The Issue Whether petitioner is entitled to benefits in excess of those paid under the Florida Employees Group Health Self-Insurance Program for medical services provided to his newborn-son at Shands Hospital during April, 1982.
Recommendation Based on the foregoing, it is RECOMMENDED: That petitioner's claim for payment of the $200.00 and $125.00 medical charges be granted; and that his remaining claims, which seek payment in excess of amounts allowed by the Approved Fee Schedule, be denied. DONE and RECOMMENDED this 29th day of April, 1983, in Tallahassee, Florida. R. L. CALEEN, JR. Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 29th day of April, 1983.
The Issue Whether Allcare Health and Human Services, Inc. (Respondent), a Medicaid provider, was overpaid by the Florida Medicaid Program as alleged in the Amended Final Audit Report (Amended FAR) dated August 31, 2012. Also at issue are the amounts of any overpayment, whether any penalty should be imposed (and the amount thereof), and whether the Agency for Health Care Administration (Petitioner) is entitled to recover its costs (and the amount thereof).
Findings Of Fact At all times relevant to this proceeding, Respondent has been a provider with the Florida Medicaid Program and has had a valid Medicaid Provider Agreement with Petitioner. Petitioner is the agency of the State of Florida charged with the responsibility of administering the Florida Medicaid Program. Among its duties, Petitioner is required to conduct audits and to recover "overpayments . . . as appropriate." Section 409.913(1)(e) defines "overpayment" to mean "any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake." Petitioner's Bureau of Medicaid Services has the responsibility for polices regarding Developmental Disabilities Waiver and Provider Reimbursement. At all times relevant to this proceeding, Respondent was subject to all applicable federal and state laws, regulations, rules, and Medicaid Handbooks. Respondent is required to comply with the Florida Medicaid Provider General Handbook, the Developmental Disabilities Waiver Services Coverage and Limitations Handbook, and the Provider Reimbursement Handbook. Respondent is an experienced Medicaid provider that provides a variety of Medicaid services. Respondent's annual billings to the Medicaid program exceed $1,000,000.00. Among the Medicaid services it provides, Respondent provides Companion Services (billing code S5135) to recipients under the Developmental Disabilities Home and Community Based Services Waiver Program. There is coverage limitation for Companion Services. A recipient can receive no more than 24 quarter-hours (six hours) of Companion Services per day and no more than 30 hours of Companion Services per week. The alleged overpayments at issue were based on billings for days on which Companion Services exceeded six hours. As part of a larger audit of Medicaid providers, Petitioner audited Respondent based on billings for Companion Services submitted by Respondent and paid by Petitioner. All of the services at issue in this proceeding were paid by Petitioner to Respondent based on Respondent's billings. Taking information reflected by Respondent's billings for Companion Services to 46 recipients during the audit period, Petitioner generated a Preliminary Audit Report (PAR) on March 14, 2012. The PAR cited the Coverage Handbook, statues, and rules Petitioner relied upon. Petitioner attached to the PAR a detailed audit report that determined that Respondent was overpaid $135,023.38 for Companion Services during the audit period. The PAR was not final agency action. Respondent was advised of the following options: Pay the identified overpayment in this notice within 15 days of the receipt of this letter and wait for the issuance of the final audit report. If you wish to submit documentation in support of the claims identified as overpayments, you must do so within 15 days of receipt of this letter. Documentation that appears to be altered, or in any other way appears not to be authentic, will not serve to reduce the overpayment. Documentation must clearly identify which discrepancy, as set forth in the attached audit findings, it purports to support. Any documentation received will be taken under consideration and you will be notified of the results of the review. If you choose not to respond, wait for the issuance of the final audit report. The PAR also contained the following advice: A final audit report will be issued that will include the final identified overpayment, applied sanctions, and assessed costs, taking into consideration any information or documentation that you have already submitted. Any amount due will be offset by any amount already received by the Agency in this matter. The final audit report will inform you of any hearing rights that you may wish to exercise. Respondent did not respond to the PAR. Ms. Williams testified, credibly, that she was out of the country because of her mother's death when the PAR was issued. Petitioner generated a Final Audit Report (FAR) dated April 13, 2012, and subsequently an Amended FAR dated August 31, 2012, which assessed against Respondent the alleged overpayment in the amount of $135,023.38, a fine in the amount of $27,004.68, and costs in the amount of $49.22.1 Ms. Williams received