04-001279MPI Arnaldo R. Quinones, M.D. vs. Agency For Health Care Administration Status: Closed Recommended Order on Thursday, January 20, 2005.

Summary: A Medicaid provider should be required to repay overpayment for unnecessary services and over-billings.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

ARNALDO R. QUINONES, M.D., )

)

Petitioner, )

)

vs. ) Case No. 04 - 1279MPI

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED O RDER

Pursuant to notice, a final hearing was conducted on

August 19 and 20, 2004, in Miami, Florida, before Administrative

Law Judge Claude B. Arrington of the Division of Administrative

Hearings (DOAH).

APPEARANCES

For Petitioner: Louise T. Jerosl ow, Esquire

Law Offices of Louise T. Jeroslow

6075 Sunset Drive, Suite 201

Miami, Florida 33143

For Respondent: Jeffries H. Duvall, Esquire

Agency for Health Ca re Administration

Fort Knox Building III, Mail Station 3

2727 Mahan Drive

Tallahassee, Florida 32308

STATEMENT OF THE ISSUE

Whether Petitioner was overpaid by the Florida Medicaid

Program and, if so, the amount of the overpayment.

PRELIMINARY STATEMENT

Respondent administers the Florida Medicaid Program.

Petitioner, a licensed physician, was enrolled as a Medicaid

provider with the Florida Medicaid Program during the subject

Audit Peri od (January 1, 1996 through May 10, 1999). Following

its audit, Respondent issued a Final Agency Audit Report (FAAR),

which asserted that Petitioner had been overpaid by the Florida

Medicaid Program in the amount of $261,336.14, and demanded

repayment of that amount.

Petitioner timely requested a formal hearing to challenge

Respondent’s determinations as reflected by the FAAR, the matter

was referred to DOAH, and this proceeding followed.

At the final hearing, Respondent presented its case first

to exped ite the presentation of the evidence. Respondent

presented the live testimony of Pamela Langford, the deposition

testimony of Dr. Joseph Shands (filed at the formal hearing),

and the deposition testimony of Dr. Jeffrey P. Nadler (taken

post - hearing and la te - filed). Respondent offered 12

sequentially numbered exhibits, each of which was admitted into

evidence. The deposition of Dr. Nadler, filed October 29, 2004,

has been marked as Respondent’s Exhibit 13 and admitted into

evidence. Respondent’s Exhibit 9 is a composite exhibit

consisting of medical records for services to the 25 patients at

issue, together with worksheets pertaining to the Medicaid

billings for those services. Petitioner testified on his own

behalf and offered 13 sequentially marked exh ibits, each of

which was admitted into evidence. Official Recognition was

taken of Chapter 409, Florida Statutes (1999). 1 On the joint

motion of the parties, the deadline for the filing of proposed

recommended orders (PROs) was extended to close of busin ess on

December 6, 2004.

A Transcript of the proceedings was filed on September 22,

2004. Each party filed a PRO, which has been duly - considered by

the undersigned in the preparation of this Recommended Order.

FINDINGS OF FACT

1. At all times materia l to this proceeding, Respondent

has been the state agency charged with responsibility for

overseeing the Florida Medicaid Program, including the recovery

of overpayments to Medicaid providers pursuant to Section

409.913, Florida Statutes.

2. At all times material to this proceeding, Petitioner

was an authorized Medicaid provider, having been issued provider

number 377290000. Petitioner had valid Medicaid Provider

Agreements with the Agency for Health Care Administration (AHCA)

during the Audit Period, wh ich began on January 1, 1996, and

ended on May 10, 1999.

