16-005641MPI Agency For Health Care Administration vs. Ronald M. Marini, D.M.D., P.A. Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Wednesday, December 6, 2017.

Summary: Respondent received Medicaid overpayments that Petitioner is entitled to recover. Petitioner is also entitled to recover its costs and impose sanctions against Respondent.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Petitioner,

vs. Case No. 16 - 5641MPI

RONALD M. MARINI, D.M.D., P.A.,

Respondent.

_______________________________/

RECOMMENDED ORDER

Pursua nt to notice, a final hearing in this cause was held

by video teleconference between sites in Orlando and Tallahassee,

Florida, on June 28 and 29, 2017, before Linzie F. Bogan,

Administrative Law Judge of the Division of Administrative

Hearings.

APPEARANCE S

For Petitioner: Ephraim Durand Livingston, Esquire 1/

Kevin Douglas Dewar, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

For Respondent: Lance O. Leider, Esquire

Michelle Bedoya, Esquire

The Health Law Firm

1101 Douglas Avenue

Altamonte Springs, Florida 32714

STATEMENT OF THE ISSUE S

Whether Ronald M. Marini, D.M.D., P.A. (Respondent) , received

Medicaid overpayments that the Agency for Health Care

Administration is entitled to recover ; and whether sanctions and

costs should be imposed against Responden t.

PRELIMINARY STATEMENT

Petitioner, Agency for Health Care Administration

(Petitioner/Agency/AHCA) , issued a Final Audit Report (FAR) dated

September 19, 2014, informing Respondent that an audit of claims

for the period March 1, 2010 , through August 31, 2012, determined

that Respondent was overpaid for Medicaid claims in the amount of

$590,008.15 (subsequently reduced to $513,246.91). The FAR also

informed Respondent of the AgencyÓs intent to impose

administrative sanctions and costs associated with the audit.

Respondent challenged the Agency action described in the FAR

by timely filing a Petition for Formal Administrative Hearing.

On October 27, 2014, Petitioner referred this matter to the

Division of Administrative Hearings (DOAH) for assignment of a n

Administrative Law Judge (ALJ) . This matter was assigned DOAH

C ase No. 14 - 5049MPI. On October 30, 2014, upon motion of the

parties, the file was closed and jurisdiction was relinquished to

the Agency.

On April 8, 2015, the ALJ, upon motion of the part ies,

issued an Order Re - Opening File, and the matter was assigned DOAH

Case No. 15 - 1888MPI. On May 15, 2015, again upon motion of the

parties, the file was closed and jurisdiction was relinquished

back to the Agency.

On September 27, 2016, the ALJ, upon motion of the parties,

issued an Order Re - Opening File, and the matter was assigned DOAH

Case No. 16 - 5641MPI.

At the final hearing, Petitioner presented the testimony of

Robi Olmstead and deposition testimony of expert/peer reviewer

Dr. Mark Kuhl, D.M.D. Respondent testified on his own behalf and

offered the testimony of Dr. W. Michael Ingalls, D.D.S., who was

accepted as an expert.

PetitionerÓs Exhibits 1 through 7, 9 through 15, 16.c, and

17 through 23 were admitted into evidence. RespondentÓs Exhibit s

1 through 22, 24 through 33, 52, 53, 57, 58, 68, 70, and 83

through 95 were admitted into evidence.

A three - volume Transcript of the final hearing was filed on

July 28, 2017. The parties were given until August 11, 2017, to

file proposed recommended or ders (PRO) . Petitioner and Respondent

each filed a PRO and the same have been considered in preparing

this Recommended Order.

FINDING S OF FACT

1. The Medicaid program (Medicaid) is a federal and state

partnership that funds health care services for quali fied

individuals.

2. Petitioner is the state agency charged with administering

Medicaid in Florida. Petitioner is legally authorized to monitor

the activities of Medicaid providers and to recover

Ðoverpayments.Ñ Overpayments include reimbursement for s ervices

that are not medically necessary, as verified by records existing

at the time of service. Petitioner is also empowered to impose

sanctions and recover costs against offending providers.

