10-010840MPI Agency For Health Care Administration vs. Florida Hospital Orlando Status: Closed Recommended Order on Wednesday, September 4, 2013.

Summary: Respondent hospital sucessfully established that some of the disputed Medicated claims were supported by records as medically necessary.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION ,

Petitioner ,

vs. Case No. 10 - 10840MPI

FLORIDA HOSPITAL ORLANDO ,

Respondent .

/

RECOMMENDED ORDER

Pursuant to notice , a formal hearing was held in this case

by video teleconference with Respondent appearing from Orlando,

and Petitioner present in Tallahassee, before J. D. Parrish, a

designated Administrative Law Judge of the Division of

Administrative Hearings (D OAH) on May 2 and 3, 2013.

APPEARANCES

For Petitioner: David W. Nam, Esquire

Agency for Health Care Administration

Fort Knox Building 3, Mail Stop 3

2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308

For Respondent: John D. Buchanan, Jr., Esquire

Henry, Buchanan, Hudson, Suber

and Carter, P.A.

Post Office Box 14079

Tallahassee, Florida 32317

STATEMEN T OF THE ISSUE S

Whether Respondent, Florida Hospital Orlando (Respondent or

FHO), was overpaid by Medicaid for care provided to patients in

the amount of $34,644.10, as alleged by Petitioner, Agency for

Health Care Administration (Petitioner or AHCA); or, as

Respondent maintains, such care was medically necessary and

supported by the record presented in this cause. Petitioner also

maintains an administrative fine in the amount of $2 , 000.00 is

warranted in this matter and that it is entitled to recover cost s

associated with the case in the sum of $7,635.27.

PRELIMINARY STATEMENT

On December 22, 2010, AHCA referred the instant matter to

DOAH for formal proceedings. Pursuant to a Medicaid audit,

Petitioner alleges Respondent was overpaid for services rendered

in connection with Medicaid claims that were identified in an

audit. Respondent asserts that the medical care and services

provided to patients associated with the disputed claims were

medically necessary; that all medical services were pre - approved

by P etitioner's fiscal agent; and that , as all medical services

were medically necessary, an administrative sanction is not

allowable in this cause. It is undisputed that Respondent timely

challenged the audit and that the matter is properly before DOAH.

At t he request of, and with the stipulation of the parties,

this case was continued on several occasions. The parties

continued to review documents related to the disputed claims and

attempted to narrow the issues to be resolved at hearing.

Respondent mainta ined that prior approval of the claims by a

fiscal agent rendered the overpayment claim moot. Initial

approval of the proposed services does not, however, equate to

the claims being Ðmedically necessaryÑ as that term is defined by

law.

At the hearing, P etitioner presented the testimony of

Johnnie L. Shepard, Shevaun Harris, Kia Tollett, and Ferdinand

Richards, M. D. AHCA Exhibits 3 through 8, 31, 32, 34 through

42, 51 through 53, and 56 were admitted into evidence.

Ross Edmundson, M. D. (by deposition ), John Busowki, M. D.

(by deposition), Susan Bihler, Tammie Rikansrud, and Christine

Howd testified on behalf of Respondent. RespondentÓs Exhibits 1

through 13 were also received in to evidence.

The T ranscript of the hearing, volumes I through IV, was

f iled on June 20, 2013. Thereafter, the parties requested and

were granted 30 days within which to file their proposed

recommended order s . The parties timely filed proposed orders

that have been fully reviewed in the preparation of this

Recommended Order. Finally, the parties' Joint Prehearing

Stipulation filed in anticipation of the hearing on April 25,

2013, has been incorporated, in pertinent part, in the findings

of fact below.

FINDING S OF FACT

1. Petitioner is the state agency charged with the

resp onsibility of monitoring the Medicaid Program in Florida.

2. Centers for Medicare and Medicaid Services ( CMS ) is the

federal agency which administers Medicare, Medicaid , and the

State Children's Health Insurance Program. CMS initiated an

audit of Respond entÓs Medicaid claims and contracted with Booz

Allen Hamilton (BAH), a Medicaid Integrity Contractor, to perform

the audit.

