Conclusions THIS CAUSE came on for consideration before the Agency for Health Care Administration (“the Agency”), which finds and concludes as follows: 1. The Agency issued the Petitioner (“the Applicant”) the attached Notice of Intent to Deem Application Incomplete and Withdrawn from Further Review (Ex. 1). The parties entered into the attached Settlement Agreement (Ex. 2), which is adopted and incorporated by reference. 2. The parties shall comply with the terms of the Settlement Agreement. If the Agency has not already completed its review of the application, it shall resume its review of the application. The Applicant shall pay the Agency an administrative fee of $100.00 within 30 days of the entry of this Final Order. A check made payable to the “Agency for Health Care Administration” containing the AHCA number(s) should be sent to: Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive, MS# 14 Tallahassee, Florida 32308 3. Any requests for an administrative hearing are withdrawn. The parties shall bear their own costs and attorney’s fees. This matter is closed. DONE and ORDERED in Tallahassee, Florida, on this 7) day of Deeerber , 2011. © be ge oan cret 1 Administration 1 Filed December 8, 2011 3:10 PM Division of Administrative Hearings
Other Judicial Opinions A party that is adversely affected by this Final Order is entitled to seek judicial review which shall be instituted by filing one copy of a notice of appeal with the agency clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The notice of appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the below- named persons/entities by the method designated on this ge day of _/f A _, 2011. Richard Shoop, Agency Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone (850) 412-3630 Jan Mills Facilities Intake Unit Agency for Health Care Administration (Interoffice Mail) Roger Bell Health Care Clinic Unit Manager Agency for Health Care Administration (Interoffice Mail) Finance and Accounting Revenue Management Unit Agency for Health Care Administration (Interoffice Mail) Zachary B. Buffington, Esquire Florida Bar No. 0087748 Williams Parker Harrison Dietz & Getzen 200 South Orange Avenue Sarasota, Florida 34236 (U. S. Mail) Warren J. Bird, Asst. General Counsel Office of the General Counsel Agency for Health Care Administration (Interoffice Mail) | lizabeth W. McArthur Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) 08/16/2011 TUE 16:05 PAX Wo11/ 027 FROM ‘NEUROMUSCULAR THERAPY CENTER FAX NO. 1941-926-3342 Jul, 29 2011 @1:4 RICK SCOTT eaetter Heat car forall Flridans BUZARETH DUDEK GOVERNOR fore SECRETARY CERTIFIED MAIL / RETURN RECEIPT REQUESTED July 28, 2014 Nouromusculge Therapy Center Inc Liconse Number: Po Box 1922) Case #; 2011 00 8175 Certified? Article Number SENDERS RECORD PUIG 9008 9411 4739 £330 | FURTHER REVIEW Your appllcatipn for licanse Is deemed Incomplete and withdrawn from further consideration pursuant to Section 408,806(3)(b), Florida Statutes, which states that “Requested Information omilted from an application for llcensure, liesnse renewal, or change of ownership, other than an Inspection] must be filed with the agency within 24 days after the agenoy's request for omitted Information or the application shall be deemed Incomplete and shall bs withdrawn from further consideration and the fees shall be forfeited”. You wore notified by correspondance dated July 6, 2011 to provide further information addressing Idpntified apparent errors ar omisatons within twenty-one days from the recelpt of the Agency's correspondence. Our records indicate you tacelved this correspondence by certified mail bn July 14, 2011. The Agency recelved your response to this requested Information on July 18, 2071. After careful review of your responge, your applicatian Is‘ deemed incomplete and withdrawn from further consideration. The outstanding Issues remaining for licansure are Medical/Ciinfe Director - The Medical/Clinic Director listed on the appiication ie not a qualified health care plofessional, You falled to provide the required licensure by the Florida Department of Health on the appileation. (AHCA Form 31 40-0013 July 08; Rute 69A-33.002 (1), F.A-. and 400,991 (3), F-S.) Finanglal Officer - No financial officer was listed on the application, You must furnish the full name, complete residence and business address, telephone number, and positlonititle for the Financial Officer. (AHCA Form 3110-0013 July 06; Rule 69A-33.002 (1), FAC.) Backgroun Sereaning — You falled to provide evidence of Level Hl background screening for the followinglindividual(a); & Van Vyven, Kathleen Gorman, Gregory Wlegers and Susan Peace. cement — Visit ANCA online at 2727 Mahan Prive, MS-53 Tallahassee, Fiogida 32308 ahco.myflorida.com 08/26/2011 TUE 16105 FAX FROM :NEUROMUSCU! : ULAR. THERAPY eee eT CENTER FAX ND. $941-926-3342 ha ul, 29 2041 1341 T41PM PS Neuromusoular' nerapy Center Inc Page 2 July 26, 2017 alive tearing. 