3. During all times relevant hereto, Respondent was a

Flori da Medicaid provider authorized to provide dental care to

Medicaid beneficiaries and to receive reimbursement for covered

services.

4. The dental practice of Ronald M. Marini, D.M.D., P.A., is

owned by Ronald M. Marini, D.M.D. Dr. Marini has continuousl y

practiced dentistry since graduating in 1967 from the University of

Pittsburgh School of Dental Medicine. Dr. MariniÓs practice focuses

primarily on the treatment of children who have dental coverage

through Medicaid. Dr. Marini is not board - certified in any

specialty.

5. Pursuant to what is commonly referred to as the Ðpay -

and - chaseÑ system, Petitioner pays Medicaid providers under an

honor system for services rendered to Medicaid recipients. If

Petitioner subsequently determines that the provider w as paid for

services rendered which were not in compliance with Medicaid

requirements, then Petitioner seeks reimbursement from the

provider.

6 . The Medicaid Provider Agreement is a voluntary contract

between Petitioner and a Medicaid provider. Paragrap h 3 of the

Medicaid Provider Agreement states that Ð[t]he provider agrees to

comply with local, state, and federal laws, as well as rules,

regulations, and statements of policy applicable to the Medicaid

program, including the Medicaid Provider Handbooks i ssued by

AHCA.Ñ During the audit period, Respondent was an enrolled

Medicaid provider and had a valid Medicaid Provider Agreement

with Petitioner.

7 . By correspondence to Respondent dated February 27, 2014,

Petitioner requested records related to claims billed to Medicaid

by Respondent for the audit period March 1, 2010 , through

August 31, 2012.

8 . Respondent provided documents in response to

PetitionerÓs request for records. Petitioner completed a review

of the records that Respondent submitted, and on July 9, 2014,

issued a Preliminary Audit Report (PAR). Petitioner advised in

the PAR that it believed Respondent was overpaid in the amount of

$590,008.15. In response to the PAR, Respondent submitted

additional information to the Agency.

9 . After receipt and evaluation of RespondentÓs additional

information, Petitioner issued its FAR finding that Respondent

was overpaid $590,008.15 during the audit period (later reduced

to $513,246.91) . The FAR also informed Respondent that

Petitioner was imposing a fine of $118,001.63 as a sanction for

violation of Florida Administrative Code Rule 59G - 9.070(7)(e),

and was seeking reimbursement of costs in the amount of

$2,223.64 .

10 . The FAR states six grounds on which Petitioner seeks to

recoup monies paid to R espondent, and provides as follows:

i. The 2007 and 2011 Dental Services

Coverage and Limitations Handbooks, page 2 - 2,

specify that Medicaid reimburses for services

that are individualized, specific, consistent

with symptoms or confirmed diagnosis of the

illness or injury under treatment, not in

excess of the recipient's needs, and reflect

the level of services that can be safely

furnished. A review of your records by a

peer consultant revealed that the level of

service for some claims submitted was not

s upported by the documentation. The

appropriate code was applied and the payment

adjusted. Payments made to you for these

services, in excess of the adjusted amount,

are considered an overpayment.

ii. The 2008 Florida Medicaid Provider

General Handbook, pages 5 - 8 and 2 - 57, defines

incomplete records as records that lack

documentation that all requirements or

conditions for service provision have been

met. A review of your records revealed that

documentation for some services for which you

billed and rec eived payment was incomplete or

not provided. Payments made to you for these

services are considered an overpayment.

iii. The 2008 Florida Medicaid Provider

General Handbook, page 5 - 4, states that when

presenting a claim for payment under the

Medicaid pr ogram, a provider has an

affirmative duty to present a claim for goods

and services that are medically necessary. A

review of your records revealed that the

medical necessity for some claims submitted

was not supported by the documentation.