3. At all times material to the instant audit, Respondent

was enrolled as a Medicaid provider, governed by a Medicaid

P rovider A g reement, and subject to all pertinent Medicaid rules

and regulations related to the provision of Medicaid goods and

services to Medicaid recipients/patients. Respondent was

required to retain records documenting goods and services billed

to the Medicaid p rogram for a period of not less than five years.

All of the disputed claims occurred within that five - year period.

BAH requested medical records pertinent to the claims and FHO

produced medical records in response to BAHÓs audit. Respondent

intended to produce all of its medical records as requested by

BAH.

4. Respondent's Medicaid Provider No. was 0010129001. All

services provided to Medicaid patients are billed and identified

by patient name, date of service, and provider. For purposes of

confiden tiality, the names of patients are redacted in audit

proceedings. All goods and services billed to Medicaid must be

medically necessary. If an audit determines that goods or

services billed to Medicaid were, in fact, not medically

necessary, Petitioner i s entitled to recover monies paid as an

overpayment claim against the Medicaid provider. The amount of

the alleged overpayment is the subject of this proceeding.

5. Before a Medicaid provider is authorized to bill

Medicaid for medical goods and services rendered to a patient,

several checks are considered. First, the patient must be

Medicaid - eligible. There is no dispute that all recipients of

care in this case were Medicaid - eligible patients.

6. Second, before an inpatient stay is reimbursable, a

Medi caid provider must seek prior authorization. To do so, at

all times material to this case, AHCA enlisted the assistance of,

and contracted with, KePro South (KePro) to perform utilization

management for inpatient hospital services for Medicaid

recipients. This meant the Medicaid provider contacted KePro by

e - mail through a system known as "I - Exchange." In this case , FHO

followed the protocol and requested prior approval for all of the

claims at issue that required prior approval. All claims at

issue wer e either approved by KePro or were exempt from the

authorization requirement. Petitioner agrees that Respondent

followed all of the protocols for approval of claims through the

KePro system. Respondent agrees that all claims at issue as

identified in the final audit report (FAR) were billed and paid.

KePro approval does not mean goods and services billed to

Medicaid are, in fact, medically necessary.

7. All patient records for the claims at issue have been

re - visited in the course of this case and have been thoroughly

debated by doctors for both parties. In summary, AHCA's expert,

Dr. Ferdinand Richards, opined that the records for the disputed

claims do not support the "medical necessity" for the claims paid

by Medicaid.

8. In contrast, Dr. John Busow ski and Dr. Ross Edmundson

opined that the disputed claims were accurately billed and all

care rendered was medically necessary.

9. Medicaid has a "pay and chase" policy of paying Medicaid

claims submitted by providers. Audits performed after - the - fact

reconcile the amounts paid to providers with the amounts that

were payable under the Medicaid guidelines, pertinent rules, and

law.

10. The Medicaid provider agreement executed between the

parties governs the contractual relationship between FHO and

AHCA. The parties do not dispute that the provider agreement ,

together with the pertinent laws or regulations , control the

billing and reimbursement of the claims that remain at issue.

The provider agreement pertinent to this case was voluntarily

entered into by the parties. Although Respondent claims it could

not negotiate the terms of the agreement, it is undisputed that

Respondent agreed to be bound by the agreement. Respondent was

not obligated to become a Medicaid provider.

11. Any Medicaid provider wh ose billing is not in

compliance with the Medicaid billing policies may be subject to

the recoupment of Medicaid overpayments. Medicaid providers are

aware that they may be audited. Audits are to assure that

providers bill and receive payment in accordan ce with applicable

rules and regulations. Respondent does not dispute Petitioner's

authority to perform audits.

12. If services rendered in this case were medically

necessary, Petitioner does not dispute the amount billed as

accurately reflecting the s ervices. There is no question that

Respondent provided the services identified in the disputed

claims.

13. For billing purposes , this case centers on three types

of billing practices dictated by the medical circumstances of the

patient. A Medicaid pat ient may be treated in an emergency room

setting and once the presenting condition is addressed the stay

may be considered outpatient, observation, or inpatient depending

on the nature of the patientÓs illness. Outpatient services may

also be appropriate when a patient presents for a scheduled test

or procedure. Observation services may be appropriate when

additional time is needed to evaluate a patientÓs condition.