1 o Section 420.589, F.S., YO ding before the Division of Administrative Hearings under Section the requirements in order to obtain a formal proceeding dminietrative hearing must co ), and must state the material facts you 420.87(4), Fog YOur request for an & Section 28-196.201, Florida Administrative Code (F.A.C). an dispute. SEB ATTACHED ELECTIO! Pursuant | AND EXPLANATION OF RIGHTS FORMS. lanage Clinic Unit ce: Agency Clerk, Mail Stop 3 Legal Intake Unit, Mall Stop 3 @o12/027 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION NEUROMUSCULAR THERAPY CENTER INC., Petitioner, FRAES No.: 2011008175 vs. Case No. 11-04459 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT The Petitioner (“the Applicant”) and the Respondent (“the Agency”) voluntarily enter into this Settlement Agreement (“Agreement”) and agree as follows: 1. Parties/Background. The Applicant filed an application seeking licensure within the jurisdiction of the Agency. After initial review, the Agency issued the Applicant a Notice of Intent to Deem Application Incomplete and Withdrawn From Further Review (“NOI”). The Applicant has since tendered to the Agency additional information and/or documentation in support of the application, which the Agency is willing to review. 2. Purpose and Effect of Settlement. Both parties wish to resolve this case without further litigation and recognize that by entering into this Agreement, both are expressly waiving their right to any legal proceeding they are entitled, including, but not limited to, formal and informal proceedings under Section 120.57, Florida Statutes, and appellate review. Both parties consent to the withdrawal of any request for formal or informal hearing if such a request has been made, as well as the relinquishment of jurisdiction of the informal hearing officer or administrative law judge. 3. Resumption of Application Review. The parties agree that this Agreement shall supersede the NOI and that the application will no longer be deemed to be incomplete and withdrawn from further review and the NOI is deem deemed superseded by this agreement . If the Agency has not already completed its review of the application, it shall resume its review of the application upon entry of the Final Order adopting this Agreement. Nothing in this Agreement, however, shall prohibit the Agency from denying the application based upon any statute, rule, or regulation, and, if applicable, an unsatisfactory licensure survey. 4. Administrative Fee. The Applicant agrees to pay the Agency an administrative fine of ($100.00) within 30 days of the entry of the Final Order. 5. Release. The Applicant releases and forever discharges the Agency, its employees and agents, both past and current, from any and all claims, including, but not limited to, damages, attorney’s fees and costs, arising from or relating to the issuance or litigation of this NOI. 6. Costs and Attorney’s Fees. Each party shall bear their own costs and attorney’s fees. Page | of 2 EXHIBIT 2 FROM :NEUROMUSCULAR THERAPY CENTER FAX NO. :941-926-3342 Oct. @5 2011 89:18AM PZ OCT-@5-2811 18) AHCA paz GENERAL COUNSEL OFFI 850 413 5313 P.e3 O42 miei te. Counsel. The Applicant acknowledges the right to retain independent counsel and has either o! its own counsel or voluntarily waived the right to counsel. The Applicant further acknowledges that Agency counsel represents solely the Agency and that Agency counsel has not previded any legal advice to, or influenced, the Applicant in the voluntary decision to enter into this Agreement. _ & Agreement. Thi: Agreement contains the entire understandings of both parties. This Agreement supersedes any prior oral or written agreements thet may have existed between tho parties, This ent may not be amended by either party except in writing. 9 of Agreement. Both parties agree that an electronic signature suffices for an cal shut htm ene o fine copy efi ania ees a tht i Agreement may be executed in counterparts. This Agreement shal] be effective upon full execution by all parties and adoption into a Final Order. After full cxecution of this Agreement, the Agency will enter a Final Order adopting this Agreement and closing the case. . The following representatives have read and understand this Agrecment, are signing it freely and voluntarily, and ainowledge that they are authorized to enter into this Agreement. f. Bew ny B n, oe Florida Bar No. 0087748 Williams Parker Harrison Dietz & Getzen 200 South Orange Avenuc Sarasota, Florida 34236 DATED: 12 “/7 “h 2727 Maban Drive, Mail Stop #3 Tallahassee, Florida 32308 DATED: |° il aan Page 2 of 2 TOTAL P.@3
Conclusions THIS CAUSE came on for consideration before the Agency for Health Care Administration (“the Agency”), which finds and concludes as follows: L The Agency issued to Hollywood Pavilion, LLC, the attached Administrative Complaint (Ex. 1), and to Larkin Community Hospital, Inc. d/b/a Larkin Community Hospital, the attached Notice of Intent to Deny Application and Withdrawn From Further Review letter (Ex. 2). The parties entered into the attached Settlement Agreement (Ex. 3), which is adopted and incorporated by reference. 2. The parties shall comply with the terms of the Settlement Agreement. 3. The Administrative Complaint is withdrawn. 4. The Notice of Intent is withdrawn and the Agency shall resume the processing of the change of ownership application. Nothing in this Agreement shall prohibit the Agency from denying the change of ownership application based upon any licensure statute or rule not set forth in the Notice of Filed November 14, 2014 2:23 PM Division of Administrative Hearings Intent. Should the Agency again deny the change of ownership application, the Applicant will be afforded all legal rights under Florida law to contest any subsequent denial. ORDERED in Tallahassee, Florida, on this _(@ dayof _ Get» ber- , 2014. ‘. mK Elizab ras a Agency for He are Administration
