petitioner, which read, in pertinent part, as follows: Medicaid Integrity has completed the review of your Medicaid claims for the procedures specified below for dates of service during the period May 22, 1998 through May 22, 2000. A Provisional Agency Audit Report, dated September 10, 2002, was sent to you indicating that we had determined you were overpaid $58,157.96. Based upon a review of all documentation submitted, we have determined that you were overpaid $58,157.96 for services that in whole or in part are not covered by Medicaid. Pursuant to Section 409.913, Florida Statutes (F.S.), this letter shall serve as notice of the following sanction(s): The provider is subject to comprehensive follow-up review in six months. In determining the appropriateness of Medicaid payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, limitations and 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[9] and Medicaid fee schedules, as promulgated in the Medicaid policy handbooks, billing bulletins, and the Medicaid provider agreement. Medicaid cannot pay for services that do not meet these guidelines. The following is our assessment of why certain claims paid to your provider number do not meet Medicaid requirements. The audit work papers detailing the claims affected by this assessment are attached. REVIEW DETERMINATION(S) Medicaid policy specifies how medical records must be maintained. A review of your medical records revealed that some services for which you billed and received payment were not documented. Medicaid requires documentation of the services and considers payments made for services not appropriately documented an overpayment. Medicaid policy defines the varying levels of care and expertise required for the evaluation and management procedure codes for office visits. The documentation you provided supports a lower level of office visit than the one for which you billed and received payment. The difference between the amounts you were paid and the correct payment for the appropriate level of service is considered an overpayment. Medicaid policy requires services performed be medically necessary for the diagnosis and treatment of an illness. You billed and received payments 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. The claims, which were considered medically unnecessary, were disallowed and the money you were paid for these procedures is considered an overpayment. Medicaid policy addresses specific billing requirements and procedures. In some instances, you billed a procedure code as global and also billed the professional when the professional component was incorporated in the global fee. The difference between the amounts you were paid and the appropriate fee is considered an overpayment. The overpayment was calculated as follows: A random sample of 41 recipients respecting whom you submitted 325 claims was reviewed. For those claims in the sample which have dates of service from May 22, 1998, through May 22, 2000, an overpayment of $5,004.04 or $15.39704606 per claim was found, as indicated on the accompanying schedule. Since you were paid for a total (population) of 4,574 claims for that period, the point estimate of the total overpayment is $15.39704606 x 4,574=$70,426.09. There is a 50 percent probability that the overpayment to you is that amount or more. There was then an explanation of the "statistical formula for cluster sampling" that AHCA used and how it "calculated that the overpayment to [Petitioner was] $58,157.96 with a ninety-five percent (95%) probability that it is that amount or more." The concluding portions of the letter advised Petitioner of his right to "request an administrative hearing [on this overpayment determination] pursuant to Sections 120.569 and 120.57, Florida Statutes." The "Medicaid physician consultant" referred to in AHCA's January 28, 2003, letter was Lisa Kohler, M.D., a Florida-licensed "family physician," who is certified by the American Board of Family Practice and is a fellow of the American Academy of Family Physicians. Dr. Kohler received her medical education at the University of South Florida College of Medicine, from which she graduated in 1985. After graduation, she did her internship and residency at Tallahassee Memorial Regional Medical Center's Family Practice Residency program. In 1988, following the completion of her residency, she entered private practice. She currently serves as the Associate Director of the Tallahassee Memorial Regional Medical Center's Family Practice Residency program. In addition, she is a Clinical Assistant Professor in the Department of Family Medicine at the University of South Florida College of Medicine and the Volunteer Medical Director of the Neighborhood Health Services in Tallahassee, Florida, a health clinic that provides free medical care to indigent patients. In accordance with the "peer review" provisions of Section 409.9131, Florida Statutes, which became effective July 1, 1999, AHCA had Dr. Kohler review all of the records that Petitioner had provided regarding the 41 patients in the "cluster sample"10 to determine whether there was documentation to support the Medicaid claims relating to these patients that Petitioner had submitted for services assertedly rendered during the Audit Period. In conducting her "peer review," Dr. Kohler did not interview any of the 41 patients in the "cluster sample," nor did she take any other steps to supplement the information contained in the records she examined. Her assessment of the propriety of Petitioner's billing was based exclusively on what was in those records and no other information. On February 19, 2003, Petitioner requested an administrative hearing on the overpayment determination (announced in AHCA's January 28, 2003, letter to Petitioner). On or about August 20, 2003, following a meeting between the parties, AHCA made a downward revision in its overpayment calculation, to $47,931.79. AHCA has made no additional revisions to its overpayment calculation in the instant case. It maintains that Petitioner received $47,931.79 in Medicaid overpayments for services claimed to have been provided during the Audit Period. In making this final overpayment calculation, AHCA determined, correctly, that Petitioner was overpaid a total of $3,867.62, or $11.90036931 per claim, for the 325 claims he had submitted seeking reimbursement from Medicaid for services assertedly rendered during the Audit Period to the 41 patients in the "cluster sample." Using a statistical formula the validity of which Petitioner has not disputed, AHCA extended these results to the total "population" of 4,574 Medicaid claims that Petitioner had submitted for services assertedly rendered during the Audit Period, and it correctly calculated that Petitioner had been overpaid a total of $47,931.79. Simple Mistake or Fraud? There has been no allegation made, nor proof submitted, that any of Petitioner's overbillings was the product of anything other than simple mistake or inadvertence on Petitioner's part.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that AHCA enter a final order finding that Petitioner received $47,931.79 in Medicaid overpayments for paid claims covering the period from May 22, 1998, through May 22, 2000, and requiring Petitioner to repay this amount to AHCA. DONE AND ENTERED this 15th day of June, 2004, in Tallahassee, Leon County, Florida. S STUART M. LERNER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 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 June, 2004.
The Issue Whether Department of Health and Rehabilitative Services ("HRS") Rules 10- and 10-17.005 (originally published as 10-16.001, 10-16.005), Florida Administrative Code, constitute an invalid exercise of delegated legislative authority.
Findings Of Fact Standing Humana is a corporation engaged in the business of constructing and operating hospitals in Florida. It has applied to HRS for a certificate of need to construct and operate a 100-bed acute care hospital to be located south of the St. Johns River in the area known as Mandarin, in Duval County, Florida. The challenged Subdistrict Rule places this area in Subdistrict 3 of HRS District IV. Humana's (Mandarin) application for a certificate of need (CON) was denied by HRS on February 23, 1983, and Humana requested a formal Section 120.57(1), hearing. The case was then transferred to the Division of Administrative Hearings and assigned Case Number 83-934. The final hearing in that CON case began on September 6, 1983, and recessed on September 7, 1983. In the instant case--on Humana's request, and without objection by HRS--official recognition was given to the transcript of that hearing, as filed with the Division of Administrative Hearings. Prior to the CON hearing in Case Number 83-934, on August 12, 1983, HRS published proposed Rules 10-16.001 and 10-16.005 ("Subdistrict Rule") at Volume 9, Number 32, pages 1952 through 1957, Florida Administrative Weekly. (Petitioner's Exhibit No. 1) After the CON hearing recessed, and after a public hearing on the proposed Subdistrict Rule, HRS published changes to the rule on September 23, 1983, at Volume 9, No. 38, page 2475-2476, Florida Administrative Weekly. These changes were made in response to comments which HRS received at a public hearing held on the proposed rule. (Petitioner's Exhibit No. 2) On September 26, 1983, HRS filed the Subdistrict Rule with the Department of State for adoption, effective October 16, 1983. (Petitioner's Exhibit No. 3) Thereafter, the Bureau of Administrative Code, Department of State, informed HRS that since other rules were already numbered in Chapter 10-16, Florida Administrative Code, the Subdistrict Rule would be published in Chapter 10-17, Florida Administrative Code. (Petitioner'S Exhibit No. 28) At the CON hearing, Humana attempted to introduce evidence which HRS challenged as inconsistent with Rule 10-5.11(23) the state-wide acute care bed- need rule, and the Subdistrict Rule--then a proposed rule not yet adopted by HRS. The presiding hearing officer, acknowledging the "proposed rule" status of the Subdistrict Rule, sustained HRS objections to the admission of evidence proposing a methodology, or subdistrict bed-need allocations, inconsistent with those contained in the (proposed) Subdistrict Rule. He did, however, rule that the two non-agency parties could offer evidence for the purpose of showing that HRS, or the local health council in conjunction with HRS, had developed bed-need formula or techniques for subdistricts beyond, or inconsistent with, the proposed Subdistrict Rule and the underlying local health council's