Payments made to you for these services are

considered an overpayment.

iv. The 2008 Florida Medicaid Provider

General Handbook, page 5 - 4, requires that

when presenting a claim for payment under the

Medicaid program, a provider has an

affirmative duty to present a clai m that is

true and accurate and is for goods and

services that have actually been furnished to

the recipient. A review of your records

revealed that some services were double

billed. Payments made to you for these

services are considered an overpayment.

v. The 2008 Florida Medicaid Provider

General Handbook, page 5 - 4, requires that

when presenting a claim for payment under the

Medicaid program, a provider has an

affirmative duty to present a claim that is

true and accurate and is for goods and

services that have actually been furnished to

the recipient. A review of your records

revealed that some services rendered were

erroneously coded. The appropriate code was

applied and the payment adjusted, if

applicable. Payments made to you for these

services, in excess of the adjusted amount,

are considered an overpayment.

vi. The 2007 and 2011 Dental Services

Coverage and Limitations Handbooks, pages 2 -

34 and 2 - 35 respectively, limit reimbursement

for restorative services to essential

services necessary to r estore and maintain

dental health; one restoration per tooth

surface except for the occlusal surface of

permanent maxillary 1st and 2nd molars; one

resin restoration for a mesial or distal

lesion; and one posterior one - surface resin

restoration every three years per tooth

number or letter per tooth surface. A review

of your dental records revealed that you

billed and received payment for a restoration

in excess of the maximum. Payment made to

you for this service is considered an

overpayment.

11 . Mark Kuhl, D.M.D., was offered and accepted as

Petitioner's expert in the areas of rendering dental care and

dental medical necessity with respect to Medicaid overpayment

cases. Dr. Kuhl was also offered and accepted as a peer reviewer

pursuant to section 409. 9131, Florida Statutes. Since 1985,

Dr. Kuhl has been continuously licensed to practice dentistry in

the State of Florida. Dr. Kuhl is not board - certified in any

specialty and operates a general dentistry practice where he

treats pediatric patients.

1 2 . W. Michael Ingalls, D.D.S., was offered and accepted as

Respondent's Ðexpert in dentistry with a focus on pediatric

dentistry.Ñ Dr. Ingalls was not, however, recognized as an expert

as to matters pertaining to Medicaid coding for services rendered.

Dr . Ingalls has practiced dentistry continuously since graduating

from the University of Washington School of Dentistry in 1984.

Dr. Ingalls has been board - certified by the American Board of

Pediatric Dentistry since 1997. Dr. Ingalls has owned and operat ed

his own pediatric dental practice in Lake Mary, Florida, since

1987.

1 3 . During the audit period, there were two versions of t he

Florida Medicaid Provider General Handbook in effect. As applied

to the instant dispute, there are no material difference s between

the two General Handbooks so, unless otherwise indicated, they will

collectively be referred to as the General Handbook.

1 4 . During the audit period, there were also two versions of

The Florida Medicaid Provider Dental Services Coverage and

Lim itations Handbook in effect. As applied to the instant dispute,

there are no material differences between the two Dental Handbooks

so, unless otherwise indicated, they will collectively be referred

to as the Dental Handbook.

A. Missing or Incomplete Doc umentation

1 5 . The General Handbook provides, in part, as follows:

When presenting a claim for payment under

the Medicaid program, a provider has an

affirmative duty to . . . present a

claim . . . that is for goods and services

that . . . [a]re docume nted 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

recipientÓs medical record.

1 6 . The General Handbook also provides that Ð[m]edical

records must state the necessity for and the extent of services

provided [and] the following requirements may vary according to

the service rendered:

Description of what was done during the

visit;

History;

Physical assessment;

Chief Complaint on each visit;

Diagnostic tests and results;

Diagnosis;

Treatment plan, including prescription;

Medications, supplies, schedu ling frequency

for follow - up or other services;

Progress reports, treatment rendered;

The author of each (medical record) entry

must be identified and must authenticate his

entry by signature, written initials or

computer entry;

Dates of service; and

Refer rals to other services.

The General Handbook does not define what constitutes a medical

record.

