The Issue Whether Petitioner received Medicaid overpayments and, if so, the total amount of the overpayments.
Findings Of Fact AHCA is charged with administration of the Medicaid program in Florida pursuant to Section 409.907, Florida Statutes. Petitioner is a durable medical equipment provider that provided Medicaid services to Medicaid beneficiaries pursuant to a valid Medicaid Provider Agreement with AHCA under provider number 9512721 00. Petitioner was an authorized Medicaid provider during the period of October 1, 1999, through September 30, 2001, which is the audit period at issue here. AHCA conducted an audit of paid Medicaid claims for services claimed to have been performed by Petitioner from October 1, 1000, through September 30, 2001. On October 16, 2002, AHCA issued a Final Agency Audit Report ("FAAR") requesting Petitioner to reimburse AHCA in the amount of $28,407.90, for Medicaid claims submitted by and paid to Petitioner, for services allegedly rendered during the audit period. When the FAAR was issued, AHCA's claims for overpayment were based upon audit findings that paid Medicaid claims for certain services performed by Petitioner did not meet Medicaid requirements. The deficiencies in the subject Medicaid claims included a lack of documentation of required medication for nebulizer equipment, payments in excess of allowable total amounts for rent-to-purchase equipment, and payments for portable oxygen with a lack of documentation that the attending practitioner has ordered a program of exercise or an activity program for therapeutic purposes, that the recommended activities cannot be accomplished by the use of stationary oxygen service, and that the use of a portable oxygen system during exercise or activity results in improvement in the individual's ability to perform the exercises or activities. During the subject audit period, the applicable statutes, rules, and Medicaid handbooks required Petitioner to retain all medical, fiscal, professional, and business records on all services provided to a Medicaid recipient. Petitioner had to retain these records for at least five years from the dates of service. Petitioner had a duty to make sure that each claim was true and accurate and was for goods and services that were provided in accordance with the requirements of Medicaid rules, handbooks, and policies, and in accordance with federal and state law. Medicaid providers who do not comply with the Medicaid documentation and record retention policies may be subject to administrative sanctions and/or recoupment of Medicaid payments. Medicaid payments for services that lack required documentation and/or appropriate signatures will be recouped. Claire Cohen, AHCA's analyst, generated a random list of 30 Medicaid recipients (cluster sample) who had received services by Petitioner during the audit period. In addition, AHCA generated work papers revealing the following: the total number of Medicaid recipients during the audit period; the total claims of Petitioner, with dates of services; the total amount of money paid to the Petitioner during the audit period; and worksheets representing the analyst's review of each recipient's claims for the audit period. After Ms. Cohen reviewed the medical records and documentation provided by Petitioner, she reviewed the Medicaid handbook requirements, and arrived at a figure of $7,572.13 as the total overpayment for all cluster sample claims. Using the Agency's formula for calculating the extrapolated overpayment, Ms. Cohen determined that the overpayment in this case amounted to $29,703.63. Ms. Cohen then prepared the June 20, 2002, Preliminary Agency Audit Report (PAAR) and mailed it to Petitioner. At that point, the case was reassigned to Ellen Williams, a program analyst/investigator. Ms. Williams reviewed additional documentation submitted by Petitioner, and on October 16, 2002, issued on behalf of AHCA, the FAAR, which reduced the alleged overpayment to $28,407.90. Part of this reduction resulted from Petitioner's paying $369.97 to satisfy the issue concerning payments in excess of allowable totals for rent-to-purchase equipment. At the hearing, Ms. Williams testified that the adjusted overpayment amount was $27,473.27. The formula used by AHCA is a valid statistical formula, the random sample used by the Agency was statistically significant, the cluster sample was random, and the algebraic formula and the statistical formula used by AHCA are valid formulas. The DME/Medical Supply Services Coverage and Limitations Handbook provides, in part: Medicaid reimburses for portable oxygen when a practitioner prescribes activities requiring portable oxygen. The oxygen provider must document the following information in the recipient's record: the recipient qualifies for oxygen service; the attending practitioner has ordered a program of exercise or an activity program for therapeutic purposes; the recommended exercises or activities cannot be accomplished by the use of stationary oxygen services; and the use of a portable oxygen system during the activity or exercise results in an improvement in the individual's ability to perform the activities and exercises. The DME/Medical Supply Services Coverage and Limitations Handbook also provides, in part: Medicaid may reimburse for a nebulizer if the recipient's ability to breathe is severely impaired. The documentation of medial necessity must include required medications. The following payments are claimed by AHCA to be overpayments for failure to provide documentation of medical necessity and required medications: Recipient Date of Service Procedure Overpayment 4 7/19/00 E0570 $106.70 9 6/30/00 E0570 $106.70 10 10/24/00 E0570 $106.70 14 02/15/00 E0570 $106.70 16 05/08/00 E0570 $106.70 23 06/09/00 E0570 $106.70 26 06/14/00 E0570 $106.70 The remaining overpayments claimed by AHCA concern the failure to document that the attending practitioner had ordered a program of exercise or an activity program for therapeutic purposes that required the use of a portable oxygen system. The Medicaid Provider Reimbursement Handbook provides, in part, that "Records must be retained for a period of at least five years from the date of service." The types of records that must be retained include "patient treatment plans" and "prescription records." The handbook goes on to provide in pertinent part: Medical records must state the necessity for and the extent of services provided. The following minimum requirements may vary according to the services rendered: * * * Treatment plan, including prescriptions; Medications, supplies, scheduling frequency for follow-up or other services; Progress reports, treatment rendered; * * * Note: See the service-specific Coverage and Limitations Handbook for record keeping requirements that are specific to a particular service. Providers who are not in compliance with the Medicaid documentation and record retention policies described in this chapter may be subject to administrative sanctions and recoupment of Medicaid Payments. Medicaid payments for services that lack required documentation or appropriate signatures will be recouped. Note: See Chapter 5 in this handbook for information on administrative sanctions and Medicaid payment recoupment. Petitioner, through its owners and operators, is of the view that it does not need to have the documentation on file, and it does not ask physicians for details about their prescriptions, "because that's something private from doctors and patient." Petitioner, by signing a Medicaid Provider agreement, agreed that all submissions for payment of claims for services will constitute a certification that the services were provided in accordance with local, state, and federal laws, as well as rules and regulations applicable to the Medicaid program, including the Medical Provider Handbooks issued by AHCA. Petitioner routinely obtained from Medicaid beneficiaries to whom it provides goods or services a written statement authorizing other healthcare provides to furnish any information needed to determine benefits.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency issue a final order requiring Petitioner to reimburse the Agency for Medicaid overpayments in the total amount of $27,473.27, plus such interest as may statutorily accrue. DONE AND ENTERED this 22nd day of September, 2003, in Tallahassee, Leon County, Florida. S MICHAEL M. PARRISH 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 22nd day of September, 2003. COPIES FURNISHED: Tom Barnhart, Esquire Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 Lawrence R. Metsch, Esquire Metsch & Metsch, P.A. 1455 Northwest 14th Street Miami, Florida 33125 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 Valda Clark Christian, General Counsel Agency for Health Care Administration Fort Knox Building, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308 Rhonda M. Medows, M.D., Secretary Agency for Health Care Administration Fort Knox Building, Suite 3116 2727 Mahan Drive Tallahassee, Florida 32308
The Issue Whether Petitioner is entitled to coverage under the State of Florida Group Health Self Insurance Plan for dental treatment, as set forth in the Petition. This proceeding arose after denial of a supplemental claim by Petitioner for dental expenses under the State of Florida Group Health Self Insurance Plan. At the hearing, Petitioner presented the testimony of one witness and testified in his own behalf. Petitioner submitted five exhibits in evidence. Respondent presented no witnesses and submitted two exhibits in evidence. Respondent's Proposed Findings of Fact and Conclusions of Law have been fully considered and those portions thereof not adopted herein are considered to be either unnecessary, irrelevant, or unsupported in law or fact, and are specifically rejected.