3. Petitioner graduated from the University of Puerto Rico

School of Medicine in 1987, did an internship at Tulane

University, did a residency in internal medicine at Eastern

Virginia Graduate Med ical School, and did a fellowship in

hematology at Washington Hospital Center. He served as Chief of

Hematology for Kessler Medical Center in Biloxi, Mississippi,

while serving in the United States Air Force (with the rank of

major). At the time of the f inal hearing, Petitioner was

licensed to practice medicine in Florida, Virginia, Puerto Rico,

and Washington, D.C. At the time of the final hearing,

Petitioner was employed by the National Institutes of Health

(NIH) as a Medical Officer, Health Scientist Administrator.

Petitioner served as an advisor to the director of the NIH on

issues related to HIV (human immunodeficiency virus) and AIDS

(acquired immunodeficiency syndrome).

4. Petitioner’s specialty is internal medicine with a sub -

specialty in hema tology. Petitioner has extensive experience

treating persons suffering with HIV and AIDS dating back to

1987.

5. Pursuant to his Medicaid Provider Agreements,

Petitioner agreed to: (1) retain for five years complete and

accurate medical records that f ully justify and disclose the

extent of the services rendered and billings made under the

Medicaid program; (2) bill Medicaid only for services or goods

that are medically necessary; and (3) abide by the Florida

Administrative Code, Florida Statutes, polic ies, procedures,

manuals of the Florida Medicaid Program and Federal laws and

regulations.

6. Respondent audited Petitioner’s Medicaid claims during

the Audit Period and conducted a peer review of Petitioner’s

billings and medical records of 25 of Petitio ner’s patients as

part of that audit. 2 Joseph W. Shands, M.D., conducted the peer

review of the documentation provided by Petitioner for purposes

of the audit conducted by AHCA. Dr. Shands first reviewed

documentation provided by Petitioner in 1999. He had no further

participation in the audit until he reviewed information in

preparation for his deposition in this proceeding.

7. Dr. Shands graduated from medical school in 1956,

trained in internal medicine, and worked as a microbiologist for

approximate ly 15 years. He served as Chief of Infectious

Diseases at the University of Florida for 23 years and also

treated patients through the Alachua County Public Health

Department and Shands Hospital at the University of Florida.

Dr. Shands' practice was devo ted almost entirely to the

treatment of patients diagnosed with HIV/AIDS.

8. Dr. Shands retired from the practice of medicine in

May 2002. For three years prior to his retirement, Dr. Shands

practiced medicine part - time.

9. Petitioner was sent a Preli minary Agency Audit Report

(PAAR) dated May 25, 1999, that found an overpayment in the

amount of $862,576.72. In response to that PAAR, Petitioner had

the attorney representing him at that time respond to AHCA in

writing. The letter from the attorney, da ted June 2, 1999,

requested a copy of AHCA’s supporting materials and

clarification of certain matters. AHCA did not respond.

10. AHCA issued its FAAR on January 22, 2004, asserting

that Petitioner was overpaid by the Florida Medicaid Program in

the tota l amount of $261,336.14 for services that in whole or in

part were not covered by Medicaid. There was no plausible

explanation why the FAAR was not issued until 2004, whereas the

audit period ended in 1999. The difference between the amount

of the allege d overpayment reflected by the PAAR and the amount

of the alleged overpayment reflected by the FAAR is attributable

to the use of different methodologies in calculating the amounts

overpaid. The FAAR used the correct methodology that was not

challenged by Petitioner.

11. The FAAR sets forth five categories of alleged

overpayments. Each category accurately describes an overpayment

based on applicable Medicaid billing criteria. The five

categories are as follows:

Medicaid policy specifies how medical

records must be maintained. A review of

your medical records revealed that some

service for which you billed and received

payment were not documented. Medicaid

requires documentation of the services and

considers payments made for services not

appropriat ely documented an overpayment.

(For ease of reference, this will be

referred to as Category I.)

Medicaid policy defines the varying levels

of care and expertise required for the

evaluation and management procedure codes

for office visits. The documenta tion you

provided supports a lower level of office

visit than the one for which you billed and

received payment. The difference between

the amount you were paid and the correct

payment for the appropriate level of service

is considered an overpayment. (F or ease of

reference, this will be referred to as

Category II.)