the FAR. The Amended FAR was filed after the matter had been referred to DOAH. The undersigned granted Petitioner's motion to file the Amended FAR without objection from Respondent. The amount of the alleged overpayment remained the same in the PAR, FAR, and Amended FAR. The amounts of the fine and costs remained the same in the FAR and Amended FAR. Billings are submitted by providers using a form that is available, together with applicable billing guidelines, on the Medicaid Fiscal Agent Web Portal at "http://mymedicaid- florida.com." Ms. Williams, who prepares all of the Medicaid billings for Respondent, routinely uses that website and is familiar with its contents. Ms. Williams knows how to access and complete billing forms. She also knows how to access handbooks, including information as to coverage limitations. The billing form used by Medicaid providers has a "from date of service" column and a "to date of service" column. For Companion Services, the form will permit a provider to put only one date of service. For each of the challenged billings at issue in this proceeding, the same date was listed in these two columns. As an example, Mr. Posey's audit analysis for recipient A.B.L. on Bates stamp page 56 of Petitioner's Exhibit 3 reflects that the first "from date of service" was March 31, 2010, and the "to date of service" was also March 31, 2010. The number of units billed and paid for was 40 quarter-hours. Since the coverage limitation is 24 quarter-hours for a day, Mr. Posey determined that the provider was overpaid by 16 quarter-hour units for that billing day. Mr. Posey determined the reimbursement rate for each quarter-hour unit of service and multiplied that rate by the number of excess quarter-hour units. That product is the amount of the overpayment for that date. Using the same example for recipient A.B.L. on March 31, 2010, the auditor multiplied 16 quarter-hour units by $3.37 (the quarter hour reimbursement rate), and determined that the provider had been overpaid $53.92 for that date of service for that recipient. Mr. Posey performed a similar analysis for each of Respondent's billings during the audit period and determined the overpayment for all days of service on which the billed amount for the recipient exceeded 16 quarter-hour units of service. The auditor then added the overpayments, with the resulting sum being $135,023.38, the amount of the claimed overpayment. Respondent asserts that it did not receive any overpayment because it utilized "span" billing, i.e., it provided services over more than one day, but billed for those services under the last day the service was performed. Some coverage limitations are based on time periods greater than one day. There are coverage limitations based on weekly, monthly, and annual periods. Span billing for those periods is acceptable in that the provider is to insert the date the service began in the "from date of service" column and the date the service ended in the "to date of service" column. While the billing form will not permit different dates in these two columns if the service has a one-day coverage limitation, the form will permit different dates if the coverage limitation for a service is based on more than a one-day period. Ms. Williams testified that she provided Petitioner with time records of her employees who actually provided the subject services to the different recipients. According to Ms. Williams, those records substantiate her claim that there was no overpayment. Those records were provided to Petitioner after the issuance of the FAR. Petitioner did not analyze those records. Those time records were not introduced as evidence, and there was no other evidence to support Ms. Williams' testimony.2 Ms. Williams testified that she had not been trained that span billing was not permitted where there is a one-day coverage limitation. Ms. Williams knew or should have known that Companion Services had a one-day coverage limitation. Respondent's billings do not justify the payments it received. Petitioner has recouped an overpayment from Respondent on one prior occasion. Among other topics, the FAR advised Respondent of its right to request an administrative hearing pursuant to the provisions of chapter 120. Thereafter, Respondent requested a formal administrative hearing, the matter was referred to DOAH, and this proceeding followed. The overpayments at issue are the result of Respondent's misinterpretation of Petitioner's billing requirements. No fraud or abuse is involved in this proceeding.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration enter a final order finding that Allcare Health and Human Services, Inc., was overpaid by the Florida Medicaid Program in the principal amount of $135,023.38. It is further recommended that the final order require Allcare Health and Human Services, Inc., to repay the Florida Medicaid the amount of $135,023.38 together with applicable interest and cost in the amount of $49.22. It is further recommended that the final order impose against Allcare Health and Human Services, Inc., an administrative fine in the amount of $27,004.68. S DONE AND ENTERED this 18th day of January, 2013, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON 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 18th day of January, 2013.