Findings Of Fact Petitioner Judge Harry Lee Coe, III, of Tampa, Florida, was insured by the Florida Group Health Self Insurance Plan during 1981 and continues to be so insured. (Stipulation) During the month of June 1981, Petitioner had an accident in his home which caused a fracture to his left upper incisor and lower incisor, teeth numbers 9 and 25, respectively. He was treated by Dr. F. A. Priede, D.D.S., in June 1981, for the damage to his teeth. The treatment consisted of crowning the two chipped teeth. The accident also damaged the lateral incisor, tooth number 10, necessitating a root canal procedure by another dentist. Petitioner filed a claim with the Administrator of the State of Florida Employee Group Health Self Insurance Plan, Blue Cross and Blue Shield of Florida, Inc., and received payment in the amount of $321.88. (Testimony of Priede, Coe, Petitioner's Exhibits 1, 3-4) In February 1982, Petitioner fractured tooth number 9 to the extent that it required extraction. Dr. Priede replaced the tooth with a temporary bridge. A permanent bridge was placed in June 1982 replacing tooth number 9 and swinging to tooth number 10 which had been crowned. Although the cause of the fractured tooth number 9 was not established, Dr. Priede testified that it is common for such a weak small tooth to fracture later as a result of the initial damage and treatment to the tooth. (Testimony of Priede, Petitioner's Exhibits 1, 3) The cost of the supplementary dental treatment was in the amount of $400 and a claim was submitted to Blue Cross and Blue Shield of Florida, Inc. for that amount. The claim was denied on the basis that the dental services did not result from accidental injury. Petitioner's counsel requested reconsideration of the denial and enclosed a letter from Dr. Priede to him, dated May 10, 1983, explaining the course of dental treatment. By letter, dated June 3, 1983, he was advised by Blue Cross and Blue Shield of Florida, Inc. that the claim was not timely under the State of Florida Employees Group Health Self Insurance Plan because dental services must be provided within 120 days of the accident unless explanation from the dentist is submitted within that period stating the extenuating circumstances requiring the treatment to be performed over a longer period of time. Petitioner then requested an administrative hearing under Chapter 120, Florida Statutes. (Testimony of Priede, Petitioner's Exhibits 1-5) The contractual provisions of the State of Florida Employees Group Health Self Insurance Plan are set forth in summarized form in a booklet issued by the Department of Administration. Paragraph 23B of the booklet, effective May 1, 1978, provided as follows: 23. LIMITATIONS The following limitations shall apply under the plan. * * * B. Any dental work, dental treatment or dental examinations necessary for the repair or alleviation of damage to an Insured caused by an Accident shall be rendered within one hundred and twenty (120) days of the accident unless a written explanation from the dentist or Physician is submitted stating the extenuating circumstances which would require treatment to be performed over a longer period of time. Such extension must be approved by the Administrator. However, in no instance shall any services be covered unless such services are rendered within one hundred and twenty (120) days of the termination of the Insured's coverage. However, this provision was subsequently changed, as set forth in the booklet, effective July 1, 1982, to require that the dentist's written explanation regarding extended treatment must also he submitted within the 120-day period. (Respondent's Exhibits 1-2)
Recommendation That a final order be entered denying Petitioner's claim. DONE AND ORDERED this 16th day of November, 1983, in Tallahassee, Florida. THOMAS C. OLDHAM 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 16th day of November, 1983. COPIES FURNISHED: Honorable Nevin G. Smith Secretary, Department of Administration Carlton Building Tallahassee, Florida 32301 Alex B. Vecchio, Esquire 620 Twiggs Street Tampa, Florida 32602 Daniel Brown, Esquire Department of Administration 435 Carlton Building Tallahassee, Florida 32301
The Issue The issues in this case are whether the Agency for Health Care Administration ("AHCA") is entitled to repayment of Medicaid reimbursements that it made to Respondent, pursuant to section 409.913(11), Florida Statues; if so, the amount of the repayment; the amount of any sanctions that should be imposed pursuant to subsections 409.913(15) through (17); and the amount of any investigative, legal, and expert witness costs that AHCA is entitled to recoup pursuant to section 409.913(23).
Findings Of Fact The Parties AHCA is the agency responsible for administering the Medicaid Program in the State of Florida, pursuant to section 403.902, Florida Statutes. During all times relevant to this proceeding, Respondent was an enrolled Medicaid provider authorized to receive reimbursement for covered services rendered to Medicaid recipients. AHCA's Agency Action Pursuant to its statutory authority to oversee the integrity of the Medicaid program in Florida, AHCA conducted an audit of Respondent's claims for Medicaid reimbursement for the period from February 1, 2010, to March 1, 2011, to verify that claims paid by AHCA to Respondent under the Medicaid program did not exceed the amount authorized by Medicaid law and applicable rules. As a result of the audit, AHCA determined it was entitled to reimbursement from Respondent for $102,444.33 that it paid to him for services not covered under the Medicaid program. AHCA also sought to impose sanctions consisting of a $20,488.86 administrative fine and investigative, legal, and expert witness costs. Respondent requested an administrative hearing under sections 120.569 and 120.57(1) to challenge the overpayment determination and imposition of sanctions. Evidence Adduced at Final Hearing At the final hearing, AHCA presented the testimony of Robi Olmstead, an administrator with AHCA's Bureau of Medicaid Program Integrity ("MPI"). Olmstead's responsibilities include supervising AHCA's staff performance of MPI audits. As a result of her employment with AHCA in this position for several years, Olmstead is very familiar with, and knowledgeable about, conducting MPI audits. No evidence was presented to show that Olmstead is a licensed physician, has any substantive medical or dental knowledge, or is a medical or dental services expert. Olmstead did not serve as a peer reviewer for AHCA in determining or describing the nature or determining medical necessity of the specific procedures at issue in this proceeding, and she was neither proffered nor accepted as a peer reviewer or expert witness for these purposes at the final hearing. Description of the Audit and Overpayment Determination Olmstead described the audit of Respondent's claims at issue in this case. For reasons unspecified in the record, AHCA initiated an audit of the Medicaid claims for which Respondent had been paid.1/ Using AHCA's data support system, investigator Theresa Mock2/ accessed the complete universe of Medicaid claims paid to Respondent.3/ Mock selected the period from February 1, 2010, to March 1, 2011, as the Audit Period ("Audit Period")4/ and selected a statistically-based claim sampling program——in this case, cluster5/ sampling——to perform the audit. A computer-generated representative sample, consisting of 30 Medicaid recipients for whom Respondent had billed claims during the Audit Period and been paid, was identified. AHCA contacted Respondent by demand letter, requesting that he submit documents to substantiate the claims. In response, Respondent provided documents consisting of his records of service and billing for each claim for each of the 30 recipients. Mock forwarded the records to AHCA's peer review coordinators, who, in turn, forwarded them to Dr. Mark Kuhl, AHCA's peer reviewer for this audit.6/ Kuhl reviewed the records and prepared worksheets reflecting his determination regarding the nature of the service rendered for each claim and whether such claim was eligible for payment under the Medicaid program. Respondent's records and Kuhl's worksheets were sent to Mock, who, based on Kuhl's determination regarding the nature and eligibility of each claim, calculated that Respondent had been overpaid by a total of $85,582.02, or $355.11211618 per claim, for the sampled claims. To extrapolate the total probable overpayment to Respondent for all claims, Mock applied the statistical formula for cluster sampling7/ to the calculated overpayment amount of $85,582.02 for the representative sample. This yielded a total extrapolated overpayment amount of $102,444.33, within a 95 percent probability that the actual overpayment amount was equal to or greater than that amount. In a Preliminary Audit Report ("PAR") dated December 12, 2011, AHCA notified Respondent that it had determined that he had been overpaid by $102,444.33 and gave him the options of paying that amount or submitting further documentation to support the claims identified as overpayments in the PAR. Respondent provided additional information in an effort to support these claims; however, AHCA apparently found the information insufficient to support changes to its previous determination that Respondent had been overpaid by $102,444.33. On March 22, 2013, AHCA issued a Final Audit Report ("FAR") stating its determination that Respondent had been overpaid by $102,444.33. The following explanation in the FAR was provided as the basis for AHCA's overpayment determination: REVIEW DETERMINATIONS A review of your dental records revealed that some services rendered were erroneously coded on the submitted claim. The procedure code that would accurately reflect the service provided is not covered by Medicaid. The payment for those claims is considered an overpayment. 