Findings Of Fact At all times here relevant Mario Aviles, Jr., was licensed by the Florida Board of Medical Examiners and held license No. ME 0020482. Clara Julio Yanes was a prenatal patient of Respondent in 1980. In 1979 Respondent had delivered Yanes' first child at Mount Sinai Hospital and Mrs. Yanes expected this second child to be delivered in a hospital. Respondent did not tell the Yaneses that he did not have hospital privileges and until the last minute they expected Respondent to deliver the baby. On 4 October 1980 Yanes called Respondent to advise him that Mrs. Yanes was in labor. Respondent's answering service said Respondent was on vacation and Dr. Pina was taking care of Respondent's patients. Pina called Yanes shortly thereafter and said he would meet them at the hospital. Shortly after the baby was born at Hialeah Hospital, Pina arrived and apologized for being late. Grisel Carbajol was a prenatal patient of Respondent in 1980. Aviles said he would take care of hospital admission at either North Shore, Hialeah, Baptist, or Mercy hospitals and that he was trying to get privileges at all of these hospitals. On October 31, 1980, Mrs. Carbajol visited Respondent's office because she was bleeding and thought she was in labor. He examined her and told her it would be a week before the baby would come. The next day, Sunday, she called his office and Respondent answered the telephone. When she described her symptoms, Respondent told her to take medication and to call him in four hours. When she called back she reached his answering service who told her they had passed her message to him, but she received no call from Respondent. Later that day when her labor pains became more frequent, Mrs. Carbajol went to the emergency room at Hialeah Hospital and her baby was delivered at Hialeah Hospital. She had been given Dr. Pina's telephone number two days before the delivery but did not call Pina. Mrs. Mario Mancebo was a prenatal patient of Respondent between January and August 1981. During her seventh month she started bleeding and attempted to contact Respondent, without success. Respondent had told her the baby could be delivered at Baptist Hospital so the Mancebos vent to Baptist Hospital where they learned Respondent did not have hospital privileges and could not have her admitted. Isabel Sierra was a prenatal patient of Respondent in March 1980. Respondent never told Mrs. Sierra which hospital to go to, nor did he tell her he did not have hospital privileges. When she started labor, the last of October 1980, she called Respondent's office but he never returned her call. After trying several times to contact him, she went to the emergency room at Jackson Memorial Hospital where her baby was born. During the period January 1980 to December 1981, Respondent did not have hospital privileges at any hospital in Miami yet he had numerous pregnant patients to whom he provided prenatal care. The practice of these patients turning up at the emergency rooms of several hospitals in the Miami area in a terminal labor state became so prevalent that Baptist Hospital wrote Respondent at least three letters (Exhibit 2) asking him to stop directing his patients to the emergency room at Baptist Hospital near the termination of their pregnancies, reminding him that he did not have privileges at Baptist Hospital, and requesting that he inform his patients that he could not deliver them at Baptist Hospital. Mercy Hospital wrote Respondent that his application for hospital privileges had been denied (Exhibit 3) and sent a complaint to the Dade County Medical Association about Respondent sending his patients in active labor to the emergency room at Mercy Hospital despite the written and oral requests that he desist from this practice The Chief, Emergency Room Service, at Mercy Hospital lodged an ethical complaint with Petitioner as a result of Respondent sending patients to the emergency room at Mercy Hospital near the termination of their pregnancies (Exhibit 4). Prenatal obstetric patients generally expect their obstetrician to deliver their babies. It is both fraudulent and unethical to take a patient for prenatal care when the obstetrician does not have privileges at a hospital and cannot provide hospital delivery for the baby. Furthermore, it is unethical to provide prenatal care up to termination of pregnancy and then send the patient to the emergency room of the nearest hospital for a strange doctor to deliver the baby. This is especially so when no record accompanies the patient, and any history obtained must come from the woman in labor or her accompanying relative. Most of these prenatal patients of Respondent had paid Respondent in full for his services, including delivery. At the termination of their pregnancies when Respondent could not be reached, their babies were delivered by a doctor strange to them when they went to a hospital emergency room. Several of these witnesses testified they could get no refund from Respondent after this happened, but one witness testified her husband had recovered those payments from Respondent after her baby had been delivered by another doctor.
The Issue The issues in this case are set forth in 11 separate counts within the four consolidated cases: Case No. 09-5360 Count I--Whether Respondent failed to properly monitor and care for a patient in restraints. Count II--Whether Respondent failed to ensure the physician's plan of care for patient was implemented. Case No. 09-5363 Count I--Whether Respondent failed to properly implement the physician's plan of care for patient. Case No. 09-5364 Count I--Whether Respondent failed to ensure a patients' right to privacy. Count II--Whether Respondent failed to ensure that food was served in the prescribed safe temperature zone. Count III--Whether Respondent failed to ensure that only authorized personnel had access to locked areas where medications were stored. Count IV--Whether Respondent failed to perform proper nursing assessments of a patient. Count V--Dismissed. Count VI--Whether Respondent failed to maintain patient care equipment in a safe operating condition. Case No. 09-5365 Count I--Whether Respondent failed to triage a patient with stroke-like symptoms in a timely fashion. Count II--Whether Respondent's nursing staff failed to assess and intervene for patients or ensure implementation of the physician's plan of care.
Findings Of Fact Petitioner is the state agency responsible for, inter alia, monitoring health care facilities in the state to ensure compliance with all governing statutes, rules and regulations. It is the responsibility of AHCA to regularly inspect facilities upon unannounced visits. Often AHCA will inspect facilities for the purpose of licensure renewal, certification, or in conjunction with federal surveys. AHCA will also inspect facilities on the basis of complaints filed by members of the general public. Respondent, Gulf Coast Medical Center ("Gulf Coast" or "GCH") is a hospital within the Lee Memorial Health System. South West Florida Regional Medical Center ("SWF") was another hospital within the Lee Memorial Health System. SWF closed in March 2009, when it was consolidated with Gulf Coast. On October 15, 2008, the Agency conducted a complaint investigation at SWF; a follow-up complaint investigation was done on November 13, 2008. SWF filed and implemented a plan of correction for the issues raised in each of the investigations. The November investigation resulted in an Administrative Complaint containing two counts. On December 16, 2008, AHCA performed another complaint investigation at Gulf Coast. Gulf Coast filed and implemented a plan of correction for the issues raised in the investigation. The investigation resulted in an Administrative Complaint containing one count. On January 5 through 9, 2009, AHCA conducted a routine licensure survey at Gulf Coast. The hospital filed and implemented a plan of correction for the issues raised in the survey. The survey resulted in an Administrative Complaint containing six counts (although Count V was dismissed during the course of the final hearing). On February 18, 2009, AHCA did its follow-up survey to the previous licensure survey. Gulf Coast filed and implemented a plan of correction for the issues raised in the survey. The survey resulted in an Administrative Complaint containing two counts. Case 09-5360 The complaint investigation at SWF on November 13, 2008, was conducted under the supervision of Charlene Fisher. Count I in this case addresses findings by the Agency concerning a patient who was placed in restraints at the hospital on August 28, 2008. The patient, A.D., came into the hospital emergency department under the Baker Act seeking medical clearance to a facility. The patient presented at approximately 4:00 p.m., with back pain. He had a history of drug abuse, so there was concern by the hospital regarding the use of narcotics or certain other medications to treat the patient. The patient engaged in some scuffling with police. A physician signed and dated a four-point restraint (one on each limb) order, resulting in the patient being physically restrained. The restraint was deemed a medical/surgical restraint, rather than a behavioral restraint. AHCA had concerns about the restraint, specifically whether there was a notation for Q 15 (or every 15 minutes) monitoring of the restrained patient. However, medical/surgical restraints only require monitoring every two hours. The restraint worksheet for the patient confirms monitoring every two hours. The patient was ultimately admitted to the hospital at 9:37 p.m., and, thereafter, began complaining of left shoulder pain. The hospital responded to the patient's complaints about back pain and began treating the pain with analgesics. However, the patient continued to complain about the pain. An X-ray of the patient's shoulder was finally done the next morning. Shoulder dislocation was confirmed by the X-ray, and the hospital (four hours later) began a more substantive regimen of treatment for pain. Surgery occurred the following morning, and the shoulder problem was resolved. It is clear the patient had a shoulder injury, but it is unclear as to when that injury became more painful than the back injury with which the patient had initially presented. The evidence is unclear whether or when the shoulder injury became obvious to hospital staff. During its course of treating this patient, the hospital provided Motrin, Tylenol, Morphine, Percocet and other medications to treat the patient's pain. Count II in this case also involved a restrained patient, M.D., who had presented to the emergency department under the Baker Act. The patient was released from handcuffs upon arrival at the hospital. After subsequently fighting with a deputy, this patient was also placed in a medical/surgical restraint pursuant to a physician's order. The doctor signed and dated, but did not put a time on, the restraint order. A time is important because there are monitoring requirements for patients in restraints. However, the time of 0050 (12:50 a.m.) appears on the patient's chart and is the approximate time the restraints were initiated. The proper procedure is to monitor a restrained patient every two hours. This patient, however, was removed from his restraints prior to the end of the first two-hour period. Thus, there are no records of monitoring for the patient (nor would any be necessary). The evidence presented by AHCA was insufficient to establish definitively whether the hospital nursing staff failed to properly respond to the aforementioned patients' needs. It is clear the patients could have received more care, but there is not enough evidence to prove the care provided was inadequate. Case No. 09-5363 On December 16, 2008, AHCA conducted a complaint investigation at SWF. The Agency had received a complaint that the hospital did not properly implement a physician's plan of care. Count I in this complaint addresses alleged errors relating to two of four patients reviewed by the surveyors. Both of the patients came to the hospital from a nursing home. One patient, I.A., had presented to the emergency department complaining of chest pains. The medication list sent to the hospital by the nursing home for I.A. actually belonged to someone other than I.A. I.A.'s name was not on the medication list. The drugs listed on the patient chart were different than the drugs I.A. had been taking at the skilled nursing facility from which she came. The skilled nursing facility actually sent I.A.'s roommate's medication list. The erroneous medications were then ordered by the admitting physician and administered to the patient. The hospital is supposed to review the medication list it receives and then enter the medications into the hospital system. The person reviewing the medication list does not necessarily have to be a nurse, and there is no evidence that the person making the error in this case was a nurse or was some other employee. It is clear, however, that the person reviewing the medication list did not properly ascertain that the list belonged to patient I.A. The other patient from the nursing home had been admitted for surgery at SWF. Again, the nursing home from whence she came sent a medication list that was incorrect. The medications on the incorrect list were entered into the system by a SWF employee. The erroneous medications were ultimately ordered by the attending physician for the patient, but there is no evidence the patient was ever administered those medications. Neither of the residents was harmed by the incorrect medications as far as could be determined. Case 09-5364 From January 5 through 8, 2009, AHCA conducted a licensure survey at Gulf Coast and SWF in conjunction with a federal certification survey. Count I of the complaint resulting from this survey addressed the right of privacy for two residents. In one instance, a patient was observed in her bed with her breasts exposed to plain view. In the other instance, a patient's personal records were found in a "public" place, i.e., hanging on the rail of a hallway in the hospital. AHCA's surveyor, Nancy Furdell, saw a female patient who was apparently asleep lying in her bed. The patient's breasts were exposed as she slept. Furdell observed this fact at approximately 1:15 p.m., on January 7, 2009. Furdell did not see a Posey vest on the patient. She did not know if anyone else saw the exposed breasts. Furdell continued with her survey duties, and at approximately 5:00 p.m., notified a staff member as to what she had seen. Furdell did not attempt to cover the patient or wake the patient to tell her to cover up. The female patient with exposed breasts was in the intensive care unit (ICU) of the hospital. Visiting hours in ICU at that time were 10:00 to 10:30 a.m., and again from 2:00 till 2:30 p.m. Thus, at the time Furdell was present, no outside visitors would have been in the ICU. ICU patients are checked on by nursing staff every half-hour to an hour, depending on their needs. This particular patient would be visited more frequently due to her medical condition. On the day in question, the patient was supposed to be wearing a Posey vest in an effort to stop the patient from removing her tubing. The patient had been agitated and very restless earlier, necessitating the Posey vest. Also on January 7, 2009, a surveyor observed some "papers" rolled up and stuffed inside a hand-rail in the hospital corridor. This occurred at 1:15 p.m., on the fourth floor of the south wing of the hospital. A review of the papers revealed them to be patient records for a patient on that floor. The surveyor could not state at final hearing whether there were hospital personnel in the vicinity of the handrail where she found the patient records, nor could she say how long the patient records had been in the handrail. Rather, the evidence is simply that the records were seen in the handrail and were not in anyone's possession at that moment in time. Count II of the complaint was concerned with the temperature of certain foods being prepared for distribution to patients. Foods for patients are supposed to be kept at certain required temperatures. There is a "danger zone" for foods which starts at 40 degrees Fahrenheit and ends at 141 degrees Fahrenheit. Temperature, along with time, food and environment, is an important factor in preventing contamination of food and the development of bacteria. Surveyor Mary Ruth Pinto took part in the survey. As part of her duties, she asked hospital staff to measure the temperature of foods on the serving line. She found some peaches at 44 degrees, yogurt at 50 degrees, and cranberry juice at 66 degrees Fahrenheit. According to Pinto, the hospital's refrigerator temperatures were appropriate, so it was only food out on the line that was at issue. Pinto remembers talking to the hospital dietary manager and remembers the dietary manager agreeing to destroy the aforementioned food items. The hospital policies and procedures in place on the date of the survey were consistent with the U.S. Food and Drug Administration Food Code concerning the storage, handling and serving of food. The policies acknowledge the danger zone for foods, but allow foods to stay within the danger zone for up to four hours. In the case of the peaches and yogurt, neither had been in the danger zone for very long (not more than two hours). The cranberry juice was "shelf stable," meaning that it could be stored at room temperature. The food services director for the hospital remembers the peaches and yogurt being re-chilled in a chill blaster. She does not believe any of the food was destroyed. Count III of the complaint addressed whether an unauthorized person had access to a room where medications were being stored. A state surveyor, Gary Furdell, was part of the survey team on January 5, 2009. Furdell was touring the second floor of the hospital when he noticed a locked door. Furdell asked a hospital medical technician who was standing nearby about the door. The medical technician gave Furdell the code to unlock the door. Furdell peeked inside and noticed bottles that he presumed were medications. It would be a violation for a medical technician to have access to medications, because medical technicians cannot distribute drugs. The room Furdell looked into is a "mixed use" room located behind a nursing station. A mixed use room is used to store medical supplies, including medications, as long as there is a locked cabinet in the room for that purpose. This particular mixed use room had a locked cabinet. The room is used for the preparation of medications and for other purposes. No narcotics were stored in this particular mixed use room. The room contained locked cabinets used to store other medications. The evidence presented was insufficient to determine what "medications" Furdell may have seen in the room. Count IV of the complaint concerned the nursing assessment of a patient, and whether the assessment was properly and timely performed. A patient, M.S., had been admitted to the hospital on June 18, 2008, for lung surgery. Following the surgery, Amiodarone (a very toxic drug which can cause clots and other complications) was administered to treat M.S. for heart arrhythmia. The Amiodarone was administered intravenously and M.S. developed blisters and irritation at the intravenous site. That is not an uncommon complication with Amiodarone. M.S.'s attending physician was notified about the irritation and prescribed a treatment. He also ordered a consult with an infectious disease specialist who ultimately changed M.S.'s antibiotics. Although M.S. was seen daily by her physicians, the nursing notes do not reflect the assessment and treatment of her blisters. It appears that proper care was rendered, but the care was not documented properly. Another patient was admitted to the hospital on December 15, 2008, with End Stage Renal Disease and diabetes mellitus for which she began dialysis treatment. The patient was not weighed before and after a particular dialysis treatment on January 5, 2009. However, the patient had been moved to an air mattress bed on that date for comfort. The air mattress bed did not allow for a weight