district plan. (DOAH Case No. 83-934, pp. 220-221, Transcript of Hearing). II. The Rule Adoption Process In response to Section 381.494(7)(b), Florida Statutes (1983), requiring local health councils to develop district plans using a "uniform methodology," HRS transmitted to the councils written guidelines for designating and allocating bed-need among various subdistricts. (Petitioner's Exhibit Dos. 9 and 10) The statute does not express or imply that the word, "methodology" should be given a meaning other than that assigned by ordinary and common usage. Webster's Seventh New Collegiate Dictionary defines the term as: "a body of methods, rules and postulates; a particular procedure or set of procedures." A methodology is not necessarily a mathematical formula. These guidelines, transmitted to the local health councils in early 1983, describe the relationship between HRS and the councils, the format and content elements of district health plans, and the requirements for stating district health care policies and priorities. Examples are provided. The guidelines require that local plans contain a district health profile--an overview of the area's population characteristics, community health status and prevailing health related attitudes and behaviors. Components are also required, including detailed information on the district's health care resource inventories, costs and utilization patterns, analysis of local services as well as recommendations and priorities for future health systems development. For at least three types of existing health care facilities--acute care hospitals, nursing homes, and psychiatric specialty hospitals information must be provided on current capacity, physical status, service areas, and recommendations for future developments. A time frame is imposed for accomplishing each phase of the plan development, with the final phase adoption of the local health plan--to be accomplished by December, 1983. Finally, the guidelines, at page 15, point out the statutory requirement that HRS adopt, by rule, those elements of the approved district plans necessary for review of applications for certificates of need: Adoption Into Rules Section 7(b) of Chapter 381.493 states that "Elements of an approved district plan necessary to the review of any certificate of need application shall be adopted by the Department as a part of its rules." This should be kept in mind through- out the plan development process. Local policies and priorities are the items most pertinent to certificate of need review since information on bed need and capacity are either determined at the state level or must be updated to the time of certificate of need application, review and appeal. There- fore, the local health council will be ex- pected to develop a separate submission of their policies and priorities in the proper format for rule promulgation within thirty days of the adoption of the local health plan. State agency staff will assist in the development and refinement of these documents. (Petitioner'S Exhibit No. 9) HRS interpreted its responsibility under Section 381.494, as one of assuring that district health plans were consistent with the state-wide uniform bed-need methodology prescribed in Rule 10-5.11(23). Under subparagraph "d" of that rule, local health plans must designate subdistricts according to HRS guidelines. Subparagraph "e" requires that beds be allocated to designated subdistricts consistent with the total number of beds allocated to the district under the rule, and consistent with subparagraph "i," which contains geographic accessibility standards. Rule 10-5.11(23) * * * * * Acute Care Service Subdistrict Designation. Acute care service sub- district designations shall be adopted, as necessary, by each Local Health Council as an element of its local health plan according to guidelines developed by the State Health Planning Agency. Designations will become effective for the purposes of this rule upon the filing of the adopted local health plan acute care subdistricting elements with the Secretary of State. Subdistrict Bed Allocations. Subdistrict bed allocations by type of service shall be made by the Local Health Councils consistent with the district total acute care bed allocation as determined by the methodology contained in paragraph (f) below, as well as any adjustments to the allocation as determined by the provisions of paragraphs and (h) below. Such allocations shall also be consistent with the provisions 9f paragraph (i) and the requirements of Section 381.494(7)(b) , Florida Statutes. * * * * * Geographic Accessibility Considerations. Acute care hospital beds should be available and accessible within an automobile travel time of 30 minutes under average travel conditions to at least 90 percent of the population residing in an urban area subdistrict. Acute care hospital beds should be available and accessible within a maximum automobile travel time of 45 minutes under average travel conditions to at least 90 percent of the population residing in a rural area sub- district. The elements of the District IV health plan contained in the Sub- district Rule are consistent with the uniform methodology prescribed in Rule 10-5.11(23) and HRS guidelines. In response to these guidelines, the District IV health council adopted and transmitted to HRS, on July 7, 1983, the acute care component of the district health plan. After the district council approved this component and allocated beds to the various subdistricts, HRS supplied updated population figures resulting in an increase in the total number of beds allocated to the district. The council's staff then adjusted the number of beds allocated to the subdistricts on a pro rata basis. These adjustments were consistent with the council's policy, as reflected by its approval of the acute care component. No evidence has been presented to show that the council's staff lacked authority to make these adjustments. (Petitioner's Exhibit No. 7) In addition to allocating district wide bed-need among the subdistricts of District IV, the acute care component contains detailed information and analysis concerning acute care bed-need. This information is pertinent but not necessary to the review of CON applications in District IV. (Petitioner's Exhibit No 7) The challenged Subdistrict Rule simply designates subdistricts and allocates bed-need among them; other data and analysis contained in the acute care component are not included. HRS, however, is now drafting an addition to the Subdistrict Rule (Section 10-17.005), titled "subsection (3), Acute Care Policies and Priorities," which incorporates additional portions of the district plan for use in reviewing CON applications in District IV. This draft rule allows exceptions based on local conditions: When there are more than one widely separated hospital service areas located within a single subdistrict, such as St. Augustine in South Duval Subdistrict 3, Bunnell and Daytona Beach in Subdistrict 4, and unforeseen growth, change and makeup of population, or other circumstances cause a significant increase in the demand for inpatient care within one of the service areas, the State should make exception to the District Health Plan when it is reasonable and logical to do so. (Petitioner'S Exhibit No. 34) This provision was contained in the district plan at the time HRS adopted the Subdistrict Rule. (Petitioner'S Exhibit No. 7) The Subdistrict Rule, with the exception of St. Lukes' Hospital, allocates beds among the subdistricts on the basis of the number of patient-days currently utilized by the hospitals in each subdistrict, projected for 1988. St. Lukes' Hospital, now located on the north side of the St. John's River in Subdistrict 1, will move to the south side of the St. John's River in Subdistrict 3, the subdistrict where Humana seeks to build its Mandarin hospital. This move from north to south is accounted in the subdistrict allocation by assuming that 34 percent of the current (north) St. Lukes' Hospital patient-days will come with the hospital when it moves from Subdistrict 1 to Subdistrict 3, and that the remainder will come from Subdistrict 3 (south) patients. With 66 percent of St. Lukes' bed capacity allocated for Subdistrict 3, there will be no additional bed-need in that subdistrict for years. HRS prepared an economic impact statement (EIS) in connection with its adoption of the subdistrict rules, including the Subdistrict Rule under challenge. The EIS addresses the agency's cost to implement the proposed rules, the cost or economic benefit to persons directly affected, and the affect on competition. The data and methods used in preparing the EIS are also briefly summarized.
The Issue Whether Petitioner was overpaid for those Medicaid claims which, according to the post-hearing submissions of the parties, remain in dispute.
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Jay's Medical Center Jay's Medical Center (hereinafter referred to as "JMC") is a medical clinic located in a low income area in Miami. It is staffed by three physicians, including Shelley Wolland, D.O., the clinic's Medical Director, 6/ and several support staff. In general, the community JMC serves is poorly educated and has a relatively high incidence of medical problems. Approximately 7,000 members of the community receive medical services at JMC, with anywhere from 40 to 80 patients receiving services in a single day. Many of the clinic's patients are Medicaid recipients. The Provider Agreement JMC is now, and has been since May of 1990, when it entered into a Non- Institutional Professional and Technical Medicaid Provider Agreement with the Department, authorized to provide physician services, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) services, and family planning services to its Medicaid patients eligible to receive such services. The provider agreement between JMC and the Department provided as follows: The provider agrees that services will be provided to recipients of the Florida Medicaid Program without regard to race, color, religion, national origin, or handicap. The provider agrees to keep for 5 years complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billing made under the Medicaid program and agrees to furnish the State Agency and Medicaid Fraud Control unit upon request such information regarding any payments claimed for providing these services. Access to the pertinent patient records and facilities by authorized Medicaid program representatives will be permitted upon reasonable request. All records relating to Medicaid recipients are to be held confidential as provided under 42 CFR 431.305 and 306. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, Medicaid compensable and of quality comparable to those furnished by the provider's peers, and the services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting a claim. The provider agrees to submit Medicaid claims in accordance with program policies and that payment by the program for services rendered will be based on the payment methodology in the applicable Florida Administrative Rule. The provider in executing this agreement acknowledges that he understands that payment of Florida Medicaid claims is made from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. The providers of Independent Laboratory, Portable X-Ray Services, Home Health Services, Hospice and Rural Health Clinic Services agree to furnish the Office of Licensure and Certifi- cation a completed copy of Form HCFA-1513 (Ownership and Control Interest Disclosure Statement) in accordance with 42 CFR 455.104. The providers of Prescribed Drug Services agree to bill the Medicaid program no more than usual and customary charges and on request, to provide access to usual and customary pricing information. The Department agrees to notify the provider of any major changes in Federal or State rules and regulations relating to Medicaid. Payment made by the State Agency shall constitute full payment for services rendered to recipients under the Medicaid program. This includes situations when no payment is made to physicians when Medicare coinsurance claims are adjudicated due to Medicaid's payment methodology. The only exception is in specific programs when Medicaid coinsurance is required from the recipient. The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. The agreement may be terminated upon thirty days written notice by either party. The Department may terminate this agreement in accordance with Chapter 120, F.S. This agreement becomes effective the date the signature of the authorized agent of the Office of Medicaid is affixed. The provider eligibility will be established at the latter of the date of licensure of the provider, if applicable, or ninety (90) days prior to receipt of the application. The provider shall be responsible for assuring that the signature on the claim form is appropriate for authorization. Persons authorized to submit Medicaid claims on behalf of the provider shall be limited to the provider, the provider's employees or authorized agent. Handbook Provisions Among the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement was the Medicaid Physician Provider Handbook (hereinafter referred to as the "MPP Handbook"). Chapter 10 of the MPP Handbook addressed the subject of "provider participation." Section 10.9 of this chapter provided as follows: RECORD KEEPING You must retain physician records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, treatment plans, prior authorization information, any third party claim information, x-rays, fiscal records, and copies of sterilization and hysterectomy consents. Medical records must contain the extent of services provided. The following is a list of minimum requirements: history, physical examination, chief complaint on each visit, diagnostic tests and results, diagnosis, a dated, signed physician order for each service rendered, treatment plan, including prescriptions for medications, supplies, scheduling frequency for follow-up or other services, signature of physician on each visit, date of service, anesthesia records, surgery records, copies of hospital and/or emergency records that fully disclose services, and referrals to other services. If time is a part of the procedure code prescription being billed, then duration of visit shown by begin time and end time must be included in the record. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the MPP Handbook addressed the subject of "covered services and limitations." Section 11.1 of this chapter provided as follows: INTRODUCTION The physician services program pays for services performed by a licensed physician or osteopath within the scope of the practice of medicine or osteopathy as defined by state law. The services of this program must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient. Delivery of the services in this manual must be done by or under the personal supervision of a physician or osteopath at any place of service. Personal supervision is defined as the physician being in the building when the service was rendered. The physician must sign and date the medical record either on the date of service or within 24 hours. Each service type listed has special policy requirements that apply specifically to it. These must be adhered to for payment. HCPCS CODES and ICD-9-CM CODES Procedure codes listed in Chapter 12 are HCPCS (Health Care Financing Administration Common Procedure Coding System) codes. These are based on the Physician's Current Procedural Terminology, Fourth Edition. Determine which procedure describes the service rendered and enter that code and description on your claim form. HCPCS codes described as "unlisted" are used when there is no procedure among those listed that describes the service rendered. Physician's Current Procedural Terminology, Fourth Edition, Copyright 1977, 1980, 1981, 1982, 1983, 1984, 1985, 1986, 1987 by the American Medical Association (CPT-4) is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. The Health Care Financing Administration Common Procedure Coding System (HCPCS) includes CPT-4 descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials contained in CPT-4 which are copyrighted by the American Medical Association. The Diagnosis Codes to be used are found in the International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM). A diagnosis code is required on all physician claims. Use the most specific code available. Fourth and fifth digits are required when available. There are six levels of service associated with the visit procedure codes. They require varying skills, effort, responsibility, and medical knowledge to complete the examination, evaluation, diagnosis, treatment and conference with the recipient about his illness or promotion of optimal health. These levels are: . Minimal is a level of service supervised by a physician. . Brief is a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and exam. . Limited is a level of service used to evaluate a circumscribed acute illness or to periodically reevaluate a problem including a history and examination, review of effectiveness of past medical management, the ordering and evaluation of appropriate diagnostic tests, the adjustments of therapeutic management as indicated and discus- sion of findings. . Intermediate level of service pertains to the evaluation of a new or existing condition compli- cated with a new diagnostic or management problem, not necessarily related to the primary diagnosis, that necessitates the obtaining of pertinent history and physical or mental status findings, diagnostic tests and procedures, and ordering appropriate therapeutic management; or a formal patient, family or a hospital staff conference regarding the patient's medical management and progress. . Extended level of service requires an unusual amount of effort or judgment including a detailed history, review of medical records, examination, and a formal conference with the patient, family, or staff; or a comparable medical diagnostic and/or therapeutic service. . Comprehensive level of service provides for an in-depth evaluation of a patient with a new or existing problem requiring the development or complete reevaluation of medical data. This service includes the recording of a chief complaint, present illness, family history, past medical history, personal review, system review, complete physical examination, and ordering appropriate tests and procedures. 7/ Section 11.2 of Chapter 11 of the MPP Handbook provided in part, that "[t]reatment of an illness found by a physician during an EPSDT screening that requires considerable office time (30 minutes or more) to treat, may also be billed as an office visit on the appropriate claim form." Another of the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement between JMC and the Department was the Medicaid EPSDT Provider Handbook (hereinafter referred to as the "EPSDT Handbook"). Chapter 10 of the EPSDT Handbook addressed the subject of "provider participation." Section 10.8 of this chapter provided as follows: RECORD KEEPING You must retain EPSDT records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, Treatment plans, Prior authorization information, Any third party claim information, X-rays, Fiscal records, and Copies of sterilization and hysterectomy consents. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the EPSDT Handbook addressed the subject of "covered services and limitations." Sections 11.3 and 11.5 of this chapter provided that the components of an EPSDT preventive health screening examination were: a health and developmental history; unclothed physical assessment or examination; nutritional assessment; updating of routine immunizations, "as indicated by the recipient's age, health history, or population group;" laboratory tests, "as indicated by the recipient's age, health history, or population group;" development assessment, vision, hearing and dental screening; and health education. Section 11.7 of Chapter 11 provided, in part, as follows: Under federal regulations the state must provide for medically necessary treatment services diagnosed as a result of screening. Once the EPSDT recipient is screened and referred for treatment, any further diagnosis and/or treatment is then provided through the individual treatment service program. For example, if an EPSDT recipient is found to have an abnormal laboratory test result, such as tuber- culin (TB) skin test, any further referral, diagnosis and treatment is considered diagnostic treatment under physician services. Billing for a treatment visit at the time of a screening visit is only allowed when the illness is discovered during the screening examination. This treatment visit must be at least 30 minutes or more. Treatment visits completed in conjunction with a screening visit must be billed on the HFCA-1500 and the fact that the visit is screening related must be noted on the claim form. Treatment procedure codes should be related to screening results as noted on the EPSDT 221 claim form. An EPSDT screening should not routinely be completed on an obviously ill child, as the illness may distort the screening results. Sound professional judgment should be exercised in