Other Judicial Opinions A party that is adversely affected by this Final Order is entitled to seek judicial review which shal! be instituted by filing one copy of a notice of appeal with the agency clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The notice of appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy pipes Final Oceanis below- named persons/entities by the method designated on this {3 ay of , 2014. Agency for Health Care Administration 2727 Mahan Drive, MS 3 Tallahassee, Florida 32308 Telephone (850) 412-3630 Jon H. Steinmeyer Bradford C. Herter Court Appointed Receiver Assistant General Counsel Hollywood Pavilion, LLC Office of the General Counsel 1201 North 37" Avenue Agency for Health Care Administration Hollywood, Florida 33012 (Interoffice Mail) (U.S. Mail) Jack Plagge, Unit Manager Hospital and Outpatient Services Unit (Interoffice Mail) Jack J. Michel, MD Chairman Larkin Community Hospital 7031 SW 62"! Avenue South Miami, Florida 33143 (U.S. Mail) Jorge Isaac, Esq. Isaac & Salgado Grondin, P.L. 267 Minorca Avenue, Suite 100 Coral Gables, Florida 33134 (U.S. Mail) Gary C. Matzner, Esq. Kopelowitz Ostrow, P.A. 2525 Ponce de Leon Boulevard Coral Gables, Florida 33134 (U.S. Mail) [Jan Mills Facilities Intake Unit Agency for Health Care Administration (Interoffice Mail)
The Issue The issue in this case is whether Respondent was overpaid Medicaid funds for services provided to his patients, and, if so, whether the alleged overpayment was properly calculated.
Findings Of Fact AHCA is the state agency responsible for, inter alia, administering the Medicaid program in the State of Florida. The Bureau, a division of AHCA located in Tallahassee, Florida, is responsible for monitoring payments to Medicaid providers, and, when necessary, collecting return of any overpayments made to the providers. Medicaid providers enter into a contract with AHCA agreeing to bill patients no more than the usual and customary charges for services provided. Charges are established, in part, in accordance with procedure codes from the Current Procedural Terminology (CPT) guidelines. The CPT codes describe the kind of office visit which occurs during treatment to individual patients. A monetary charge is then assigned to the CPT code so that Medicaid will know how much to pay for the visit in question. The provider submits its claim for payments each month to AHCA, setting forth the number of visits within each CPT procedure code. The Bureau then determines the amount of Medicaid payment earned by the provider pursuant to the claimed services. The payment is then made by AHCA to the provider. The Bureau periodically performs audits of the claims submitted by providers. If a discrepancy or overpayment is discovered during the audit process, the Bureau notifies the provider by way of a demand letter. The Bureau then requests records and documents from the provider concerning the patients and charges in question. Upon review of the provider's records, the Bureau issues a Preliminary Audit Report setting forth its findings. The provider may agree (and repay the overpayment amount) or challenge the audit findings. In the present case, Respondent challenged the audit findings. As a result of that challenge, AHCA requested and Respondent provided additional documentation concerning Respondent's provision of services to certain patients. The Bureau then issued a Final Audit Report, again stating the amount of the overpayment and imposing a fine. The overpayment amount in this case is $82,836.07 and a fine of $3,000 was imposed. The overpayment discovered by AHCA relates to 40 individual patients who Respondent treated during the period January 1, 2002, through August 31, 2006. Each will be more fully discussed below. For some of the patients, there was only one charge in dispute; for others there are numerous charges. There are a small number of CPT procedure codes relevant to Respondent's patients at issue in this proceeding. A discussion of them is necessary to the analysis of the individual cases. Definitions and descriptions of the various codes are found in the Evaluation and Management Services Guidelines manual issued by the American Medical Association (AMA). The codes at issue are: 99201--Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; a problem focused examination; and Straightforward medical decision making. Usually, the presenting problems are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 99202--Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Usually, the presenting problems are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. 99203--Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Usually the presenting problems are of moderate severity. Physicians usually spend 30 minutes face-to-face with the patient and/or family. 99204--Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Usually the presenting problems are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. 99205--Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Usually, the presenting problems are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. 99211--Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. 