to be taken as it could be on a regular bed. There is an allegation in the Administrative Complaint concerning the discontinuation of the calorie count for a patient. This issue was not discussed in AHCA's Proposed Recommended Order, nor was sufficient evidence of any wrong- doing concerning this matter presented at final hearing. During the survey, the hospital was found to be storing the medication Mannitol in blanket warmers, rather than in warmers specifically designed for the drug. The blanket warmers maintained the Mannitol at 100-to-110 degrees Fahrenheit. The manufacturer's label on the drug calls for it to be dispensed (injected) at between 86 and 98.5 degrees Fahrenheit. In order to meet this requirement, the hospital takes the drug out of the blanket warmer in time for it to cool sufficiently before it is injected. There is nothing inherently wrong with using a blanket warmer to store Mannitol. On January 5, 2009, a surveyor found two vials of Thrombin, one vial of half-percent Lidocaine and Epi, and one vial of Bacitracin in operating room No. 4. The operating room is within the secured and locked suite of surgical rooms on the second floor. Two of the vials had syringes stuck in them and one of them was spiked. Whoever had mixed the medications was not attending to them at the time the surveyor made her observation. There were two unlicensed technicians in the room preparing for the next surgery. A registered nurse anesthetist was present as well. There was no identifying patient information on the medications. The hospital's policies and procedures do not require the patient's name to be on the label of medications prepared for impending surgery. That is because the procedures for the operating room include a process for ensuring that only the correct patient can be in the designated operating room. There is a fail-safe process for ensuring that only the proper patient can receive the medications that are set out. At around 2:45 p.m. on January 5, 2009, there were patient records in the emergency department showing that several drugs had been administered to a patient. The surveyor did not see a written order signed by a physician authorizing the drugs. When the surveyor returned the next morning, the order had been signed by the physician. The hospital policy is that such orders may be carried out in the emergency department without a doctor's signature, but that a physician must sign the order before the end of their shift. AHCA cannot say whether the physician signed the order at the end of his shift or early the next day. Count V of the complaint was voluntarily dismissed by the Agency. Count VI of the complaint concerned the status of certain patient care equipment, and whether such equipment was being maintained in a safe operating condition. A patient was weighed at the hospital upon admission on December 27, 2008, and found to weigh 130 pounds using a bed scale. Six days later, on January 2, 2009, the patient's weight was recorded as 134 pounds. Two days later, in the same unit, the patient weighed 147 pounds and the next day was recorded as weighing 166 pounds. During the survey process, the patient was weighed and recorded at 123 pounds on a chair scale. The hospital does not dispute the weights which were recorded, but suggests there are many factors other than calibration of the equipment that could explain the discrepant weights. For example, the AHCA surveyor could not say whether the patient sometimes had necessary medical equipment on his bed while being weighed, whether different beds were involved, or whether any other factors existed. AHCA relies solely on the weight records of this single patient to conclude that the hospital scales were inaccurate. Case No. 09-5365 On February 18, 2009, AHCA conducted a licensure survey at Gulf Coast. Count I of the complaint from this survey concerned the timeliness of triage for a patient who presented at the hospital emergency department with stroke-like symptoms. AHCA surveyors witnessed two patients on stretchers in the ambulance entrance hallway leading to the emergency department. Each of the two patients had been brought in by a separate emergency medical service (EMS) team and was awaiting triage. One patient was taken to an emergency department room (ER room) 50 minutes after his/her arrival at the hospital. The other patient waited 45 minutes after arrival before being admitted to an ER room. Meanwhile, a third patient arrived at 2:20 p.m., and was awaiting triage 25 minutes later. During their observation, the surveyors saw several nursing staff in the desk area of the emergency department, i.e., they did not appear to be performing triage duties. The emergency department on that date was quite busy. That is not unusual during February, as census tends to rise during the winter months due to the influx of seasonal residents. A summary of the action within the emergency department from 1:00 p.m. to 3:00 p.m., on the day of the survey shows the following: Patient L.G., 74 years old with stable vital signs, was radioed in by her EMS team at 1:08; L.G. was processed into the ER at 1:21 (which is not an unreasonable time; EMS teams call in when they arrive at or near the hospital. By the time they gain access, wait their turn if multiple ambulances are present, and get the patient inside, several minutes may lapse). L.G. was stabilized and quickly reviewed by ER staff, then officially triaged at 2:04. Patient H.M., an 89-year-old male residing in a nursing home, arrived at 1:20 and was processed in at 1:59. He was triaged at 2:01, but ultimately signed out of the hospital against medical advice. Patient E.M. arrived at 2:18 and was processed at 2:25. Triage occurred one minute later. This patient presented as a stroke alert, and hospital protocol for that type patient was followed. Patient C.J. arrived at 1:08 and was processed at 2:38. Triage occurred immediately after C.J. was processed. This patient was not stroke alert, but had some stroke-like symptoms.1 C.J. had not been transported to the hospital as emergent, because the symptoms had been going on for 24 hours. Patient W.M., an auto accident victim, arrived at 1:40 and was processed at 1:49. Triage occurred within six minutes. Patient M.M., W.M.'s wife (who had been with M.M. in the automobile accident, but was placed in a separate ambulance), arrived at 2:06 and was triaged at 2:34. There is no record of when M.M. was processed. Patient L.M. came to the hospital from a nursing home. She arrived at 1:43 and was processed at 2:35. L.M. was triaged at 2:37. Patient K.M. arrived at 2:45 and was processed within three minutes. Triage occurred at 2:52. Her triage was done very quickly due to the condition in which she arrived, i.e., shortness of breath and low oxygen saturation. Patient R.S. arrived at 1:00 and was triaged at 1:15. The aforementioned patients represent the patients presenting to the emergency department by ambulance during a two-hour period on a very busy day. It is the customary procedure for ER staff to make a quick visual review (rapid triage) of patients as they come into the hospital. Those with obvious distress or life-threatening conditions are officially triaged first. Others, as long as they are stable, are allowed to wait until staff is available for them. As part of their duties, nurses necessarily have to be in the desk area (nursing station) in order to field phone calls from physicians concerning treatment of the patients who present. It is not unusual or improper for nurses to be in the nursing station while residents are waiting in the processing area. It is clear that some patients waited a much longer time for triage than others. However, without a complete record of all patients who presented that day and a complete review of each of their conditions, it is impossible to say whether the hospital was dilatory in triaging any of them. Count II of the complaint addressed the nursing staff and whether it failed to assess and intervene in the care of a patient or failed to implement a physician's plan of care for the patient. Patient D.W. was a 67-year-old female who was morbidly obese, diabetic, debilitated, had end stage renal disease, and was receiving dialysis. Upon admission, D.W. had a Stage 3 pressure ulcer to her sacrum and a Stage 4 ulcer on her left calf. A wound care protocol was initiated immediately, and a Clinitron bed was obtained for her on the day of admission. Due to the seriousness of her condition, the wound care physician declined to accept her case at first. He later ordered Panafil, and it became part of the protocol for treating the patient. The nursing documentation for D.W. was only minimally sufficient, but it does indicate that care was provided. Patient R.H. was an 83-year-old male who presented on February 10, 2009, in critical condition. R.H. was suffering from congestive heart failure, pneumonia, and respiratory failure. Due to the critical nature of his respiratory problems, R.H. was placed on a ventilator. As a ventilator patient, he did not fit the profile for obtaining wound care. Nonetheless, the hospital implemented various other measures to deal with R.H.'s pressure wounds.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by Petitioner, Agency for Health Care Administration, imposing a fine in the amount of $500.00 in DOAH Case No. 09-5363 and a fine in the amount of $500.00 in DOAH Case No. 09-5364, Count VI. DONE AND ENTERED this 30th day of April, 2010, in Tallahassee, Leon County, Florida. R. BRUCE MCKIBBEN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of April, 2010.
The Issue The issue is whether Respondent's medical license should be disciplined for alleged violations of Chapter 458, Florida Statutes.
Findings Of Fact Respondent is, and has been at all times material hereto, a licensed physician in the State of Florida, having been issued license number ME 0027368. Respondent is board certified in family practice; however, he is not board certified in emergency medicine. On May 30, 1994, Dr. Dulay was on call in the hospital emergency room at Madison County Memorial Hospital (MCMH) in Madison, Florida. On May 30, 1994, Patient T.H. an obese, forty-eight year-old male was found unconscious on the floor of the bathroom by his brother, Wallace. T.H. had an arteriovenous malformation (AVM) in his brain. An AVM is a weakened area of a blood vessel which can fill with blood, expand and/or burst. AVMs located in the brain are very dangerous since a ruptured AVM can damage the brains tissue. The amount of damage depends on the amount and rapidity of the bleeding. Under any circumstances, a ruptured AVM is an emergency medical condition where time is of the essence in diagnosing and treating usually with some neurosurgical intervention. On May 30, 1994, at approximately 4:56 a.m., Carol Wells a Madison County 911 Operator received an emergency call regarding T.H. The call was originally received as a fall. An Advanced Life Support (ALS) ambulance was dispatched to T.H.'s location in Cherry Lake Garden Trailer Park. An ALS unit is intended to be a mobile critical care unit, able to render critical care and stabilization to a patient enroute to an appropriate hospital. An Advanced Life Support unit contains equipment needed for insertion of a chest tube, a lab, and an x-ray, as well as equipment and medications for cardiac emergencies. The equipment and medications needed for T.H.'s case were present. The ALS unit arrived at T.H.'s location at 5:19 a.m. Jimmy Kent was an EMT and driver of the ALS unit that responded to the 911 emergency call on T.H. Richard Kline was the paramedic on the ambulance. Mr. Kline was trained in ALS care and could administer certain drugs, including Procardia without a physician's order. Paramedic Kline found patient T.H. on the floor of the trailer. He observed T.H. to be comatose, unresponsive to painful stimuli, and exhibiting snoring-type respirations. His skin was hot and dry, and his face was red. T.H. scored a three on the Glasgow Coma Scale, the lowest possible score. T.H.'s vital signs were blood pressure estimated at 300 plus over 150, respiratory rate of 40, heart rate "tacking" at approximately 170, with raspy breathing. T.H. was considered in critical condition. At the scene, Paramedic Kline was having problems with his cardiac monitor, which became non-functional due to battery problems. However, patient T.H. could still be adequately monitored manually. Additionally, within twenty-five minutes of beginning the run, the cardiac monitor on the ALS unit was non- functional due to failure of the primary and back-up batteries. The lack of the units equipment did not significantly impact the paramedic's ability to monitor or treat T.H.'s condition. Paramedic Kline was informed by T.H.'s family that he had a history of Arterial Venous Malformation, paralysis on the right side, and strokes. T.H.'s sister was called and she advised that T.H. not be brought to Madison County Memorial Hospital (MCMH) because they usually don't have a doctor available. She wanted T.H. to go to South Georgia Medical Center (SGMC) in Valdosta, Georgia. The paramedic thought that they needed to take T.H. to MCMH because of the serious vital statistics that T.H. had. The paramedic felt T.H. could go into cardiac arrest. After being advised by the paramedic that T.H. needed immediate assistance at MCMH, T.H.'s sister agreed to have T.H. taken to MCMH. There are two hospital emergency facilities to choose from when transporting an emergency case in the Madison, Florida, area, MCMH and SGMC. In driving terms MCMH is slightly, but not significantly, closer to Cherry Lake Garden Trailer Park than SGMC. However, the facilities are very different in the services each can offer in an emergency situation. MCMH is not a trauma center. MCMH does not have any neurosurgical facilities, neurosurgical consults, diagnostic MRI's, diagnostic CT scans, or cerebral monitoring equipment available. MCMH cannot treat a cerebral vascular accident or bleeding in the brain. On the other hand, SGMC is a tertiary care facility. It has neurosurgical facilities, neurosurgical consults, diagnostic CT scans, and cerebral monitoring equipment available. SGMC can treat a cerebral vascular accident and is the closest facility which can provide such care. The ambulance was en route to MCMH when it contacted the hospital by radio; Joanie Cruce, R.N., spoke to the ambulance driver over the radio. Paramedic Kline informed Nurse Cruce of T.H.'s history, including the presence of T.H.'s AVM and vital signs. He also informed Nurse Cruce that he was bringing the T.H. to MCMH. Nurse Cruce relayed T.H.'s information to Joe Jaime, R.N. Nurse Jaimie was on the telephone to Dr. Dulay who was in another room at the hospital. Nurse Jaimie relayed over the telephone to Dr. Dulay the information Nurse Cruce gave her. At no time did Dr. Dulay speak directly with the paramedic. Dr. Dulay was informed that the patient had high blood pressure, was unconscious, and had a history that included an arterial venous malformation. Due to the patient being unconscious, he suspected a cerebral vascular accident/stroke (CVA). At approximately 5:40 a.m., while en route to MCMH, the paramedic asked for advice on whether to administer Procardia. Procardia is used to reduce blood pressure. Respondent advised that it was appropriate to administer 10mg of Procardia. There was some uncertainty in the testimony as to whether the administration of Procardia was requested by the paramedic and approved by Dr. Dulay, or ordered by Dr. Dulay. Either person could have authorized the use of the drug. In any event, 10mg of Procardia was the appropriate medication for the patient's condition and met or exceeded the appropriate standard of care for an emergency room physician under the circumstances. At some point, Dr. Dulay advised the ambulance to have T.H. taken to the nearest appropriate facility. The ALS unit was one to two miles from MCMH when Joanie Cruce, R.N., advised the ambulance driver to take T.H. to the nearest appropriate facility. Either Nurse Cruce misspoke and said Tallahassee or Richard Kline misunderstood her to say Tallahassee. Richard Kline questioned the direction to take T.H. to Tallahassee. He told nurse Cruce that the family wanted T.H. to go to the hospital in Valdosta. The information was passed to Dr. Dulay. He agreed that SGMC was an appropriate facility for T.H. and in fact SGMC was the closest appropriate facility for T.H.'s condition. Dr. Dulay never informed the nursing staff that T.H. could not be brought to MCMH and indeed the nurses thought that the ambulance was on its way even after the conversation about Valdosta. Patient T.H. was not in respiratory or cardiac arrest at the time the ambulance was turned around to go to Valdosta. After the change of direction, which is always within the discretion of the ambulance crew, there was no further contact with MCMH. Therefore Dr. Dulay was never informed of the results of the Procardia. Additionally, T.H. was never admitted to MCMH and never became a patient of Dr. Dulay or the hospital. Therefore, since T.H. was not a patient of the hospital no transfer from one facility to another facility occurred. While en route to SGMC, the ambulance contacted SGMC's emergency room. The staff advised the paramedic to give T.H. sodium nitroprusside. However, the ambulance did not carry sodium nitroprusside. Instead the paramedic was advised by SGMC staff to administer Lasix IV and nitroglycerine. Patient T.H. suffered respiratory arrest just outside the city limits of Valdosta. Efforts to intubate and revive him were unsuccessful. Patient T.H. arrived at SGMC in full arrest. The ambulance arrived at SGMC at 6:25 a.m. Attempts to revive the patient at the hospital were unsuccessful. T.H. was pronounced deceased shortly after his arrival at SGMC. T.H.'s cause of death was cardiopulmonary arrest with an underlying cause of intracranial hemorrhage, probably due to an aneurysm. In short, all of T.H.'s symptoms were caused by a rapidly expanding and bleeding cerebral vascular incident from his AVM. T.H.'s condition was not due to a cardiac problem. The medical condition of T.H. at the time he was transported by Madison County ALS was indicative of an intracranial hemorrhage. Such a condition could only be evaluated for surgical treatment through the utilization of an MRI and CT scan, and required the immediate consultation of a neurosurgeon. None of which were available at MCMH. Moreover, it would generally be preferable to transport a patient with a score of three on the Glasgow Coma Scale to a trauma center. SGMC was the closet facility to Cherry Lake at which a neurosurgical consult was available, and which had the capability of treating an intracranial hemorrahage; therefore, patient T.H. was appropriately diverted to that facility. Dr. Dulay did not open a chart on T.H., and could not recall whether he made written notes during T.H.'s emergency. However, it is not customary practice that a medical chart be opened for an emergency case when consults are made via radio and the person is diverted or otherwise delivered to a separate facility. Generally, neither the hospital nor the doctor know the name of the person being transported. If the person does not arrive at the hospital, that facility has no information on which to open a patient record. Under such circumstances, the person's history, vital signs, and medication administration are recorded in the ALS run sheet, which accompanies the person to his or her ultimate destination. The radio communications are recorded by audiotape. In this case, the history, vital signs, and medication administration to T.H. were in fact recorded in the ALS run sheet. The run sheet appropriately accompanied T.H. to SGMC. The radio communications were recorded by audiotape. These documents are adequate records in emergency situations. Given these facts, there was no deviation by Dr. Aldolfo Dulay from the applicable standard of care for a physician under the circumstances presented in this case or that there was a failure to keep adequate written medical records justifying the course of treatment of the patient.