determining the appropriate- ness of screening an ill child. If screening results are questionable, treatment should be provided and the screening appointment rescheduled. If, however, an illness is detected during a screening examination, the screening may be completed and treatment provided on the same date, billing the treatment on the appropriate Medicaid claim form. Billing for treat- ment on the same day as the screening evaluation should be done only when a detected illness or condition requires significant time and procedures in addition to the time usually spent for a screening evaluation. The Audit Commencing in 1992, the Department conducted an audit of Medicaid claims submitted by JMC for services rendered from July 1, 1990, through December 31, 1991. During the course of the audit, the Department examined the files of 40 patients (Patients 1 through 19 and 21 through 41, hereinafter also referred to by their initials) who had received services during the audit period. Patient 1 (S.M.) January 16, 1991, Visit On January 16, 1991, S.M. presented at the clinic complaining of a sore throat and fever. The attending physician determined that S.M. had an upper respiratory tract infection, as well as vaginitis. Treatment was provided. JMC billed this as a "comprehensive" visit (procedure code 90020) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one (procedure code 90060), as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 29, 1991, Visit S.M. next visited the clinic on January 29, 1991. JMC billed this visit as a "limited" one (procedure code 90050) and payment was made accordingly. Respondent does not dispute the appropriateness of such billing and payment. 8/ April 23, 1991, Visit On April 23, 1991, S.M. presented at the clinic complaining of blood in her urine. She further indicated that she had recently had a Pap smear test, the results of which reflected a possible precancerous condition. A pregnancy test revealed that S.M. was pregnant. She was also diagnosed as having an upper respiratory tract infection, for which she was treated. A gynecological referral was made. JMC billed this visit as a "extended" one (procedure code 90070) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 9, 1991, Visit and Streptococcal Test S.M. visited the clinic again on October 9, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. It also sought and obtained separate payment for a streptococcal (hereinafter referred to as "strep") test (procedure code 86317) given during the visit. Both parties are now in agreement that the billing and payment for the strep test was appropriate 9/ and that the office visit should have been billed and paid, not as an "extended" visit, but as an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. November 6, 1991, Visit Cerumen Removal and Strep Test On November 6, 1991, S.M. presented at the clinic complaining of sinus problems and pustules on her nose. She was diagnosed as having folliculitis, pharyngitis and sinusitis. Treatment was provided. JMC billed this visit as a "extended" one and payment was made accordingly. It also sought and obtained separate payment for impacted cerumen removal (procedure code 69210) and a strep test. The parties are in agreement that the billings and payments for the impacted cerumen removal and strep test were appropriate. 10/ A dispute still exists, however, as to the appropriateness of JMC billing and receiving payment for an "extended" visit. JMC's medical records pertaining to the visit, to the extent that they are legible, document that the visit was not an "extended" visit, but was merely an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. Moreover, these records were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. 11/ Accordingly, JMC should not have received any payment for this office visit. Patient 2 (O.R.) October 7, 1991, Billings JMC billed and was paid for a "comprehensive" visit and other services (procedure codes 86317, 94010 and 94664) it claimed it rendered Patient 2, O.R., on October 7, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that, on that date, O.R. was seen at the clinic by a physician or that she received the other billed for services. Accordingly, payment should not have been made to Petitioner for an office visit of any type or for any of the other services Petitioner claimed it rendered O.R. on October 7, 1991. October 22, 1991, Visit On October 22, 1991, O.R. presented at the clinic with a fever, sore throat and high blood pressure. In addition, she complained that she was wheezing, suffering from headaches and had a runny nose. At the time of the visit, O.R. was five feet, two inches tall and weighed 206 pounds. The attending physician determined that O.R. was suffering from asthma. Using a nebulizer, he treated her with Ventolin. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit, Routine Venipuncture and Therapeutic Injection O.R. returned to the clinic two days later, on October 24, 1991, with respiratory problems. She was coughing and wheezing severely. Her throat was red. The attending physician determined that O.R. had pharyngitis, pneumonia and severe asthma. Treatment was provided. Medications were prescribed and oral instructions regarding medication administration and compliance were given. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC also sought and obtained separate payment for a routine venipuncture (procedure code 36415) and a therapeutic injection for asthma (procedure code 90782). The parties are in agreement that the routine venipuncture was appropriately billed and paid. The appropriateness of the billing and payment for a therapeutic injection, however, is still in dispute. JMC's medical records, to the extent that they are legible, do not document that O.R. was given the billed and paid-for therapeutic injection on October 24, 1991. Accordingly, it should not have been paid for this service. Patient 3 (T.F.) January 31, 1991, Visit On January 31, 1991, Patient 3, T.F., a ten-year old girl who had already begun menstruating, presented at the clinic with complaints of vomiting for the past two days, as well as cramps and abdominal pain. She further indicated that she had had her last menstrual period two weeks previous. A physical examination, which included the genital and rectal areas, was conducted, a history was taken and a strep test was given. The results of the strep test were positive. The attending physician determined that T.F. had strep throat, for which she received treatment. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 19, 1991, Visit On September 19, 1991, T.F. presented at the clinic complaining of a high fever and a sore throat. She further indicated that she had vomited earlier in the morning. A physical examination, which did not include the genital area, was conducted, an updated history was taken and a strep test was given. The attending physician determined that T.F. had tonsillitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 4 (K.W.) October 3, 1991, Visit On October 3, 1991, Patient 4, K.W., presented at the clinic. He had lower back pain, an upper respiratory tract infection, trauma to his right ankle and folliculitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 4, 1991, Billings JMC billed and was paid for an "extended" visit and another service (procedure code 86317) it claimed it rendered K.W. on November 4, 1991, but the medical records maintained by JMC do not contain legible, physician-signed and dated documentation substantiating that, on that date, K.W. was seen at the clinic by a physician or that he received the other billed-for service. Accordingly, payment should not have been made to Petitioner for any type of office visit or for the other service Petitioner claimed it rendered K.W. on November 4, 1991. Patient 5 (S.W.) October 19, 1990, Visit JMC billed and was paid for a "comprehensive" office visit, in addition to an EPSDT screen (procedure code W9881), for services rendered to Patient 5, S.W., on October 19, 1990. The parties are in agreement that the EPSDT screen was appropriately billed and paid. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. The medical records maintained by JMC do not contain legible, physician-signed and dated documentation justifying JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. October 29, 1990, Visit S.W. again visited the clinic on October 29, 1990. This was a follow- up visit. She had been to the clinic four days previous with a high fever and complaining of a headache, stuffiness and a cough. JMC billed S.W.'s October 29, 1990, visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 14, 1991, Visit On May 14, 1991, S.W. presented at the clinic complaining of a cough. She was diagnosed as having an upper respiratory tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit Two weeks later, on May 29, 1991, S.W. returned to the clinic for a follow-up visit. She was still coughing. Tests taken before the visit revealed that, in addition to her respiratory problems, S.W. was suffering from iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 12, 1991, Visit On June 12, 1991, S.W. paid another follow-up visit to the clinic. During the visit, she admitted that she had not taken her medication "properly." A spirometry test taken before the visit revealed "severe obstruction." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 6 (B.F.) July 12, 1990, Visit On July 12, 1990, Patient 6, B.F., a 32-year old woman, presented at the clinic complaining of chest palpitations and abdominal pain. A physical examination, which included an examination of the vaginal and pelvic areas, was conducted, a history was taken, tests were ordered and treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, a "comprehensive" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. January 14, 1991, Visit B.F. visited the clinic on January 14, 1991, complaining of lower abdominal discomfort, which, she claimed, she had been experiencing for the past two weeks. The attending physician determined that, in addition to the abdominal discomfort B.F. was experiencing, she also had vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 28, 1991, Visit On January 28, 1991, B.F. presented at the clinic complaining of general malaise and a cough that she claimed she had had for four or five days. The attending physician determined that B.F. was suffering from acute bronchitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 24, 1991, Visit On April 24, 1991, B.F. presented at the clinic complaining of chest pain, headaches and dizziness she had been experiencing for several days. She also had shortness of breath. A physical examination, which included an examination of the genital and rectal areas, was conducted, an updated history was taken and tests were ordered. The chest pain was determined to be non-cardiac in nature. It was thought to be caused by a tender rib. Medication was prescribed to combat B.F.'s headaches and dizziness. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, B.F. paid a followup visit to the clinic. She reported that she was still experiencing dizziness, but no longer had any chest pain or headaches. She further advised that she was unable to tolerate the medication that had been prescribed on the previous visit. A rhythm strip test was administered. A new medication was prescribed to combat B.F.'s dizziness. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 7 (C.C.) July 23, 1991, Visit On July 23, 1991, Patient 7, C.C., visited the clinic for the removal of a lesion from her nose by electrodesiccation. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 8 (L.F.) October 21, 1991, Visit On October 21, 1991, Patient 8, L.F., presented at the clinic complaining of a skin rash. The attending physician determined that L.F. was suffering from impetigo, as well as bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 9 (L.A.) November 26, 1990, Visit On November 26, 1990, Patient 9, L.A., presented at the clinic complaining of chest pain. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that such billing and payment was appropriate and thus JMC was not overpaid for this visit. March 28, 1991, Visit On March 28, 1991, L.A. presented at the clinic complaining of chest and abdominal pain. 152. The attending physician determined that the chest pain was non- cardiac in nature and that L.A. was suffering from gastritis. 153. Medication was prescribed. 154. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 6, 1991, Visit On May 6, 1991, L.A. visited the clinic to obtain birth control pills. JMC billed this visit as an "extended" one. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 17, 1991, Visit On June 17, 1991, L.A. presented to the clinic complaining of a sore throat and back pain. The latter ailment was the result of her having been hit in the back with a chair that was thrown at her at work. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 8, 1991, Debridement On August 8, 1991, L.A. presented to the clinic complaining of a gash on her left leg that she had received the night before, as well as a headache and continuing back pain. The leg wound was cleaned. Necrotic tissue around the edge of the wound was removed. JMC billed for a debridement (procedure code 11042) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC. JMC was therefore appropriately paid for this procedure. September 27, 1991, Visit On September 27, 1991, L.A. presented at the clinic complaining of diarrhea, a cold and postnasal drip. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 28, 1991, Visit On October 28, 1991, L.A. presented to the clinic complaining of a sore throat. She further indicated that she had been exposed to the flu. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 10 (B.W.) February 26, 1991, Visit and EPSDT Screen On February 26, 1991, Patient 10, B.W., who was then twelve years old, presented at the clinic for an EPSDT screen. complaining of an abscess behind her ear and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 12/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. March 1, 1991, Billing JMC billed and was paid for services rendered B.W. during an "intermediate" office visit it claimed took place on March 1, 1991, but the physician signed-medical records maintained by JMC, to the extent that they are legible, do not document that B.W. was seen that day at the clinic by a physician. Payment for such an office visit therefore should not have been made. March 13, 1991, Visit On March 13, 1991, B.W. presented at the clinic with multiple, yet relatively uncomplicated, medical problems, including iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. June 24, 1991, Visit On June 24, 1991, B.W. presented at the clinic complaining of a skin rash. She also had a slightly elevated temperature. The attending physician determined that B.W had dermatitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 27, 1991 Visit Three days later, on June 27, 1991, B.W. again visited the clinic. This time she had an abscess in the area of her left armpit. The abscess was drained. JMC billed this visit as an "extended" one and payment was made accordingly. 13/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit and EPSDT Screen On October 18, 1991, B.W. presented at the clinic for an EPSDT screen complaining of an abscess in the area of her right armpit and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 14/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 11 (T.M.) October 30, 1990, Visit On October 30, 1990, Patient 11, T.M., who was then six years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, a wart was discovered on T.M.'s left wrist. The wart was removed. The procedure took approximately 15 minutes. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 15/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. May 9, 1991, Visit T.M. presented at the clinic on May 9, 1991, with an elevated temperature. The attending physician determined that he had an upper respiratory tract infection. Medication was prescribed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 12 (D.W.) November 30, 1990, Visit On November 30, 1990, Patient 11, D.W., who was then three months old, presented at the clinic for an EPSDT screen. He had a stuffy nose. The screen was performed. The physician performing the screen determined that D.W. was suffering from an upper respiratory tract infection and otitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 14, 1990, Visit On December 14, 1990, D.W. presented at the clinic. His mother reported that D.W. had a persistent cough. D.W. was given a strep test, the results of which were negative. The attending physician determined that D.W. still had an upper respiratory tract infection and otitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 17 and 27, 1990, Visits D.W. visited the clinic on December 17, 1990, and again on December 27, 1990. JMC billed these visits as "intermediate" ones and payments were made accordingly. The parties agree that these billings and payments were appropriate. January 21, 1991, Visit On January 21, 1991, D.W. returned to the clinic with his mother. He had a fever of 102 degrees Fahrenheit, which, his mother reported, he had had for the past four days. Following an examination and a strep test, the attending physician determined that D.W. had a strep throat and an ear infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 7, 1991, Visit On June 7, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was discovered that D.W had an ear problem, for which he received treatment. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office on this date. June 21, 1991, Visit 254. D.W. returned to the clinic on June 21, 1991, with an ear infection and a rash behind his right ear. 255. Treatment was provided. 256. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. July 23, 1991, Visit On July 23, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that D.W. was suffering from diaper rash. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 13 (J.H.) December 29, 1990, Visit and EPSDT Screen On December 29, 1990, J.H., who was then three years of age, presented at the clinic for an EPSDT screen. She was suffering from constipation. During the screen, the attending physician determined that J.H. also had vaginitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, there is no indication that J.H.'s teeth and gums were examined during the visit. Accordingly, JMC was not entitled to receive any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 4, 1991, Visit On January 4, 1991, J.H. presented at the clinic. She looked ill and had glassy eyes. It was reported that her temperature (taken with a rectal thermometer) had reached 104 degrees Fahrenheit at home. When her temperature was taken (again rectally) at the clinic, however, it was only 99.2 degrees Fahrenheit. The attending physician determined that J.H. had a urinary tract infection and pharyngitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 14 (J.Y.) April 20, 1991, Visit On April 20, 1991, Patient 14, J.Y., a 25-year old woman suffering from obesity and hypertension, presented at the clinic to obtain a refill of medication that she had been given on a previous visit. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 15 (K.C.) September 20, 1991, Visit On September 20, 1991, Patient 15, K.C., who was then four years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that K.C. was suffering from an upper respiratory ailment. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "intermediate" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "intermediate" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 16 (D.W.) December 17, 1991, Visit On December 17, 1991, Patient 16, D.W., who was then eight years of age, presented to the clinic for an EPSDT screen. During the screen, the attending physician determined that D.W. was suffering from dermatitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks adequate supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 17 (R.G.) There are no issues in dispute concerning any billings and payments made in connection with services JMC rendered to Patient 17, R.G. Patient 18 (C.F.) February 12, 1991, Visit On February 12, 1991, C.F., a 25-year old woman, presented at the clinic complaining of profuse menstrual bleeding. The attending physician determined that C.F. was simply having irregular menstrual periods and that medical intervention was not warranted. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 18, 1991, Visit On November 18, 1991, C.F. returned to the clinic. She still had irregular menstrual periods and, in addition, she complained of a heavy discharge of breast milk from both of her breasts. Tests were ordered. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991, Visit On December 9, 1991, C.F. again visited the clinic. This time she had an upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 19 (J.R.) September 17, 1990, Visit On September 17, 1990, Patient 19, J.R., who was then six months old, visited the clinic. 