1 7 . The General Handbook further provides that a Medicaid

provider has an affirmative duty to provide services Ðin accord

with applicable provisions of all M edicaid rules, regulations,

handbooks, and policies and in accordance with federal, state and

local law.Ñ

1 8 . For the applicable audit period, section 466.018(3),

Florida Statutes (2011), required, in part, that Ð[e]very dentist

shall maintain written de ntal records and medical history records

which justify the course of treatment of the patient.Ñ

Additionally, section 466.028(1)(m) subjects a dentist to

disciplinary action for Ð[f]ailing to keep written dental records

and medical history records justify ing the course of treatment of

the patient.Ñ

1 9 . Section 466.018(3) makes clear that dental records and

medical history records must justify, or explain why, a

particular course of treatment was undertaken by a dental care

provider.

20 . Respondent util izes software to capture the services

provided to his patients. The software has a Ðpatient notes

masterÑ section, which allows the user to post narrative

information about a patient, including information related to

patient evaluation and insurance claim s status. The software

also has a Ðpatient chartÑ section which reflects information

such as dates of service, a description of services provided

(with Current Dental Terminology codes, hereinafter CDT code(s)),

the tooth and surface involved, and the tre atment status of the

affected tooth. The patient chart section also has a colorized

tooth chart that visually depicts information found in the

description, tooth, and surface sections of the patient chart.

21 . The Ðpatient notes masterÑ section and all parts of the

Ðpatient chart , Ñ collectively and substantively , comprise the

patient medical record contemplated by the General and Dental

H andbooks , respectively. There is nothing in PetitionerÓs rules,

regulations, General or Dental H andbooks, or section 466.018(3) ,

that requires patient treatment information to be gleaned only

from the patient notes section of a patientÓs dental record.

Recipient 1 (Not in Patient Notes)

2 2 . On January 14, 2011, patient K.A., who at the time was

an existing patient, wa s treated by Respondent. According to the

dental records, Respondent performed a Ðperiodic oral evaluation

[CDT code 0120],Ñ took several x - rays, and removed Ðplaque,

calculus and stains from the tooth structures in the primary and

transitional dentition [CDT code 1120].Ñ The results of the

evaluation revealed that K.A. had ÐdecayÑ in teeth ÐSÑ and ÐA.Ñ

K.A. was given a topical fluoride treatment ( CDT code 1203 ) and

oral hygiene instructions ( CDT code 1330 ) . Petitioner denied

treatment related to CDT co des 1203 and 1330 on the basis that

there is no documentation in the Ðpatient notesÑ to warrant

payment for these services.

2 3 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for K.A. offers no justification or

otherwise documents the need for CDT codes 1203 and 1330, the

Ðpatient chartÑ portion of K.A.Ós dental record clearly documents

that these services were provided to K.A. Payment for these

services should be allowed.

2 4 . On February 15, 2012, K.A. was treated by R espondent.

According to the dental record, Respondent performed a Ðperiodic

oral evaluation [CDT code 0120],Ñ took several X - rays, and

removed Ðplaque, calculus and stains from the tooth structures in

the primary and transitional dentition [CDT code 1120] .Ñ The

results of the evaluation revealed that K.A. had ÐdecayÑ in teeth

14, 19 and 30. K.A. was given a topical fluoride treatment ( CDT

code 1203 ) and oral hygiene instructions ( CDT code 1330 ) .

Petitioner denied treatment related to CDT codes 0120, 120 3 and

1330 on the basis that there is no documentation in the Ðpatient

notesÑ to warrant payment for these services.

2 5 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for K.A. offers no justification or

otherwise documen ts the need for CDT codes 0120, 1203 and 1330,

the Ðpatient chartÑ portion of K.A.Ós dental record clearly

documents that these services were provided by Respondent to K.A.

Payment for these services should be allowed.

2 6 . On March 9, 2012, K.A. was tre ated by Respondent.

According to the patient chart, Respondent applied a resin - based

composite to K.A.Ós teeth 14, 19 and 30 ( CDT codes 2391 and

2392 ) . Petitioner denied payment for treatment related to these

services on the basis that there is no docume ntation in the

Ðpatient notesÑ to warrant payment.