99212--Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Usually the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient or family. 99213--Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99214--Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. 99215--Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 99382--Initial comprehensive preventive medicine evaluation and management . . . for a child age 1 through 4 years. 99384--An initial comprehensive preventive medicine evaluation and management . . . of a new patient, aged 12 through 17 years. 99385--An initial comprehensive preventive medicine evaluation and management . . . of a new patient, aged 18 to 39 years. 99392--A periodic comprehensive preventive medicine evaluation and management . . . for a child age 1 to 4 years. 99393--A periodic comprehensive preventive medicine evaluation and management . . . of a child age 5 through 11 years. 99395--A periodic comprehensive preventive medicine evaluation and management . . . of an existing patient, aged 18 through 39 years. 99396--A periodic comprehensive preventive medicine evaluation and management . . . of an existing patient, aged 40 through 64 years. W9881--A checkup and screening for a child.4 The exact correlation between the CPT procedure codes and specific dollar amounts was not provided at final hearing, but there was a dollar amount assigned (by AHCA) to each of the services provided by Respondent to his patients. The Medicaid Fee Schedules (of which official recognition were taken) do provide a maximum fee for each code, but there was no testimony as to how each fee was assigned in this case, i.e., whether it was the maximum fee or not. AHCA used the services of a hired consultant (Dr. Sloan) to review Respondent's patient records concerning the assignment of CPT procedure codes for services rendered. Dr. Sloan is an experienced physician with a family practice in Chipley, Florida (a city in the Florida panhandle). Dr. Sloan had never, prior to the instant action, performed a review of another physician's records for the purpose of ascertaining the proper procedure code. This was his first foray into this process. Dr. Sloan reviewed Respondent's patient records and determined that all 40 patient records at issue had at least one erroneous procedure code, resulting in the reduction of allowable charges for those procedures. After Dr. Sloan's review was completed, another medical professional (Greg Riley, a registered nurse) reviewed the charts and made some adjustments to the monetary charges. Riley had reviewed the records initially just to make sure the records were complete. His subsequent review, after Dr. Sloan, was to determine the correct charges based on Dr. Sloan's adjustments of the procedure codes. For the purposes of reviewing the following paragraph, the patients were each assigned a number (1 through 40) and will be referenced by their assigned number herein with a parenthetical number, e.g., (1) (2) (3), etc. Some patients had more than one visit at issue. For those patients, the visit will be referred to by a written number, e.g., One, Two, Three, etc. A review of each patient and each office visit will be discussed in the following Findings of Fact. The original code and monetary charge will be stated, followed by Dr. Sloan's revised code and Riley's reduction in monetary charge. A statement of Respondent's position concerning the charge will come next, followed by a conclusion as to the proper charge based on all the evidence presented. The evidence at final hearing as to each resident was presented by way of three groups of documentation. First, there is an AHCA form listing all claims in the Medicaid sample, showing the CPT code for each patient and each patient visit. Second, there is the Respondent's office chart from each patient visit. Third, there is a written response from Respondent's former counsel as to each patient visit. This evidence, along with the testimony of witnesses, shows: One: Coded 99205 with a charge of $85.41--Dr. Sloan reduced the code to 99203, due to lack of a comprehensive history; charge was reduced to $48.68. Respondent showed that, according to annotations in the chart, the patient presented with multiple problems and a comprehensive examination was conducted. 99205 is supported. Two: Coded 99214 for $39.46--claim denied in full, as visit was a follow up only; no face-to-face time with doctor. Respondent's records show he did meet with patient, but did not exercise complex medical decision-making. The evidence supports a reduction to 99211, with the appropriate charge for that code. One: Coded 99205 for $85.41--reduced to 99202 due to lack of documentation. Respondent did not prove entitlement to a higher code. 99202 is appropriate. Two: Coded 99215 for $58.28--reduced to 99212 for $21.84, because visit was not deemed "extensive" by Dr. Sloan. Respondent did not prove elements of 99215. 99212 is appropriate. Three: Coded 99395 for $51.85--denied in full due to lack of documentation and no management issues during the visit. Respondent's records indicate comprehensive exam, and he testified to long face-to- face visit with resident. 