Medicaid policy addresses the type of

pathology services covered by Medicaid. You

billed and received payment for laboratory

tests that were performed outside your

facility by an independen t laboratory.

Payments made to you in these instances are

considered overpayments. (For ease of

reference, this will be referred to as

Category III.)

Medicaid policy requires the Medicaid

services be provided by or under the

personal supervision of a p hysician.

Personal supervision is defined as the

physician being in the building when the

services are rendered and signing and dating

the medical records within twenty - four hours

of service delivery. You billed and

received payment for services which yo ur

medical records reflect you neither

personally provided nor supervised. Payment

made to you for all or a part of those

services is considered an overpayment. (For

ease of reference, this will be referred to

as Category IV.)

Medicaid policy requires services

performed be medically necessary for the

diagnosis and treatment of an illness. You

billed and received payments for services

for which the medical records, when reviewed

by a Medicaid physician consultant,

indicated that the services provided di d not

meet the Medicaid criteria for medical

necessity. The claims which were considered

medically unnecessary were disallowed and

the money you were paid for these procedures

is considered an overpayment. (For ease of

reference, this will be referred to as

Category V.)

CATEGORY I CLAIMS

12. The disputed Category I claims can be separated into

two subcategories: services performed while an employee of a

corporate employer and services performed while a recipient was

hospitalized. As to both subcategori es Petitioner argues that

he has been prejudiced by Respondent’s delay in issuing the FAAR

because Medicaid requires providers to retain medical records

only for five years from the date of service. 3 Although

Respondent was dilatory in prosecuting this ma tter, Petitioner’s

argument that Respondent should be barred (presumably on

equitable grounds such as the doctrine of laches) should be

rejected. Petitioner has cited no case law in support of his

contention, and it is clear that any equitable relief to w hich

Petitioner may be entitled should come from a court of competent

jurisdiction, not from this forum or from an administrative

agency. All billings for which there are no medical records

justifying the services rendered should be denied.

CATEGOR Y II CLAIMS

13. The following findings as to the Category II claims

are based on the testimony of the witnesses and on the

information contained in the exhibits. 4 Although nothing in the

record prior to the final hearing reflects that position,

Petition er did not dispute most of the down - codings at the final

hearing. Office visits, whether supported by a doctor’s note or

a nurse’s note, for the sole purpose of administering IVIG

treatment, will be discussed in the section of this Recommended

Order deali ng with Category V claims. The office visits, which

were for the purpose of intravenous immunoglobulin (IVIG)

treatment and for other reimbursable medical services, are set

forth as part of the Category II disputes.

14. The following findings resolve t he Category II

disputes. The date listed is the date the service was rendered.

The billing code following the date is the billing code that is

supported by the greater weight of the evidence.