2 7 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for K.A. fails to mention that these

services were provided, the Ðpatient chartÑ portion of K.A.Ós

dental record clearl y documents that these services were provided

by Respondent to K.A. and payment for these services should be

allowed.

Recipient 2 (Not in Patient Notes)

2 8 . On April 5, 2011, E.B. was treated by Respondent.

According to the dental record, Respondent pe rformed a

Ðcomprehensive oral evaluation [CDT code 0145]Ñ and removed

Ðplaque, calculus and stains from the tooth structures in the

primary and transitional dentition [CDT code 1120].Ñ E.B. was

given a topical fluoride treatment ( CDT code 1203 ) and oral

h ygiene instructions ( CDT code 1330 ) . Petitioner denied payment

for the fluoride treatment on the basis that there is no

documentation in the Ðpatient notesÑ for these services.

2 9 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for E.B. fails to mention the fluoride

treatment, the Ðpatient chartÑ portion of E.B.Ós dental record

clearly documents that these services were provided by Respondent

to E.B. and payment for these services should be allowed.

Recipient 11 (Not in P atient Notes)

30 . On April 26 and May 23, 2012, P.D. was treated by

Respondent. According to the dental record, Respondent, during

these visits, applied Ðresin - based composite Î two surface,

posterior [CDT code 239 3] ,Ñ to the distal and occlusal surface s

of teeth 4 and 5, and the mesial and occlusal surfaces of

tooth 3. Petitioner denied payment for treatment related to

these services on the basis that there is no documentation in the

Ðpatient notesÑ to warrant payment.

31 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for P.D. fails to mention that these

services were provided, the Ðpatient chartÑ portion of P.D.Ós

dental record clearly documents that these services were provided

and payment for these services should be allowed.

Recipient 20 (Not in Record)

3 2 . On February 7, 2012, M.J. was treated by Respondent.

According to the dental record, Respondent performed an

Ðextraction, erupted tooth or exposed root [CDT code 7140]Ñ for

teeth D and E. Petitioner denied payment for treatment related

to these services on the basis that there is no documentation in

the patient record to warrant payment. The Ðpatient chartÑ

portion of M.J.Ós dental record clearly documents that these

services were provided and payment for t he same should be

allowed.

Recipient 23 (Not in Patient Notes)

3 3 . On July 5, 2012, M.M. was treated by Respondent.

According to the dental record, Respondent applied a Ðresin - based

composite Î three surfaces, anterior [CDT code 23 93 ]Ñ to teeth E

and F. The dental record also reflects that behavior management

techniques (CDT code 9920) were applied during the procedure.

Petitioner denied payment for treatment related to these services

on the basis that there is no documentation in the Ðpatient

notesÑ t o warrant payment.

3 4 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for M.M. fails to mention that these

services were provided, the Ðpatient chartÑ portion of M.M.Ós

dental record clearly documents that these services were provided

and payment for these services should therefore be allowed.

Recipient 24 (Not in Patient Notes)

3 5 . On October 19, 2010, A.M. was treated by Respondent.

According to the dental record, Respondent applied a Ðresin - based

composite Î two surf aces, posterior [ CDT code 2392 ],Ñ to teeth A

and J. The dental record also shows that a Ðpulp cap Î indirect

[ CDT code 3120]Ñ was applied to tooth A. Petitioner denied

payment for treatment related to the application of the pulp cap

on the basis that the re is no documentation of the same in the

patient Ðnotes.Ñ

3 6 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for A.M. fails to mention the

application of a pulp cap, the Ðpatient chartÑ portion of A.M.Ós

dental record cl early documents that this service was provided

and payment for should therefore be allowed.

Recipient 25 (Not in Patient Notes)

3 7 . On February 16, 2011, I.O. was treated by Respondent.