99395 is supported. One: Coded 99204 for $66.74--reduced to 99203 for $48.37, because the examination was deficient. Respondent's records show that comprehensive examination done, history taken, and moderate complexity medical decisions made. 99204 is supported. Two: Coded 99215 for $58.94--reduced to 99213 for $26.47, due to lack of complex history or exam. The records show some level of medical decision-making that could support a higher code. 99214 would be appropriate. One: Coded 99204 for $66.74--reduced to 99203 for $48.37, due to lack of complex history. Respondent did not prove otherwise. 99203 is appropriate. Three: Coded 99214 for $39.51--reduced to 99213 for $26.61 for lack of documentation. Respondent did not prove otherwise. 99212 is appropriate. Four: Coded 99213 for $24.47--reduced to 99212 for $21.84 (a difference of $2.63) for lack of complexity. Respondent did not prove otherwise. 99212 is appropriate. One: Coded 99204 for $68.74--reduced to 99203 for $48.66, due to lack of complexity. Respondent explained his notations in the patient chart and proved the complex nature of the patient's medical problems. 99204 is supported. Four: Coded 99214 for $39.64--reduced to 99212 for $21.84, because the examination lacked detail. Respondent's records and testimony established that a detailed examination was performed. 99214 is supported. One: Coded 99204 for $66.74--reduced to 99202 for $32.44, because of lack of complexity, i.e., upper respiratory infection. Respondent did not prove that a higher code was justified. 99202 is appropriate. One: Coded 99205 for $6.74--denied in full, because the exam lacked a review of services (ROS) component. Respondent's records showed otherwise. 99205 is supported. Three: Coded 99214 for $39.49--reduced to 99212 for $21.84 due to lack of exam and/or exam was "problem focused."5 Respondent indicated patient had undergone complete physical three days prior. Visit at issue was for a specific problem. 99212 is appropriate. Four: Coded 99213 for $24.47--reduced to 99212 for $21.84, because no exam shown; visit was problem focused. Respondent's records indicate only a brief visit. 99212 is appropriate. Five: Coded 99213 for $24.4--reduced to 99211 for $12.48, due to visit being solely to refill medication. Respondent states, erroneously, that the 99211 code means that only a nurse saw the patient. In actuality, the code says that the physician does not have to see the patient, but may do so. 99211 is appropriate. Six: Coded 99214 for $39.49--reduced to 99212 for $21.84, because the visit was only problem focused. The examination performed by Respondent appears to be just that, for an oral problem. 99212 is appropriate. Seven: Coded 99213 for $24.47--denied in full, because of absence of history taken and examination record. Doctor appeared to only provide results of prior test. Respondent did not prove otherwise. Denial is appropriate. One: Coded 99204 for $68.74--denied in full by Dr. Sloan, but upgraded to 99203 for $50.64, by the RN. No comprehensive history or exam was proven by Respondent. 99203 is appropriate. One: Coded 99384 for $71.54--reduced to 99213 for $32.56 due to insufficient documentation. Respondent showed that the patient came in for a school checkup. 99384 is supported. One: Coded 99204 for $68.74--reduced to 99202 for $34.01, because the visit was only problem focused. But Respondent showed that although patient showed with only one problem (toothache), other problems were identified during the visit. 99204 is supported. One: Coded 99204 for $68.74--reduced to 99202 for $32.71, because visit was only problem focused, i.e., skin irritation. Respondent showed that patient was also in a high risk pregnancy and additional services were provided. 99204 is supported. Two: Coded 99395 for $71.54--denied in full by Dr. Sloan for failure to do more than an abdominal exam and take vital signs. Respondent did show that an annual evaluation was done, but the records do not appear to indicate a full examination. 99212 would be warranted. One: Coded 99214 for $41.51--reduced to 99213 for $32.56, because the visit was problem focused. Respondent did spend some time with patient, but did not show elements of higher code. 99213 is appropriate. One: Coded 99204 for $68.74--reduced to 99202 for $34.01, because visit was problem focused for an ingrown toenail. Respondent showed that the patient actually had multiple issues and Respondent did a fairly comprehensive history and examination. 99204 is supported. (14) One: Coded 99204 for $68.74--reduced to $32.71, because visit was problem focused for an upper respiratory infection. Respondent showed that a comprehensive history and examination were done in order to more adequately address the new patient's needs. 99204 is supported. Two: Coded 99395 for $68.84; denied in full, because of full examination done just one week prior. Respondent showed that the annual evaluation done on this date had a different focus than the prior visit and was justified and necessary. 99395 is supported. One: Coded 99215 for $58.29--reduced to 99212 for $21.84, because the visit was only to refill a prescription. A one-item exam plus vitals was performed. Respondent did not establish need for higher code. 99212 is appropriate. Two: Coded 99214 for $39.46--reduced to 99213 for $26.61, because the visit was only to address dermatitis. Respondent showed the existence of multiple problems and extensive time spent with patient. 