Recommendation Based upon the findings of fact and conclusions of law, it is, RECOMMENDED: That the Board of Medicine enter a final order finding that Adolofo Dulay, M.D. did not practice below the accepted standard of care in his handling of the diversion of patient T.H. to a tertiary care facility, that there was no transfer of patient T.H. and that the records maintained were appropriate under the circumstances and that the Administrative Complaint be dismissed. DONE AND ENTERED this 2nd day of June, 1998, in Tallahassee, Leon County, Florida. DIANE CLEAVINGER 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 Filed with the Clerk of the Division of Administrative Hearings this 2nd day of June, 1998. COPIES FURNISHED: John Terrell, Esquire Agency for Health Care Administration Post Office Box 14229 Tallahassee, Florida 32317-4229 Richard B. Collins, Esquire Ryan Garrett, Esquire Collins and Truett, P.A. 2804 Remington Green Circle, Suite 4 Tallahassee, Florida 32308 Angela T. Hall, Agency Clerk Department of Health Building 6, Room 136 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Pete Peterson, Esquire Department of Health Building 6, Room 102-E 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Dr. James Howell, Secretary Department of Health Building 6, Room 306 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Dr. Marm Harris, Executive Director Department of Health 1940 North Monroe Street Tallahassee, Florida 32399-0792
The Issue The issue presented is whether the application of Respondent Adventist Health System/Sunbelt, Inc. d/b/a East Pasco Medical Center for a certificate of need to add 24 acute care beds to its existing facility should be approved.
Findings Of Fact The Seventh Day Adventist Church owns Respondent Advent-ist Health System/Sunbelt, Inc. That corporation, which occupies a strong financial position, operates not-for-profit hospitals in several states, including Florida. One of the Florida hospitals is East Pasco Medical Center (East Pasco), located in Zephyrhills. Zephyrhills is in eastern Pasco County, which, for health planning purposes, is known as Subdistrict 2 of District 5. East Pasco is an 85-bed acute care hospital which provides most of the common services found in a community hospital. In addition to providing general acute care and obstetrics (OB), it has an intensive care unit (ICU) and offers neurosurgery and kidney dialysis services. East Pasco also has completed but not yet opened an 11-bed skilled nursing unit (SNU) and a 10-bed observation unit. The 11 beds in the SNU and the 10 beds in the observation unit are in addition to the 85 acute care beds for which East Pasco is licensed. For licensure purposes, acute care beds are not divided into types of service. East Pasco's current configuration for its 85 acute care beds is as follows: 68 medical-surgical beds, 8 ICU beds, and 9 OB beds. East Pasco has an active emergency room which experiences up to 30,000 visits per year. East Pasco obtains approximately 55 percent of its in-patient admissions through its emergency room. East Pasco is accredited by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). Petitioner Humana of Florida, Inc. d/b/a Humana Hospital Pasco (Humana) is an existing 120-bed acute care hospital in Dade City. It is situated approximately 10 minutes away from East Pasco. Humana provides the same services that East Pasco provides, including medical-surgical, ICU/CCU, OB, kidney dialysis, and neurosurgery. Like East Pasco, Humana is accredited by the JCAHO. However, Humana's accreditation is "with commendation", the highest rating given by the JCAHO. Like East Pasco, Humana has a large medical staff, primarily consisting of physicians who have their offices located in Zephyrhills or Dade City. The medical staff rosters of Humana and East Pasco are virtually identical. Dade City is also located in east Pasco County, and the primary service areas of Humana and East Pasco are virtually identical. Like East Pasco, Humana serves the Medicaid and indigent patient populations. In its fiscal year 1991, Humana provided 6 percent of its patient days to Medicaid patients. In fiscal year 1992, that increased to 8.8 percent, the same as East Pasco. Humana's Medicaid patient days increased substantially with the introduction of OB services at Humana since Medicaid patients receive primarily OB services. East Pasco has been designated as a disproportionate share provider under the State's program to give economic incentives to hospitals serving a certain percentage of Medicaid patients. East Pasco also serves the indigent patient population pursuant to a contract between it and Pasco County. In September, 1991, East Pasco filed its application for a certificate of need (CON) requesting approval for 24 additional medical-surgical beds (acute care beds) for the July, 1996, planning horizon. In January, 1992, the Agency notified East Pasco of its intent to approve the application and issue to East Pasco CON No. 6783. Humana filed this challenge to the Agency's intent to grant the application, and this proceeding ensued. All parties subsequently stipulated that Humana has standing to initiate and maintain this proceeding and that Humana was not obligated to present evidence of its standing. East Pasco has proposed a new unit to house the 24 additional medical- surgical beds to be located on the third floor of a new three-story tower. That third floor would consist of 13,000 gross square feet (GSF), would cost $4,087,810, and would consist of only private rooms with three nurse stations. East Pasco proposes no new services, only additional beds. Construction of the three-story tower has not yet commenced but is awaiting the outcome of this proceeding. The first floor of the new tower will be a wellness center, a project which did not require CON review. The second floor will house a new ICU. East Pasco presented conflicting evidence as to the size of that new ICU. The Agency approved East Pasco's second floor ICU as a 12-bed ICU with a cost below the threshold cost which would have required CON review. In spite of the exemption from review obtained by East Pasco, it is specifically found that East Pasco intends to place a 16-bed ICU on the second floor of the yet-to-be-constructed tower. Thus, East Pasco would achieve its 16-bed ICU by relocating its existing 8-bed ICU and converting other beds to ICU beds. Thus, if the 24 new beds sought are approved they will produce 16 additional medical-surgical beds and 8 additional ICU beds. Resolution of the number of beds proposed for the second floor of the new tower is required in this proceeding for two reasons. First, the cost of this project is impacted. If 8 of the new beds are to be used as ICU beds rather than as medical-surgical beds, they will be more expensive to construct and equip. Second, corporate approval of corporate projects is a prerequisite in Florida's CON process. East Pasco's Board of Directors met on August 14, 1991, to authorize the filing of this application. This application proposes 24 medical-surgical beds, the corporate resolution filed with the Agency authorized 24 acute care beds, but the minutes of the Board's meeting reflect that the Board itself approved 24 beds for ICU and PCU services. Although ICU, PCU, and medical-surgical beds are all acute care beds, they are constructed, equipped, and staffed differently. For the reasons described below, there is no need in District 5 or in the east Pasco County Subdistrict for East Pasco's proposed 24 additional medical-surgical beds. Rule 59C-1.038, Florida Administrative Code, includes the numeric need methodology for projecting acute care bed need. Under that Rule, applications for acute care beds will "not normally" be approved unless there is numeric need. For the September, 1991, application batching cycle, the Agency published a fixed need of zero acute care beds needed in District 5, Subdistrict 2, which is composed of only East Pasco and Humana hospitals. This fixed and published need of zero was not challenged. Per paragraph (7)(d) of the Rule, additional acute care beds will "not normally" be approved unless the subdistrict occupancy is at or exceeds 75 percent. All parties agree that calendar year 1990 is the proper period to ascertain whether this standard is met. In 1990, the acute care bed occupancy rate in the Subdistrict was 55.33 percent. The parties agree that the Rule's occupancy standard is not met. Therefore, no additional beds should normally be approved. There is ample unused capacity in District 5 and in the Subdistrict to meet acute care demand. Humana's occupancy is well below 50 percent. In years and 2 for the proposed unit, East Pasco projects 1,042 and 1,760 patient days, respectively. Humana has sufficient unused capacity to accommodate that projected demand. Utilization trends support the lack of need shown by the need methodology and the occupancy standard. Acute care utilization in the Subdistrict has decreased since 1986. In 1986, the two Subdistrict hospitals generated 42,830 patient days, a 57.2 percent occupancy. In 1991, notwithstanding population growth in the Subdistrict, the two Subdistrict hospitals generated 41,756 patient days, a 55.8 percent occupancy. Clearly, then, there is no increased demand for acute care services, but only a reshuffling of market share between the two hospitals. Contrary to East Pasco's suggestion, first quarter utilization does not show need and has, in fact, been decreasing. For example, the first quarter (January-March) of 1986 generated 13,572 patient days in the Subdistrict, a 73.6 percent occupancy; in the first quarter of 1992, there were 12,482 patient days, a 66.9 percent occupancy, the lowest first quarter utilization in the last 6 years in the Subdistrict. Additionally, the average length of stay (ALOS) in the Subdistrict continues to decline. In the first quarter of 1991, the ALOS was 5.4 days; in the first quarter of 1992, the ALOS was 5.1 days. Accordingly, although East Pasco shows an increased number of admissions over the last several years, the continued decline in the ALOS has resulted in a decreasing number of patient days. The population growth in the Subdistrict is not so substantial as to demonstrate need. Humana relied upon population projections produced by a national firm specializing in demographic analyses. Such a population data source is generally more reliable than a county's own projections, relied upon by East Pasco. The Subdistrict is growing but not at an extraordinary pace. In comparison, the West Pasco Subdistrict is growing faster. There are no geographic access problems to receiving acute care services which would support a finding of need. There are many hospitals available and accessible to residents of the Subdistrict within 30 minutes travel time or less. The entire Subdistrict is within a 30-minute travel time of Humana and of East Pasco. Most of the Subdistrict is also within 30 minutes travel time to other acute care hospitals, including University Community Hospital in Tampa, Lakeland Regional Medical Center in Lakeland, and South Florida Baptist Hospital in Plant City. The Zephyrhills area in particular is within 30 minutes travel time to those other facilities. Humana is an available alternative to the proposed project. Humana is geographically accessible to the entire Subdistrict, provides all the services that East Pasco provides, and provides good quality of care. Humana's medical staff roster includes the same physicians that practice at East Pasco. Humana already serves the same geographic service area that East Pasco serves. Indeed, several East Pasco witnesses testified that patients are transferred to Humana when East Pasco is full, thereby acknowledging Humana as an alternative for Subdistrict residents. Hospitals situated outside the Subdistrict are also available and appropriate alternatives to the proposed project. These hospitals have unused capacity to accommodate the projected demand from the Subdistrict. Notably, residents of the Subdistrict have historically greatly utilized hospitals located outside the Subdistrict. In 1990, 63.7 percent of the Subdistrict's residents went to a hospital other than Humana or East Pasco. Thus, physicians and residents regard hospitals situated outside the Subdistrict as appropriate and viable alternatives. Since East Pasco does not propose to offer any new service, and since there is accessible unused capacity at Humana and these other facilities, there are better alternatives to adding new beds at East Pasco. In addition, although approving more beds at East Pasco would improve availability of services at East Pasco, such is not a planning consideration or a review criterion. East Pasco and Humana provide similar levels of Medicaid care. In calendar year 1991, Medicaid comprised 8.8 percent of all patient days at East Pasco, less than in 1990. From September, 1991, to August, 1992, 8.8 percent of all patient days at Humana were Medicaid days. The two hospitals also provide similar amounts of indigent care. Therefore, Humana is economically accessible to all residents of the Subdistrict. Facilities located outside the Subdistrict also are economically accessible. Physician preferences are not significant in formulating conclusions of need on a District or Subdistrict basis. Physicians may well have their own reasons for doing things which may be contrary to sound health care planning principles. Further, physicians' personal preferences are not relevant to ascertaining how existing resources can be best and most efficiently used. The acute care bed Rule provides that additional beds "may" be approved at a specific facility if its occupancy exceeds 75 percent even though no beds can be authorized pursuant to the mathematical calculations established by the Rule. While East Pasco achieved an occupancy rate of 78.78 percent in calendar year 1990, that statistic merely "opens the door" for an evaluation of whether there are compelling circumstances to justify the approval of beds at a specific facility despite the absence of need demonstrated by the acute bed methodology. There are no factors or circumstances which would justify the approval of 24 additional medical-surgical beds at East Pasco pursuant to the specific facility provision. First, there are accessible and available alternatives for meeting projected demand. The majority of east Pasco County residents outmigrate even when beds are available at East Pasco. There is an excess capacity in the Subdistrict and in the District. Second, East Pasco's application discusses seasonal overcrowding due, in large part, to using in-patient beds for "observation" patients. Observation patients are those with a hospital stay of less than 24 hours. East Pasco has recently completed a new 10-bed observation unit. In 1991, East Pasco averaged observation patients per day; therefore, this new 10-bed unit will ease the strain on East Pasco's in-patient beds. Third, East Pasco's application relies on the "overflow" of patients in the winter season to justify its proposed bed addition. The actual amount of "overflow" is reflected in East Pasco's transfer log, which shows that there were not that many patients transferred in 1991. In fact, there were several months in which there were zero transfers. Fourth, the proposed beds are only intended to handle "seasonal" population demands. The proposed unit would not be open year-round. East Pasco was below 75 percent occupancy from May to October, 1991. East Pasco acknowledges that the proposed beds are only for part of the year and are intended to accommodate the demands of the seasonal population, who are not necessarily residents of the Subdistrict. East Pasco's application in reality requests approval for adding 24 beds at a cost of over $4,000,000 to accommodate, by East Pasco's own projections, an average daily census of three patients the first year and five patients the second year in a unit that would be closed at least six months out of each year. That is an excessive expenditure to provide access to relatively few people, where access to nearby facilities exists. Although East Pasco has shown that on certain days it has exceeded its OB capacity, and although East Pasco maintains that its most common capacity problem is the lack of available ICU beds, East Pasco's application itself does not suggest that it intends to increase the number of OB or ICU beds. Further, although on certain days East Pasco has experienced over 100 percent occupancy and has placed patients in the hallways, that situation can be obviated by referring patients to other hospitals, and the situation will be alleviated when East Pasco soon opens its additional 10-bed observation unit and 11-bed SNU. East Pasco has, therefore, shown that it has an occupancy rate sufficient to entitle it to review despite the lack of need under the acute care bed Rule, but it has shown no other reasons why its application should be approved. The Florida State Health Plan includes various preferences for reviewing CON applications. On balance, the East Pasco application is not consistent with that Plan. The first group of preferences relates to the addition of hospital beds. The first item in that group provides that no additional beds should generally be approved unless the subdistrict occupancy is at or exceeds 75 percent or unless the applicant-facility is at 80 percent. Since calendar year 1990 data was used to calculate the need formula and Subdistrict occupancy standard, it is appropriate to use that same data to determine East Pasco's occupancy for evaluating this preference, rather than using two different time periods as the Agency did. In 1990, the Subdistrict was below 75 percent, and East Pasco's occupancy was below 80 percent. Therefore, this preference is not met. The second item under this group provides that "in the event that acute care bed need is shown", preference shall be given to an applicant who provides a disproportionate share of Medicaid and indigent services in the Subdistrict. This preference is not met since no "acute care bed need is shown". The next group of preferences is entitled "transfer and conversion of acute care beds". Because East Pasco does not propose to transfer or convert acute care beds, East Pasco does not satisfy any of the preferences included under this grouping. The next group of preferences is entitled "indigent care". The first item provides that preference shall be given to an applicant who provides a disproportionate share of Medicaid and charity care in relation to other hospitals in the District or Subdistrict. This preference is not met. Although East Pasco has historically provided more Medicaid and indigent care than Humana, there is no showing that East Pasco will provide disproportionately more Medicaid and indigent care for medical-surgical services specifically. Most of East Pasco's Medicaid participation is for OB and newborn services, not medical- surgical services. Both Humana and East Pasco provide less than 1 percent of their gross revenues for indigent care. Given that most of the Subdistrict population is elderly, indigent care is not a major issue. Also, it was stipulated that East Pasco does not know how much indigent care it provides for medical-surgical services only. The second item under this group relates to whether CON approval would negatively affect the financial viability of a disproportionate share hospital. This preference is not relevant to East Pasco's application. The third group of preferences is entitled "emergency services". The first item relates to the applicant's record of accepting indigent patients for emergency care. East Pasco presented no information on this in its application except for its proof that it has a contractual obligation to do so. The second item relates to whether the facility/applicant is a trauma center. East Pasco is not a designated trauma center. The third item relates to whether the applicant demonstrates a full range of emergency services. East Pasco did not address this in its application. The fourth item addresses whether the facility has ever been fined by HRS for violations of emergency services statutes. East Pasco did not address this item in its application. Therefore, East Pasco does not meet the preferences in this group. The fourth group of preferences is entitled "teaching, research, and referral hospitals". The application does not address these particular preferences, and East Pasco does not hold itself out as a teaching, research or referral hospital. Therefore, East Pasco does not satisfy the items under this grouping. The fifth group of preferences is entitled "specialized services". East Pasco does not propose to provide any specialized services and, therefore, items under this grouping are not satisfied. The District 5 Local Health Plan includes recommendations for reviewing CON applications. On balance, the East Pasco application does not satisfy that plan. The first preference relates to whether the applicant provides a disproportionate share of Medicaid and charity care. For the reasons indicated above regarding the State Health Plan, this preference is not met. Further, East Pasco's application does not suggest that the 24 medical-surgical beds sought will enhance its Medicaid or indigent participation. The second recommendation provides that "if a numeric bed need exists as shown by the state bed methodology", preference is given to an applicant who has generated certain occupancy levels. Because no numeric bed need was shown per the Rule methodology, this recommendation is not met. The third recommendation relates to the transfer of existing acute care beds. Because East Pasco does not propose a transfer of beds, its application is not consistent with this recommendation. The fourth recommendation gives preference to applicants who document the cost-effectiveness and efficiency of their project. East Pasco does not satisfy this preference. East Pasco failed to show any cost efficiencies for its project. East Pasco proposes to spend over $4 million to serve, on the average, 3 to 5 patients per day in years 1 and 2. That is cost-inefficient. East Pasco did not prove that the charges or costs of providing medical-surgical services would be any less than what it currently charges. East Pasco's application includes two pro formas: a hospital-wide pro forma and an incremental pro forma for the proposed 24-bed unit. The person who prepared those pro formas did not testify, and the person who did testify did not participate in preparing the pro formas. Further, the witness only testified to the reasonableness of the incremental pro forma; he did not testify, directly or indirectly, regarding the hospital-wide pro forma. An incremental pro forma alone does not demonstrate long-term financial feasibility, even if the incremental pro