Inpatient care is dictated when the patient requires medical

services or treatments becau se the severity of an illness or

condition dictates an intensity of care that could not be

provided at a less acute level. The levels of care at issue in

this case are defined and specified in the Medicaid Hospital

Services Coverage and Limitation Handboo k and by Florida

Administrative Code Rule. In this case, the disputed claims

center on whether the claims were billed at the appropriate level

of care. That is, if billed at the inpatient level should the

claim have been billed as observation or outpatie nt? If billed

as observation , should the claim have been billed as outpatient?

Each disputed claim is listed and explained below. Each claim is

described and evaluated based upon the medical documentation

available to the treating physician at the time the services were

rendered. The expert opinions of the partiesÓ witnesses have

been fully considered and weighed in reaching the findings noted.

14 . The first five claims, identified as Adventist - FL - 3006,

6, 7, 8, 9 and 11, concerned a three - year - old p atient with Acute

Lymphocytic Leukemia . The child required five separate

intravenous chemotherapy treatments. The five claims ($1,503.04

per day) were billed at an inpatient rate. For each of the

claims , the patientÓs hospital stay was for less than 24 hours,

the patient had no significant complications from the treatments,

and was able to return home at the conclusion of the treatment.

Based upon the weight of the persuasive evidence in this case, it

is determined that these claims should have been bil led as

scheduled outpatient services. Petitioner is entitled to recoup

the difference between the inpatient rate and an outpatient rate

for these five claims. The amount of the overpayment is

$7,515.20.

15 . Claim Adventist - FL - 3006 - 21 concerned a 40 - year - old

morbidly obese female who went to the hospital emergency room

(ER) on July 28, 2007. This patient complained of shortness of

breath and chest pains. By history , it was known this patient

had bipolar disorder, sarcoidosis, hypertension, and a record of

being non - compliant with medications. A pulmonary function test

was administered by ER staff and it was discovered the patient

was at 50 percent of the expected function level. Although the

initial admission to inpatient status was well documented, th e

record in this case is deficient, and the physicians who reviewed

the record could not indicate why a four - day admission was

required for this patient. Once the patient was provided a

treatment for asthma (including IV steroids) and the evaluation

for c ongestive heart failure proved negative, the patient should

have been discharged. Based upon the weight of the persuasive

evidence in this case, it is determined that this claim should be

discounted to only two days of inpatient stay and not the four

days billed. The exact amount of the overpayment for this claim

cannot be determined from the evidence but is less than the

$5,723.60 claimed by Petitioner.

16 . Claim Adventist - FL - 3006 - 22, involved the same patient

as described in paragraph 14. Less than two months after the

visit described above, the patient returned to the ER with mild

wheezing, and the patient was admitted for three days as an

inpatient. Given the history of this patient, and the lack of

significant change to the presenting symptoms, i t is determined

that the weight of the persuasive evidence would require this

claim to be reduced to two days of observation, not inpatient

services. This patient did not have a medical condition to

justify a three - day stay. It may have been that the pat ient

needed a place to stay, and her shortness of breath was a

convenient excuse for her to seek medical attention ; in any

event , she did not have a medical condition of the acuity

requiring a multi - day inpatient stay. Respondent does not turn

patients aw ay. Nevertheless, Medicaid does not provide for

housing of patients who need care other than to meet medical

needs. It is undoubted Respondent provided a meaningful service

to this patient , but the level of medical care is not supported

by the record in this case. AHCA is entitled to recover

$2,717.52 for this claim.

17 . The next disputed claim, Adventist - FL - 3006 - 30,

concerned a 31 - year - old male who went to the ER after having

thrown - up blood. The patient reported a history of blood in his

stools and g astro - esophageal reflux disease. Although the

patientÓs vital signs were normal, and there was no evidence of

bleeding in the ER, the patient was admitted to the intensive

care inpatient unit (ICU) and monitored. After a period of time

in the ICU , it was noted that the patientÓs hemodynamic was

stable and he was moved to a Ðstep downÑ inpatient room. The

weight of the persuasive evidence would require this claim to be

reduced to two days of observation services not the two days of

inpatient billed. The record does not support any acuity

requiring intensive care services. Moreover, the endoscopy

resulted in normal findings. Had the endoscopy been performed on

admission, the normal findings could have ruled out the need for

inpatient services. In this c ase, the treating physician did not

think the patientÓs condition required an emergency endoscopy.