99214 is supported. Three: Coded 99214 for $41.46--reduced to 99212 for $21.84, because visit was problem focused for an insect bite. Respondent did not prove higher code was needed. 99212 is appropriate. Four: Coded 99214 for $39.46--reduced to 99213 for $23.61, because visit was problem focused for vaginitis. Respondent did not prove otherwise. 99213 is appropriate. Five: Coded 99396 for $53.72--initially denied in full by Dr. Sloan, then reduced to 99211 by the RN. Respondent showed that a legitimate annual evaluation of patient was done. 99396 is supported. Six: Coded 99215 for $60.29--reduced to 99213 for $26.61, because Dr. Sloan deemed the examination inadequate; Respondent failed to do a ROS. Respondent showed that he spent a lot of time with the patient, but not that there was any degree of medical decision-making at a high complexity level involved. 99214 would be appropriate. Seven: Coded 99214 for $41.46--reduced to 99213 for $26.21, because visit was for an expanded problem- focused reason (ear infection). Respondent did not prove otherwise. 99213 is appropriate. One: Coded 99215 for $58.88--reduced to 99212 for $21.84, due to lack of examination documentation and that visit was problem focused. Respondent showed that additional issues were presented and discussed. 99215 is supported. Four: Coded 99214 for $41.49--reduced to 99212 for $21.84 for same reasons as prior visit. Respondent did not provide evidence of further issues. 99212 is appropriate. One: Coded 99214 for $41.51--reduced to 99213 for $27.67, due to lack of examination details. Respondent could not support higher code. 99213 is appropriate. One: Coded 99204 for $66.73--reduced to 99203 for $48.25, due to inadequate ROS and low complexity of the patient. Respondent could not support higher code. 99203 is appropriate. One: Coded 99204 for $68.74--reduced to 99202 for $34.01, because visit was for an expanded problem focus reason with straightforward medical decision- making. Respondent did not establish reason for higher code. 99202 is appropriate. One: Coded 99204 for $66.74--reduced to 99202 for $32.37, because it was a problem focused visit for an upper respiratory infection (URI). Respondent found patient to be in a high risk pregnancy and examination escalated due to that fact. 99204 is supported. One: Coded 99204 for $66.74--reduced to 99202 for $37.37, because visit was problem focused for URI. Respondent did not support higher code. 99202 is appropriate. One: Claim was allowed. Two: Coded 99214 for $41.51--reduced to 99213 for $32.56, because the visit was problem-focused for a URI. Respondent could not prove higher code was necessary. 99213 is appropriate. Three: Coded 99213 for $26.47--reduced to 99212 for $26.45 (two cent difference). Respondent acquiesced. 99212 is appropriate. Four: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem-focused for an allergic reaction. Respondent noted that patient had allergic rhinitis and perhaps pneumonia. 99214 is supported. Five: Coded 99213 for $26.47--reduced to 99212 for $26.45 (two cent difference). Respondent acquiesced. 99212 is appropriate. Six: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem focused for URI. Respondent did not prove need for higher code. 99213 is appropriate. Eight: Coded 99393 for $71.54--denied in full, due to fact that prior visit should have covered examination. Respondent showed that the annual evaluation or physical focused on different aspects of patient's wellbeing than regular office visits. 99393 is supported. Ten: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem focused for gastrointestinal problem. Respondent did not sufficiently justify the higher code. 99213 is appropriate. Twelve: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. Thirteen: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. Fourteen: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. Sixteen: Coded 99214 for $41.51--reduced to 99213 for $27.67, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. One: Coded 99205 for $85.11--reduced to 99203 for $48.69, because of lack of documentation. The evidence and documentation presented by Respondent was sufficient to validate higher code. 99205 is supported. Two: Coded 99214 for $41.51--reduced to 99212 for $26.45, because visit was problem focused. Respondent did not support a higher code. 99212 is appropriate. Three: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. One: Claim was allowed. One: Coded 99205 for $87.41--reduced to 99202 for $34.01, due to inadequate documentation. Respondent showed sufficient documentation to warrant code. 99205 is supported. Three: Coded 99215 for $60.95--reduced to 99213 for $27.67, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. Four: Coded 99212 for $21.84--reduced to 99211 for $12.97, because visit was for a lab draw only. Respondent did not prove otherwise. 99211 is appropriate. Five: Coded 99214 for $41.51--reduced to 99212 for $27.71, because visit was problem focused. Respondent failed to show all elements of higher code. 99212 is appropriate. Six: Coded 99214 for $41.51--reduced to 99213 for $27.67, because visit was problem focused. Respondent failed to show all elements of higher code. 99213 is appropriate. One: Coded 99214 for $41.49--reduced to 99213 for $32.56, because visit was problem focused. Respondent showed that patient had several complex problems. 