Recipient 1: 5

01 - 20 - 98 99213

Recipient 2

09 - 27 - 96 99214

10 - 10 - 96 992 13

11 - 13 - 96 99214

12 - 23 - 96 99212

02 - 24 - 97 99214

04 - 21 - 97 99213

04 - 28 - 97 99214

05 - 21 - 97 99213

06 - 02 - 97 99213

07 - 09 - 97 99213

07 - 23 - 97 99212

08 - 06 - 97 99213

08 - 11 - 97 99212

10 - 01 - 97 99213

10 - 10 - 97 99213

10 - 15 - 97 99214

10 - 21 - 97 99214

11 - 10 - 97 99213

12 - 08 - 97 99213

12 - 17 - 97 99213

12 - 29 - 97 99213

01 - 21 - 98 99213

Recipient 3

10 - 21 - 97 99213

11 - 04 - 97 99213

11 - 25 - 97 99213

12 - 16 - 97 99213

01 - 27 - 98 99214

02 - 26 - 98 99214

Recipient 4

01 - 03 - 98 99254

01 - 04 - 98 99261

01 - 05 - 98 99261

Recipient 5

09 - 29 - 97 99204

Recipient 6

11 - 11 - 97 99204

11 - 18 - 97 99213

Recipient 7

01 - 26 - 98 99204

02 - 23 - 98 99213

Recipient 8

09 - 26 - 96 99214

09 - 30 - 96 99213

10 - 03 - 96 99213

10 - 10 - 96 99212

10 - 25 - 96 99214

11 - 29 - 96 99213

12 - 04 - 96 99213

12 - 30 - 96 99213

01 - 22 - 97 99214

01 - 31 - 97 99211

02 - 14 - 97 99212

03 - 17 - 97 99214

04 - 04 - 97 99213

04 - 25 - 97 99212

05 - 30 - 97 99211

07 - 11 - 97 99213

08 - 08 - 97 99213

08 - 22 - 97 99213

09 - 05 - 97 9 9212

09 - 19 - 97 99214

10 - 31 - 97 99214

11 - 24 - 97 99214

12 - 03 - 97 99213

12 - 29 - 97 99213

01 - 09 - 98 99214

01 - 16 - 98 99213

01 - 30 - 98 99214

02 - 13 - 98 99214

Recipient 9

11 - 24 - 97 99203

Recipient 10

10 - 14 - 96 99205

11 - 04 - 96 99213

11 - 11 - 96 99213

11 - 25 - 96 99214

12 - 30 - 96 99213

01 - 27 - 97 99214

02 - 24 - 97 99214

03 - 10 - 97 99213

03 - 24 - 97 99212

04 - 07 - 97 99213

04 - 21 - 97 99214

05 - 05 - 97 99212

05 - 19 - 97 99213

05 - 21 - 97 Deny

06 - 09 - 97 99213

07 - 07 - 97 99212

08 - 04 - 97 99213

08 - 18 - 97 99213

09 - 24 - 97 99213 6

10 - 06 - 97 99213

10 - 10 - 97 99214

10 - 27 - 97 99213

11 - 10 - 97 99213

11 - 19 - 97 99214

11 - 24 - 97 99213

12 - 08 - 97 99 213

02 - 02 - 98 99213

Recipient 11

06 - 30 - 97 99204

11 - 06 - 97 Deny due to lack of

documentation.

Recipient 12

10 - 14 - 97 99213

11 - 06 - 97 99204

11 - 20 - 97 99213

12 - 16 - 97 99213

01 - 06 - 98 99213

Recipient 13

There are no Category II billings at issue

for this Recipient.

Recipient 14

There are no Category II billings at issue

for this Recipient.

Recipient 15

09 - 16 - 97 99215 7

Recipient 16

02 - 19 - 98 99212

Recipient 17

There are no Category II billings at issue

for this Recipient.

Recipient 18

There are no Category II billings at issue

for this Recipien t.

Recipient 19

09 - 27 - 96 99212

10 - 01 - 96 99213

10 - 10 - 96 99213

10 - 23 - 96 99213

11 - 06 - 96 99213

11 - 20 - 96 99213

12 - 18 - 96 99211

12 - 30 - 96 Deny due to lack of

documentation.

01 - 09 - 97 Deny due to lack of

documentation.

01 - 22 - 97 99211

02 - 05 - 97 99214

03 - 05 - 97 99214

03 - 19 - 97 99211

03 - 24 - 97 99214

03 - 26 - 97 Deny due to lack of

documentation.

04 - 02 - 97 99213

04 - 21 - 97 99213

05 - 05 - 97 99212

05 - 19 - 97 99213

06 - 02 - 97 99212

06 - 30 - 97 99213

07 - 07 - 97 99213

07 - 14 - 97 99213

07 - 28 - 97 99212

08 - 18 - 97 99213

08 - 25 - 97 99213

09 - 08 - 97 99213

09 - 15 - 97 99214

09 - 22 - 97 99213

10 - 28 - 97 99214

11 - 04 - 97 Deny due to lack of

documentation.