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 sufficiently. Therefore, the payment for those claims is considered an overpayment. A review of your records indicated that some procedure codes were double billed in error. In those instances, the amount paid for the second (duplicate) procedure is considered an overpayment. The FAR also notified Respondent that AHCA had assessed an administrative fine of $20,488.86 and audit costs of $576.83. In sum, the FAR notified Respondent that he was required to remit a total of $123,510.02. The FAR also notified Respondent that AHCA was entitled to recover all investigative, legal, and expert witness costs. Following issuance of the FAR, Respondent provided additional records to support claims that AHCA asserted were ineligible for payment. After considering these records, AHCA determined that some of these claims had not been overpaid, and on June 17, 2014, performed another calculation of the alleged overpayment for the entire universe of Respondent's claims using the cluster sampling formula. AHCA ultimately determined that Respondent had been overpaid by a total of $102,410.79, the alleged overpayment amount at issue in this proceeding. Requirements for Payment of Claims by Medicaid To be eligible for coverage by Medicaid, a procedure must be "medically necessary," which is defined as follows: “Medical necessity” or “medically necessary” means any goods or services necessary to palliate the effects of a terminal condition, or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity, which goods or services are provided in accordance with generally accepted standards of medical practice. § 403.913(1)(d), Fla. Stat. (2010).8/ AHCA is the final arbiter of medical necessity for purposes of determining Medicaid reimbursement. Id. The statute expressly requires that determinations of medical necessity be made by a licensed physician employed by or under contract with the agency——i.e., a peer reviewer——based on information available at the time the goods or services are provided. Id. To ensure that services rendered by a provider are correctly billed to and paid by Medicaid, the provider must identify the services by referring to specific codes corresponding to the specific procedure or service rendered. If services rendered are incorrectly coded on a provider's billing submittals, they may be determined ineligible for payment by Medicaid. Applicable Medicaid Handbooks, Codes, and Fee Schedules To guide and inform providers regarding the types of services that are covered by the Medicaid program and how to correctly bill Medicaid for those services, AHCA has adopted several documents by rule through incorporation by reference. The documents incorporated by reference that are applicable to this case are the Florida Medicaid Provider General Handbook (July 2008)9/; the Florida Medicaid Dental Services Coverages and Limitations Handbook (January 2006)10/; the Florida Medicaid Provider Reimbursement Handbook, CMS-1500 (July 2008)11/; the Dental Oral/Maxillofacial Surgery Fee Schedule (effective January 1, 2010)12/; and the Dental General Fee Schedule (effective January 1, 2010)13/. Additionally, AHCA rule14/ refers to "CPT" codes, which are the Current Procedural Terminology® codes developed and kept up-to-date by the American Medical Association. These codes, which are published, are used by AHCA to identify the specific services rendered by providers for purposes of determining whether the service is covered by Medicaid. In this proceeding, AHCA provided, for admission into evidence, excerpts from the 2010 CPT codes, which were in effect during the Audit Period. AHCA rules adopted in the Florida Administrative Code do not expressly define, incorporate, or otherwise refer to "CDT" codes, which are the Current Dental Terminology© codes published by the American Dental Association. The Florida Medicaid Dental Services Coverages and Limitations Handbook (January 2006) was in effect during the Audit Period. This handbook refers to the Current Dental Terminology© codes, but does not specify the version of the CDT codes by year that were applicable to that version of the handbook.15/ AHCA provided, as exhibits, portions of the 2011/2012 CDT codes.16/ The Specific Claims at Issue Respondent's records and other documentation regarding the services for which he submitted claims for payment under Medicaid were admitted into evidence at the final hearing. The claims at issue in this proceeding are identified on worksheets prepared by Kuhl, who reviewed Respondent's records and documents provided in response to AHCA's demand letter. Kuhl's worksheets were admitted into evidence. These worksheets document, for each claim reviewed, Kuhl's determination regarding the nature of the service rendered by Respondent and whether the claim was eligible for payment under the Medicaid program. As noted above, Kuhl did not testify at the final hearing. Accordingly, the sole evidence in the record regarding Kuhl's determinations consists of the notations on his worksheets and Ms. Olmstead's testimony regarding his conclusions. As discerned from Kuhl's worksheets, Kuhl determined that Respondent had been overpaid for three reasons: (1) for some claims, Respondent did not provide records, such as x-rays or other documents, to support or verify that he had, in fact, rendered the service; (2) for some claims, Respondent billed twice (i.e., duplicate-billed) and was paid twice for the same service rendered to a recipient; and (3) for some claims, Respondent performed, and billed for, procedures that were not medically necessary so were not payable by Medicaid. Each of these bases is addressed below. Lack of Documentation to Support Claims Based on his review of Respondent's records, Kuhl determined that Respondent did not provide adequate documentation to support some claims for which he was paid. For each such claim, Kuhl wrote on the applicable worksheet next to the applicable claim: "not in the record" or "not in record." As noted above, Respondent subsequently submitted additional documentation for some claims. Based on Kuhl's worksheets and this additional documentation, AHCA determined that Respondent had been overpaid a total of $3,091.91 for the sampled claims as a result of his failure to provide supporting information. The table below summarizes AHCA's overpayment determinations for the sampled claims on this basis. Undocumented Claims Recipient No. No. of Claims Overpaid Amount of Overpayment 1 2 $8.00 17 2 $3.00 21 3 $1,120.75 26 1 $4.00 28 3 $1,956.16 Total Amount of Overpayment $3,091.91 Double-billed Claims Kuhl determined that for some claims, Respondent duplicate-billed and was paid twice for the same service. For each such claim, Kuhl wrote on the applicable worksheet next to the applicable claim, what appears to be a notation stating "duplicate charge amt" or "duplicate charge out."17/ Either way, it is clear from the worksheets that Kuhl determined that Respondent had duplicate-billed for certain services rendered to certain recipients. Based on Kuhl's worksheets and Respondent's billing records, AHCA determined that due to duplicate billing, Respondent had been overpaid a total of $30.00 for the sampled claims. The table below summarizes AHCA's overpayment determinations for the sampled claims on this basis. Duplicate-Billed Claims Recipient No. No. of Claims Double-Billed Amount of Overpayment 8 1 $27.00 9 1 $3.00 Total Amount of Overpayment $30.00 Claims for Face Bone Graft and Lower Jaw Graft Three Medicaid billing codes are implicated in this proceeding: CPT codes 21210 and 21215, and CDT code D7953. The 2010 version of CPT code 21210 is defined as "graft, bone; nasal, maxillary, or malar areas (includes obtaining graft)." The notations on AHCA's spreadsheet summarizing its overpayments refer to this procedure, in lay terms, as a "face bone graft." The 2010 version of CPT code 21215 is defined as "mandible (includes obtaining graft)." The notations on AHCA's spreadsheet summarizing its overpayments refer to this procedure, in lay terms, as a "lower jaw bone graft." Respondent billed and was paid for 44 claims under CPT code 21210 for face bone grafts and 25 claims under CPT code 21215 for lower jaw bone grafts. For each claim identified on Kuhl's worksheets as either "21210 ## ## Face Bone Graft" or "21215 ## ## Lower Jaw Bone Graft," Kuhl made the notation "correct code = D7953 = bone graft place in ext site at time of ext" or a similar notation to that effect. For each such claim, Kuhl checked the "deny" option on the worksheet. Below the "deny" option, Kuhl made the following or a similar notation: "as it was stated by Robi Olmstead it is a non-covered procedure" or "if a non-covered procedure." CDT code D7953 is defined in the 2011-201218/ version of the CDT codes as: bone replacement graft for ridge preservation – per site Osseous autograft, allograft, or non-osseous graft is placed in an extraction or implant removal site at the time of the extraction or removal to preserve ridge integrity (e.g., clinically indicated in preparation for implant reconstruction or where alveolar contour is critical to planned prosthetic reconstruction). Membrane, if used, should be reported separately. Olmstead testified that the D7953 procedure is not medically necessary so is not covered by Medicaid. According to Olmstead, the D7953 procedure is not considered medically necessary because "most often sufficient bone will be regenerated or, you know, you won't really need it unless you [are] getting implants are (sic) [or] dentures, and it's just not always——infrequently medically necessary to do this according to some of the literature, and so Medicaid, you know, as they're allowed to do, has decided not to cover this procedure, and it's clearly not covered except for the oral surgeon19/ under these two codes, but again, it still has to be medically necessary." Olmstead testified that the absence of D7953 as a listed procedure on the Dental General Fee Schedule (January 2010) and the Dental Oral/Maxillofacial Surgery Fee Schedule (January 2010) further evidences that D7953 is not covered by Medicaid. Kuhl did not make any express finding on his worksheets that the D7953 procedure is not medically necessary. Indeed, Olmstead acknowledged that Kuhl's worksheets did not state that the D7953 procedure is not medically necessary. Kuhl also did not make any express finding on his worksheets that the CPT code 21210 and CPT code 21215 procedures were not medically necessary. Based on Kuhl's worksheets, AHCA determined that for each claim Respondent billed under CPT codes 21210 or 21215, the claim was not covered by Medicaid, so should not have been paid. The table below summarizes AHCA's determinations of overpayment, on the basis of lack of medical necessity, for the sampled claims for CPT Code 21210 for face bone grafts performed by Respondent. CPT Code 21210 - Face Bone Graft Recipient No. No. of Claims for CPT Code 21210 Total Amount of Overpayment for Recipient 1 1 $1,089.75 2 1 $ 544.88 4 4 $3,814.13 5 2 $1,634.63 6 1 $1,089.75 7 1 $1,089.75 9 3 $2,724.38 10 1 $1,089.75 11 6 $4,903.89 12 1 $1,089.75 17 2 $1,634.63 19 2 $1,634.63 20 1 $1,089.75 21 2 $1,634.6320/ 22 1 $ 544.88 23 3 $1,847.07 24 1 $1,089.75 25 6 $5,448.76 26 3 $3,269.25 29 1 $1,089.75 30 1 $1,089.75 The table below summarizes AHCA's determinations of overpayment, on the basis of lack of medical necessity, for the sampled claims for CPT Code 21215 for lower jaw bone grafts performed by Respondent. CPT Code 21215 - Lower Jaw Bone Graft Recipient No. No. of Claims for CPT Code 21215 Total Amount of Overpayment for Recipient 1 5 $8,591.22 2 1 $1,909.16 4 1 $1,909.16 5 1 $1,909.16 8 3 $4,772.90 11 2 $3,818.32 14 1 $1,909.16 15 1 $1,909.16 16 2 $3,818.32 17 1 $1,909.16 18 2 $3,817.82 22 1 $1,909.16 27 2 $2,863.74 28 2 $1,909.16 Findings Regarding Alleged Overpayment The undersigned determines that the record evidence supports AHCA's determinations that Respondent was overpaid in the amount of $3,091.91 for claims for which he did not provide required documentation. The undersigned determines that the record evidence supports AHCA's determinations that Respondent was overpaid in the amount of $30.00 for claims for which he duplicate-billed Medicaid. As previously noted, the Florida Medicaid Dental Services Coverages and Limitations Handbook (January 2006) was in effect during the Audit Period. However, AHCA did not provide, as part of its evidence, pertinent excerpts of this version of the handbook referencing the CDT codes in effect during the Audit Period. AHCA also failed to provide the version of the CDT codes in effect during the Audit Period. Thus, the undersigned is left without any evidence regarding the nature or description of procedure D7953 as it was defined under the version of the CDT codes in effect during the Audit Period. Accordingly, the undersigned is unable to verify the correctness of Kuhl's notations stating that CDT code D7953, rather than CPT codes 21210 or 21215, was the correct notation for the procedures Respondent performed. As discussed above, AHCA's audit supervisor, Robi Olmstead, testified regarding the nature of the procedure identified in D7953 and distinguished that procedure from the procedures to which CPT codes 21210 and 21215 apply. However, there is no evidence establishing that she was competent to testify about the medical nature of the D7953 procedure, how it substantively differs from the other procedures at issue as defined in CPT codes 21210 or 21215, whether or not the procedures Respondent performed were medically necessary, or whether the D7953 procedure is medically necessary. As such, the undersigned finds her testimony unpersuasive to show that the procedures Respondent performed and billed under CPT codes 21210 and 21215 were not medically necessary and therefore not billable to Medicaid, that D7953 was the correct billing code for the procedures Respondent performed, and that the procedure corresponding with code D7953 is not medically necessary.21/ AHCA chose not to present testimony by its peer reviewer, Dr. Mark Kuhl, at the final hearing.22/ Although Kuhl's worksheets were admitted into evidence, they do not provide a credible, independently verifiable explanation for his conclusion that Respondent incorrectly billed a particular procedure by using either CPT code 21210 or 21215 instead of CDT code D7953. Moreover, the worksheets contain notations, discussed above, which indicate or appear to indicate that Kuhl relied on Olmstead's direction that the bone graft procedures for which Respondent billed were not medically necessary. Olmstead is not competent to determine medical necessity, and Kuhl's apparent reliance on her direction regarding medical necessity is directly contrary to section 409.913(1)(d), which expressly requires that "[d]eterminations of medical necessity must be made by a licensed physician employed by or under contract with the agency." As such, the undersigned finds Kuhl's worksheets unpersuasive to show that the procedures Respondent performed and billed under CPT codes 21210 and 21215 were not medically necessary and therefore not billable to Medicaid, that D7953 was the correct billing code for the procedures Respondent performed, and that the procedure corresponding with code D7953 is not medically necessary. For these reasons, it is determined that AHCA has not proven, by a preponderance of the competent substantial evidence in the record, that Respondent was overpaid for the claims he billed for bone grafts using CPT codes 21210 and 21215. Based on the foregoing, it is determined that AHCA overpaid Respondent in the total amount of $3,121.91. Determination of Administrative Fine As found above, Respondent was overpaid in the amount of $3,091.91 for undocumented claims. Pursuant to Florida Administrative Code Rule 59G- 9.070(7), sanctions are required to be imposed for failure to furnish all Medicaid-related records to be used by AHCA in determining whether Medicaid payments are or were due. Under rule 59G-9.070(7)(d), a $2,500 fine is to be imposed for the first offense23/ of failing to furnish all Medicaid-related records. AHCA proved that Respondent was paid for undocumented claims, and Respondent does not appear to challenge that. Accordingly, it is determined that sanctions consisting of a $2,500 administrative fine should be imposed for this violation. Duplicate-billed Claims As found above, Respondent was overpaid in the amount of $30.00 for duplicate-billing of services. AHCA did not present any evidence that Respondent engaged in a "pattern of erroneous claims." Rather, the evidence indicates that Respondent inadvertently duplicate- billed for services rendered to two recipients for a total of $30.00. Moreover, in its Proposed Recommended Order, AHCA did not cite and otherwise discuss any basis for the imposition of an administrative fine for Respondent's duplicate-billing. Therefore, it is determined that no administrative fine should be imposed for Respondent's violations consisting of two incidents of duplicate billing.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that AHCA issue a final order finding that Respondent was overpaid, and therefore is liable for reimbursement to AHCA, the total amount of $3,121.91; imposing an administrative fine of $2,500; and remanding the matter to the Division of Administrative Hearings for an evidentiary hearing on the recovery of AHCA's costs, if necessary. DONE AND ENTERED this 29th day of May, 2015, in Tallahassee, Leon County, Florida. S CATHY M. SELLERS 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 29th day of May, 2015.
The Issue The issue for determination in this case is whether the agency's interpretation of its Title XIX, ICF/MR Reimbursement Plan is a rule, and if so, whether it is an invalid rule.
Findings Of Fact Friendly Village of Brevard, Inc. d/b/a Washington Square (herein, Washington Square) is an intermediate care facility for the mentally retarded (ICF/MR), located at 2055 North U.S. 1, in Titusville, Florida. Friendly Village of Orange, Inc., d/b/a Lake View Court (herein, Lake View Court), is also an ICF/MR located at 920 W. Kennedy Boulevard, in Eatonville, Florida. Both facilities are operated by Developmental Services, Inc. Both are certified ICF/MR's participating in the Florida Medicaid Program. The Department of Health and Rehabilitative Services (HRS) is the state agency responsible for overseeing the ICF/MR Medicaid Program. Representatives of HRS and Florida's ICF/MR industry began negotiations on a new state Medicaid reimbursement plan in 1982 and 1983. The participants in the negotiations sought to remove certain cost limitations and to insure that individual facilities would receive fair reimbursement of their allowable costs. The negotiations resulted in the Title XIX ICF/MR Reimbursement Plan dated July 1, 1984 (the 1984 Plan). The 1984 Plan provides, in part, for the establishment of reimbursement rates for new ICF/MR's entering the Florida Medicaid program after January 1, 1983. Under the plan, a provider is required, prior to beginning operations, to prepare a budgeted costs report projecting what it expects to spend in allowable costs during the next year for care to its residents. HRS reviews these budgets and establishes a per diem rate, using the budgeted costs and the number of patients, arriving at a per patient, per day rate. Each month, as services are provided, the ICF/MR bills the state Medicaid program for the number of patient days times the per diem. During the period in question, cost settlement occurred at the conclusion of the budgeted period. The provider filed his cost report detailing what was actually spent in allowable costs, HRS compared that amount with the amount budgeted and settled with the provider. Washington Square entered the Florida Medicaid program on January 19, 1983; Lake View Court entered the program in February 1983. Both facilities filed cost reports for periods ending on February 29, 1984. Sometimes cost settlements occur quickly through a desk review. Other times, as here, audits are performed and settlement may occur much later. The audits of Washington Square and Lake View Court were conducted in 1985 for their initial cost reports ending February 1984. The audits were issued in April and May 1988. Those audits state that prior to July 1, 1984, the Florida Medicaid Program recognized only those interim rate settlements resulting in an overpayment. This is an interpretation of the 1984 Plan which Petitioners dispute and which, in this case, Petitioners contend is an invalid rule. ICF/MR Reimbursement plans prior to July 1, 1984, had one-way cost settlement, which meant that if the provider as overpaid, the funds had to be returned to HRS; if the facility as underpaid, it did not receive additional reimbursement. The 1984 ICF/MR Plan was changed to allow two-way cost settlement, thus allowing an underpaid provider to recover its approved costs. Petitioners claim that a proper interpretation of the 1984 Plan, especially when read with the 1985 Plan, is that two-way cost settlement is retroactive to January 1983, for new providers entering the program after January 1, 1983. HRS disagrees with that interpretation and this issue is the subject of the consolidated case, #88-2938. HRS' interpretation means that Petitioners will not be reimbursed for underpayments received during their first reporting period. The 1984 Plan was adopted as a rule by incorporation, in Rule 10C- 7.49(4)(a)2. Florida Administrative Code.