16/ He had, what his mother described as, a "bad cold." The attending physician determined that J.R. had an upper respiratory tract infection and bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 31, 1991, Visit On January 31, 1991, J.R. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that J.R. was suffering from a rash, a mild upper respiratory ailment, and a sore throat. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "extended" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. February 26, 1991, Visit On February 26, 1991, J.R. again visited the clinic. He had an ear infection and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, J.R. paid another visit to the clinic. Diaper rash was still a problem. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit J.R. returned to the clinic on May 29, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that any of JMC's staff physicians provided medically necessary services to J.R. on this date. While these records do reflect that J.R. received an abbreviated physical examination during his visit to the clinic, they do not reveal why the examination was conducted or what conclusions the attending physician reached as a result of the examination. Accordingly, JMC should not have received any payment for an office visit on this date. Patient 21 (T.M.) April 26, 1991, Visit On April 26, 1991, Patient 21, T.M., who was then five years of age, presented at the clinic for an EPSDT screen. He had sickle cell anemia, but was doing well. The screen was performed. Following the screen, the attending physician recommended that T.R. continue taking folic acid and vitamins. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 22 ( K.C.) August 28, 1990, Visit On August 28, 1990, Patient 22, K.C., who was then six months old and had recently been exposed to hepatitis B, presented at the clinic for an EPSDT screen. The screen was performed. The attending physician did not believe that K.C. had contracted hepatitis B. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 23 ( K.G.) July 10, 1990, Visit On July 10, 1990, Patient 23, K.G., presented at the clinic complaining of a vaginal discharge. The attending physician determined that K.G. was suffering from vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 15, 1990, Visit On October 15, 1990, K.G. presented at the clinic complaining of a rash in the area of her groin. The attending physician determined that K.G. had folliculitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. February 15, 1991, Visit On February 15, 1991, K.G. presented at the clinic complaining of swelling in her legs. 17/ The attending physician determined that she had pinworms. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. March 8, 1991, Visit On March 8, 1991, K.G. presented at the clinic complaining of rectal pain and a persistent cough. The attending physician determined that K.G. had pharyngitis, pneumonia and an anal fissure. Treatment, which included the use of an aerosol spray, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 18/ 372. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. June 6, 1991, Visit On June 6, 1991, K.G. visited the clinic complaining of weight gain and pain in her left side. The attending physician determined that the pain was caused by gas and prescribed medication to combat the problem. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 28, 1991, Visit On June 28, 1991, K.G. presented at the clinic complaining of a sore throat and a cough producing yellowish sputum. She claimed that she had had the sore throat for three to four days. A strep test was given, the results of which were negative. The attending physician determined that K.G. had bronchitis and pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 1, 1991, Visit On August 1, 1991, K.G. presented at the clinic. 19/ She had a pararectal abscess and a urinary tract infection. The abscess was drained. In addition, treatment was provided for the urinary tract infection. JMC billed this visit as an "extended" one and payment was made accordingly. 20/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 5, 1991, Visit On September 5, 1991, K.G. presented at the clinic. She had a cough and sore throat. A strep test was given, the results of which were negative. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 24 (L.W.) December 10, 1990, Visit On December 10, 1990, Patient 24, L.W., who was then five years of age, presented at the clinic for an EPSDT screen. The screen was performed. As part of the screen, her weight was taken. She weighed only 30 pounds. 401. Because she had a persistent cough and a runny nose, a strep test was given, the results of which were positive. 402. JMC billed for an EPSDT screen and a "comprehensive" visit. 403. The parties agree that the billing and payment for an EPSDT screen was appropriate. The billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. July 2, 1991, Visit On July 2, 1991, L.W. presented at the clinic. 21/ Her right breast was enlarged. In addition, she had pharyngitis and impacted cerumen in her ears. A strep test was given, the results of which were negative. Treatment, which included the removal of the impacted cerumen, was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 22/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 25 (R.W.) October 3, 1991, Visit On October 3, 1991, Patient 25, R.W., who was then four months old, presented at the clinic for an EPSDT screen. 23/ He had an asthmatic condition and bronchitis. The screen was performed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 24/ JMC therefore should not have received any payment for an office visit on this date. October 10, 1991, Visit On October 10, 1991, R.W. presented at the clinic for another EPSDT screen. His asthma and bronchitis were much improved. The screen was performed. No new problems were discovered. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 25/ JMC therefore should not have received any payment for an office visit on this date. October 16, 1991, Visit On October 16, 1991, R.W. returned to the clinic. His condition had worsened and he was crying in his mother's arms. In addition to the problems he had had previously, he now also had an ear infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit R.W. paid a follow-up visit to the clinic on October 24, 1991. His condition had improved since his last visit to the clinic on October 16, 1991. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that this visit, like R.W.'s prior visit to the clinic, was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 26 (E.W.) September 16, 1991, Visit On September 16, 1991, Patient 26, E.W., who was then four months old, presented at the clinic with a cold and cough. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks sufficient supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 27 (C.S.) 26/ November 4, 1991, Visit and EPSDT Screen On November 4, 1991, Patient 27, C.S., who was then seven months old, presented at the clinic. She was suffering from a cold. Treatment was provided. JMC billed for an EPSDT screen and an "extended" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, these records contain no nutritional or developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not an "extended" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 28 (S.S.) 27/ May 15, 1991, Visit On May 15, 1991, Patient 28, S.S., presented at the clinic complaining of keloid skin masses on both of her ears which, she indicated, she wanted removed. JMC billed this visit as a "comprehensive" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as an "intermediate" one and that therefore JMC was overpaid for this visit. May 29, 1991, Visit On May 29, 1991, S.S. returned to the clinic for evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on May 29, 1991. June 12, 1991, Visit On June 12, 1991, S.S. paid another visit to the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on June 12, 1991. July 10, 1991, Visit On July 10, 1991, S.S. again visited the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on July 10, 1991. August 7, 1991, Visit S.S. went back to the clinic on August 7, 1991, for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 12, 1991, Visit On September 12, 1991, S.S. presented at the clinic for additional evaluation and treatment of her keloids, which were scheduled to be removed the following day. She also had a sore throat. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 19, 1991, Visit Only one of the keloids, the one on her left ear, was removed on September 13, 1991. Six days later, on September 19, 1991, S.S. visited the clinic for a postsurgical examination and to discuss the removal of the keloid on her right ear. She presented at the clinic with a sore throat and earache. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 26, 1991, Visit S.S. returned to the clinic on September 26, 1991. She had an abscess on her ear. The abscess was incised and drained. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 28/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Debridement On October 7, 1991, S.S. presented at the clinic complaining of continuing skin problems on and behind her ears. An abscess and "raggedy" skin were discovered. The abscess was incised and drained and the "raggedy" skin was removed. JMC billed and was paid for a debridement. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC, and that therefore JMC was entitled to the payment it received for the debridement. Patient 29 (T.J.) January 28, 1991, Visit On January 28, 1991, Patient 29, T.J., who was then one month old, was seen at the clinic. She had congenitally deformed ("toe[d] in") feet, multiple insect bites and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 30, 1991, Visit T.J. returned to the clinic two days later. She had been vomiting for the past two days. In addition, she had a sore throat and an earache. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 22, 1991, Visit On April 22, 1991, T.J. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was determined that T.J. had dermatitis caused by insect bites. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 24, 1991, Visit On April 24, 1991, T.J. again visited the clinic. Her dermatitis was still causing her some discomfort. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 30 (G.D.) March 11, 1991, Visit On March 11, 1991, Patient 30, G.D., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed that G.D. had upper respiratory problems, as well as an umbilical hernia. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 22, 1991, Visit G.D. was next seen at the clinic on April 22, 1991. He had pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 3, 1991, Visit G.D. next visited the clinic on June 3, 1991. He had a mild upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 31 (H.C.) October 15, 1990, Visit On October 15, 1990, H.C., who was then 18 years old, presented at the clinic complaining of delayed menstruation. She was given a pregnancy test, the results of which revealed that she was pregnant. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 32 (R.M.) February 12, 1991, Visit On February 12, 1991, Patient 32, R.M., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in R.M.'s ears. The impacted cerumen was removed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 29/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 33 (C.W.) December 3, 1990, Visit On December 3, 1990, Patient 33, C.W., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in C.W.'s ears and that R.M. had pharyngitis. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 30/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. August 22, 1991, Visit 534. On August 22, 1991, C.W. presented at the clinic complaining of a headache. 535. The attending physician determined that C.W. had pharyngitis. 536. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Visit On October 7, 1991, C.W. again visited the clinic. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed and paid for as a "limited" one, as described in Chapter 11 of the MPP Handbook. October 10, 1991, Visit Three days later, on October 10, 1991, C.W. returned to the clinic. She had tonsillitis, pharyngitis and an upper respiratory infection. Her temperature was 103.4 degrees Fahrenheit. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 34 (K.K.) September 19, 1990, Visit On September 19, 1990, Patient 34, K.K., who was then three years old, presented at the clinic for an EPSDT screen. He had a runny nose and a cough. His mother also complained that he was hyperactive. 549. The screen was performed. 550. The screen revealed that K.K. had impacted cerumen in his ears. 551. provided. Treatment, including the removal of the impacted cerumen, was 552. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 31/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 17, 1990, Visit On or about December 17, 1990, K.K. returned to the clinic. He had dermatitis, as well as impacted cerumen in his ears. In addition, his mother was concerned about his behavior. Treatment, including the removal of the impacted cerumen, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 32/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 3, 1991, Visit On January 3, 1991, K.K. returned to the clinic for a physical examination for school. During the visit, his mother complained that K.K.'s appetite for food had decreased. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 35 (T.B.) November 15, 1990, Visit On November 15, 1990, Patient 35, T.B., presented at the clinic for a physical examination for work. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 20, 1990, Visit T.B. returned to the clinic on December 20, 1990, complaining that she was not feeling well. During the visit, impacted cerumen was removed from her ears. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 33/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. July 18, 1991, Visit On July 18, 1991, T.B. went to the clinic to obtain "medical certificates." A routine physical examination was performed, but no history was taken. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 4, 1991, Visit On December 4, 1991, T.B. presented at the clinic with "pink eye." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 36 (D.W.) January 2, 1991, Visit On January 2, 1991, Patient 36, D.W., who was then 19 years of age, visited the clinic for a checkup. The attending physician determined that D.W. had an iron deficiency and anemia, for which treatment was provided. During the visit, family planning issues were also addressed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit On April 17, 1991, D.W. presented at the clinic complaining that she had been feeling ill for two days. 34/ 592. A strep test was given, the results of which were negative. The attending physician determined that D.W had tonsillitis and was still suffering from anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 16, 1991, Visit On September 16, 1991, D.W. presented at the clinic. She had a sore throat and vaginitis. 35/ In addition, she was now pregnant and still anemic. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. 601. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 17, 1991, Visit On October 17, 1991, D.W., who was still pregnant at the time, made a follow-up visit to the clinic. She complained of shortness of breath and tightness in her chest, as well as a sore throat. A fetal examination was conducted. A strep test was given, the results of which were negative. The attending physician determined that D.W. had a urinary tract infection, sinusitis, pharyngitis and anemia. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 14, 1991, Visit and Echography D.W. returned to the clinic on November 14, 1991. She was in approximately the thirty-second week of her pregnancy and she was still suffering from a urinary tract infection and anemia. Her sinus condition was improving. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. It also sought and received separate payment for an echography (procedure code 76855). The parties now agree that JMC should not have been paid for an echography. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 3, 1991, Visit A still-pregnant D.W. visited the clinic again on December 3, 1991, complaining of shortness of breath. The attending physician determined that she was still suffering from a urinary tract infection and anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 10, 1991, Visit A week later, on December 10, 1991, with her anticipated date of delivery approaching, D.W. returned to the clinic complaining of vaginal irritation and pain in her left wrist. Her urinary tract infection was improving. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 37 (E.A.) September 27, 1991, Visit On September 27, 1991, Patient 37, E.A., who was then seven weeks old, presented at the clinic with an upper respiratory infection, pharyngitis and thrush. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit E.A. returned to the clinic on October 18, 1991, for an EPSDT screen. 633. The screen was performed. The screen revealed that he still had an upper respiratory infection and thrush. Treatment was provided. JMC billed for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. November 20, 1991, Visit E.A. visited the clinic again on November 20, 1991. He had a bad cough and a green discharge from his eyes and nose. The attending physician determined that E.A. had an upper respiratory infection and pharyngitis, as well as a "foreign body" in his nose. Treatment, including the removal of the "foreign body," was provided. 36/ JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore entitled to the payment it received for this visit. November 21, 1991, Incision and Removal JMC billed and was paid for an incision and removal of a "foreign body" (procedure code 10120) it claimed had been performed on E.A. at the clinic on November 21, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that E.A. received an incision and removal at the clinic on this date. Accordingly, payment should not have been made to JMC for this billed-for service. Patient 38 (O.S.) December 2, 1991, Visit and EPSDT Screen On December 2, 1991, Patient 38, O.S., who was then three months old, presented at the clinic for an EPSDT screen. She had a cold and blotches all over her body and her hair was falling out. The screen revealed that O.S. had tinea capitis, otodynia, and pharyngitis, as well as impacted cerumen in her ears. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 37/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete EPSDT screen was performed. For example, these records contain no developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991 O.S. returned to the clinic a week later on December 9, 1991. She had a new rash on her left arm. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 39 (T.G.) September 5, 1991, Visit On September 5, 1991, Patient 39, T.G., who was then three months old, presented at the clinic for an EPSDT screen. She had a stuffy nose and was crying. According to his mother, he had been crying for the past 12 hours. The screen was performed. A strep test was given, the results of which were negative. The attending physician determined that T.G. had an ear infection, an upper respiratory tract infection and phayrngitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, justify JMC billing and receiving payment for, in addition to an EPSDT screen, only an "intermediate" office visit and not a "comprehensive" one. JMC was therefore overpaid for this visit. September 19, 1991, Visit T.G. returned to the clinic for a follow-up visit on September 19, 1991. He had diaper rash. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 40 (T.B.) November 26, 1991, Visit On November 26, 1991, T.B., a 62-year old man with a history of heart disease, hypertension and stroke, presented at the clinic with a periorbital abscess. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. 38/ JMC was therefore overpaid for this visit. November 29, 1991, Visit Three days later, on November 29, 1991, T.B. returned to the clinic again complaining about the abscess. The attending physician reevaluated the problem and referred T.B. to Jackson Memorial Hospital for treatment. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 41 (L.B.) January 25, 1991, Visit On January 25, 1991, Patient 41, L.B., who was then 19 years of age and had history of mental illness, presented at the clinic stating that she was pregnant and complaining, among other things, of abdominal pain. She appeared to be confused and it was difficult to obtain an accurate history from her. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit L.B. returned to the clinic on April 17, 1991, complaining of continuing abdominal pain, vaginal discharge, breast tenderness and nausea. The attending physician determined that L.B. had vaginitis and a urinary tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 25, 1991, Visit L.B. visited the clinic again on November 25, 1991. On this visit she complained of a rash. The attending physician determined that L.B. had dermatitis. 694. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 6, 1991, Visit On December 6, 1991, L.B. presented at the clinic claiming that there were things crawling on her scalp. The attending physician determined that L.B. was demented. He filled out a Social Security Administration form indicating that it was his opinion that L.B. was "not medically competent." JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. Simple Mistake or Fraud? There has been no allegation made, nor proof submitted, that any of the overbillings referenced above were the product of anything other than simple mistake or inadvertence.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration adopt the findings made by the Hearing Officer regarding the sampled claims remaining in dispute in the instant case and use these findings to redetermine the total amount of Medicaid overpayments made to Petitioner during the audit period and the amount of the fine Petitioner should be required to pay for its erroneous billings during this period of time. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd of May, 1995. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of May, 1995.