11 - 07 - 97 99213

11 - 24 - 97 99213

12 - 29 - 97 99213

01 - 12 - 98 99213

01 - 26 - 98 99213

02 - 19 - 98 99214

02 - 23 - 98 99213

Recipient 20

12 - 04 - 96 99204

12 - 13 - 96 99213

01 - 03 - 97 99213

01 - 17 - 97 99213

01 - 27 - 97 99213

02 - 07 - 97 99214

02 - 21 - 97 99213

03 - 07 - 97 99214

03 - 21 - 97 99212

04 - 04 - 97 99214

04 - 21 - 97 99212

05 - 06 - 97 99213

06 - 04 - 97 99213

06 - 13 - 97 99213

06 - 30 - 97 99213

07 - 14 - 97 99213

08 - 04 - 97 99213

01 - 19 - 98 99213

Recipient 21

04 - 29 - 97 99204

05 - 13 - 97 99214

05 - 16 - 97 99213

05 - 23 - 97 99212

06 - 09 - 97 99212

06 - 23 - 97 99212

07 - 11 - 97 99211

07 - 25 - 97 99213

08 - 11 - 97 99213

09 - 10 - 97 99213

11 - 05 - 97 99214

11 - 19 - 97 99213

12 - 22 - 97 99213

01 - 07 - 98 99214

01 - 21 - 98 99213

02 - 04 - 98 99213

Recipient 22

02 - 16 - 98 99205

02 - 20 - 98 99213

02 - 23 - 98 99213

Recipient 23

06 - 23 - 97 99215

10 - 02 - 97 99213 8

Recipient 24

There are no Category II billings at issue

for this Recipient.

Recipient 25

01 - 24 - 97 99213

02 - 07 - 97 99213

02 - 24 - 97 99212

03 - 10 - 97 99213

03 - 24 - 97 99212

05 - 05 - 97 99212

05 - 19 - 97 99212

06 - 02 - 97 99212

06 - 16 - 97 99212

07 - 14 - 97 99213

07 - 23 - 97 99212

07 - 28 - 97 99213

08 - 18 - 97 99213

08 - 25 - 97 99213

09 - 15 - 97 99213

10 - 01 - 97 99213

10 - 13 - 97 99213

10 - 27 - 97 99214

12 - 08 - 97 99213

12 - 22 - 97 99213

12 - 29 - 97 99213

01 - 13 - 98 99212

01 - 19 - 98 99214

02 - 02 - 98 99212

CATEGORY III

15. As set forth in the Physician Coverage and Limitation

Handbook (Respondent’s Exhibit 6), Petitioner is not entitled to

billings for laboratory tests that were performed outside his

facility by an independent laboratory. The only billing

arguably in Category III is the billing for Recipient 1 on

February 19, 1998. That billing should have been approved

because it was for a urinalysis by dip stick or tablet that was

administered and analyzed by Petitioner. It was not analyzed by

an independent laboratory.

CATEGORY IV

16. All Category IV billings pertained to Petitioner’s

supervision of his staff while patients were receiving

treatments of IVIG. Those billings will be subsumed in the

Category V billings discussion.

CATEGORY V

17. The alleged Category V overpayments relate to

Petitioner’s IVIG treatment of Patients 2, 8, 10, 19, 20, 21,

and 25, each of whom was an adult diagnosed with AIDS. In many

of these cases a nurse adm inistered the IVIG treatment. A

dispute as to whether Petitioner properly supervised the nurse

while he or she administered the IVIG treatment is moot because

of the findings pertaining to the IVIG treatments set forth in

Paragraphs 20 and 21.