forma were reasonable. An incremental pro forma alone does not reflect the project as a whole. At East Pasco, there are several projects and activities on-going or planned that must be evaluated. In addition to the existing 85 beds, East Pasco has underway: (1) opening a 10-bed observation unit; (2) opening an 11-bed SNU; (3) a planned wellness center on the first floor of the proposed 3-story tower; and (4) the planned relocation and enlargement of its ICU to the second floor of the proposed tower. Those projects add expenses, put strains on cash, and require debt. Without considering all the activity at the hospital, one cannot reasonably ascertain whether the proposed $4.1 Million third-floor project is financially feasible. For example, a small project could show an incremental profit but the hospital as a whole could lose money. East Pasco simply assumes that its 24-bed unit will be financially feasible in 1994 and 1995, years 1 and 2 of the project. The health care field is too dynamic and volatile for such assumptions. For example, East Pasco had an operating loss in 1990 but did well in 1991. By not analyzing the hospital-wide pro forma and proving its reasonableness, East Pasco did not show the required financial feasibility. It only demonstrated the results of one component of an entire operation. East Pasco has left unanswered the question of whether the facility as a whole will be able to finance this project in conjunction with all its other requirements. Further, the application lacked sufficient and clear presentation of the assumptions underlying the hospital-wide pro forma. Restated, the hospital-wide pro forma is not self-explanatory. The incremental pro forma, showing the proposed revenues and expenses for the 24-bed medical-surgical unit for years 1994 and 1995, is not reasonable. The projected revenues are overstated, and the projected expenses are understated. The assumptions underlying the financial projections are unreasonable. Further, the profit projections are unrealistic; in year two, East Pasco projects a profit of about $615,000 on an average daily census of less than 5 patients per day. On its face, that is unrealistic. In 1991, East Pasco generated 24,517 patient days, which was virtually the same as its 1990 utilization. In 1993, East Pasco projects 26,220 days. In year 1 of this project (1994), East Pasco projects 27,262 days hospital-wide, including the 1,042 incremental days associated with this project. Thus, in just a 3-year period, East Pasco projects almost 3,000 additional patient days, and even more for year 2 (1995). It is not reasonable to assume such an increase in utilization since utilization during the first quarter of 1992 declined from first quarter 1991. Therefore, patient day projections are overstated, thereby causing overstated projected gross revenue. East Pasco's projected daily charge is based on the hospital-wide average charge. It is not based on historical charges for medical-surgical services specifically. It is unreasonable to use charges for hospital services as a whole when the proposed project is for medical-surgical services only. Because the underlying assumption is invalid, projected revenues lack credibility. In calculating deductions from gross revenues, East Pasco assumed the hospital-wide payor mix and did not specifically ascertain the payor mix (and, therefore, the deductions) for medical-surgical services specifically. Again, this is an unreasonable assumption. Deductions from gross revenue should have been analyzed for medical-surgical services specifically. Due to the invalid assumption, the deductions from revenue figures lack credibility. East Pasco projects 5.8 FTEs for year 1 and 6.0 FTEs for year 2. East Pasco proposes to operate the 24-bed unit as an independent unit. These staffing levels are insufficient. East Pasco's proposed utilization equates to a 4.8 average daily census, which requires two nurses at all times. By East Pasco's admission, to staff a unit with two persons at all times throughout the year requires 9.2 paid nursing FTEs in addition to ward clerks and other support personnel. If the volume fluctuated and the census exceeded 7 or 8, more than two nurses would be needed. Thus, the 5.8 and the 6.0 FTE numbers are too low. The proposed staffing does not allow one RN to be on the floor at all times. To maintain one RN on the floor at all times throughout the year requires 4.2 FTEs; East Pasco budgeted for one. East Pasco does not have excess RNs available from its existing staff to cover the proposed addition. The supplies expense shown on the incremental pro forma was based on a hospital-wide average. The proposed project is for a specific service, and one cannot reasonably use a hospital-wide average instead. Accordingly, the calculation of expense for supplies is not reasonable. The pro forma includes an expense item entitled "other". East Pasco offered no explanation for that expense. Also, the pro forma did not include a line-item for the HCCCB indigent care tax, which is 1.5 percent of net revenue. East Pasco's proposed 24-bed medical-surgical unit will cover 13,000 GSF and will cost more than $4.1 million. All rooms will be private. The unit will have three nurse stations. According to East Pasco, the unit is to be a basic medical-surgical floor and is not intended to be a progressive care unit (PCU). This proposed design is not reasonable and is excessively large by at least 30 percent. This design is inefficient and, in reality, is not the design of a basic medical-surgical unit, but is instead the design of a PCU. There are three main reasons why the design is excessive. First, it is not necessary or reasonable to have all private rooms. A regular medical- surgical unit should have about an equal split of semi-private rooms. Notably, East Pasco's new 11-bed SNU has 5 private and 3 semi-private rooms for patients who will require hospitalization for up to 90 days. Second, these private rooms are almost twice the minimum size required by state licensure regulations. Third, three nurse stations are unnecessary; only one nurse station is needed for a basic 24-bed medial-surgical unit. East Pasco currently has 68 medical- surgical beds on 2 units, and each such unit has only 1 nurse station. The existing 68 medical-surgical beds at East Pasco average about 360 GSF per bed. The proposed 24 beds will average 542 GSF per bed. All private rooms and 3 nurse stations are, clearly, the design for a PCU. A PCU is a step- down unit from an ICU, which has high staff-to-patient ratios thereby requiring more nurse stations. East Pasco's projected construction cost for the 24-bed medical- surgical unit is $142.91 per GSF. This is unreasonably understated. It is uncontroverted that an SNU is less costly to construct than a medical-surgical unit. According to its projections, East Pasco's 11-bed SNU cost $171 per GSF in 1992. Clearly, that SNU cost is substantially greater than East Pasco's projected construction cost at issue. This inconsistency was never explained by competent evidence. In evaluating East Pasco's estimates, the Agency's architect relied upon 1991 Means construction cost data. He averaged the Means' medium figure ($123 per GSF) with the high figure ($172 per GSF) to derive a 1991 estimate of $147.50 per GSF. To that, one must add a 10 percent contingency factor, inflation, and an architectural fee. That totals $187.69 per GSF. The $187.69 projected figure is consistent with the 1992 SNU cost figure of $171. Thus, for construction costs alone, East Pasco underestimated by $44.77 per square foot, which is about $582,000. East Pasco proposed to construct a three-story tower; the third floor will house the proposed 24 medical-surgical beds. The second floor will house a 16-bed ICU, comprised of relocating the existing 8 ICU beds and converting 8 other acute care beds. East Pasco's application project costs only cover the third floor; East Pasco maintains the second floor is exempt from CON review and thus its cost is not relevant. As described below, East Pasco unreasonably failed to include costs of the second floor in its application. A hospital project costing $1,000,000 or more (other than an out- patient project) requires CON review. In its letter for exemption East Pasco states that the second floor would contain 12 ICU beds and cost $975,000 (calculated by multiplying 6,500 GSF by $150/foot). That letter is erroneous for several reasons: (1) the $150/foot is in 1992 dollars and does not include inflation; (2) the $150/foot does not include a 10 percent construction contingency fee, which is necessary and reasonable; (3) the $150/foot does not include an 8.4 percent architectural/engineering fee, which is necessary and reasonable; and (4) the $150/foot does not include any debt or financing fee. Including these necessary amounts alone shows that the second floor, in truth, exceeds the $1,000,000 threshold. Also, the cost for equipping an ICU bed is $45,000 per bed; for 16 beds, that is $720,000 for equipment. Surely the size and cost of a 16-bed ICU is different from and greater than a 12-bed ICU. East Pasco stated in its exemption request letter that the second floor would have 12 beds even though East Pasco intends 16 beds. East Pasco and the Agency correctly argue that the exemption given to East Pasco by the Agency for its second-floor ICU project is not part of the instant application and cannot be considered in this proceeding. However, the accuracy and reasonableness of the costs projected by East Pasco attendant to the 24 additional beds it seeks are an integral part of this proceeding, as is the scope of the project being reviewed and challenged. The second and third floor projects are, in truth, one project. It is East Pasco's intention to add 16 medical-surgical beds and 8 ICU beds to its facility. To establish the 16-bed ICU unit, East Pasco needs additional acute care beds; East Pasco does not have 8 available beds among its existing bed complement to convert to ICU purposes. The OB beds often run at 100 percent occupancy and, during the peak season, the medical-surgical beds run high occupancy. Thus, East Pasco cannot fully implement the second floor without approval of the proposed 24 new beds. There will be no community benefits in terms of charges if this application is approved. "Net revenues" must be the basis for comparing charges between facilities. Net revenues refers to what third party payors (such as Medicare, Medicaid, HMO/PPOs and most insurors) actually pay for hospital services as opposed to what hospitals charge. Few patients ever pay gross charges, particularly in the elderly East Pasco Subdistrict. In 1991, Humana's average net revenue per day was lower than East Pasco's. Humana's actual net revenue per admission in its fiscal year 1992 was $4,180. East Pasco's projected 1992 net revenue per admission is $5,301. Thus, for 1992, third party payors paid, on behalf of their patients, less per admission at Humana than at East Pasco. In its application, East Pasco projects an 8 percent per year increase in charges. An annual increase of 8 percent is not promoting charge-efficiency. East Pasco's application did not demonstrate cost-efficiencies resulting from approval, but rather, cost-inefficiencies. First, Humana would lose patient volume should East Pasco be approved. Humana currently receives transfers and direct admissions when East Pasco is full. Loss of patient volume would increase operating costs per patient day at Humana. Second, there is no need for additional beds in the Subdistrict. There is already excess capacity in the Subdistrict. Exacerbating excess capacity promotes cost-inefficiency. East Pasco admits the unit will not even be open six months out of the year because there is no need for it then. Third, East Pasco projects very low census in years 1 and 2, about 3 patients per day in year 1 and less than 5 patients per day in year 2. Spending over $4,000,000 to accommodate such low utilization is inefficient and unreasonable. Approval of East Pasco's application would not promote positive competition. There is competition now in the Subdistrict between Humana and East Pasco. East Pasco already captures a larger market share of the Subdistrict than Humana. Approving this application would only tip the scales more in favor of East Pasco and would adversely impact Humana's already poor financial condition. The quality of care delivered at Humana is very good. The JCAHO rates all acute care hospitals, and its rating is widely recognized in the hospital industry. The JCAHO evaluates many factors and components of a hospital. Humana is accredited "with commendation", the highest rating given. Only 5-6 percent of all acute care hospital in the country receive that highest ranking. Humana maintains a good utilization management program. Humana implements an excellent quality improvement plan, including soliciting and reviewing patient satisfaction comments. Mortality statistics cannot, by themselves, meaningfully measure the quality of care delivered at a hospital. Although the Health Care Finance Administration (HCFA) produces such a report for Medicare patients, the report itself represents that it is not intended to measure quality of care, and the American Hospital Association does not view HCFA mortality statistics as a measure of quality of care. There are many factors which influence mortality statistics at a hospital and, even more importantly, mortality is only one clinical outcome resulting from a hospital admission. When East Pasco is full, there is no medical problem or complication resulting from transferring patients to Humana or from directly admitting patients at Humana. There is no diminution of care or loss of continuity of care in transferring to or directly admitting to Humana. Emergency medical services are available in the Subdistrict, and, therefore, transfer is not a problem. Also, driving to Humana or to a hospital outside the Subdistrict is neither a problem nor an unusual circumstance. The large seasonal population drive to Florida in the winter, and, therefore, it is a mobile patient population. Most of its residents seeking hospital services receive them outside the Subdistrict. Subdistrict residents currently leave the Subdistrict to receive a variety of hospital services, including: in-patient cardiac cath, open heart surgery, Level II NICU, psychiatric services, substance abuse services, and comprehensive rehabilitation services. Thus, there is no merit to the suggestion that transferring patients from East Pasco to Humana or elsewhere is problematic. There would not be community benefits regarding Medicaid/indigent care by approving this application. As indicated, for all hospital services, Humana and East Pasco provide similar amounts of Medicaid and indigent care, although indigent care at both facilities is relatively insignificant. Therefore, access to Medicaid and indigent care does not provide a basis for approving East Pasco's application. Also, East Pasco's payor mix in its application was based on hospital-wide averages. East Pasco has not shown the amount of Medicaid or indigent care which would be specifically provided to, or which is needed for, medical-surgical patients. Finally, East Pasco's Policy and Procedure Manual includes several provisions requiring deposits upon in-patient admission absent verification of third party payor coverage. Such provisions are inconsistent with the proposition that East Pasco accepts all patients regardless of ability to pay. In Florida, an application for a CON must include a certified copy of an authorizing resolution of the applicant's Board of Directors. East Pasco included its corporate resolution in its CON application, that resolution being adopted at an August 14, 1991, meeting. That resolution clearly states, among other things, authorization to file an application for up to 24 additional acute care beds. The minutes of that meeting clearly reflect the Board's approval for 24 beds for ICU and PCU. The application itself requests approval of 24 medical-surgical beds. PCU, ICU, and medical-surgical beds are all types of acute care beds. Accordingly, East Pasco did file a proper corporate resolution consistent with the minutes and consistent with the application. The minutes and the application, however, are inconsistent. Although the corporation resolution is technically correct and fulfills the requirements for a CON application, the inconsistency among the corporate resolution, the minutes, and the application raised questions about the actual intent of East Pasco. The intent became more questionable during the final hearing when East Pasco's witnesses contradicted each other as to the number of beds to be placed in the to-be-constructed ICU on the second floor of the to-be-constructed 3-story tower. It is clear that the Agency only approved the construction of a 12-bed ICU on the second floor. It is also clear that East Pasco in fact intends to construct a 16-bed ICU on that second floor. It is also clear that East Pasco intends to construct a "medical-surgical" unit on the third floor in accordance with a design for a PCU. While the corporate resolution technically complies with the requirements for a CON application, the questionable nature of its accuracy, when considered in conjunction with the conflicting evidence of the scope of this project, raises concern as to East Pasco's projections regarding revenue, expenses, staffing, and the actual services to be made available in the Subdistrict. The lack of clarity as to East Pasco's proposal is a compelling reason to deny East Pasco's application. East Pasco's occupancy rate is quite high. It is higher even during the "peak season," i.e., November through April. The projections contained in East Pasco's application are based upon the historic high occupancy rate experienced at East Pasco. Those projections, however, do not take into account, nor did the Agency consider in reviewing East Pasco's application, the fact that East Pasco now has more than the 85 beds which formed the basis for its historic occupancy rate and its projections related to this project. Construction has been completed on the 10-bed observation unit and the 11-bed SNU. East Pasco already has an expanded capacity in place which should alleviate some of its occupancy problems. For example, East Pasco has experienced an increased number of out-patient observation days. With its new observation unit, the beds previously used for observation days are now available for in-patients which, in turn, will likely alleviate East Pasco's most common capacity problem-the lack of available ICU beds. Similarly, the SNU beds will also be available for in-patients.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is, RECOMMENDED that a Final Order be entered denying East Pasco's application for Certificate of Need No. 6783. DONE and ENTERED this 9th day of February, 1993, at Tallahassee, Florida. LINDA M. RIGOT Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 9th day of February, 1993. APPENDIX TO RECOMMENDED ORDER DOAH CASE NO. 92-1497 Petitioner's proposed findings of fact numbered 1-32, 34-82, and 84-96 have been adopted either verbatim or in substance in this Recommended Order. Petitioner's proposed finding of fact numbered 83 has been rejected as being unnecessary for determination of the issues herein. Petitioner's proposed findings of fact numbered 33 and 97 have been rejected as not constituting findings of fact but rather as constituting recitation of the testimony, argument of counsel, or conclusions of law. The Agency's proposed findings of fact numbered 2-6, 8, 13, 14, 27, 28, 31-33, 37, 40, 41, 43, 44, 47, 49, 51, and 90 have been adopted either verbatim or in substance in this Recommended Order. The Agency's proposed findings of fact numbered 20, 21, 34, 45, 52, 54, 56-58, 68, 71, 73, 82, and 89 have been rejected as being unnecessary for determination of the issues herein. The Agency's proposed finding of fact numbered 1 has been rejected as not constituting a finding of fact but rather as constituting recitation of the testimony, argument of counsel, or a conclusion of law. The Agency's proposed findings of fact numbered 7, 9, 19, 26, 48, 59, 61, 62, and 64 have been rejected as being irrelevant to the issues under consideration herein. The Agency's proposed finding of fact numbered 46 has been rejected as being subordinate to the issues involved in this proceeding. The Agency's proposed findings of fact numbered 10-12, 15-18, 22-25, 29, 30, 35, 36, 38, 39, 42, 50, 53, 55, 60, 63, 65-67, 69, 70, 72, 74-81, 83-88, and 91-93 have been rejected as not being supported by the weight of the credible, competent evidence in this cause. East Pasco's proposed findings of fact numbered 1-3, 5-7, 10, 13, 16- 18, 20, 22-24, 37, 38, 40, 45, 46, 48, 62, 63, 66-69, 73, 78, 79, 81, 82, 85, 89, 118, 119, 131, 135, 140, 174, 178-180, and 192 have been adopted either verbatim or in substance in this Recommended Order. East Pasco's proposed findings of fact numbered 15, 25, 26, 55, 56, 70, 83, 90, 92, 94, 95, 100, 121, 127-129, 145, 146, 163, 164, 171-173, 176, 177, 184-189, 191, and 194 have been rejected as being unnecessary for determination of the issues herein. East Pasco's proposed findings of fact numbered 19, 87, and 88 have been rejected as not constituting findings of fact but rather as constituting recitation of the testimony, argument of counsel, or conclusions of law. East Pasco's proposed findings of fact numbered 4, 8, 9, 11, 12, 14, 21, 30, 31, 33-36, 39, 41, 51, 61, 86, 96-98, 102, 103, 105, and 154 have been rejected as being irrelevant to the issues under consideration herein. East Pasco's proposed finding of fact numbered 84 has been rejected as being subordinate to the issues involved in this proceeding. East Pasco's proposed findings of fact numbered 27-29, 32, 42-44, 47, 49, 50, 52-54, 57-60, 64, 65, 71, 72, 74-77, 80, 91, 93, 99, 101, 104, 106-117, 120, 122-126, 130, 132-134, 136-139, 141-144, 147-153, 155-162, 165-170, 175, 181-183, 190, and 193 have been rejected as not being supported by the weight of the credible, competent evidence in this cause. COPIES FURNISHED: Edward G. Labrador, Esquire Agency for Health Care Administration 2727 Mahan Drive, Suite 103 Tallahassee, Florida 32308 James C. Hauser, Esquire Messer, Vickers, Caparello, Madsen, Lewis, Goldman & Metz Post Office Box 1876 Tallahassee, Florida 32302-1876 Darrell White, Esquire William Wiley, Esquire McFarlain, Wiley, Cassedy & Jones 215 South Monroe Street Suite 600 Tallahassee, Florida 32301 Sam Power, Agency Clerk Agency for Health Care Administration The Atrium, Suite 301 325 John Knox Road Tallahassee, Florida 32303
The Issue Whether Petitioner was overpaid for those Medicaid claims which, according to the post-hearing submissions of the parties, remain in dispute.