99214 is supported. One: Coded 99204 for $68.74--reduced to 99202 for $33.66, because visit was problem focused for a URI. Respondent did not prove otherwise. 99202 is appropriate. One: Coded 99214 for $41.51--reduced to 99212 for $26.45, because no examination done on a problem focused visit. Respondent showed that more extensive examination was done, that patient had disappeared for two years and doctor needed to catch up on their history, and diagnoses were complex. 99214 is supported. Two: Coded W9881 for $68.74--reduced to 99211 for $12.48, because visit was for minor checkup. Respondent showed that visit was a legitimate checkup for the child. W9881 is supported. Three: Coded 99212 for $21.84--reduced to 99211 for $12.97, because visit was just for refills and vital signs taken. Respondent did not show otherwise. 99211 is appropriate. Four: 99214 for $41.51--reduced to 99213 for $32.56, because visit was only for expanded problem focus. Respondent did not prove elements of higher code. 99213 is appropriate. One: Coded 99204 for $68.74--reduced to 99202 for $33.74, because visit was problem focused. Respondent showed the patient had multiple problems that required treatment. 99204 is supported. Three: Coded 99214 for $41.51--reduced to 99213 for $32.56, because visit was problem focused for URI. Respondent showed the elements of the higher code. 99214 is supported. Four: Coded 99392 for $71.54--reduced to 99212 for $26.45, because it was deemed a simple office visit. Respondent proved that the visit was indeed an annual evaluation. 99392 is supported. Five: Coded 99214 for $41.51--reduced to 69210 (a procedure code having to do with cerumen impaction removal, i.e., removing wax from the patient's ear) for $25.31. Respondent proved the difficulty of that procedure for a child and that by doing so he saved the family a much higher medical charge had they gone to a specialist. 99214 is supported. One: Claim was allowed. One: Coded 99204 for $66.74--reduced to 99202 for $33.66, because visit was problem focused for a depressive disorder. Respondent did not prove otherwise. 99202 is appropriate. One: Coded 99215 for $60.35--denied, in full, because of lack of evidence that face-to-face examination occurred. Respondent showed sufficient evidence that such an examination did occur. 99215 is supported. One: Coded 99382 for $71.54--initially denied, in full, but then reduced to 99202 for $34.01 by the RN. Respondent showed that a full screening for a new patient was done. 99382 is supported. One: Coded 99204 for $66.74--reduced to 99202 for $33.74, because visit was problem focused for hypertension. Respondent indicated he spent considerable time with the patient, but did not meet the requirements for a higher code. 99202 is appropriate. Two and Three: The dates and designations for these two visits are confused in the record. One visit is coded 99396 for $55.16, the other is 99215 for $58.35. The first was allowed, the second denied. Respondent did not prove the elements of the two higher codes. 99396 is appropriate. 99215 is denied. Four: Coded 99212 for $19.84--reduced to 99211 for $12.48, because the visit was simply a blood pressure check. Respondent did not prove otherwise. 99211 is appropriate. Five: Coded 99214 for $39.46--reduced to 99212 for $21.84, because visit was problem focused, and there was no examination. Respondent did not prove otherwise. 99212 is appropriate. Six: Coded 99396 for $54.75--denied, in full, because of lack of documentation. Respondent showed the existence of a legitimate annual exam. 99396 is supported. Seven: Coded 99214 for $39.46--reduced to 99213 for $26.61, because visit was an expanded problem focused relating to hypertension. Respondent did not prove otherwise. 99213 is appropriate. Eight: Coded 99214 for $39.46--reduced to 99212 for $21.84, because visit was problem focused with only vitals taken. Respondent showed the visit was more extensive than that, but not to the level of 99214. 99213 would be supported. One: Coded 99204 for $66.74--reduced to 99202 for $32.37, because visit was problem focused. Respondent showed that patient had many special needs and additional services were required. 99204 is supported. Two: Coded 99214 for $39.51--amount was adjusted to $34.75, due to fact that wrong code was used. Respondent provided sufficient evidence to support his code. 99214 is supported. Four: Coded 99214 for $39.51--denied, in full, because lack of documentation and belief that visit was simply a pre-op visit. Respondent did not support the higher procedure code, but did support a code of 99202. Six: Coded 99214 for $41.49--reduced to 99213 for $26.61, because visit was problem focused to remove foreign object from patient's ear. Respondent satisfied elements of the higher procedure code. 99214 is supported. Seven: Coded 99212 for $19.84--denied, in full, because of lack of documentation. Respondent's testimony and documents show that services were performed. 99212 is supported. Nine: Coded 99213 for $24.47--denied, in full, because visit seemed to be only an interpretation on a test. Respondent did not prove otherwise. Claim is denied. Ten: Coded 99214 for $41.46--reduced to 99213 for $26.61, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. Eleven: Coded 99395 for $51.83--denied in full, because the issues had been covered during the patient's prior visit. Respondent showed that the visit was an annual periodic visit and was legitimate. 