18. The Physician Coverage and Limitations Handbook

requires that rendered services be medically necessary, as

follows:

Medicaid reimburses for services that are

determined medically necessary and do not

duplicate another provider’s service. In

addition, the se rvices must meet the

following criteria:

the services must be individualized,

specific, consistent with symptoms or

confirmed diagnosis of the illness or injury

under treatment, and not in excess of the

recipient’s needs;

the services cannot be experim ental or

investigational;

the services must reflect the level of

services that can be safely furnished, and

for which no equally effective and more

conservative or less costly treatment is

available statewide; and

the services must be furnished in a m anner

not primarily intended for the convenience

of the recipient, the recipient’s caretaker,

or the provider.

19. The use of IVIG in adult AIDS patients is not approved

by the Federal Drug Administration (FDA). The use of a drug for

a purpose other tha n the uses approved by the FDA is referred to

as an “off - label” use. The off - label use of IVIG in adult AIDS

patients is not effective either from a medical standpoint or

from an economic standpoint. There was a conflict in the

evidence as to whether any of the Recipients at issue in this

proceeding had a medical condition or conditions other than AIDS

that would justify the IVIG treatment administered by

Petitioner. The following finding resolves that conflict.

Utilizing applicable Medicaid billing cri teria, the medical

records produced by Petitioner fail to document that any of the

Recipients at issue in this proceeding had a medical condition

or conditions that warranted treatment with IVIG. 9

20. All of Petitioner’s billings for IVIG treatments f or

Recipients 2, 8, 10, 19, 20, 21, and 25 were properly denied

under the rationale of the FAAR’s Category V. Included in the

billings that were properly denied were billings for office

visits (whether documented by a doctor’s note or a nurse’s note)

when the sole purpose of the office visit was the administration

of an IVIG treatment.

CONCLUSIONS OF LAW

21. The Division of Administrative Hearings has

jurisdiction over the subject matter of this proceeding and of

the parties thereto pursuant to Section s 120.569 and 120.57(1),

Florida Statutes (2004).

22. An "overpayment" is defined by Section 409.913(1)(d),

Florida Statutes, to include "any amount that is not authorized

to be paid by the Medicaid program whether paid as a result of

inaccurate or improp er cost reporting, improper claiming,

unacceptable practices, fraud, abuse, or mistake." Respondent

is empowered to recover overpayments. Section 409.913(10),

Florida Statutes, provides part that:

(10) The agency may require repayment for

inappropri ate, medically unnecessary, or

excessive goods or services from the person

furnishing them, the person under whose

supervision they were furnished, or the

person causing them to be furnished.

23. AHCA has the burden of proving an alleged Medicaid

overpay ment by a preponderance of the evidence. South Medical

Services, Inc. v. Agency for Health Care Admin. , 653 So. 2d 440,

441 (Fla. 3d DCA 1995); Southpointe Pharmacy v. Department of

Health and Rehabilitative Services , 596 So. 2d 106, 109 (Fla.

1st DCA 199 2).

24. Pertinent to this proceeding, Section 409.913(7),

Florida Statutes, spells out the duties of providers who make

claims under Medicaid:

(7) When presenting a claim for payment

under the Medicaid program, a provider has

an affirmative duty to sup ervise the

provision of, and be responsible for, goods

and services claimed to have been provided,

to supervise and be responsible for

preparation and submission of the claim, and

to present a claim that is true and accurate

and that is for goods and servi ces that:

* * *

(b) Are Medicaid - covered goods or services

that are medically necessary.

* * *

(e) Are provided in accord with applicable

provisions of all Medicaid rules,

regulations, handbooks, and policies and in

accordance with federal, state, and local

law.

(f) Are documented by records made at the

time the goods or services were provided,

demonstrating the medical necessity for the

goods or services rendered. Medicaid goods

or services are excessive or not medically

necessary unless both the medical basis and

the specific need for them are fully and

properly documented in the recipient's

medical record.