The Issue The issue for determination is whether Respondent is liable to Petitioner for the principal sum of $94,675.83, which equals the amount that the Florida Medicaid Program paid Respondent for the "professional component" of claims for radiologic services rendered to Respondent's patients between July 1, 2001 and December 31, 2005.
Findings Of Fact Petitioner Agency for Health Care Administration ("AHCA" or the "Agency") is the state agency responsible for administering the Florida Medicaid Program ("Medicaid"). Respondent Harold L. Murray, M.D. ("Murray") was, at all relevant times, a Medicaid provider authorized to receive reimbursement for covered services rendered to Medicaid beneficiaries. Exercising its statutory authority to oversee the integrity of Medicaid, the Agency sent investigators to Murray's office on November 22, 2005. The purpose of this visit was to verify that claims paid by Medicaid had not exceeded authorized amounts. To this end, the investigators inspected Murray's facilities and reviewed his medical records. What the investigators saw gave them reasons to believe that Medicaid had been overpaying Murray for radiologic services. They focused on the period from July 1, 2001 to December 31, 2005 (the "Audit Period"). During the Audit Period, Murray had submitted approximately 2,000 claims seeking the "maximum fee" for radiologic services, which Medicaid had paid. The maximum fee includes compensation for "professional component" services. (Medicaid uses the term "professional component" to describe the physician's services of interpreting a radiologic study and reporting his or her findings. These services are distinguished from those comprising the "technical component," which are routinely performed by technicians. These latter services include operating the radiologic equipment (e.g. an X-ray or sonographic machine) and performing the exam.) It appeared to the investigators that Murray had not, in fact, been performing the professional component. Using information in its database, the Agency determined that, during the Audit Period, Murray had received Medicaid payments totaling $94,675.83 for professional component services. The Agency repeatedly requested that Murray supply additional information that might substantiate his prior claims for fees relating to the professional component. Murray failed, refused, or was unable to comply with the Agency's requests. Murray did testify at hearing, however, providing a reasonably clear picture of what had occurred. On direct examination, Murray explained that he had performed the "first preliminary" review of each radiologic examination in question before sending the study to a radiologist, whom he paid "out of [his own] pocket" to interpret the exam and make a report. According to Murray, Medicaid paid only for his (Murray's) professional component services——not the radiologist's. Murray argues that he is entitled to compensation for the professional component services that he personally performed, notwithstanding that another doctor performed the same services. Analysis of the Facts Although Murray's position might have some superficial appeal, it does not withstand scrutiny as a matter of fact, the undersigned has determined. To explain why this is so requires an analysis of Murray's testimony that entails neither legal conclusions nor findings of historical fact. The undersigned's rationale, being essentially fact-based, is explicated here in the interests of organizational coherence and readability. Assume first, for the sake of argument, that Murray's "first preliminary" review constituted an authoritative interpretation of the radiologic study. Because it is reasonable to infer (and the undersigned finds) that the radiologist's subsequent interpretation of the study was authoritative——Murray's routine practice of ordering and personally paying for the "second opinion" would have been inexplicable, and indeed irrational, if the radiologist's interpretation were of dubious value——the inevitable conclusion, assuming Murray's findings were authoritative, is that the "second opinion" was nearly always duplicative, excessive, and unnecessary.i Murray's responses to that conclusion doubtless would be: (1) Medicaid did not pay for the second opinion, so whether it was excessive and unnecessary is irrelevant; and (2) there is no statute, rule, or Medicaid policy that forbids a provider from procuring, at his own expense, a second opinion——even an unnecessary one. It is not accurate to say, however, that Medicaid did not pay for the second opinion; this, ultimately, is the fatal flaw in Murray's reasoning. To the contrary, Murray's testimony shows clearly that Medicaid did pay for some or all of the expense of the second opinion, albeit indirectly, when it paid Murray for the same work. As his own account reveals, Murray was, in effect, merely a conduit for the Medicaid money, which passed through his hands on its way to the radiologist. Murray contends, of course, that the Medicaid payments for the professional component were "his," that he had earned them by performing the "first preliminary" read, and that he was free to spend his income however he chose. If our initial assumption were true, namely that Murray's preliminary interpretation were authoritative, then his claim to the Medicaid payments at issue might have merit. But, on reflection, this assumption is difficult, if not impossible, to square with the fact that Murray found it necessary always to pay another doctor to perform the very same professional component services. Indeed, having a second opinion was so important to Murray that he was willing to perform his purported preliminary read at a substantially discounted rate, at least, if not for free——or even, maybe, at a financial loss: in every instance, one of these was necessarily the net economic result of his actions.ii If, as we have assumed, Murray were performing a valuable professional service each time he interpreted a radiologic exam, then——the question naturally arises——why would he effectively have given away his expert opinions? Murray testified that he did so for "the safety of [his] patient" and because the radiologist is "educated for that." But these "answers," far from being persuasive, actually undermine the assumption that spawns the question of motive. Indeed, Murray's testimony confirms a reasonable inference contrary to our initial assumption, which inference is that Murray lacked sufficient confidence in his so-called "preliminary" interpretations ever to rely on them alone. This inference, which the undersigned accepts as a finding, arises from the basic undisputed fact that Murray routinely sought "second opinions" for every patient. It is ultimately determined, therefore, that whatever Murray's "first preliminary" reviews comprised, they did not constitute authoritative interpretations of the radiologic studies at hand. That being the case, it is determined that Murray's preliminary opinions added little or no actual value to the subject medical transactions. Offering some sort of provisional opinion that holds only until the "real" opinion can be obtained from the radiologist is not tantamount to performing the professional component.iii Based on the evidence presented, it is determined that the radiologist performed the professional component of the radiologic studies at issue, not Murray. As a result of improperly claiming that he had performed professional component services when in fact he had not, Murray received from Medicaid a total of $94,675.83 in payments that were not authorized to be paid. This grand total of $94,675.83 constitutes an overpayment that Murray must return to the Agency.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency enter a final order requiring Murray to repay the Agency the principal amount of $94,675.83, together with an administrative fine of $1,000. DONE AND ENTERED this 10th day of July, 2007, in Tallahassee, Leon County, Florida. S JOHN G. VAN LANINGHAM 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 10th day of July, 2007.
The Issue The issues in this case are whether Respondent applied the proper reimbursement principles to Petitioners' initial Medicaid rate setting, and whether elements of detrimental reliance exist so as to require Respondent to establish a particular initial rate for Petitioners' facilities.