According to the dental record, Respondent applied a Ðresin - based

c omposite Î two surfaces, posterior [CDT code 2392],Ñ to the

occlusal/lingual and distal/buccal surfaces of tooth A.

Petitioner denied payment for these services on the basis that

there is no documentation of the same in the Ðpatient notes.Ñ

3 8 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for I.O. fails to mention that these

services were provided, the Ðpatient chartÑ portion of I.O.Ós

dental record clearly documents that these services were provided

and payment for the same should be allowed.

Recipient 26 (Not in Patient Notes)

3 9 . On November 1, 2010, C.R. was treated by Respondent.

According to the dental record, Respondent, during these visits,

applied Ðresin - based composite Î one surface, posterior [CDT code

2391 ],Ñ to the occlusal surfaces of teeth L and S, and both the

occlusal and buccal surfaces of teeth K and T. Petitioner denied

payment for treatment related to the application of the resin -

based composite to the occlusal surface for tooth S on the basis

tha t there is no documentation of this service in the Ðpatient

notes.Ñ

40 . While it is true that the Ðpatient notesÑ portion of

RespondentÓs dental record for C.R. fails to mention that this

service was provided, the Ðpatient chartÑ portion of C.R.Ós

dental record clearly documents that this service was provided

and payment for the same should be allowed.

B. Services Billed at Lower Level

41 . The Dental Handbook provides in part that Ð[a]

comprehensive oral evaluation is used by a dentist when

evaluating a patient comprehensively. This applies to new

patients and to established patients who have a significant

change in health conditions or who have been absent from

treatment for three or more years.Ñ The Dental handbook also

states that Ð[a] provider ma y only be reimbursed for a

comprehensive oral evaluation once every three years for the same

recipient.Ñ Respondent contends that Petitioner erroneously

adjusted payment for this service because the comprehensive

evaluations were conducted more than three years apart.

Recipient 20 Î J.M.

4 2 . On February 2, 2012, Respondent treated J.M. For this

service date, Respondent billed for a comprehensive oral

evaluation (CDT code 0150). According to J.M.Ós dental record,

Respondent previously performed a compre hensive evaluation on

January 5, 2009. J.M.Ós dental record also indicates that

between these dates, Respondent treated her on seven different

occasions. While it is true that the time between comprehensive

evaluations is more than three years, Petitione r properly

adjusted payment for the February 2, 2012, service because J.M.

was not absent from treatment during this interval.

Recipient 22 Î S.M.

4 3 . On July 18, 2011, Respondent treated S.M. For this

service date, Respondent billed for a comprehensiv e oral

evaluation (CDT code 0150). According to S.M.Ós dental record,

Respondent previously performed a comprehensive evaluation on

January 14, 2011. Petitioner adjusted the July 18, 2011, service

to a Ðperiodic oral evaluation [ CDT code 0120 ] , Ñ which re imburses

at a lower rate. Respondent does not dispute that Petitioner

properly adjusted the reimbursement rate for this service.

C. Not Medically Necessary

4 4 . Applicable Medicaid regulations require that Ðmedical

necessityÑ be documented by specific r ecords made at the time the

services were provided, and that the records fully identify the

medical basis and the need for the services. In other words, a

provider must document the rationale for conducting a particular

service at the time of making the d ecision to perform the same.

Petitioner asserts that Respondent failed to submit sufficient

documentation to establish that the disputed charges were for

"medically necessary" services.

4 5 . FAR Finding No. 3 involves CDT codes 0240, 0250 and

0260. The se codes reflect services for radiograph/diagnostic

imaging procedures that Ð[s]hould be taken only for clinical

reasons as determined by the patientÓs dentist.Ñ According to the

Dental Handbook, these radiographs will not, however, be

reimbursed for cari es (decay) detection. The Dental Handbook also

states that Ð[r]eimbursement for a complete series of intraoral

radiographs is limited to once in a three (3) year period, per

recipient.Ñ

4 6 . Petitioner asserts that Respondent failed to establish

that the use of CDT codes 0240, 0250, and 0260 was medically

necessary for certain claims related to patients 1, 5, 8, 9, 10,

14, 20, 22, 26, 31, and 32. Respondent contends that services

related to the disputed charges were necessary to monitor growth

and develo pment and screen for oral pathology because childrenÓs

dentition is rapidly changing during early adolescence. In other

words, Respondent suggests that medical necessity exists for the

radiographs essentially for no other reason than because the child

is of a particular age.