Findings Of Fact At all times material hereto, Dr. Esteban Valdes-Castillo, a Board- certified psychiatrist, was the Medical Director of Progressive Health Center, Inc. Blanche Lear, a psychiatric social worker, was an employee of the Center. Between 1978 and August, 1981, Petitioner paid Respondent $45,627.16 in Medicaid payments for counseling ser- vices rendered by Blanche Lear. A two-way mirror was located in the common wall between Lear's and Valdes-Castillo's offices. Of the Medicaid recipients counseled by Lear, Valdes-Castillo did not meet, interview, counsel or even observe all of the patients for whom payments were made to the Center by Petitioner. Further, Valdes-Castillo only observed Lear's coun- seling sessions approximately once a month over the time period involved and then only upon the specific request of Lear to observe a specific patient for a specific reason.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered by Petitioner directing Respondent Progressive Health Center, Inc., to reimburse to Petitioner the amount of $45,627.16. DONE and RECOMMENDED this 14th day of March, 1983, in Tallahassee, Leon County, Florida. LINDA M. RIGOT Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 14th day of March, 1983. COPIES FURNISHED: Robert A. Weiss, Esquire Medicaid Program Office Department of Health and Rehabilitative Services 1317 Winewood Boulevard, Suite 233 Tallahassee, Florida 32301 J. Michael Sara, Esquire 2153 Coral Way, Suite 400 Miami, Florida 33145 David H. Pingree, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32301
Findings Of Fact Provider received the correspondence giving notice of Provider’s right to an administrative hearing regarding the improper Medicaid reimbursement. Provider filed a petition requesting an administrative hearing, and then caused that petition to be withdrawn and the administrative hearing case to be closed. Provider chose not to dispute the facts set forth in the letter dated August 1, 2011. The facts alleged in the letter are hereby deemed admitted, including the total improper reimbursement amount of twelve thousand, one hundred sixty-four dollars ($12,164.00). The Agency hereby adopts the facts as set forth in the letter, including the improper reimbursement amount of twelve thousand, one hundred sixty-four dollars ($12,164.00). CONCLUSIONS OF LAW. The Agency incorporates and adopts each and every relevant statement and conclusion of law set forth in the August 1, 2011, letter. The admitted facts support the legal conclusion that the improper reimbursement in the amount of twelve thousand, one hundred sixty-four dollars ($12,164.00) was appropriate. As partial payment has previously been made, five thousand, eight hundred sixty-four dollars ($5,864.00) is now due and owing from Provider to the Agency. Based on the foregoing it is ORDERD AND ADJUDGED that Provider remit, forthwith, the amount of five thousand, eight hundred sixty-four dollars ($5,864). Provider’s request for an administrative hearing is hereby dismissed. DONE and ORDERED on this the We day of fojtimla__. 2012, in Tallahassee, Florida. and Mf SECRETARY Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Rachic’ Wilson, Esquire Agency for Health Care Administration (Interoffice Mail) Roberto E. Moran, Esq. Rasco, Klock, Reininger, et al 283 Catalonia Avenue Second Floor Coral Gables, Florida 33134 (U.S. Mail) June C. McKinney Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Mike Blackburn, Chief, Medicaid Program Integrity Finance and Accounting HOA Agency for Persons with Disabilities (Facility) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addressees by U.S. Mail on this the Ainot Sek W12. = —az, Richard Shoop, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 412-3630
Conclusions THIS CAUSE came before me for issuance of a Final Order on an August 1, 2011, letter from the Agency for Health Care Administration (“Agency”) to Bay Point Schools, Inc. (“Provider”) notifying Provider that it had been improperly reimbursed twelve thousand, one hundred sixty-four dollars ($12,264.00) by Medicaid. The August 1, 2011, letter indicated that partial payment had already been remitted by Provider and that five thousand, eight hundred sixty-four dollars ($5,864.00) remained due and owing from Provider to the Agency. The August 1, 2011, letter provided full disclosure and notice to Provider of procedures for requesting an administrative hearing to contest the allegations made in the letter. Provider filed a petition with the Agency requesting a formal administrative hearing on September 6, 2011. The Agency forwarded Provider’s hearing request to the Division of Administrative Hearings (“DOAH”) for a formal administrative hearing. On March 9, 2012, Provider filed a Motion to Withdraw Petition for Formal Hearing. DOAH issued an Order Filed September 6, 2012 1:46 PM Division of Administrative Hearings Closing File and Relinquishing Jurisdiction on March 12, 2012, closing the above-styled cause and relinquishing jurisdiction back to the Agency.
The Issue Petitioner seeks licensure by respondent as an acupuncturist, and contends that respondent's proposed denial of his application would be improper because respondent proposes to rely on Rule 21-12.08, Florida Administrative Code, even though it was adopted after the application petitioner filed, and because respondent allowed too much time to pass (a) before requesting additional information from petitioner, (b) before acting dispositively on his application, and (c) before forwarding his request for a formal hearing to the Division of Administrative Hearings. Neither Mr. Bell's age nor whether he paid the $200 application fee is at issue in these proceedings. Petitioner seemed to contend, in a pleading filed three days before the final hearing, that Rule 21-12.08, Florida Administrative Code, is invalid. At the hearing, petitioner argued that Rule 21-12.08, Florida Administrative Code, did not square with Section 455.201, Florida Statutes (1981). The hearing officer declined to reach the merits of this contention, but without prejudice to petitioner's filing a rule challenge pursuant to Section 120.56, Florida Statutes (1981), or pursuing the matter on appeal under the authority of State ex rel. Department of General Services v. Willis, 344 So.2d 580, 592 (Fla. 1st DCA 1977).