Findings Of Fact There are nine Petitioners in this case. Each of them is a long-term health care facility (nursing home) operated under independent and separate legal entities, but, generally, under the umbrella of a single owner, Tzvi "Steve" Bogomilsky. The issues in this case are essentially the same for all nine Petitioners, but the specific monetary impact on each Petitioner may differ. For purposes of addressing the issues at final hearing, only one of the Petitioners, Madison Pointe Rehabilitation and Health Center (Madison Pointe), was discussed, but the pertinent facts are relevant to each of the other Petitioners as well. Each of the Petitioners has standing in this case. The Amended Petition for Formal Administrative Hearing filed by each Petitioner was timely and satisfied minimum requirements. In September 2008, Bogomilsky caused to be filed with AHCA a Change of Licensed Operator ("CHOP") application for Madison Pointe.1 The purpose of that application was to allow a new entity owned by Bogomilsky to become the authorized licensee of that facility. Part and parcel of the CHOP application was a Form 1332, PFA. The PFA sets forth projected revenues, expenses, costs and charges anticipated for the facility in its first year of operation by the new operator. The PFA also contained projected (or budgeted) balance sheets and a projected Medicaid cost report for the facility. AHCA is the state agency responsible for licensing nursing homes in this state. AHCA also is responsible for managing the federal Medicaid program within this state. Further, AHCA monitors nursing homes within the state for compliance with state and federal regulations, both operating and financial in nature. The AHCA Division of Health Quality Assurance, Bureau of Long-Term Care Services, Long-Term Care Unit ("Long-Term Care Unit") is responsible for reviewing and approving CHOP applications and issuance of an operating license to the new licensee. The AHCA Division of Health Quality Assurance, Bureau of Health Facility Regulation, Financial Analysis Unit ("Financial Analysis Unit") is responsible for reviewing the PFA contained in the CHOP application and determining an applicant's financial ability to operate a facility in accordance with the applicable statutes and rules. Neither the Long-Term Care Unit nor the Financial Analysis Unit is a part of the Florida Medicaid Program. Madison Pointe also chose to submit a Medicaid provider application to the Medicaid program fiscal agent to enroll as a Medicaid provider and to be eligible for Medicaid reimbursement. (Participation by nursing homes in the Medicaid program is voluntary.) The Medicaid provider application was reviewed by the Medicaid Program Analysis Office (MPA) which, pursuant to its normal practices, reviewed the application and set an interim per diem rate for reimbursement. Interim rate-setting is dependent upon legislative direction provided in the General Appropriations Act and also in the Title XIX Long-Term Care Reimbursement Plan (the Plan). The Plan is created by the federal Centers for Medicare and Medicaid Services (CMS). CMS (formerly known as the Health Care Financing Administration) is a federal agency within the Department of Health and Human Services. CMS is responsible for administering the Medicare and Medicaid programs, utilizing state agencies for assistance when appropriate. In its PFA filed with the Financial Analysis Unit, Madison Pointe proposed an interim Medicaid rate of $203.50 per patient day (ppd) as part of its budgeted revenues. The projected interim rate was based on Madison Pointe's expected occupancy rate, projected expenses, and allowable costs. The projected rate was higher than the previous owner's actual rate in large part based on Madison Pointe's anticipation of pending legislative action concerning Medicaid reimbursement issues. That is, Madison Pointe projected higher spending and allowable costs based on expected increases proposed in the upcoming legislative session. Legislative Changes to the Medicaid Reimbursement System During the 2007 Florida Legislative Session, the Legislature addressed the status of Medicaid reimbursement for long-term care facilities. During that session, the Legislature enacted the 2007 Appropriations Act, Chapter 2007-72, Laws of Florida. The industry proposed, and the Legislature seemed to accept, that it was necessary to rebase nursing homes in the Medicaid program. Rebasing is a method employed by the Agency periodically to calibrate the target rate system and adjust Medicaid rates (pursuant to the amount of funds allowed by the Legislature) to reflect more realistic allowable expenditures by providers. Rebasing had previously occurred in 1992 and 2002. The rebasing would result in a "step-up" in the Medicaid rate for providers. In response to a stated need for rebasing, the 2007 Legislature earmarked funds to address Medicaid reimbursement. The Legislature passed Senate Bill 2800, which included provisions for modifying the Plan as follows: To establish a target rate class ceiling floor equal to 90 percent of the cost- based class ceiling. To establish an individual provider- specific target floor equal to 75 percent of the cost-based class ceiling. To modify the inflation multiplier to equal 2.0 times inflation for the individual provider-specific target. (The inflation multiplier for the target rate class ceiling shall remain at 1.4 times inflation.) To modify the calculation of the change of ownership target to equal the previous provider's operating and indirect patient care cost per diem (excluding incentives), plus 50 percent of the difference between the previous providers' per diem (excluding incentives) and the effect class ceiling and use an inflation multiplier of 2.0 times inflation. The Plan was modified in accordance with this legislation with an effective date of July 1, 2007. Four relevant sentences from the modified Plan are relevant to this proceeding, to wit: For a new provider with no cost history resulting from a change of ownership or operator, where the previous provider participated in the Medicaid program, the interim operating and patient care per diems shall be the lesser of: the class reimbursement ceiling based on Section V of this Plan, the budgeted per diems approved by AHCA based on Section III of this Plan, or the previous providers' operating and patient care cost per diem (excluding incentives), plus 50% of the difference between the previous providers' per diem (excluding incentives) and the class ceiling. The above new provider ceilings, based on the district average per diem or the previous providers' per diem, shall apply to all new providers with a Medicaid certification effective on or after July 1, 1991. The new provider reimbursement limitation above, based on the district average per diem or the previous providers' per diem, which affects providers already in the Medicaid program, shall not apply to these same providers beginning with the rate semester in which the target reimbursement provision in Section V.B.16. of this plan does not apply. This new provider reimbursement limitation shall apply to new providers entering the Medicaid program, even if the new provider enters the program during a rate semester in which Section V.B.16 of this plan does not apply. [The above cited sentences will be referred to herein as Plan Sentence 1, Plan Sentence 2, etc.] Madison Pointe's Projected Medicaid Rate Relying on the proposed legislation, including the proposed rebasing and step-up in rate, Madison Pointe projected an interim Medicaid rate of $203.50 ppd for its initial year of operation. Madison Pointe's new projected rate assumed a rebasing by the Legislature to eliminate existing targets, thereby, allowing more reimbursable costs. Although no legislation had been passed at that time, Madison Pointe's consultants made calculations and projections as to how the rebasing would likely affect Petitioners. Those projections were the basis for the $203.50 ppd interim rate. The projected rate with limitations applied (i.e., if Madison Pointe did not anticipate rebasing or believe the Plan revisions applied) would have been $194.26. The PFA portion of Madison Pointe's CHOP application was submitted to AHCA containing the $203.50 ppd interim rate. The Financial Analysis Unit, as stated, is responsible for, inter alia, reviewing PFAs submitted as part of a CHOP application. In the present case, Ryan Fitch was the person within the Financial Analysis Unit assigned responsibility for reviewing Madison Pointe's PFA. Fitch testified that the purpose of his review was to determine whether the applicant had projected sufficient monetary resources to successfully operate the facility. This would include a contingency fund (equal to one month's anticipated expenses) available to the applicant and reasonable projections of cost and expenses versus anticipated revenues.2 Upon his initial review of the Madison Pointe PFA, Fitch determined that the projected Medicaid interim rate was considerably higher than the previous operator's actual rate. This raised a red flag and prompted Fitch to question the propriety of the proposed rate. In his omissions letter to the applicant, Fitch wrote (as the fourth bullet point of the letter), "The projected Medicaid rate appears to be high relative to the current per diem rate and the rate realized in 2006 cost reports (which includes ancillaries and is net of contractual adjustments). Please explain or revise the projections." In response to the omissions letter, Laura Wilson, a health care accountant working for Madison Pointe, sent Fitch an email on June 27, 2008. The subject line of the email says, "FW: Omissions Letter for 11 CHOW applications."3 Then the email addressed several items from the omissions letter, including a response to the fourth bullet point which says: Item #4 - Effective July 1, 2007, it is anticipated that AHCA will be rebasing Medicaid rates (the money made available through elimination of some of Medicaid's participation in covering Medicare Part A bad debts). Based on discussions with AHCA and the two Associations (FHCA & FAHSA), there is absolute confidence that this rebasing will occur. The rebasing is expected to increase the Medicaid rates at all of the facilities based on the current operator's spending levels. As there is no definitive methodology yet developed, the rebased rates in the projections have been calculated based on the historical methodologies that were used in the 2 most recent rebasings (1992 and 2002). The rates also include the reestablishment of the 50% step-up that is also anticipated to begin again. The rebasing will serve to increase reimbursement and cover costs which were previously limited by ceilings. As noted in Note 6 of the financials, if something occurs which prevents the rebasing, Management will be reducing expenditures to align them with the available reimbursement. It is clear Madison Pointe's projected Medicaid rate was based upon proposed legislative actions which would result in changes to the Plan. It is also clear that should those changes not occur, Madison Pointe was going to be able to address the shortfall by way of reduced expenditures. Each of those facts was relevant to the financial viability of Madison Pointe's proposed operations. Madison Pointe's financial condition was approved by Fitch based