25. Respondent has met its burden of proving by a

preponderance of the evidence that Petitioner received

overpayments from the Med icaid Program. The amount of that

overpayment should be recomputed by Respondent’s staff based on

the findings of fact set forth in this Recommended Order.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that the Agency for Health Care

Administration enter a final order adopting the Findings of Fact

and Conclusions of Law set forth in this Recommended Order. It

is further RECOMMENDED that the Final Order require that

Petitioner repay the sum of the overp ayment as determined by

Respondent’s staff based on the Findings of Fact set forth in

this Recommended Order.

DONE AND ENTERED this 20th day of January, 2005, in

Tallahassee, Leon County, Florida.

S

CLAUDE B. ARRINGTON

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675 SUNCOM 278 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 20th day of January, 2005.

ENDNOTES

1/ All references to statutes are to Florida Statutes (1999),

unless otherwise indicated, and all references to rules are to

the version published in Florida Administrative Code in eff ect

as of the date of the FAAR.

2/ The selected patients were chosen at random by computer using

a program routinely employed by Respondent in conducting such

audits. The medical records, to the extent they were available,

were provided by Petitioner. The billings, records, and the

audit worksheets constitute Respondent’s composite Exhibit 9.

Although the patients are identified in the medical records by

name or initials, the undersigned will refer to the patients

numerically consistent with the numbe ring set forth on the audit

worksheets.

3/ Chapter 5 of the Medicaid Provider Reimbursement Handbook

provides the following record retention requirement:

The provider must retain professional and

business records on all services provided to

all Medi caid recipients. All fiscal records

must be retained. These records must be

kept for a period of five years from the

date of service.

4/ In particular, the medical records of the various patients

have been reviewed as have the exhibits setting fort h the

Medicaid billing criteria, including the criteria for the

billing codes for the various services of providers. Much of

the dispute centered on the proper level of coding for a

particular office visit or other service. Petitioner’s billing

codes wer e frequently reduced by Dr. Shands, a process referred

to as down - coding, based on the criteria for the different

codes, including complexity of the service and the time expended

by the provider. Typically, a lower billing code for a category

of services (such as office visits) will result in a lower

Medicaid reimbursement. For example, a billing code of 99213

entitles the provider to a lower reimbursement than a billing

code of 99214.

5/ Due to an error, the only billing overpayments claimed for

this Recipient were on the second page of the two - page

worksheet. The billing overpayments the peer reviewer

identified on the first page of the worksheet are not at issue

in this proceeding.

6/ The records supporting this billing were misdated.

7/ The records supporting this billing were misdated.

8/ The records supporting this billing were misdated.

9/ In reaching these findings, the undersigned has carefully

considered the Petitioner’s testimony pertaining to each

Recipient who was administered IV IG treatment, which included

the reasons he believed justified the treatment, and the medical

records provided by Petitioner to Respondent. The undersigned

is persuaded by the testimony of Dr. Shands, who reviewed the

medical records for each Recipient wh o had been treated with

IVIG, and whose testimony is consistent with the findings made,

and the failure of Petitioner to demonstrate documentation in

his medical records that would justify IVIG treatment. The

undersigned has also considered the literature submitted by

Petitioner, but finds that the principal authority he relied

upon, a 1996 study led by a German doctor named Kiehl, should

not be credited because of the flawed methodology of the study.

COPIES FURNISHED :

Jeffries H. Duvall, Esquire

A gency for Health Care Administration

Fort Knox Building III, Mail Station 3

2727 Mahan Drive

Tallahassee, Florida 32308

Arnaldo R. Quinones, M.D.

3725 Ingalls Avenue

Alexandria, Virginia 22302

Louise T. Jeroslow, Esquire

Law Offices of Louise T. Jerosl ow

6075 Sunset Drive, Suite 201

Miami, Florida 33143

Charlene Thompson, Acting Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308

Valda Clark Christian, General Counsel

Agency for Health Care Administration

Fort Knox Building

2727 Mahan Drive

Tallahassee, Florida 32308

Alan Levine, Secretary

Agency for Health Care Administration

Fort Knox Building, Suite 3116

2727 Mahan Drive

Tallahassee, Florida 32308

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.