The Issue Whether the Respondent committed the violations alleged in the Administrative Complaint dated March 27, 2009, and, if so, the penalty that should be imposed.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made:1 At the times material to this proceeding, the Department was the state agency responsible for the investigation and prosecution of complaints involving physicians licensed to practice medicine in Florida. See § 456.072, Fla. Stat. (2004-2005). At the times material to this proceeding, the Board of Medicine ("Board") was the entity responsible for regulating the practice of medicine and for imposing penalties on physicians found to have violated the provisions of Section 458.331(1), Florida Statutes (2004-2005). See § 458.331(2), Fla. Stat. (2004-2005). At the times material to this proceeding, Dr. Genao was a physician licensed to practice medicine in Florida, having been issued license number ME 58604. Dr. Genao practiced in the field of pediatric medicine, and he was board-certified in pediatrics. His practice was located at 13059 Southwest 112th Street, Miami, Florida. In or about 2005, Dr. Genao became aware that so-called "infusion centers" were opening in Miami-Dade and Broward Counties, Florida, to treat patients who had been diagnosed with HIV/AIDS and who required injections and infusion treatments for HIV/AIDS-related conditions. Dr. Genao visited one such center and observed a physician, a Dr. Fauler, as he provided infusion treatments to HIV/AIDS patients. Dr. Genao believed that Dr. Fauler's treatment of the HIV/AIDS patients was appropriate. Dr. Genao had training in intravenous treatments, and, after observing Dr. Fauler and working for a time under Dr. Fauler's supervision, Dr. Genao considered himself ready to begin treating HIV/AIDS patients in an "infusion center" that he intended to operate out of the office housing his pediatric practice. By his own admission, Dr. Genao had no formal training or experience treating patients with HIV/AIDS. Dr. Genao's first patient was G.M., whom Dr. Genao treated for HIV/AIDS-related conditions between May 25, 2005, and June 20, 2005. At the end of July, Dr. Genao was approached by two men who offered to bring him HIV/AIDS patients for injections and infusion treatment for HIV/AIDS-related conditions. Dr. Genao felt he was competent to treat HIV/AIDS patients with infusion therapy, and he signed a contract with the two men in which he agreed to see HIV/AIDS patients in exchange for a salary. Dr. Genao assumed that the patients he would see also had primary care physicians who were treating the patients for HIV/AIDS. In mid-August, 2005, Dr. Genao began to see HIV/AIDS patients regularly at his office in the mornings, before his pediatric patients arrived. Between August 15, 2005, and October 14, 2005, Dr. Genao treated 11 HIV/AIDS patients. Dr. Genao diagnosed these patients as suffering from conditions associated with HIV/AIDS, such as neuropathy; neutropenia; thrombocytopenia; and diarrhea. Dr. Genao ordered various treatments for these patients, including intramuscular injections of drugs such as Sandostatin and infusion of such drugs as Rituxan, Neupogen, and Neumega. Shortly after he began treating these HIV/AIDS patients, Dr. Genao began to question the appropriateness of the modes of treatment he had observed at Dr. Fauler's infusion center and to feel uncomfortable about treating the HIV/AIDS patients. He sought training at Jackson Memorial Hospital in Miami, Florida, and attended training sessions during which he observed a physician who specialized in the treatment of HIV/AIDS patients and who ran the HIV/AIDS clinic at Jackson Memorial Hospital. Dr. Genao attended these training sessions three days per week for two weeks. Dr. Genao realized that the treatment given by the physician at Jackson Memorial Hospital was completely different from the treatment he was providing the HIV/AIDS patients in his office. Dr. Genao also realized that the patients he was treating for HIV/AIDS-related conditions were not being treated for the underlying HIV/AIDS by primary care doctors. Dr. Genao decided to stop treating the HIV/AIDS patients that he was seeing pursuant to the contract with the two men, who were not physicians. When he told the men that he wanted to renege on the agreement, they told Dr. Genao that he had to continue treating the HIV/AIDS patients until they could find another physician to provide them treatment. Dr. Genao felt threatened by the men, and he continued to treat the patients until on or about October 14, 2005. During the time that Dr. Genao treated the HIV/AIDS patients brought to him by the two men, the men prepared all of the bills to be submitted to Medicare and/or Medicaid. Dr. Genao signed each bill in the large stacks of bills presented to him without reviewing any of them. The Department's expert testified at length about the treatment that Dr. Genao provided to the 12 HIV/AIDS patients he had treated, and the expert enumerated the ways in which Dr. Genao had violated the standard of care in their diagnosis and treatment. In his responses to the Department's request for admissions, Dr. Genao admitted that he failed to diagnose and treat these patients properly.2 Furthermore, in his testimony at the final hearing, Dr. Genao admitted that his treatment of these patients fell below the standard of care, and he agreed with the Department's expert that he misused some of the drugs he prescribed for the patients, failed to follow through with necessary treatment for these patients, and neglected their care.3 Based on the patients' medical records, on testimony of the Department's expert, and on Dr. Genao's admissions and testimony, the ways in which Dr. Genao failed to meet the applicable standard of care in treating the 12 HIV/AIDS patients may be grouped into categories and summarized as follows: Dr. Genao treated patients S.B. and J.S. for diarrhea with intramuscular injections of Sandostatin; Sandostatin is a medication that is not appropriate for the treatment diarrhea but is used to treat the very rare disease, acromegaly. Dr. Genao treated patients S.B. and G.M. for thrombocytopenia with multiple intravenous infusions of Rituxan, a drug that is not appropriate for the treatment of thrombocytopenia, which is a bleeding disorder caused by an abnormally low level of platelets. Rituxan is used to treat lymphoma and rheumatoid arthritis, and it is a very expensive and dangerous drug that can sometimes cause death. Dr. Genao failed to follow-up with diagnoses and treatment for seriously abnormal values that showed up in the results of blood work ordered by Dr. Genao for patients S.B., S.E., L.G., G.M., J.S., and J.T. Dr. Genao failed to refer patients S.B., S.E., M.E., L.G., J.T., E.T., and J.T. 2 to specialists for evaluation when such evaluation was indicted by the patients' complaints and symptoms. Dr. Genao failed to notify patient M.E., whom Dr. Genao saw only once, of abnormal blood test results that should have been evaluated and treated. Dr. Genao failed to revise his treatment of patients S.E., L.G., J.T., and E.T. when it became clear that there had been no improvement in the conditions of the patients after Dr. Genao had treated them for a month or more. Dr. Genao administered Neupogen to patients E.T. and J.T. 2 when treatment with this drug, which is used primarily to treat patients with a critically low white blood cell count resulting from chemotherapy, was not indicated by the results of blood tests. Dr. Genao failed to diagnose accurately and/or timely conditions that were indicated by the complaints, symptoms, and results of blood tests for patients S.B., S.E., M.E., L.G., G.M. J.S., J.T., E.T. and J.T. 2. By his own admission, Dr. Genao failed to keep appropriate medical records of the treatment of these 12 patients. Dr. Genao's medical records were often illegible4; there were no medical records for patients M.C. and R.M., just billing records; and the medical records were incomplete and generally failed to justify the course of treatment for patients S.B., S.E., M.E., L.G., G.M., J.S., M.S., J.T., E.T., and J.T. 2. Summary and findings of ultimate fact The evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao committed medical malpractice because he did not provide to the 12 HIV/AIDS patients he treated the level of treatment, skill, and care that would be found acceptable by a reasonable prudent similar physician under similar circumstances. Even though the evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao prescribed and administered Rituxan, Sandostatin, and Neupogen inappropriately and in excessive quantities for some of his HIV/AIDS patients, the evidence is not sufficient to establish that this conduct occurred outside Dr. Genao's professional practice. The evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao failed to keep medical records that were legible and complete and that justified the treatment that he provided his HIV/AIDS patients.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Medicine enter a final order finding that Estaban Antonio Genao, M.D., violated Section 458.331(1)(m) and (t), Florida Statutes (2004 and 2005), and revoking the license of Estaban Antonio Genao, M.D., to practice medicine in the State of Florida. DONE AND ENTERED this 30th day of November, 2010, in Tallahassee, Leon County, Florida. S Patricia M. Hart Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of November, 2010.