4 7 . According to Dr. Kuhl, the ADA Guidelines, which are

authoritative and instructive, provide that for radiographs to be

medically necessary there should be sufficient documentation in

the dental record to indicate the specific, in dividualized

indication for why Respondent billed for the radiograph procedure

and any results that were obtained pursuant to that procedure.

Dr. Kuhl testified that RespondentÓs dental records for each of

the disputed claims provide no indication for or need as to why

the X - rays were taken.

4 8 . According to RespondentÓs expert, Dr. Ingalls, the

standard of care for taking occlusal X - rays is that they are to be

taken Ðwhen there was decay present or trauma had occurredÑ and

that they are not taken simply as screening X - rays. The following

testimony from Dr. Ingalls is instructive:

Q: Okay. If you were to take an

intraoral occlusal radiograph, would you

document why you took it?

A: I would have a description of what

was found from taking it, which wou ld say

why you took it. YouÓd have a reason to

take it to begin with and then you write

a comment of what was found.

Q: And do you write that in the

narrative form?

A: I have it in the narrative form.

Sometimes, again, if I gave you an

example, a chi ld comes whoÓs fallen and

hit their front teeth on the floor at

home and displaced or broken a tooth or

even the parent was concerned with

bleeding from the gumline, I would take

an occlusal radiograph to record what was

there, partly to assure that there was

nothing that required treatment and also

to provide a baseline for future

comparison where I would take future

occlusal radiographs to monitor any

changes over time. And I would have a

record of that traumatic incident, every

part of it; where it occu rred, how it

occurred, all of the examination findings

around it on a trauma evaluation and the

outcome of the findings in the x - ray and

any treatment plan and instructions given

to the parent.

Q: Would you say that approach to

medical records is standar d?

A: Within my specialty, that is the

guideline that is taught to us that we

follow so that we do not miss anything.

Hearing Transcript pp. 411 - 413.

4 9 . The opinions of Dr. Kuhl and Dr. Inglass are consistent

and provide that a medical basis and need for the X - rays at issue

must be established and documented, and that the X - rays in

question are not to be used as a screening device as suggested by

Respondent.

Recipient 1

50 . Recipient 1, K.A., had four claims that were denied as

to CDT codes 0240, 025 0, and 0260. The dental records for this

recipient provide d no indication why the X - rays needed to be

taken . A ccordingly, Petitioner properly denied payment of these

claims.

Recipient 5

51 . Recipient 5, S.C., had a single claim that was denied as

to CD T code 0240. The dental records for this recipient provide d

no indication why the X - rays needed to be taken . A ccordingly,

Petitioner properly denied payment of this claim.

Recipient 8

5 2 . Recipient 8, D.C., had a single claim that was denied as

to CDT code 0240. The dental records for this recipient provide d

no indication why the X - rays needed to be taken . A ccordingly,

Petitioner properly denied payment of this claim.

Recipient 9

5 3 . Recipient 9, D.D., had two claims that were denied as to

CDT code 0240. The dental records for this recipient provide d no

indication why the X - rays needed to be taken . A ccordingly,

Petitioner properly denied payment of these claims.

Recipient 10

5 4 . Recipient 10, G.D., had two claims that were denied as

to CDT code 0 240. The dental records for this recipient provide d

no indication why the X - rays needed to be taken . A ccordingly,

Petitioner properly denied payment of these claims.

Recipient 14

5 5 . Recipient 14, E.E., had a single claim that was denied

as to CDT code 0240. The dental records for this recipient

provide d no indication why the X - rays needed to be taken .

A ccordingly, Petitioner properly denied payment of this claim.