Findings Of Fact On July 27, 1981, respondent Department received petitioner's form "Application for Acupuncture Examination." Petitioner's Exhibit No. 1. Thereafter, on September 18, 1981, the Department filed its acupuncture rules with the office of the Secretary of State. Petitioner's Exhibit No. 3. These rules, including Rule 21-12.08, Florida Administrative Code, became effective 20 days later on October 8, 1981. Petitioner's Exhibit No. 3. On September 22, 1981, Mrs. Ann M. Mayne wrote petitioner Bell on behalf of the Department advising him that his "application for the acupuncture examination ha[d] been reviewed . . . [and determined to be] incomplete . . . [for failure to include an] official transcript from a school . . . approved in accordance with Rule 21-12.08 . . . [and/or failure to include an] affidavit . . . signed by an officer of the school . . . certifying to applicant's satisfactory completion of . . . training." Hearing Officer's Exhibit No. 2. The letter also advised: Your school or college has not been approved by this Department. The Department is in the process of trying to determine if your school meets the qualifications as set forth in Rule 21-12.08 in order for your school or college to be considered for approval. [Y]our acupuncture license and admission to the next acupuncture examination is denied, based on the deficiencies as indicated above. If all of this material is received in this office by October 9, 1981, your application will be reconsidered for the November 1981 examination. Otherwise, you will have to be considered for a subsequent examination. In accordance with 120.60(2), Florida Stat- utes, you have a right to a 120.57 hearing on this matter, if you request same within thirty (30) days of the date of this letter. Hearing Officer's Exhibit No. 2. On October 6, 1981, petitioner furnished the Department an official transcript attested to by one Walter D. Sturm, "President and Alumni Director" of the Occidental Institute of Chinese Studies Alumni Association. Petitioner's Exhibit No. 1. The Department of Professional Regulation received a telegram on October 16, 1981, which read: "REQUEST 120.57 HEARING REGARDING ACUPUNCTURE EXAM JASPER ODELL BELL AND YVONNE MARION BELL." Petitioner's Exhibit No. 4. The Department received a letter from petitioner on October 22, 1981, "a follow- up letter to telegram of October 16, 1981." Petitioner's Exhibit No. 1. In this letter, dated October 20, 1981, petitioner stated, "I request a 120.57 hearing . . . due to the September 22nd letter's denial of admission to November acupuncture examination based on deficiencies indicated in that letter and the lack of your response within the 30-day hearing deadline." Petitioner's Exhibit No. 1. From records of the Division of Administrative Hearings, it appears that this letter, together with a request that a hearing officer be assigned, was received by the Division of Administrative Hearings on November 12, 1981. Mr. Inge, deputy director of respondent's Division of Professions, wrote Mr. Bell on November 18, 1981, as follows: Your application for the acupuncture examination has been reviewed and is hereby denied based on the information contained in your application and the findings thereof. Based on the information received from your school or college, it has been deter- mined that your school or college does not meet the criteria as set forth in Rule 21-12.08 in order to be approved by this Department. Pursuant to 120.60(2), Florida Stat- utes, your acupuncture license and admis- sion to the next examination is denied, based on your failure to qualify pursuant to Chapter 468, Part VIII and the rules adopted thereunder. In accordance with 120.60(2), Florida Statutes, you have a right to a 120.57 hear- ing on this matter, if you request same within 30 days of the date of this letter. Hearing Officer's Exhibit No. 1. The parties stipulated that the Department has yet to approve any school or college as meeting the criteria set forth in Rule 21-12.08, Florida Administrative Code. Petitioner's proposed findings of fact and conclusions of law have been given careful consideration, and the proposed fact findings have been adopted to the extent that they were relevant and supported by the evidence, but not otherwise.
Recommendation Upon consideration of the foregoing, it is RECOMMENDED: That the Department deem petitioner's application approved and, subject to the satisfactory completion of an examination, license petitioner as an acupuncturist. DONE AND ENTERED this 29th day of March, 1982, in Tallahassee, Florida. ROBERT T. BENTON, II Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 29th day of March, 1982.