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Jay's Medical Center Jay's Medical Center (hereinafter referred to as "JMC") is a medical clinic located in a low income area in Miami. It is staffed by three physicians, including Shelley Wolland, D.O., the clinic's Medical Director, 6/ and several support staff. In general, the community JMC serves is poorly educated and has a relatively high incidence of medical problems. Approximately 7,000 members of the community receive medical services at JMC, with anywhere from 40 to 80 patients receiving services in a single day. Many of the clinic's patients are Medicaid recipients. The Provider Agreement JMC is now, and has been since May of 1990, when it entered into a Non- Institutional Professional and Technical Medicaid Provider Agreement with the Department, authorized to provide physician services, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) services, and family planning services to its Medicaid patients eligible to receive such services. The provider agreement between JMC and the Department provided as follows: The provider agrees that services will be provided to recipients of the Florida Medicaid Program without regard to race, color, religion, national origin, or handicap. The provider agrees to keep for 5 years complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billing made under the Medicaid program and agrees to furnish the State Agency and Medicaid Fraud Control unit upon request such information regarding any payments claimed for providing these services. Access to the pertinent patient records and facilities by authorized Medicaid program representatives will be permitted upon reasonable request. All records relating to Medicaid recipients are to be held confidential as provided under 42 CFR 431.305 and 306. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, Medicaid compensable and of quality comparable to those furnished by the provider's peers, and the services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting a claim. The provider agrees to submit Medicaid claims in accordance with program policies and that payment by the program for services rendered will be based on the payment methodology in the applicable Florida Administrative Rule. The provider in executing this agreement acknowledges that he understands that payment of Florida Medicaid claims is made from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. The providers of Independent Laboratory, Portable X-Ray Services, Home Health Services, Hospice and Rural Health Clinic Services agree to furnish the Office of Licensure and Certifi- cation a completed copy of Form HCFA-1513 (Ownership and Control Interest Disclosure Statement) in accordance with 42 CFR 455.104. The providers of Prescribed Drug Services agree to bill the Medicaid program no more than usual and customary charges and on request, to provide access to usual and customary pricing information. The Department agrees to notify the provider of any major changes in Federal or State rules and regulations relating to Medicaid. Payment made by the State Agency shall constitute full payment for services rendered to recipients under the Medicaid program. This includes situations when no payment is made to physicians when Medicare coinsurance claims are adjudicated due to Medicaid's payment methodology. The only exception is in specific programs when Medicaid coinsurance is required from the recipient. The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. The agreement may be terminated upon thirty days written notice by either party. The Department may terminate this agreement in accordance with Chapter 120, F.S. This agreement becomes effective the date the signature of the authorized agent of the Office of Medicaid is affixed. The provider eligibility will be established at the latter of the date of licensure of the provider, if applicable, or ninety (90) days prior to receipt of the application. The provider shall be responsible for assuring that the signature on the claim form is appropriate for authorization. Persons authorized to submit Medicaid claims on behalf of the provider shall be limited to the provider, the provider's employees or authorized agent. Handbook Provisions Among the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement was the Medicaid Physician Provider Handbook (hereinafter referred to as the "MPP Handbook"). Chapter 10 of the MPP Handbook addressed the subject of "provider participation." Section 10.9 of this chapter provided as follows: RECORD KEEPING You must retain physician records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, treatment plans, prior authorization information, any third party claim information, x-rays, fiscal records, and copies of sterilization and hysterectomy consents. Medical records must contain the extent of services provided. The following is a list of minimum requirements: history, physical examination, chief complaint on each visit, diagnostic tests and results, diagnosis, a dated, signed physician order for each service rendered, treatment plan, including prescriptions for medications, supplies, scheduling frequency for follow-up or other services, signature of physician on each visit, date of service, anesthesia records, surgery records, copies of hospital and/or emergency records that fully disclose services, and referrals to other services. If time is a part of the procedure code prescription being billed, then duration of visit shown by begin time and end time must be included in the record. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the MPP Handbook addressed the subject of "covered services and limitations." Section 11.1 of this chapter provided as follows: INTRODUCTION The physician services program pays for services performed by a licensed physician or osteopath within the scope of the practice of medicine or osteopathy as defined by state law. The services of this program must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient. Delivery of the services in this manual must be done by or under the personal supervision of a physician or osteopath at any place of service. Personal supervision is defined as the physician being in the building when the service was rendered. The physician must sign and date the medical record either on the date of service or within 24 hours. Each service type listed has special policy requirements that apply specifically to it. These must be adhered to for payment. HCPCS CODES and ICD-9-CM CODES Procedure codes listed in Chapter 12 are HCPCS (Health Care Financing Administration Common Procedure Coding System) codes. These are based on the Physician's Current Procedural Terminology, Fourth Edition. Determine which procedure describes the service rendered and enter that code and description on your claim form. HCPCS codes described as "unlisted" are used when there is no procedure among those listed that describes the service rendered. Physician's Current Procedural Terminology, Fourth Edition, Copyright 1977, 1980, 1981, 1982, 1983, 1984, 1985, 1986, 1987 by the American Medical Association (CPT-4) is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. The Health Care Financing Administration Common Procedure Coding System (HCPCS) includes CPT-4 descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials contained in CPT-4 which are copyrighted by the American Medical Association. The Diagnosis Codes to be used are found in the International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM). A diagnosis code is required on all physician claims. Use the most specific code available. Fourth and fifth digits are required when available. There are six levels of service associated with the visit procedure codes. They require varying skills, effort, responsibility, and medical knowledge to complete the examination, evaluation, diagnosis, treatment and conference with the recipient about his illness or promotion of optimal health. These levels are: . Minimal is a level of service supervised by a physician. . Brief is a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and exam. . Limited is a level of service used to evaluate a circumscribed acute illness or to periodically reevaluate a problem including a history and examination, review of effectiveness of past medical management, the ordering and evaluation of appropriate diagnostic tests, the adjustments of therapeutic management as indicated and discus- sion of findings. . Intermediate level of service pertains to the evaluation of a new or existing condition compli- cated with a new diagnostic or management problem, not necessarily related to the primary diagnosis, that necessitates the obtaining of pertinent history and physical or mental status findings, diagnostic tests and procedures, and ordering appropriate therapeutic management; or a formal patient, family or a hospital staff conference regarding the patient's medical management and progress. . Extended level of service requires an unusual amount of effort or judgment including a detailed history, review of medical records, examination, and a formal conference with the patient, family, or staff; or a comparable medical diagnostic and/or therapeutic service. . Comprehensive level of service provides for an in-depth evaluation of a patient with a new or existing problem requiring the development or complete reevaluation of medical data. This service includes the recording of a chief complaint, present illness, family history, past medical history, personal review, system review, complete physical examination, and ordering appropriate tests and procedures. 7/ Section 11.2 of Chapter 11 of the MPP Handbook provided in part, that "[t]reatment of an illness found by a physician during an EPSDT screening that requires considerable office time (30 minutes or more) to treat, may also be billed as an office visit on the appropriate claim form." Another of the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement between JMC and the Department was the Medicaid EPSDT Provider Handbook (hereinafter referred to as the "EPSDT Handbook"). Chapter 10 of the EPSDT Handbook addressed the subject of "provider participation." Section 10.8 of this chapter provided as follows: RECORD KEEPING You must retain EPSDT records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, Treatment plans, Prior authorization information, Any third party claim information, X-rays, Fiscal records, and Copies of sterilization and hysterectomy consents. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the EPSDT Handbook addressed the subject of "covered services and limitations." Sections 11.3 and 11.5 of this chapter provided that the components of an EPSDT preventive health screening examination were: a health and developmental history; unclothed physical assessment or examination; nutritional assessment; updating of routine immunizations, "as indicated by the recipient's age, health history, or population group;" laboratory tests, "as indicated by the recipient's age, health history, or population group;" development assessment, vision, hearing and dental screening; and health education. Section 11.7 of Chapter 11 provided, in part, as follows: Under federal regulations the state must provide for medically necessary treatment services diagnosed as a result of screening. Once the EPSDT recipient is screened and referred for treatment, any further diagnosis and/or treatment is then provided through the individual treatment service program. For example, if an EPSDT recipient is found to have an abnormal laboratory test result, such as tuber- culin (TB) skin test, any further referral, diagnosis and treatment is considered diagnostic treatment under physician services. Billing for a treatment visit at the time of a screening visit is only allowed when the illness is discovered during the screening examination. This treatment visit must be at least 30 minutes or more. Treatment visits completed in conjunction with a screening visit must be billed on the HFCA-1500 and the fact that the visit is screening related must be noted on the claim form. Treatment procedure codes should be related to screening results as noted on the EPSDT 221 claim form. An EPSDT screening should not routinely be completed on an obviously ill child, as the illness may distort the screening results. Sound professional judgment should be exercised in determining the appropriate- ness of screening an ill child. If screening results are questionable, treatment should be provided and the screening appointment rescheduled. If, however, an illness is detected during a screening examination, the screening may be completed and treatment provided on the same date, billing the treatment on the appropriate Medicaid claim form. Billing for treat- ment on the same day as the screening evaluation should be done only when a detected illness or condition requires significant time and procedures in addition to the time usually spent for a screening evaluation. The Audit Commencing in 1992, the Department conducted an audit of Medicaid claims submitted by JMC for services rendered from July 1, 1990, through December 31, 1991. During the course of the audit, the Department examined the files of 40 patients (Patients 1 through 19 and 21 through 41, hereinafter also referred to by their initials) who had received services during the audit period. Patient 1 (S.M.) January 16, 1991, Visit On January 16, 1991, S.M. presented at the clinic complaining of a sore throat and fever. The attending physician determined that S.M. had an upper respiratory tract infection, as well as vaginitis. Treatment was provided. JMC billed this as a "comprehensive" visit (procedure code 90020) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one (procedure code 90060), as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 29, 1991, Visit S.M. next visited the clinic on January 29, 1991. JMC billed this visit as a "limited" one (procedure code 90050) and payment was made accordingly. Respondent does not dispute the appropriateness of such billing and payment. 8/ April 23, 1991, Visit On April 23, 1991, S.M. presented at the clinic complaining of blood in her urine. She further indicated that she had recently had a Pap smear test, the results of which reflected a possible precancerous condition. A pregnancy test revealed that S.M. was pregnant. She was also diagnosed as having an upper respiratory tract infection, for which she was treated. A gynecological referral was made. JMC billed this visit as a "extended" one (procedure code 90070) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 9, 1991, Visit and Streptococcal Test S.M. visited the clinic again on October 9, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. It also sought and obtained separate payment for a streptococcal (hereinafter referred to as "strep") test (procedure code 86317) given during the visit. Both parties are now in agreement that the billing and payment for the strep test was appropriate 9/ and that the office visit should have been billed and paid, not as an "extended" visit, but as an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. November 6, 1991, Visit Cerumen Removal and Strep Test On November 6, 1991, S.M. presented at the clinic complaining of sinus problems and pustules on her nose. She was diagnosed as having folliculitis, pharyngitis and sinusitis. Treatment was provided. JMC billed this visit as a "extended" one and payment was made accordingly. It also sought and obtained separate payment for impacted cerumen removal (procedure code 69210) and a strep test. The parties are in agreement that the billings and payments for the impacted cerumen removal and strep test were appropriate. 10/ A dispute still exists, however, as to the appropriateness of JMC billing and receiving payment for an "extended" visit. JMC's medical records pertaining to the visit, to the extent that they are legible, document that the visit was not an "extended" visit, but was merely an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. Moreover, these records were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. 11/ Accordingly, JMC should not have received any payment for this office visit. Patient 2 (O.R.) October 7, 1991, Billings JMC billed and was paid for a "comprehensive" visit and other services (procedure codes 86317, 94010 and 94664) it claimed it rendered Patient 2, O.R., on October 7, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that, on that date, O.R. was seen at the clinic by a physician or that she received the other billed for services. Accordingly, payment should not have been made to Petitioner for an office visit of any type or for any of the other services Petitioner claimed it rendered O.R. on October 7, 1991. October 22, 1991, Visit On October 22, 1991, O.R. presented at the clinic with a fever, sore throat and high blood pressure. In addition, she complained that she was wheezing, suffering from headaches and had a runny nose. At the time of the visit, O.R. was five feet, two inches tall and weighed 206 pounds. The attending physician determined that O.R. was suffering from asthma. Using a nebulizer, he treated her with Ventolin. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit, Routine Venipuncture and Therapeutic Injection O.R. returned to the clinic two days later, on October 24, 1991, with respiratory problems. She was coughing and wheezing severely. Her throat was red. The attending physician determined that O.R. had pharyngitis, pneumonia and severe asthma. Treatment was provided. Medications were prescribed and oral instructions regarding medication administration and compliance were given. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC also sought and obtained separate payment for a routine venipuncture (procedure code 36415) and a therapeutic injection for asthma (procedure code 90782). The parties are in agreement that the routine venipuncture was appropriately billed and paid. The appropriateness of the billing and payment for a therapeutic injection, however, is still in dispute. JMC's medical records, to the extent that they are legible, do not document that O.R. was given the billed and paid-for therapeutic injection on October 24, 1991. Accordingly, it should not have been paid for this service. Patient 3 (T.F.) January 31, 1991, Visit On January 31, 1991, Patient 3, T.F., a ten-year old girl who had already begun menstruating, presented at the clinic with complaints of vomiting for the past two days, as well as cramps and abdominal pain. She further indicated that she had had her last menstrual period two weeks previous. A physical examination, which included the genital and rectal areas, was conducted, a history was taken and a strep test was given. The results of the strep test were positive. The attending physician determined that T.F. had strep throat, for which she received treatment. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 19, 1991, Visit On September 19, 1991, T.F. presented at the clinic complaining of a high fever and a sore throat. She further indicated that she had vomited earlier in the morning. A physical examination, which did not include the genital area, was conducted, an updated history was taken and a strep test was given. The attending physician determined that T.F. had tonsillitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 4 (K.W.) October 3, 1991, Visit On October 3, 1991, Patient 4, K.W., presented at the clinic. He had lower back pain, an upper respiratory tract infection, trauma to his right ankle and folliculitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 4, 1991, Billings JMC billed and was paid for an "extended" visit and another service (procedure code 86317) it claimed it rendered K.W. on November 4, 1991, but the medical records maintained by JMC do not contain legible, physician-signed and dated documentation substantiating that, on that date, K.W. was seen at the clinic by a physician or that he received the other billed-for service. Accordingly, payment should not have been made to Petitioner for any type of office visit or for the other service Petitioner claimed it rendered K.W. on November 4, 1991. Patient 5 (S.W.) October 19, 1990, Visit JMC billed and was paid for a "comprehensive" office visit, in addition to an EPSDT screen (procedure code W9881), for services rendered to Patient 5, S.W., on October 19, 1990. The parties are in agreement that the EPSDT screen was appropriately billed and paid. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. The medical records maintained by JMC do not contain legible, physician-signed and dated documentation justifying JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. October 29, 1990, Visit S.W. again visited the clinic on October 29, 1990. This was a follow- up visit. She had been to the clinic four days previous with a high fever and complaining of a headache, stuffiness and a cough. JMC billed S.W.'s October 29, 1990, visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 14, 1991, Visit On May 14, 1991, S.W. presented at the clinic complaining of a cough. She was diagnosed as having an upper respiratory tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit Two weeks later, on May 29, 1991, S.W. returned to the clinic for a follow-up visit. She was still coughing. Tests taken before the visit revealed that, in addition to her respiratory problems, S.W. was suffering from iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 12, 1991, Visit On June 12, 1991, S.W. paid another follow-up visit to the clinic. During the visit, she admitted that she had not taken her medication "properly." A spirometry test taken before the visit revealed "severe obstruction." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 6 (B.F.) July 12, 1990, Visit On July 12, 1990, Patient 6, B.F., a 32-year old woman, presented at the clinic complaining of chest palpitations and abdominal pain. A physical examination, which included an examination of the vaginal and pelvic areas, was conducted, a history was taken, tests were ordered and treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, a "comprehensive" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. January 14, 1991, Visit B.F. visited the clinic on January 14, 1991, complaining of lower abdominal discomfort, which, she claimed, she had been experiencing for the past two weeks. The attending physician determined that, in addition to the abdominal discomfort B.F. was experiencing, she also had vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 28, 1991, Visit On January 28, 1991, B.F. presented at the clinic complaining of general malaise and a cough that she claimed she had had for four or five days. The attending physician determined that B.F. was suffering from acute bronchitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 24, 1991, Visit On April 24, 1991, B.F. presented at the clinic complaining of chest pain, headaches and dizziness she had been experiencing for several days. She also had shortness of breath. A physical examination, which included an examination of the genital and rectal areas, was conducted, an updated history was taken and tests were ordered. The chest pain was determined to be non-cardiac in nature. It was thought to be caused by a tender rib. Medication was prescribed to combat B.F.'s headaches and dizziness. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, B.F. paid a followup visit to the clinic. She reported that she was still experiencing dizziness, but no longer had any chest pain or headaches. She further advised that she was unable to tolerate the medication that had been prescribed on the previous visit. A rhythm strip test was administered. A new medication was prescribed to combat B.F.'s dizziness. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 7 (C.C.) July 23, 1991, Visit On July 23, 1991, Patient 7, C.C., visited the clinic for the removal of a lesion from her nose by electrodesiccation. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 8 (L.F.) October 21, 1991, Visit On October 21, 1991, Patient 8, L.F., presented at the clinic complaining of a skin rash. The attending physician determined that L.F. was suffering from impetigo, as well as bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 9 (L.A.) November 26, 1990, Visit On November 26, 1990, Patient 9, L.A., presented at the clinic complaining of chest pain. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that such billing and payment was appropriate and thus JMC was not overpaid for this visit. March 28, 1991, Visit On March 28, 1991, L.A. presented at the clinic complaining of chest and abdominal pain. 152. The attending physician determined that the chest pain was non- cardiac in nature and that L.A. was suffering from gastritis. 153. Medication was prescribed. 154. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 6, 1991, Visit On May 6, 1991, L.A. visited the clinic to obtain birth control pills. JMC billed this visit as an "extended" one. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 17, 1991, Visit On June 17, 1991, L.A. presented to the clinic complaining of a sore throat and back pain. The latter ailment was the result of her having been hit in the back with a chair that was thrown at her at work. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 8, 1991, Debridement On August 8, 1991, L.A. presented to the clinic complaining of a gash on her left leg that she had received the night before, as well as a headache and continuing back pain. The leg wound was cleaned. Necrotic tissue around the edge of the wound was removed. JMC billed for a debridement (procedure code 11042) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC. JMC was therefore appropriately paid for this procedure. September 27, 1991, Visit On September 27, 1991, L.A. presented at the clinic complaining of diarrhea, a cold and postnasal drip. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 28, 1991, Visit On October 28, 1991, L.A. presented to the clinic complaining of a sore throat. She further indicated that she had been exposed to the flu. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 10 (B.W.) February 26, 1991, Visit and EPSDT Screen On February 26, 1991, Patient 10, B.W., who was then twelve years old, presented at the clinic for an EPSDT screen. complaining of an abscess behind her ear and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 12/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. March 1, 1991, Billing JMC billed and was paid for services rendered B.W. during an "intermediate" office visit it claimed took place on March 1, 1991, but the physician signed-medical records maintained by JMC, to the extent that they are legible, do not document that B.W. was seen that day at the clinic by a physician. Payment for such an office visit therefore should not have been made. March 13, 1991, Visit On March 13, 1991, B.W. presented at the clinic with multiple, yet relatively uncomplicated, medical problems, including iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. June 24, 1991, Visit On June 24, 1991, B.W. presented at the clinic complaining of a skin rash. She also had a slightly elevated temperature. The attending physician determined that B.W had dermatitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 27, 1991 Visit Three days later, on June 27, 1991, B.W. again visited the clinic. This time she had an abscess in the area of her left armpit. The abscess was drained. JMC billed this visit as an "extended" one and payment was made accordingly. 13/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit and EPSDT Screen On October 18, 1991, B.W. presented at the clinic for an EPSDT screen complaining of an abscess in the area of her right armpit and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 14/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 11 (T.M.) October 30, 1990, Visit On October 30, 1990, Patient 11, T.M., who was then six years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, a wart was discovered on T.M.'s left wrist. The wart was removed. The procedure took approximately 15 minutes. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 15/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. May 9, 1991, Visit T.M. presented at the clinic on May 9, 1991, with an elevated temperature. The attending physician determined that he had an upper respiratory tract infection. Medication was prescribed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 12 (D.W.) November 30, 1990, Visit On November 30, 1990, Patient 11, D.W., who was then three months old, presented at the clinic for an EPSDT screen. He had a stuffy nose. The screen was performed. The physician performing the screen determined that D.W. was suffering from an upper respiratory tract infection and otitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 14, 1990, Visit On December 14, 1990, D.W. presented at the clinic. His mother reported that D.W. had a persistent cough. D.W. was given a strep test, the results of which were negative. The attending physician determined that D.W. still had an upper respiratory tract infection and otitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 17 and 27, 1990, Visits D.W. visited the clinic on December 17, 1990, and again on December 27, 1990. JMC billed these visits as "intermediate" ones and payments were made accordingly. The parties agree that these billings and payments were appropriate. January 21, 1991, Visit On January 21, 1991, D.W. returned to the clinic with his mother. He had a fever of 102 degrees Fahrenheit, which, his mother reported, he had had for the past four days. Following an examination and a strep test, the attending physician determined that D.W. had a strep throat and an ear infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 7, 1991, Visit On June 7, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was discovered that D.W had an ear problem, for which he received treatment. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office on this date. June 21, 1991, Visit 254. D.W. returned to the clinic on June 21, 1991, with an ear infection and a rash behind his right ear. 255. Treatment was provided. 256. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. July 23, 1991, Visit On July 23, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that D.W. was suffering from diaper rash. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 13 (J.H.) December 29, 1990, Visit and EPSDT Screen On December 29, 1990, J.H., who was then three years of age, presented at the clinic for an EPSDT screen. She was suffering from constipation. During the screen, the attending physician determined that J.H. also had vaginitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, there is no indication that J.H.'s teeth and gums were examined during the visit. Accordingly, JMC was not entitled to receive any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 4, 1991, Visit On January 4, 1991, J.H. presented at the clinic. She looked ill and had glassy eyes. It was reported that her temperature (taken with a rectal thermometer) had reached 104 degrees Fahrenheit at home. When her temperature was taken (again rectally) at the clinic, however, it was only 99.2 degrees Fahrenheit. The attending physician determined that J.H. had a urinary tract infection and pharyngitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 14 (J.Y.) April 20, 1991, Visit On April 20, 1991, Patient 14, J.Y., a 25-year old woman suffering from obesity and hypertension, presented at the clinic to obtain a refill of medication that she had been given on a previous visit. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 15 (K.C.) September 20, 1991, Visit On September 20, 1991, Patient 15, K.C., who was then four years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that K.C. was suffering from an upper respiratory ailment. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "intermediate" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "intermediate" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 16 (D.W.) December 17, 1991, Visit On December 17, 1991, Patient 16, D.W., who was then eight years of age, presented to the clinic for an EPSDT screen. During the screen, the attending physician determined that D.W. was suffering from dermatitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks adequate supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 17 (R.G.) There are no issues in dispute concerning any billings and payments made in connection with services JMC rendered to Patient 17, R.G. Patient 18 (C.F.) February 12, 1991, Visit On February 12, 1991, C.F., a 25-year old woman, presented at the clinic complaining of profuse menstrual bleeding. The attending physician determined that C.F. was simply having irregular menstrual periods and that medical intervention was not warranted. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 18, 1991, Visit On November 18, 1991, C.F. returned to the clinic. She still had irregular menstrual periods and, in addition, she complained of a heavy discharge of breast milk from both of her breasts. Tests were ordered. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991, Visit On December 9, 1991, C.F. again visited the clinic. This time she had an upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 19 (J.R.) September 17, 1990, Visit On September 17, 1990, Patient 19, J.R., who was then six months old, visited the clinic. 16/ He had, what his mother described as, a "bad cold." The attending physician determined that J.R. had an upper respiratory tract infection and bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 31, 1991, Visit On January 31, 1991, J.R. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that J.R. was suffering from a rash, a mild upper respiratory ailment, and a sore throat. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "extended" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. February 26, 1991, Visit On February 26, 1991, J.R. again visited the clinic. He had an ear infection and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, J.R. paid another visit to the clinic. Diaper rash was still a problem. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit J.R. returned to the clinic on May 29, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that any of JMC's staff physicians provided medically necessary services to J.R. on this date. While these records do reflect that J.R. received an abbreviated physical examination during his visit to the clinic, they do not reveal why the examination was conducted or what conclusions the attending physician reached as a result of the examination. Accordingly, JMC should not have received any payment for an office visit on this date. Patient 21 (T.M.) April 26, 1991, Visit On April 26, 1991, Patient 21, T.M., who was then five years of age, presented at the clinic for an EPSDT screen. He had sickle cell anemia, but was doing well. The screen was performed. Following the screen, the attending physician recommended that T.R. continue taking folic acid and vitamins. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 22 ( K.C.) August 28, 1990, Visit On August 28, 1990, Patient 22, K.C., who was then six months old and had recently been exposed to hepatitis B, presented at the clinic for an EPSDT screen. The screen was performed. The attending physician did not believe that K.C. had contracted hepatitis B. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 23 ( K.G.) July 10, 1990, Visit On July 10, 1990, Patient 23, K.G., presented at the clinic complaining of a vaginal discharge. The attending physician determined that K.G. was suffering from vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 15, 1990, Visit On October 15, 1990, K.G. presented at the clinic complaining of a rash in the area of her groin. The attending physician determined that K.G. had folliculitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. February 15, 1991, Visit On February 15, 1991, K.G. presented at the clinic complaining of swelling in her legs. 17/ The attending physician determined that she had pinworms. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. March 8, 1991, Visit On March 8, 1991, K.G. presented at the clinic complaining of rectal pain and a persistent cough. The attending physician determined that K.G. had pharyngitis, pneumonia and an anal fissure. Treatment, which included the use of an aerosol spray, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 18/ 372. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. June 6, 1991, Visit On June 6, 1991, K.G. visited the clinic complaining of weight gain and pain in her left side. The attending physician determined that the pain was caused by gas and prescribed medication to combat the problem. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 28, 1991, Visit On June 28, 1991, K.G. presented at the clinic complaining of a sore throat and a cough producing yellowish sputum. She claimed that she had had the sore throat for three to four days. A strep test was given, the results of which were negative. The attending physician determined that K.G. had bronchitis and pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 1, 1991, Visit On August 1, 1991, K.G. presented at the clinic. 