Based upon that determination and the patientÓs normal hemoglobin

and hematocrit, it was unlikely the patient required more than

observation. Giving Respon dent the benefit of the doubt with

regard to this claim, and assuming this patient required more

care than observation to rule out a more acute illness, that

determination could have easily been concluded within a one - day

inpatient stay. A HC A accepts a t wo - day observation stay for this

patient thereby reducing the overpayment to $2,716.18 for this

claim.

18 . Adventist - FL - 48 claim was a 44 - year - old male who, while

working on a ladder, touched a live electrical wire. This

patient was taken by rescue squ ad to the ER and presented with

atrial fibrillation. The patient was admitted to inpatient

status , and it was recommended he be given a full cardiac work -

up. At some point during his ER stay, and prior to the cardiac

testing, the patient returned to a no rmal cardiac rhythm.

Against the recommendation of medical staff, the patient left the

hospital. Approximately three days later this patient returned

to the ER and requested the cardiac testing he had declined on

his prior visit. When he returned, the p atient had a normal

heart rhythm, had no other symptoms to suggest a cardiac

irregularity, and had normal vital signs. Instead of billing the

cardiac testing as outpatient services, the patient was admitted

for inpatient status and given the full compleme nt of cardiac

tests to rule out any adverse cardiac condition resulting from

the electrical shock. The weight of persuasive evidence supports

that the testing should have been given with this patient in an

outpatient status. There was no medical instabil ity supporting a

more acute setting for the testing that was done. The

overpayment for this claim is $1,503.04.

19 . The patient described in Adventist - FL - 78 claim was a

63 - year - old female who went to the ER with stomach discomfort,

nausea, and headache . It was feared the patient was in a

cardiac - related condition as the patient had multiple risk

factors including atrial fibrillation. By history , the patient

had suffered a heart attack in the recent past , and the ER

physician rightly admitted the patie nt for inpatient care to

perform a cardiac work - up and to rule out any cardiac event. The

inpatient stay was for a 24 - hour period so that the testing could

be concluded. The weight of persuasive evidence supports this

stay. Respondent has shown the medi cal necessity for the

treatment provided for this patient.

20 . Adventist - FL - 96 claim concerned a patient with a

significant bone marrow disorder similar to l eukemia. The

patient had had a bone marrow transplant. Upon admission to the

hospital he suffere d nausea, vomiting, and abdominal pain. He

was admitted for a one - day inpatient stay and treated for

dehydration. He was given a white blood count test and once

stabilized was discharged (within 24 hours) with the

recommendation that the patient return t o his regular provider in

Tampa. The weight of persuasive evidence supports this stay.

Respondent has shown the medical necessity for the treatment

provided for this patient.

21 . The patient in Adventist - FL - 98 claim was a 45 - year - old

male with a history of Chronic Obstructive Pulmonary Disease

(COPD), smoking, and alcohol abuse. The patient had a history of

hospitalizations related to COPD and upon admission complained of

shortness of breath. At the time of admission, the patient had

normal vital signs , acceptable oxygen saturation levels, no

wheezing, and a chest x - ray that showed no acute abnormalities.

The weight of persuasive evidence supports the finding that a

level of care of observation, and not inpatient, was the correct

level Respondent shoul d have billed for this patient. The

patient had no medical acuity to support a one - day inpatient

stay. AHCA is entitled to recover the overpayment in the amount

of $1,358.09.

22 . AHCA no longer disputes Adventist - FL - 154 claim.

Consequently, the overpay ment associated with the audit must be

reduced by $3,856.68. It is determined Respondent accurately

billed for this claim.

23 . Similarly, Respondent no longer disputes claims

Adventist - FL - 155 - 156. These claims should have been billed as

observation, not inpatient stays. Accordingly, Petitioner is

entitled to recover the overpayment associated with these claims

in the amount of $2,672.98.