99395 is supported. Twelve: Coded 99213 for $24.47--denied, in full, because of lack of documentation and visit was only for lab work. Respondent did not prove otherwise. Claim is denied. One: Coded W9881 for $68.74--reduced to 99212 for $26.45, because visit was only a skin evaluation. Respondent showed that the patient was brought in by a state agency for a physical. W9881 is supported. One: Coded 99204 for $66.74--reduced to 99201 for $31.20, because visit was problem focused on obesity. Respondent spent time with the patient, but did not prove the elements of the higher code. 99202 would be appropriate. Two: Coded 99212 for $19.84--denied, in full, because there is no evidence of a visit. Respondent did not prove otherwise. The claim is denied. Three: Coded 99396 for $54.75--denied, in full, because of lack of medical necessity. Respondent did not prove otherwise. Claim is denied. Four: Coded 99214 for $39.46--reduced to 99211 for $12.48, because no exam was conducted. Respondent did not prove otherwise. 99211 is appropriate. Five: Coded 99212 for $19.84--denied, in full, because the visit was for a lab draw only. Respondent did not prove otherwise. 99211 is appropriate. Six: Coded 99214 for $39.46--reduced to 99211 for $12.48, because visit was only for lab work review. Respondent proved that more services were provided. 99214 is supported. Seven: Coded 99212 for $19.84--denied, in full, because of absence of face-to-face meeting. Respondent showed documentation that such a meeting occurred. 99212 is supported. Eight: Coded 99213 for $24.47--denied, in full, because no face-to-face meeting occurred. Respondent did not prove otherwise. Claim is denied. One: Coded 99204 for $68.74--reduced to 99202 for $32.71, because visit was problem focused for HIV patient. Respondent did not prove otherwise. 99202 is appropriate. Two: Coded 99385 for $49.83--denied, in full, because of lack of medical necessity. Respondent showed need for annual medical evaluation. 99385 is supported. Three: Coded 99214 for $39.46--reduced to 99213 for $26.61, because visit was problem focused. Respondent did not prove otherwise. 99213 is appropriate. Four: Coded 99214 for $39.46--reduced to 99212 for $21.84, because visit was problem focused. Respondent showed that more than a simple visit occurred. 99213 would be appropriate. Dr. Sloan, although undeniably a qualified family medicine practitioner in his own right, operates his business in a geographic area far removed from Respondent. Dr. Sloan's office is located in Chipley. Respondent's office is in central Florida, in Winter Haven. No evidence was presented to indicate how the diversity of those two areas would affect Dr. Sloan's ability to accurately address Respondent's coding. Thus, it is presumed for purposes of this proceeding that Dr. Sloan was competent to perform the review of records. Nonetheless, Respondent is uniquely positioned to evaluate the patients who came to his office. Respondent is the only witness who testified at final hearing who knows exactly what kind of treatment each such patient received. His descriptions of the office visits and interpretation of the patient charts are, therefore, given great weight. Further, Respondent's testimony was very credible as to his description of his patients and their various ailments. The assignment of charges to each code was not discussed sufficiently at final hearing for the undersigned to make any specific findings as to the proper Medicaid charges for the revised codes. That is the purview of AHCA. The fee schedule introduced into evidence contains only the maximum fee for each CPT code; it does not provide guidance in setting a fee less than the maximum. No evidence was presented to refute Respondent's description of his services to the 40 patients at issue; nor did Dr. Sloan address Respondent's explanation and interpretation of the patient charts. The Agency used the technique of "cluster sampling" to determine the amount of overpayment to Respondent. This technique, which has been upheld in Agency for Health Care Administration v. Custom Mobility, 995 So. 2d 984 (Fla. 1st DCA 2008), rev. den., Custom Mobility, Inc. v. Agency for Health Care Administration (Fla. Feb. 2, 2009), was correctly applied in the instant case. It was the cluster sampling of Respondent's 40 patients that resulted in the calculation of overpayment by AHCA.
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, setting forth the following: That each CPT code substantiated by Respondent, Hamid Bagloo, M.D., be deemed proper and that the amount paid for those office visits be allowed; That the codes validated by Respondent pursuant to his testimony at final hearing in this matter be assigned a monetary charge consistent with the Medicaid Fee Schedule; That the sum total of AHCA's overpayment to Respondent be reduced in an amount commensurate with the findings herein; and That the fine imposed against Respondent be stricken. DONE AND ENTERED this 10th day of September, 2009, in Tallahassee, Leon County, Florida. R. BRUCE MCKIBBEN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 10th day of September, 2009.