upon his review of the PFA and the responses to his questions. Madison Pointe became the new licensed operator of the facility. That is, the Long-Term Care Unit deemed the application to have met all requirements, including financial ability to operate, and issued a license to the applicant. Subsequently, MPA provided to Madison Pointe its interim Medicaid rate. MPA advised Madison Pointe that its rate would be $194.55 ppd, some $8.95 ppd less than Madison Pointe had projected in its PFA (but slightly more than Madison Pointe would have projected with the 50 percent limitation from Plan Sentence 1 in effect, i.e., $194.26). The PFA projected 25,135 annual Medicaid patient days, which multiplied by $8.95, would equate to a reduction in revenues of approximately $225,000 for the first year of operation.4 MPA assigned Madison Pointe's interim Medicaid rate by applying the provisions of the Plan as it existed as of the date Madison Pointe's new operating license was issued, i.e., September 1, 2007. Specifically, MPA limited Madison Pointe's per diem to 50 percent of the difference between the previous provider's per diem and the applicable ceilings, as dictated by the changes to the Plan. (See Plan Sentence 1 set forth above.) Madison Pointe's projected Medicaid rate in the PFA had not taken any such limitations into account because of Madison Pointe's interpretation of the Plan provisions. Specifically, that Plan Sentence 3 applies to Madison Pointe and, therefore, exempts Madison Pointe from the new provider limitation set forth in Plan Sentences 1 and 2. However, Madison Pointe was not "already in the Medicaid program" as of July 1, 2007, as called for in Plan Sentence 3. Rather, Madison Pointe's commencement date in the Medicaid program was September 1, 2007. Plan Sentence 1 is applicable to a "new provider with no cost history resulting from a change of ownership or operator, where the previous operator participated in the Medicaid program." Madison Pointe falls within that definition. Thus, Madison Pointe's interim operating and patient care per diems would be the lesser of: (1) The class reimbursement ceiling based on Section V of the Plan; (2) The budgeted per diems approved by AHCA based on Section III of the Plan; or (3) The previous provider's operating and patient care cost per diem (excluding incentives), plus 50 percent of the difference between the previous provider's per diem and the class ceiling. Based upon the language of Plan Sentence 1, MPA approved an interim operating and patient care per diem of $194.55 for Madison Pointe. Plan Sentence 2 is applicable to Madison Pointe, because it applies to all new providers with a Medicaid certification effective after July 1, 1991. Madison Pointe's certification was effective September 1, 2007. Plan Sentence 3 is the primary point of contention between the parties. AHCA correctly contends that Plan Sentence 3 is not applicable to Petitioner, because it addresses rebasing that occurred on July 1, 2007, i.e., prior to Madison Pointe coming into the Medicaid system. The language of Plan Sentence 3 is clear and unambiguous that it applies to "providers already in the Medicaid program." Plan Sentence 4 is applicable to Madison Pointe, which entered the system during a rate semester, in which no other provider had a new provider limitation because of the rebasing. Again, the language is unambiguous that "[t]his new provider reimbursement limitation shall apply to new providers entering the Medicaid program. . . ." Madison Pointe is a new provider entering the program. Detrimental Reliance and Estoppel Madison Pointe submitted its CHOP application to the Long-Term Care Unit of AHCA for approval. That office has the clear responsibility for reviewing and approving (or denying) CHOP applications for nursing homes. The Long-Term Care Unit requires, as part of the CHOP application, submission of the PFA which sets forth certain financial information used to determine whether the applicant has the financial resources to operate the nursing home for which it is applying. The Long-Term Care Unit has another office within AHCA, the Financial Analysis Unit, to review the PFA. The Financial Analysis Unit is found within the Bureau of Health Facility Regulation. That Bureau is responsible for certificates of need and other issues, but has no authority concerning the issuance, or not, of a nursing home license. Nor does the Financial Analysis Unit have any authority to set an interim Medicaid rate. Rather, the Financial Analysis Unit employs certain individuals who have the skills and training necessary to review financial documents and determine an applicant's financial ability to operate. A nursing home licensee must obtain Medicaid certification if it wishes to participate in the program. Madison Pointe applied for Medicaid certification, filing its application with a Medicaid intermediary which works for CMS. The issuance of a Medicaid certification is separate and distinct from the issuance of a license to operate. When Madison Pointe submitted its PFA for review, it was aware that an office other than the Long-Term Care Unit would be reviewing the PFA. Madison Pointe believed the two offices within AHCA would communicate with one another, however. But even if the offices communicated with one another, there is no evidence that the Financial Analysis Unit has authority to approve or disapprove a CHOP application. That unit's sole purpose is to review the PFA and make a finding regarding financial ability to operate. Likewise, MPA--which determines the interim Medicaid rate for a newly licensed operator--operates independently of the Long-Term Care Unit or the Financial Analysis Unit. While contained within the umbrella of AHCA, each office has separate and distinct duties and responsibilities. There is no competent evidence that an applicant for a nursing home license can rely upon its budgeted interim rate--as proposed by the applicant and approved as reasonable by MPA--as the ultimate interim rate set by the Medicaid Program Analysis Office. At no point in time did Fitch tell Madison Pointe that a rate of $203.50 ppd would be assigned. Rather, he said that the rate seemed high; Madison Pointe responded that it could "eliminate expenditures to align them with the available reimbursement." The interim rate proposed by the applicant is an estimate made upon its own determination of possible facts and anticipated operating experience. The interim rate assigned by MPA is calculated based on the applicant's projections as affected by provisions in the Plan. Furthermore, it is clear that Madison Pointe was on notice that its proposed interim rate seemed excessive. In response to that notice, Madison Pointe did not reduce the projected rate, but agreed that spending would be curtailed if a lower interim rate was assigned. There was, in short, no reliance by Madison Pointe on Fitch's approval of the PFA as a de facto approval of the proposed interim rate. MPA never made a representation to Madison Pointe as to the interim rate it would receive until after the license was approved. There was, therefore, no subsequent representation made to Madison Pointe that was contrary to a previous statement. The Financial Analysis Unit's approval of the PFA was done with a clear and unequivocal concern about the propriety of the rate as stated. The approval was finalized only after a representation by Madison Pointe that it would reduce expenditures if a lower rate was imposed. Thus, Madison Pointe did not change its position based on any representation made by AHCA.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by Respondent, Agency for Health Care Administration, approving the Medicaid interim per diem rates established by AHCA and dismissing each of the Amended Petitions for Formal Administrative Hearing. DONE AND ENTERED this 23rd day of February, 2009, 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 23rd day of February, 2009.
The Issue Whether Medicaid overpayments were made to Respondent and, if so, what is the total amount of those overpayments. Whether, as a "sanction," Respondent should be directed to submit to a "comprehensive follow-up review in six months."
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following findings s of fact are made to supplement and clarify the factual stipulations set forth in the parties' Joint Prehearing Stipulation and their January 26, 2007, pleading:4 Respondent and his Practice Respondent is a pediatric physician whose office is located in a poor neighborhood in Hialeah, Florida. He has a very busy practice, seeing approximately 50 to 60 patients each day the office is open. Respondent documents patient visits by making handwritten notations on printed "progress note" forms. Because of the fast-paced nature of his practice, he does not always "have time to write everything as [he] would like, because [there] is too much" for him to do. Respondent's Participation in the Medicaid Program During the Audit Period, Respondent was authorized to provide physician services to eligible Medicaid patients. Respondent provided such services pursuant to a valid Provider Agreement (Provider Agreement) with AHCA, which 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 may 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. . . . 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. * * * (i) . . . . 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. * * * Respondent's Medicaid provider number (under which he billed the Medicaid program for providing these services) was (and remains) 370947700. Handbook Provisions The handbooks with which Petitioner was required to comply in order to receive Medicaid payment for services rendered during the Audit Period included the Medicaid Provider Reimbursement Handbook, HCFA-1500 (MPR Handbook); Physician Coverage and Limitations Handbook (PCL Handbook); the Early and Periodic Screening, Diagnosis and Treatment Coverage and Limitations Handbook (EPSDTCL Handbook); and the Child Health Check-up Coverage and Limitations Handbook (CHCUCL Handbook). Medical Necessity 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 services 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.