24 . The patient associated with Adventist - FL - 180 claim was

a 53 - year - old female with a history of breast cancer and

metastatic disease. On the date of her admission , she had had

radiation therapy. She suffered nausea and vomiting and

presented to the ER. She received an IV of fluids and IV Zofran,

felt better, and left the hospital against medical advice. In

total, the patient was in the hospital approximately three hours

or less. The claim billed her admission as inpatient. This

claim should have been billed as observation. Accordingly, the

weight of persuasive evidence supports that an overpayment

occurred with regard to this claim. Petitioner is entitled to

recover the difference between inpatient and observation for this

patient. The amount of the overpayment is unknown.

25 . With regard to Adventist - FL - 230 claim, this patient was

a 58 - year - old male complai ning of shortness of breath with a

history of atrial fibrillation. The patient was admitted for a

five - day inpatient admission. Respondent was paid for a four - day

inpatient stay because that length of stay was approved by KePro.

Petitioner disputes that an inpatient stay was required. The

weight of persuasive evidence supports an inpatient stay of three

days. The patient had stabilized, testing had been completed,

and there was no significant medical basis for an inpatient stay

beyond that point. The amount of the overpayment is unknown as

the audit sought reimbursement at an observation rate. Although

not entitled to the four days of inpatient as billed for this

patient, Respondent has established it was entitled to a three -

day inpatient compensation based upon the medical necessity

established for this patient.

26 . Respon dent, and other providers may adjust Medicaid

billings after - the - fact to conform to medical necessity for any

claim filed. In this case, Respondent did not review its claims

once K ePro approval had been secured. That is to say, if the

KePro approval was documented, Respondent did not question the

claim for medical necessity once treatment was given. Billings

were adjusted to conform to KePro approval , but were not

questioned or re - visited as to whether the appropriate level of

acuity was documented.

27 . Petitioner asserts that Respondent failed to submit the

complete medical records for Adventist - FL - 98 claim until after

the audit was issued. RespondentÓs response that it provid ed all

medical records timely to the auditor, BAH, is accepted. It is

unlikely the records of one claim would have been omitted from

the hundreds of pages of records given to the auditor. BAH

conducted their audit over an extensive period of time. The

I nterim Audit Report was issued on October 4, 2010. The

overpayment at that time was alleged to be $42,848.29. That

amount was also noted in the FAR dated November 16, 2010.

Concurrent with the FAR , Petitioner announced its intention to

impose sanctions against FHO. The July 20, 2011, audit report

reduced the overpayment to $38,790.68 , but again claimed

Petitioner was entitled to impose sanctions. The June 12, 2012,

audit report further reduced the overpayment to $38,500.78.

Subsequent to the hearing, Petitioner acknowledged that the

overpayment should be reduced another $3,856.68 to $34,644.10.

28 . Petitioner incurred investigative and legal costs in

connection with this case in the amount of $7,635.27. Respondent

has not challenged the reasonablen ess of that amount.

29 . Petitioner seeks sanctions against Respondent in the

amount of $2,000.00.

30 . Respondent submitted records to BAH for 285 claims that

had to be reviewed. Of that total, only those claims addressed

above remain at issue. Ninety - four percent of the claims

reviewed/audited by BAH were resolved without dispute.

CONCLUSIONS OF LAW

31 . DOAH has jurisdiction over the parties to and the

subject matter of these proceedings. § 120.57(1), Fla. Stat.

32 . All provisions of Florida law applicable to this case

have essentially remained the same for the period 2006 - 2012. The

parties have not challenged the provisions of law that would have

been in effect at the time of the claims, the audit, or the final

hearing in this cause. While the numbering of some provisions

may have changed, the verbiage has remained the same. The

citations to law noted herein are consistent with those cited by

the parties.

33 . Pursuant to c hapter 409, Florida Statutes, Petitioner

is responsible for administerin g the Medicaid Program in Florida.

34 . As the party asserting the overpayment, Petitioner

bears the burden of proof to establish the alleged overpayment by

a preponderance of the evidence. Southpointe Pharmacy v. Dep Ó t

of HRS , 596 So. 2d 106 (Fla. 1st DCA 1992). AHCA has failed, in

part, to meet its burden.

35 . Section 409.913, Florida Statutes, provides, in

pertinent part:

The agency shall operate a program to oversee

the activities of Florida Medicaid

recipients, and providers and their

representa tives, to ensure that fraudulent

and abusive behavior and neglect of

recipients occur to the minimum extent

possible, and to recover overpayments and

impose sanctions as appropriate.