19/ She had a pararectal abscess and a urinary tract infection. The abscess was drained. In addition, treatment was provided for the urinary tract infection. JMC billed this visit as an "extended" one and payment was made accordingly. 20/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 5, 1991, Visit On September 5, 1991, K.G. presented at the clinic. She had a cough and sore throat. A strep test was given, the results of which were negative. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 24 (L.W.) December 10, 1990, Visit On December 10, 1990, Patient 24, L.W., who was then five years of age, presented at the clinic for an EPSDT screen. The screen was performed. As part of the screen, her weight was taken. She weighed only 30 pounds. 401. Because she had a persistent cough and a runny nose, a strep test was given, the results of which were positive. 402. JMC billed for an EPSDT screen and a "comprehensive" visit. 403. The parties agree that the billing and payment for an EPSDT screen was appropriate. The billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. July 2, 1991, Visit On July 2, 1991, L.W. presented at the clinic. 21/ Her right breast was enlarged. In addition, she had pharyngitis and impacted cerumen in her ears. A strep test was given, the results of which were negative. Treatment, which included the removal of the impacted cerumen, was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 22/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 25 (R.W.) October 3, 1991, Visit On October 3, 1991, Patient 25, R.W., who was then four months old, presented at the clinic for an EPSDT screen. 23/ He had an asthmatic condition and bronchitis. The screen was performed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 24/ JMC therefore should not have received any payment for an office visit on this date. October 10, 1991, Visit On October 10, 1991, R.W. presented at the clinic for another EPSDT screen. His asthma and bronchitis were much improved. The screen was performed. No new problems were discovered. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 25/ JMC therefore should not have received any payment for an office visit on this date. October 16, 1991, Visit On October 16, 1991, R.W. returned to the clinic. His condition had worsened and he was crying in his mother's arms. In addition to the problems he had had previously, he now also had an ear infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit R.W. paid a follow-up visit to the clinic on October 24, 1991. His condition had improved since his last visit to the clinic on October 16, 1991. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that this visit, like R.W.'s prior visit to the clinic, was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 26 (E.W.) September 16, 1991, Visit On September 16, 1991, Patient 26, E.W., who was then four months old, presented at the clinic with a cold and cough. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks sufficient supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 27 (C.S.) 26/ November 4, 1991, Visit and EPSDT Screen On November 4, 1991, Patient 27, C.S., who was then seven months old, presented at the clinic. She was suffering from a cold. Treatment was provided. JMC billed for an EPSDT screen and an "extended" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, these records contain no nutritional or developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not an "extended" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 28 (S.S.) 27/ May 15, 1991, Visit On May 15, 1991, Patient 28, S.S., presented at the clinic complaining of keloid skin masses on both of her ears which, she indicated, she wanted removed. JMC billed this visit as a "comprehensive" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as an "intermediate" one and that therefore JMC was overpaid for this visit. May 29, 1991, Visit On May 29, 1991, S.S. returned to the clinic for evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on May 29, 1991. June 12, 1991, Visit On June 12, 1991, S.S. paid another visit to the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on June 12, 1991. July 10, 1991, Visit On July 10, 1991, S.S. again visited the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on July 10, 1991. August 7, 1991, Visit S.S. went back to the clinic on August 7, 1991, for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 12, 1991, Visit On September 12, 1991, S.S. presented at the clinic for additional evaluation and treatment of her keloids, which were scheduled to be removed the following day. She also had a sore throat. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 19, 1991, Visit Only one of the keloids, the one on her left ear, was removed on September 13, 1991. Six days later, on September 19, 1991, S.S. visited the clinic for a postsurgical examination and to discuss the removal of the keloid on her right ear. She presented at the clinic with a sore throat and earache. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 26, 1991, Visit S.S. returned to the clinic on September 26, 1991. She had an abscess on her ear. The abscess was incised and drained. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 28/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Debridement On October 7, 1991, S.S. presented at the clinic complaining of continuing skin problems on and behind her ears. An abscess and "raggedy" skin were discovered. The abscess was incised and drained and the "raggedy" skin was removed. JMC billed and was paid for a debridement. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC, and that therefore JMC was entitled to the payment it received for the debridement. Patient 29 (T.J.) January 28, 1991, Visit On January 28, 1991, Patient 29, T.J., who was then one month old, was seen at the clinic. She had congenitally deformed ("toe[d] in") feet, multiple insect bites and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 30, 1991, Visit T.J. returned to the clinic two days later. She had been vomiting for the past two days. In addition, she had a sore throat and an earache. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 22, 1991, Visit On April 22, 1991, T.J. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was determined that T.J. had dermatitis caused by insect bites. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 24, 1991, Visit On April 24, 1991, T.J. again visited the clinic. Her dermatitis was still causing her some discomfort. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 30 (G.D.) March 11, 1991, Visit On March 11, 1991, Patient 30, G.D., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed that G.D. had upper respiratory problems, as well as an umbilical hernia. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 22, 1991, Visit G.D. was next seen at the clinic on April 22, 1991. He had pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 3, 1991, Visit G.D. next visited the clinic on June 3, 1991. He had a mild upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 31 (H.C.) October 15, 1990, Visit On October 15, 1990, H.C., who was then 18 years old, presented at the clinic complaining of delayed menstruation. She was given a pregnancy test, the results of which revealed that she was pregnant. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 32 (R.M.) February 12, 1991, Visit On February 12, 1991, Patient 32, R.M., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in R.M.'s ears. The impacted cerumen was removed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 29/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 33 (C.W.) December 3, 1990, Visit On December 3, 1990, Patient 33, C.W., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in C.W.'s ears and that R.M. had pharyngitis. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 30/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. August 22, 1991, Visit 534. On August 22, 1991, C.W. presented at the clinic complaining of a headache. 535. The attending physician determined that C.W. had pharyngitis. 536. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Visit On October 7, 1991, C.W. again visited the clinic. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed and paid for as a "limited" one, as described in Chapter 11 of the MPP Handbook. October 10, 1991, Visit Three days later, on October 10, 1991, C.W. returned to the clinic. She had tonsillitis, pharyngitis and an upper respiratory infection. Her temperature was 103.4 degrees Fahrenheit. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 34 (K.K.) September 19, 1990, Visit On September 19, 1990, Patient 34, K.K., who was then three years old, presented at the clinic for an EPSDT screen. He had a runny nose and a cough. His mother also complained that he was hyperactive. 549. The screen was performed. 550. The screen revealed that K.K. had impacted cerumen in his ears. 551. provided. Treatment, including the removal of the impacted cerumen, was 552. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 31/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 17, 1990, Visit On or about December 17, 1990, K.K. returned to the clinic. He had dermatitis, as well as impacted cerumen in his ears. In addition, his mother was concerned about his behavior. Treatment, including the removal of the impacted cerumen, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 32/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 3, 1991, Visit On January 3, 1991, K.K. returned to the clinic for a physical examination for school. During the visit, his mother complained that K.K.'s appetite for food had decreased. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 35 (T.B.) November 15, 1990, Visit On November 15, 1990, Patient 35, T.B., presented at the clinic for a physical examination for work. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 20, 1990, Visit T.B. returned to the clinic on December 20, 1990, complaining that she was not feeling well. During the visit, impacted cerumen was removed from her ears. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 33/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. July 18, 1991, Visit On July 18, 1991, T.B. went to the clinic to obtain "medical certificates." A routine physical examination was performed, but no history was taken. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 4, 1991, Visit On December 4, 1991, T.B. presented at the clinic with "pink eye." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 36 (D.W.) January 2, 1991, Visit On January 2, 1991, Patient 36, D.W., who was then 19 years of age, visited the clinic for a checkup. The attending physician determined that D.W. had an iron deficiency and anemia, for which treatment was provided. During the visit, family planning issues were also addressed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit On April 17, 1991, D.W. presented at the clinic complaining that she had been feeling ill for two days. 34/ 592. A strep test was given, the results of which were negative. The attending physician determined that D.W had tonsillitis and was still suffering from anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 16, 1991, Visit On September 16, 1991, D.W. presented at the clinic. She had a sore throat and vaginitis. 35/ In addition, she was now pregnant and still anemic. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. 601. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 17, 1991, Visit On October 17, 1991, D.W., who was still pregnant at the time, made a follow-up visit to the clinic. She complained of shortness of breath and tightness in her chest, as well as a sore throat. A fetal examination was conducted. A strep test was given, the results of which were negative. The attending physician determined that D.W. had a urinary tract infection, sinusitis, pharyngitis and anemia. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 14, 1991, Visit and Echography D.W. returned to the clinic on November 14, 1991. She was in approximately the thirty-second week of her pregnancy and she was still suffering from a urinary tract infection and anemia. Her sinus condition was improving. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. It also sought and received separate payment for an echography (procedure code 76855). The parties now agree that JMC should not have been paid for an echography. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 3, 1991, Visit A still-pregnant D.W. visited the clinic again on December 3, 1991, complaining of shortness of breath. The attending physician determined that she was still suffering from a urinary tract infection and anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 10, 1991, Visit A week later, on December 10, 1991, with her anticipated date of delivery approaching, D.W. returned to the clinic complaining of vaginal irritation and pain in her left wrist. Her urinary tract infection was improving. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 37 (E.A.) September 27, 1991, Visit On September 27, 1991, Patient 37, E.A., who was then seven weeks old, presented at the clinic with an upper respiratory infection, pharyngitis and thrush. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit E.A. returned to the clinic on October 18, 1991, for an EPSDT screen. 633. The screen was performed. The screen revealed that he still had an upper respiratory infection and thrush. Treatment was provided. JMC billed for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. November 20, 1991, Visit E.A. visited the clinic again on November 20, 1991. He had a bad cough and a green discharge from his eyes and nose. The attending physician determined that E.A. had an upper respiratory infection and pharyngitis, as well as a "foreign body" in his nose. Treatment, including the removal of the "foreign body," was provided. 36/ JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore entitled to the payment it received for this visit. November 21, 1991, Incision and Removal JMC billed and was paid for an incision and removal of a "foreign body" (procedure code 10120) it claimed had been performed on E.A. at the clinic on November 21, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that E.A. received an incision and removal at the clinic on this date. Accordingly, payment should not have been made to JMC for this billed-for service. Patient 38 (O.S.) December 2, 1991, Visit and EPSDT Screen On December 2, 1991, Patient 38, O.S., who was then three months old, presented at the clinic for an EPSDT screen. She had a cold and blotches all over her body and her hair was falling out. The screen revealed that O.S. had tinea capitis, otodynia, and pharyngitis, as well as impacted cerumen in her ears. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 37/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete EPSDT screen was performed. For example, these records contain no developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991 O.S. returned to the clinic a week later on December 9, 1991. She had a new rash on her left arm. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 39 (T.G.) September 5, 1991, Visit On September 5, 1991, Patient 39, T.G., who was then three months old, presented at the clinic for an EPSDT screen. She had a stuffy nose and was crying. According to his mother, he had been crying for the past 12 hours. The screen was performed. A strep test was given, the results of which were negative. The attending physician determined that T.G. had an ear infection, an upper respiratory tract infection and phayrngitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, justify JMC billing and receiving payment for, in addition to an EPSDT screen, only an "intermediate" office visit and not a "comprehensive" one. JMC was therefore overpaid for this visit. September 19, 1991, Visit T.G. returned to the clinic for a follow-up visit on September 19, 1991. He had diaper rash. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 40 (T.B.) November 26, 1991, Visit On November 26, 1991, T.B., a 62-year old man with a history of heart disease, hypertension and stroke, presented at the clinic with a periorbital abscess. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. 38/ JMC was therefore overpaid for this visit. November 29, 1991, Visit Three days later, on November 29, 1991, T.B. returned to the clinic again complaining about the abscess. The attending physician reevaluated the problem and referred T.B. to Jackson Memorial Hospital for treatment. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 41 (L.B.) January 25, 1991, Visit On January 25, 1991, Patient 41, L.B., who was then 19 years of age and had history of mental illness, presented at the clinic stating that she was pregnant and complaining, among other things, of abdominal pain. She appeared to be confused and it was difficult to obtain an accurate history from her. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit L.B. returned to the clinic on April 17, 1991, complaining of continuing abdominal pain, vaginal discharge, breast tenderness and nausea. The attending physician determined that L.B. had vaginitis and a urinary tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 25, 1991, Visit L.B. visited the clinic again on November 25, 1991. On this visit she complained of a rash. The attending physician determined that L.B. had dermatitis. 694. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 6, 1991, Visit On December 6, 1991, L.B. presented at the clinic claiming that there were things crawling on her scalp. The attending physician determined that L.B. was demented. He filled out a Social Security Administration form indicating that it was his opinion that L.B. was "not medically competent." JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. Simple Mistake or Fraud? There has been no allegation made, nor proof submitted, that any of the overbillings referenced above were the product of anything other than simple mistake or inadvertence.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration adopt the findings made by the Hearing Officer regarding the sampled claims remaining in dispute in the instant case and use these findings to redetermine the total amount of Medicaid overpayments made to Petitioner during the audit period and the amount of the fine Petitioner should be required to pay for its erroneous billings during this period of time. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd of May, 1995. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of May, 1995.
The Issue Whether Respondent should recoup Medicaid payments made to Petitioner for health care services provided to eight patients.