[5] The EPSDTCL and CHCUCL Handbooks had similar provisions. Documentation Requirements The MPR Handbook required the provider to keep "accessible, legible and comprehensible" medical records that "state[d] the necessity for and the extent of services" billed the Medicaid program and that were "signed and dated at the time of service." The handbook further required, among other things, that the provider retain such records for "at least five years from the date of service" and "send, at his or her expense, legible copies of all Medicaid-related information to the authorized state and federal agencies and their authorized representatives." The MPR Handbook warned that providers "not in compliance with the Medicaid documentation and record retention policies [described therein] may be subject to administrative sanctions and recoupment of Medicaid payments" and that "Medicaid payments for services that lack required documentation or appropriate signatures will be recouped." EPSDT Screening/Child Health Check-Up The EPSDTCL Handbook provided: To be reimbursed by Medicaid, the provider must address and document in the recipient's medical record all the required components of an EPSDT screening. The following required components are listed in the order that they appear on the optional EPSDT screening form: Health and developmental history Nutritional assessment Developmental assessment Physical examination Dental screening Vision screening Hearing screening Laboratory tests Immunization Health education Diagnosis and treatment The CHCUCL Handbook, which replaced the EPSDTCL Handbook in or around May 2000, similarly provided as follows: To be reimbursed by Medicaid, the provider must assess and document in the child's medical record all the required components of a Child Health Check-Up. The required components are as follows: Comprehensive Health and Developmental History, including assessment of past medical history, developmental history and behavioral health status; Nutritional assessment; Developmental assessment; Comprehensive Unclothed Physical Examination Dental screening including dental referral, where required; Vision screening including objective testing, where required; Hearing screening including objective testing, where required; Laboratory tests including blood lead testing, where required; Appropriate immunizations; Health education, anticipatory guidance; Diagnosis and treatment; and Referral and follow-up, as appropriate. 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 Current Procedural Terminology (CPT) book referred to in Chapter 3 of the PCL Handbook was a publication of the American Medical Association. It contained a listing of procedures and services performed by physicians in different settings, each identified by a "procedure code" consisting of five digits or a letter followed by four digits. For instance, there were various "procedure codes" for office visits. These "procedure codes" included the following, among others: New Patient * * * 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. * * * Established Patient * * * 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. * * * Fee Schedules In Appendix J of the PCL Handbook, there was a "fee schedule," which established the amount physicians would be paid by the Medicaid program for each reimbursable procedure and service (identified by "procedure code"). For both "new patient" office visits (99201-99205 "procedure code" series) and "established patient" office visits (99211-99215 "procedure code" series), the higher numbered the "procedure code" in the series, the more a physician would be reimbursed under the "fee schedule." The Audit and Aftermath Commencing in or around August 2002, AHCA conducted an audit of Respondent's Medicaid claims for services rendered during the Audit Period (Audit Period Claims).6 Respondent had submitted 18,102 such Audit Period Claims, for which he had received payments totaling $596,623.15. These Audit Period Claims involved 1,372 different Medicaid patients. From this group, AHCA randomly selected a "cluster sample" of 40 patients. Of the 18,102 Audit Period Claims, 713 had been for services that, according to the claims, had been provided to the 40 patients in the "cluster sample" (Sample Claims). Respondent had received a total of $23,263.18 for these 713 Sample Claims. During an August 28, 2002, visit to Respondent's office, AHCA personnel "explain[ed] to [Respondent] what the audit was about [and] why [AHCA] was doing it" and requested Respondent to provide AHCA with copies of the medical records Respondent had on file for the 40 patients in the "cluster sample" documenting the services provided to them during the Audit Period. The originals of these records were not inspected by AHCA personnel or agents during, or any time after, this August 28, 2002, site visit. Sometime within approximately 30 to 45 days of the August 28, 2002, site visit, Respondent, through his office staff, made the requested copies (First Set of Copies) and provided them to AHCA. There is nothing on the face of these documents to suggest that they were not true, accurate, and complete copies of the originals in Respondent's possession, as they existed at the time of copying (Copied Originals). They do not appear, upon visual examination, to be the product of "bad photocopying." While the handwritten entries and writing are oftentimes difficult (at least for the undersigned) to decipher, this is because of the poor legibility of the handwriting, not because the copies are faint or otherwise of poor quality. Each of the Sample Claims was reviewed to determine whether it was supported by information contained in the First Set of Copies. An initial review was conducted by AHCA Program Analyst Theresa Mock and AHCA Registered Nurse Consultant Blanca Notman. AHCA then contracted with Larry Deeb, M.D., to conduct an independent "peer review" in accordance with the provisions of Section 409.9131, Florida Statutes. Since 1980, Dr. Deeb has been a Florida-licensed pediatric physician, certified by the American Board of Pediatrics, in active practice in Tallahassee. AHCA provided Dr. Deeb with the First Set of Copies, along with worksheets containing a "[l]isting of [a]ll claims in [the] sample" on which Ms. Notman had made handwritten notations indicating her preliminary determination as to each of the Sample Claims (Claims Worksheets). In conducting his "peer review," Dr. Deeb did not interview any of the 40 patients in the "cluster sample," nor did he take any other steps to supplement the information contained in the documents that he was provided. Dr. Deeb examined the First Set of Copies. He conveyed to AHCA his findings regarding the sufficiency of these documents to support the Sample Claims by making appropriate handwritten notations on the Claims Worksheets before returning them to AHCA. Based on Dr. Deeb's sufficiency findings, as well as Ms. Notman's "no documentation" determinations, AHCA "provisional[ly]" determined that Respondent had been overpaid a total $80,788.23 for the Audit Period Claims. By letter dated July 7, 2003 (Provisional Agency Audit Report), AHCA advised Petitioner of this "provisional" determination and invited Respondent to "submit further documentation in support of the claims identified as overpayment," adding that "[d]ocumentation that appear[ed] to be altered, or in any other way appear[ed] not to be authentic, [would] not serve to reduce the overpayment." Appended to the letter were "[t]he audit work papers [containing a] listing [of] the claims that [were] affected by this determination." In the Provisional Agency Audit Report, AHCA gave the following explanation as to how it arrived at its overpayment determination: REVIEW DETERMINATION(S) 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 amount you were paid and the correct payment for the appropriate level of service is considered an overpayment. 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 payment made for services not appropriately documented an overpayment. Medicaid policy addresses specific billing requirements and procedures. You billed Medicaid for Child Health Check Up (CHCUP) services and office visits for the same child on the same day. Child Health Check- Up Providers may only bill for one visit, a Child Health Check-Up or a sick visit. The difference between the amount you were paid and the appropriate fee is considered an overpayment. The overpayment was calculated as follows: A random sample of 40 recipients respecting whom you submitted 713 claims was reviewed. For those claims in the sample which have dates of service from January 01, 2000 through December 31, 2001 an overpayment of $4,168.00 or $5.84667601 per claim was found, as indicated on the accompanying schedule. Since you were paid for a total (population) of 18,102 claims for that period, the point estimate of the total overpayment is 18,102 x $5.84667601= $105,836.33. 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 [Respondent was] $80,788.23 with a ninety-five percent (95%) probability that it [was] that amount or more." After receiving the Provisional Agency Audit Report, Respondent requested to meet with Dr. Deeb to discuss Dr. Deeb's sufficiency findings. The meeting was held on September 25, 2003, approximately six months after Dr. Deeb had reviewed the First Set of Copies and a year after AHCA had received the First Set of Copies from Respondent. At the meeting, Respondent presented to Dr. Deeb what Respondent represented was a better set of copies of the Copied Originals than the First Set of Copies (on which Dr. Deeb had based the sufficiency findings AHCA relied on in making its "provisional" overpayment determination). According to Respondent, the First Set of Copies "had not been properly Xeroxed." He stated that his office staff "had not copied the back section of the documentation and that was one of the major factors in the documentation not supporting the [claimed] level of service." The copies that Respondent produced at this meeting (Second Set of Copies) had additional handwritten entries and writing (both on the backs and fronts of pages) not found in the First Set of Copies: the backs of "progress note" pages that were completely blank in the First Set of Copies contained handwritten narratives, and there were handwritten entries and writing in numerous places on the fronts of these pages where, on the fronts of the corresponding pages in the First Set of Copies, just blank, printed lines appeared (with no other discernible markings). The Second Set of Copies was not appreciably clearer than the First Set of Copies. In the two hours that he had set aside to meet with Respondent, Dr. Deeb only had time to conduct a "quick[]," partial review of the Second Set of Copies. Based on this review (which involved looking at documents concerning approximately half of the 40 patients in the "cluster sample"), Dr. Deeb preliminarily determined to "allow" many of the Sample Claims relating to these patients that he had previously determined (based on his review of the First Set of Copies) were not supported by sufficient documentation. Following this September 25, 2003, meeting, after comparing the Second Set of Copies with the First Set of Copies and noting the differences between the two, AHCA "made the decision that [it] would not accept the [S]econd [S]et [of Copies]" because these documents contained entries and writing that appeared to have been made, not contemporaneously with the provision of the goods or services they purported to document (as required), but rather after the post-Audit Period preparation of the First Set of Copies. Instead, AHCA, reasonably, based its finalized overpayment determination on the First Set of Copies. Thereafter, AHCA prepared and sent to Respondent a Final Agency Audit Report, which was in the form of a letter dated June 29, 2004, advising Respondent that AHCA had finalized the "provisional" determination announced in the Provisional Agency Audit that he had been overpaid $80,788.23 for the Audit Period Claims (a determination that the preponderance of the record evidence in this case establishes is a correct one).
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that AHCA enter a final order finding that Respondent received $80,788.23 in Medicaid overpayments for the Audit Period Claims, and requiring Respondent to repay this amount to AHCA. DONE AND ENTERED this 30th day of April, 2007, 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 30th day of April, 2007.