(1) For the purposes of this section, the

term:

* * *

(e) " Overpayment" includes any amount that

is not authorized to be paid by the Medicaid

program whether paid as a result of

inaccurate or improper cost reporting,

improper claiming, unacceptable practices,

fraud, abuse, or mistake.

* * *

(7) When pre senting a claim for payment

under the Medicaid program, a provider has an

affirmative duty to supervise the provision

of, and be responsible for, goods and

services claimed to have been provided, to

supervise and be responsible for preparation

and submissi on of the claim, and to present a

claim that is true and accurate and that is

for goods and services that:

* * *

(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.

* * *

(21) When making a determination that an

overpayment has occurred, the agency shall

prepare and issue an audit report to the

provider showing the calculation of

overpayments.

36 . In this case , Petitio ner seeks reimbursement of

overpayments based upon the lack of medical necessity for the

disputed claims. Section 409.913(1)(d), Florida Statutes,

provides:

(d) ÐMedical necessityÑ or Ðmedically

necessaryÑ means any goods or services

necessary to palliat e the effects of a

terminal condition, or to prevent, diagnose,

correct, cure, alleviate, or preclude

deterioration of a condition that threatens

life, causes pain or suffering, or results in

illness or infirmity, which goods or services

are provided in ac cordance with generally

accepted standards of medical practice. For

purposes of determining Medicaid

reimbursement, the agency is the final

arbiter of medical necessity. Determinations

of medical necessity must be made by a

licensed physician employed by or under

contract with the agency and must be based

upon information available at the time the

goods or services are provided.

37 . In this case, although the audit supports the

overpayment claimed, it must be adjusted in light of the totality

of the evi dence presented in this cause. Petitioner acknowledged

subsequent to hearing that Adventist - FL - 154 was correct thereby

reducing RespondentÓs overpayment by $3,856.68. Respondent

acknowledged Adventist - FL - 155, 156 claims were overpayments.

More important , Respondent presented substantial, credible

evidence to establish medical necessity for portions of the

remaining disputed claims. The findings set forth above

chronicle the medical necessity for the patients treated claim by

claim . The overpayment clai med by Petitioner must be adjusted to

conform to the findings reached in this case.

38 . With regard to sanctions, Petitioner maintains

Respondent should be required to remit $2,000.00 in sanctions for

failure to submit complete records or failure to acc urately bill

Medicaid as required by law. It is concluded Respondent did not

fail to submit complete records. RespondentÓs contention that it

timely submitted records as required by BAH is accepted.

39 . As to the inaccuracy of its billings, Respondent has

attempted to explain and has successfully defended its Medicaid

billing related to several of the disputed claims. This case

demonstrated on more than one claim that reasonable medical minds

may differ as to the prudent course of treatment for a pati ent.

Respondent erred in providing a higher level of care than was

medically necessary based upon the acuity of the patient. While

commendable from a social standpoint, Medicaid provisions do not

allow reimbursement on that basis. Even so, the inaccurat e

records would not support a sanction in the amount sought.

Petitioner should recover a sanction in the amount of $500.00 not

$2,000.00 as charged.

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 adjusting the recoupment for

the Medicaid overpayment as indicated in the foregoing findings

of fact, imposing a sanction in the amount of $500.00, and

recovering its costs in the amount of $7,635.2 7.

DONE AND ENTERED this 4 th day of September , 2013 , in

Tallahassee, Leon County, Florida.

S

J. D. PARRISH

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahasse e, 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 4 th day of September , 2013 .

COPIES FURNISHED:

John D. Buchanan, Jr., Esquire

Henry, Buchanan, Huds on,

Suber, and Carter, P.A.

Post Office Drawer 14079

2508 Barrington Circle (32308)

Tallahassee, Florida 32317 - 4079

David W. Nam, Esquire

Agency for Health Care Administration

Fort Knox Building 3, Mail Stop 3

2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308

Richard Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

Elizabeth Dudek, Secretary

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 1

Tallahassee, Florida 32308

Stuart Williams, General Counsel

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from th e 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.