Findings Of Fact Petitioner, Indian River Memorial Hospital, Inc., (Hospital), has contracted with Respondent, Agency for Health Care Administration (AHCA), to provide services to Medicaid patients. The parties have agreed that there is a dispute for Medicaid reimbursement for goods and services provided to eight patients: S.G., J.D., R.J., C.A., G.M., S.S., M.P., and C.T. The Agency has paid the Hospital for the services rendered to these eight patients and seeks to recoup the payment based on a retrospective review by a peer review organization, Keystone Peer Review Organization (KePro). The Agency claims that either the admission or a portion of the length-of-stay for the eight patients was medically unnecessary. Services were provided to C.T. in 1994 and to the remainder of the patients at issue in 1995. Payment for Medicaid services is on a per diem basis. The rate for 1994 is $473.22 per day, and the rate for 1995 is $752.14. The Agency contracted with KePro to do a review of the Medicaid payments to the Hospital. KePro employs nurses to review the patient files based on criteria on discharge screens. If the services meet the criteria, there is no further review and the payment is approved. If the nurse determines that the services do not meet the criteria on the discharge screens, the patient's files are reviewed by a board certified physician, who in this case would be a psychiatrist. If the physician determines that the services are not medically necessary, a letter is sent to the Medicaid provider, giving the provider an opportunity to submit additional information. Additional information submitted by the provider is reviewed by a board certified physician. If the doctor concludes that the services are still medically unnecessary, the provider is notified that that services do not qualify for reimbursement and the provider may ask for a reconsideration of the denial. If the provider seeks reconsideration, the file is reviewed by a physician, and the provider has an opportunity to be present during the review. If the physician determines that the services are medically unnecessary, KePro sends a letter to the Agency stating the reasons for denial. The denial letters that KePro sends to the Agency are reviewed by the Medical Director of KePro, who is not a psychiatrist. Dr. John Sullenberger, the Agency's Medicaid physician, reviews the KePro denial letters sent to the Agency, and 99.9 percent of the time he agrees with the findings of KePro regarding whether the services were medically necessary. Dr. Sullenberger does not review the patient's charts when he does this review. The Agency sends a recoupment letter to the Medicaid provider requesting repayment for services provided. Patient S.G., a 12 year-old boy, was being treated pursuant to the Baker Act. He was admitted to the Hospital on March 8, 1995, and discharged on March 25, 1995. The Agency denied Medicaid reimbursement for the admission and the entire length-of-stay for S.G. based on KePro's determination that it was not medically necessary for the services to S.G. to be rendered in an acute care setting because the patient was neither suicidal nor homicidal. Three to five days prior to his admission to the Hospital, S.G. had attempted to stab his father. He also had further violent episodes, including jumping his father from behind and choking him and pulling knives on his parents. S.G. had a history of attention deficit and hyperactive disorder. He had been using multiple substances, such as alcohol, LSD, cocaine, and marijuana, prior to his admission. His behavior was a clear reference that he was suffering from a psychosis. A psychosis is a significant inability to understand what is reality, including delusions of false beliefs, hallucinations, hearing and seeing things which do not exist, and ways of thinking that are bizarre. Psychosis is a reason to admit a patient, particularly combined with substance abuse. S.G.'s treating psychiatrist noted that S.G. had tangentiality, which means that his thoughts did not stay together. He did not have a connection between thoughts, which is a sign of a psychosis. The chart demonstrated that S.G. had disorder thinking, which includes the possibility of a psychosis. There was also a reference in the charts to organic mental disturbance which could infer brain damage as the cause for the mental disturbance. Two days after admission, there was an issue of possible drug withdrawal because S.G. was agitated and anxious and showed other symptoms. Drug withdrawal, psychosis, and a demonstration of overt violence require a stay in an acute care facility. There was some indication that S.G. was suicidal. While in the Hospital he was placed under close observation, which is a schedule of 15-minute checks to determine if the patient was physically out of harm's way. S.G. was started on an antidepressant, Wellbutrin, because the treating physician thought S.G. was becoming increasingly depressed and was having trouble organizing his thoughts. Antidepressants, as contrasted to a medication such as an antibiotic, may take a minimum of two to three weeks before the patient will benefit from the full effect of the drug. It is difficult to stabilize the dosage for an antidepressant on an outpatient basis. S.G. was taking Ritalin, which is commonly used for children with attention deficit, hyperactivity disorders. During his stay at the Hospital, S.G. was engaging in strange behavior, including absence seizures. On March 16, 1995, he was still lunging and threatening harm. On March 20, 1995, he was still unstable and at risk. The dosage of Wellbutrin was increased. On March 21 and 22, 1995, S.G. was still threatening and confused. S.G. was discharged on March 25, 1995. The admission and length-of-stay for S.G. were medically necessary. Patient J.D. was a 16 year-old boy who was admitted to the Hospital on March 7, 1995, and discharged on March 14, 1995. The Agency denied the admission and entire length-of-stay based on KePro's determination that the patient was not actively suicidal or psychotic and services could have been rendered in a less acute setting. J.D. was admitted from a partial hospitalization program pursuant to the Baker Act because he was observed by a health care professional banging his head against the wall and throwing himself on the floor. He had a history of depression and out-of-control behavior, including being a danger to himself and running away. At the time of his admission, he was taking Prozac. Banging his head against the wall can mean that the patient is psychotic, can cause brain damage, and can be dangerous if the cause of the behavior is unknown. Admission to the Hospital was justified because the patient was extremely agitated and self abusive, requiring restraints and medication to decrease his agitation and self abusiveness. One of the tests administered during his hospital stay indicated that J.D. was a moderate risk for suicidal behavior. During his hospital stay, it was discovered that J.D. had threatened to kill himself while at school. He had been in a partial treatment program during the day, but that environment was not working. There was violence in the home, and J.D. was becoming overtly depressed. During his stay at the Hospital, J.D. was placed on close observation with 15-minute checks. His dosage of Prozac was increased. The admission and length-of-stay for J.D. were medically necessary. R.J., a 10 year-old male, was admitted to the Hospital on January 1, 1995, and discharged on February 9, 1995. The Agency denied Medicaid reimbursement based on a determination by KePro that the treatment in an acute care facility was not medically necessary because R.J. was not psychotic, not suicidal, and not a threat to others; thus treatment could have been provided in an alternate setting. R.J. had been referred by a health care professional at Horizon Center, an outpatient center, because of progressive deterioration over the previous fourteen months despite outpatient treatment. His deterioration included anger with temper outbursts, uncontrollable behavior at school, failing grades, sadness, depressed mood, extreme anxiety, extensive worrying and a fear of his grandmother. R.J. also suffered from encopresis, a bowel incontinence. He was agitated, lacked energy, neglected his hygiene, experienced crying spells, and had difficulty concentrating. R.J. needed to be admitted for an evaluation to rule out a paranoid psychosis. It was necessary to do a 24-hour EEG as opposed to a 45-minute EEG. In order to do a 24-hour EEG, the patient is typically placed in an acute care facility. The EEG showed abnormal discharge in the brain, which could be contributing to a psychiatric illness. At school R.J. had smeared feces on the walls, behavior that could be seen in psychotic persons. There was evidence that he had been hitting and throwing his stepbrother and 3 year-old brother. He was fearful of his grandmother and, based on his family history, there was reason to fear her. R.J. was placed on Buspar, a medication which generally takes two weeks to take effect. Contrary to the Agency's determination, R.J. was disorganized. He was also violent in terms of threatening danger and extreme anger. The admission and length-of-stay for R.J. at the Hospital were medically necessary. Patient C.A., a 9 year-old male, was admitted to the Hospital on June 1, 1995, and discharged on June 12, 1995. The Agency disallowed one day of the length-of-stay based on a determination by KePro that the services provided on June 11, 1995, could have been provided in a less restrictive setting. C.A. was admitted for violent and disruptive behavior. He also had an attention deficit, hyperactivity disorder and was taking Lithium and Depakote. These medications are used for patients who experience serious mood swings and abrupt changes in mood, going from depression to anger to euphoria. To be effective, medicating with Lithium and Depakote requires that the blood levels of the patient be monitored and the dosage titrated according to blood level. C.A. also was given Wellbutrin during his hospital stay. On June 11, 1995, C.A. was given an eight-hour pass to leave the hospital in the care of his mother. The physician's orders indicated that the pass was to determine how well C.A. did in a less restrictive setting. He returned to the Hospital without incident. He was discharged the next day to his mother. The treatment on June 11, 1995, could have been provided in an environment other than an acute facility; thus the stay on June 11, 1995, was not medically necessary for Medicaid reimbursement purposes. Patient G.M., an 11 year-old male with a history of being physically and sexually abused by his parents, was admitted to the Hospital on March 21, 1995, and was discharged on April 3, 1995. The Agency denied Medicaid reimbursement for inpatient hospital treatment from March 28 to April 3, 1995, based on KePro's determination that the length of hospital stay exceeded health care needs at an inpatient level and could have been provided in a less acute setting. At the time of admission, G.M. had suicidal ideation. His school had reported that G.M. had mutilated himself with a pencil, banged himself on the knuckles, and told the school nurse that he wanted to die. Prior to admission, G.M. had been taking Ritalin. His treating physician took G.M. off the Ritalin so that she could assess his condition and start another medication after a base-line period. The doctor prescribed Clonidine for G.M. Clonidine is a drug used in children to control reckless, agressive and angry behavior. Clonidine must be titrated in order to establish the correct dosage for the patient. During his hospital stay, G.M. was yelling and threatening staff. He was placed in locked seclusion, where he began hitting the wall. G.M. was put in a papoose, which is similar to a straitjacket. The papoose is used when there is no other way to control the patient. The patient cannot use his arms or legs while in a papoose. This type of behavior and confinement was occurring as late as March 31, 1995. G.M. was given a pass to go to his grandparents on April 2, 1995. He did well during his pass, and was discharged on April 3, 1995. Treatment in an acute facility was medically necessary through April 1, 1995. Treatment on April 2, 1995, could have been provided in a less acute setting. Patient S.S., a 5 year-old male, was admitted to the Hospital on March 9, 1995, and was discharged on April 3, 1995. The Agency denied Medicaid reimbursement for the admission and entire length of his hospital stay based on a determination by KePro that S.S. was not psychotic or an immediate danger to himself or others and the evaluation and treatment could have been rendered in a less acute setting. Prior to admission to the Hospital, S.S. was threatening suicide, ran into a chalk board at school, scratched his arms until they bled, and showed aggressive intent toward his sister, saying that he would kill her with a saw. S.S.'s condition had been deteriorating for approximately three months before his admission. At the time of admission, he had been suicidal, hyperactive, restless, and experiencing hallucinations. The hallucinations imply a psychosis. S.S. was put on Trofanil, an antidepressant which needs to be titrated. The patient's blood level had to be monitored while taking this drug. During his hospital stay, S.S. was on close observation. All objects which he could use to harm himself were removed from his possession. After he ate his meals, the hospital staff would immediately remove all eating utensils. On March 28, 1995, S.S. threatened to kill himself and became self-abusive. His blood level on March 31, 1995, was sub-therapeutic, and his medication dosage was increased. On April 1, 1995, S.S. had a temper tantrum. The admission and length-of-stay for the treatment of S.S. were medically necessary. Patient M.P., a 10 year-old male, was admitted to the Hospital on April 27, 1995, and was discharged on May 6, 1995. The Agency denied Medicaid reimbursement for the admission and entire length-of-stay based on a determination by KePro that the patient functions on an eighteen to twenty-four month level but is not psychotic and the treatment could have been provided in a less acute setting. M.P.'s IQ is between 44 and 51. He was diagnosed with a pervasive development disorder, which is a serious lack of development attributed to significant brain damage. His condition had deteriorated in the six months prior to his admission. He had episodes of inappropriate laughter, fits of anger, hit his head, hit windows, and put his arm in contact with the broken glass through the window. At the time of his admission, he had a seizure disorder. An EEG and an MRI needed to be performed on M.P. in order to evaluate his condition. M.P. had to have a regular EEG, a 24-hour EEG, and a neurological examination. The patient was aggressive, restless, and uncooperative. In order for the MRI to be performed, M.P. had to be anesthetized. The admission and length-of-stay for M.P. were medically necessary. Patient C.T., a 34 year-old female, was admitted to the Hospital on November 11, 1994, and was discharged on November 26, 1994. The Agency denied the treatment from November 17, 1994, to November 26, 1994, based on a determination by a peer review organization that the patient was stable by November 17, 1994, and psychiatric follow-up could have been performed in an outpatient setting. C.T. was admitted for kidney stones. She did pass the kidney stones but continued to have severe pain. Her doctor asked for a psychiatric consult. The psychiatrist diagnosed C.T. as having a personality disorder, chronic psychogenic pain disorder, and an eating disorder. Her depressive disorder exacerbated pain. C.T. had been given narcotics for the pain associated with the kidney stones. In order to assess her mental status, the physicians needed to taper the dosage of Demerol which she had been receiving. She was started on Sinequan, which is an anti-depressant given to alleviate the psychological condition and to help with the physical complaints. C.T. was later put on Vicodin, an oral narcotic, which seemed to bring the pain under control. The drugs used could cause a drop in blood pressure; therefore, they had to be titrated slowly. Her treating physician was trying to find an appropriate anti-depressant, while weaning the patient from intramuscular narcotics. On November 17, 1994, C.T. left her room and went to the hospital lobby, where she was found by nursing staff. C.T. was crying and saying that she was in pain and wanted to die. During her hospital stay, C.T. was in much distress; she would scream out that she was in pain. On November 18, 1994, she was found crying on the floor of the hospital chapel and had to be returned to her room. It was the opinion of Dr. Bernard Frankel, an expert retained by the Hospital, that C.T. probably could have been discharged a day earlier. The hospital stay for C.T. from November 17, 1994, to November 25, 1994, was medically necessary. The last day of her stay was not medically necessary.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered requiring Indian River Memorial Hospital, Inc., to pay to the Agency $752.14 for one day of service provided to G.M., $752.14 for one day of service provided to C.A., and $473.22 for one day of service provided to C.T. and finding that the Hospital is not liable for payment for any of the other services at issue in this proceeding. DONE AND ENTERED this 2nd day of November, 1998, in Tallahassee, Leon County, Florida. SUSAN B. KIRKLAND 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 Filed with the Clerk of the Division of Administrative Hearings this 2nd day of November, 1998. COPIES FURNISHED: Thomas Falkinburg, Esquire Agency for Health Care Administration Fort Knox Building 3 2727 Mahan Drive, Suite 3431 Tallahassee, Florida 32308 John D. Buchanan, Jr., Esquire Henry, Buchanan, Hudson, Suber & Williams, P.A. 117 South Gadsden Street Tallahassee, Florida 32302 Sam Power, Agency Clerk Agency for Health Care Administration Fort Knox Building 3 2727 Mahan Drive, Suite 3431 Tallahassee, Florida 32308 Paul J. Martin, General Counsel Agency for Health Care Administration Fort Knox Building 3 2727 Mahan Drive, Suite 3431 Tallahassee, Florida 32308
Findings Of Fact Petitioner is a hospital licensed by the State of Florida and is located in Jacksonville, Florida. Respondent, the affected state agency, as defined in Subsection 120.52(1), Florida Statutes, is responsible for the regulation of health care facilities, to include Petitioner. The Department also considers the question of provision of additional health care in the community through its certificate of need program. Intervenor has made application to provide ambulatory surgery in Duval County, Florida, through a freestanding surgery center. Jacksonville, Florida, is in Duval County. This case is part of a consolidated hearing process and is the companion matter to Saint Vincent's Medical Center, Petitioner v. State of Florida, Department of Health and Rehabilitative Services and Ambulatory Care - Duval Development Corp., d/b/a Jacksonville Surgical Center - Ambulatory Surgical Center, Respondents, D.O.A.H. Case No. 83-337 and Riverside Hospital, Petitioner v. State of Florida, Department of Health and Rehabilitative Services and Ambulatory Care - Duval Development Corp. d/b/a Jacksonville Surgical Center - Ambulatory Surgical Center, Respondents, D.O.A.H. Case No. 83-482. The first three days of the hearing were conducted on the dates alluded to in this order. That presentation was transcribed. In addition, deposition testimony was presented and accepted as part of the record in this matter. The campanion cases concern the propriety of the grant of a certificate of need to the Intervenor in this cause to allow construction and operation of a freestanding ambulatory surgery center which would be used for performing outpatient surgeries. At all times relevant to this case, Saint Vincent's had a department in which outpatient surgical procedures were performed and are expected to be performed in the future. With the advent of the establishment of the Intervenor's facility, that health care unit will be in competition with Petitioner in the realm of providing surgical procedures. As recently as 1975, Respondent knew that ambulatory surgery centers, such as that proposed by the Intervenor, would need permission to construct such a facility. This permission relates to the need to apply and receive a certificate of need from the Department. The authority for such regulation was pursuant to applicable provisions of Chapter 381, Florida Statutes. Notwithstanding this regulatory role to be fulfilled, Respondent did not undertake a program for enacting rules to consider the question of need for ambulatory surgical centers. This lack of rulemaking was primarily due to inactivity of applicants seeking ambulatory surgical center certificates of need. This circumstance changed in late 1982. In December, 1982, Respondent received approximately thirteen applications for ambulatory surgical center certificates of need, as contrasted with approximately ten applications over the prior three years. At the same time Respondent was in the throes of having to revamp its certificate of need review process related to the overall health industry, brought about by statutory changes which abolished health system agencies and created local health councils. In 1983, at the time of the hearings, Respondent had received 27 applications for ambulatory surgery centers. This glut of applications by would-be ambulatory surgical centers and the 1982 applications were examined without formal rules defining the need question, related to expected numbers of surgical procedures that might be conducted on an outpatient or ambulatory basis. The determination of this ratio of outpatient surgical procedures to inpatient surgical procedures is a vital part of the need question. 1/ Absent promulgated rules, Department officials began their attempt to ascertain the percentage comparison between outpatient and inpatient surgeries, as that item was involved in the establishment of a methodology for considering the need question. Based upon information provided by applicants for ambulatory surgery centers and its own research, Respondent concluded that anywhere from 18 to 40 percent of total surgeries could be expected to be outpatient surgeries. Having utilized a median projection related to population expectations in the certificate of need process, the Department decided to use a median projection for the expected percentage of outpatient surgery. Thus, 29 percent was selected as the percentage of outpatient surgeries in the total number of surgical procedures and that percentage was utilized in the computation of the number of expected outpatient surgical procedures. Utilization of this 29 percent factor in the computation of the number of procedures to be expected on an outpatient basis may be seen in Petitioner's Exhibit 2 and Respondent's Exhibit 1, application reviews. Once the Department decided to employ the 29 percent factor, it has consistently, on a statewide basis, utilized that factor in evaluating the question of the grant of certificates of need for ambulatory surgical center applicants. This has been done in more than one batch or cycle and was done in the instance of Intervenor's application which is at issue. Although the 29 percent factor is not the only determining element of the certificate of need process, it is an integral part of that process and can affect the outcome of the grant of the certificate, as has been the case in two instances alluded to in the course of the hearing. This policy choice by the agency is not emerging. It is not one of a series of approaches that have been experimented with in trying to arrive at a concluding agency position, prior to the formal adoption of a rule. This percentage factor has been the only number utilized in the review of all ambulatory surgery center applications commencing late 1982 to the time of final hearing in this action. This choice has not stood the test or scrutiny of the rulemaking process set forth in Section 120.54, Florida Statutes. Notwithstanding the stated willingness of the agency to modify its position when presented with a more credible method, that contingency or eventuality has not occurred and every applicant for ambulatory surgery center certificate of need has had its application measured against the 29 percent factor commencing December 1982, to the exclusion of other techniques suggested by applicants. In the face of the facts reported above and the record considered, and recognizing that the agency should be afforded an opportunity to establish a record basis for the utilization of the 29 percent factor, even if it were found to be an invalid rule, a decision was reached at the time of hearing on the question of the utilization of the 29 percent factor and whether it was a rule not duly promulgated. It was found that the 29 percent factor is an unpromulgated rule and could not stand as law without first being subject to an assessment of the quality of the record basis for the agency's policy choice. The argument related to this case may be found at pages 798 through 829 of the transcript. The ruling is announced at pages 829 through 832. Respondent subsequently presented additional evidence in support of its policy choice and that may be found in succeeding sections within the transcript. This written order memorializes the ruling announced at hearing.