Recipient 20

5 6 . Recipient 20, M.J., had six claims that were denied as

to CDT codes 0 240, 0250, and 0260. The dental records for this

recipient provide d no indication why the X - rays needed to be

taken . A ccordingly, Petitioner properly denied payment of these

claims.

Recipient 22

5 7 . Recipient 22, K.A., had two claims that were denied.

Each claim was billed using CDT code 0250. The dental records for

2 3

this recipient provide d no indication why the X - rays needed to be

taken . A ccordingly, Petitioner properly denied payment of these

claims.

Recipient 26

5 8 . Recipient 26, C.R., had a sing le claim that was denied

as to CDT code 0240. The dental records for this recipient

provide d no indication why the X - rays needed to be taken .

A ccordingly, Petitioner properly denied payment of this claim.

Recipient 31

5 9 . Recipient 31, J.R., had two cla ims that were denied.

Each claim was billed using CDT code 0240. The dental records for

this recipient provide d no indication why the X - rays needed to be

taken . A ccordingly, Petitioner properly denied payment of these

claims.

Recipient 32

60 . Recipien t 32, J.R., had a single claim that was denied

as to CDT code 0240. The dental records for this recipient

provide d no indication why the X - rays needed to be taken .

A ccordingly, Petitioner properly denied payment of this claim.

D. Erroneous Coding

61 . According to the Dental Handbook, Ð[s]ealants are

applied to pits and fissures of permanent teeth to prevent caries

[and] [t]he enamel surface of the tooth may be mechanically or

chemically[,] or mechanically and chemically prepared.Ñ The

Dental Handbook also states that Ð[s]ealants applied to deciduous

(primary) teeth will not be reimbursed by Medicaid.Ñ CDT code

D1351 (sealant Î per tooth) describes this service as

Ð[mechanically and/or chemically prepared enamel surface sealed

to prevent decay.Ñ

6 2 . As for resin restorations, the Dental Handbook provides

that ÐMedicaid may reimburse for . . . [r]esin restorations . . .

[and that] [t]he fee for resin restorations includes local

anesthesia, tooth preparation, routine lining and base,

polishing, and the use of any adhesive, such as amalgam bonding

agents.Ñ As a restriction on the use of resin restorations, the

Handbook provides that Ð[r]esin restorations may be used to

restore carious lesions that extend into the dentin or areas that

are deeply eroded in to dentin.Ñ CDT codes 2391/2392 provide that

the resin composite is Ð[u]sed to restore a carious lesion into

the dentin or a deeply eroded area into the dentin.Ñ

6 3 . In comparing sealant and resin restoration services , it

is evident that sealants are fo r the enamel surface of the tooth

whereas restorations, when undertaken to eliminate carious

lesions, are appropriate only when the lesions extend into the

dentin. In understanding the sealant and restoration provisions

of the Dental Handbook, it is also evident that in order to be

reimbursed for either CDT code 2391 or 2392 there must be

sufficient justification of carious intrusion into the dentin and

in the absence of such justification it may be appropriate to

adjust the service to CDT code 1351, unles s, of course, the

service relates to a deciduous tooth.

6 4 . FAR f inding No. 5 involves CDT codes 2391, 2392 and

1351 and applies to recipients 8, 13, 19, 22, 23, 24, 26, 28, 29,

and 32.

6 5 . Petitioner, based on Dr. KuhlÓs analysis, adjusted

reimburseme nt for CDT codes D2391 and D2392 downward to CDT code

D1351 when the following criteria were present: X - rays did not

show any decay, RespondentÓs dental record for the recipient did

not specifically indicate that any decay was removed,

RespondentÓs dental record for the recipient stated that only a

ÐflowableÑ resin was used, and RespondentÓs dental record for the

recipient did not indicate that anesthesia was used.

66 . Dr. Kuhl evaluated the criteria and, when all four were

met, he concluded that it was very likely that any decay present

did not extend into the dentin as required for CDT code

descriptions and applicable Florida Medicaid Handbooks.

Dr. KuhlÓs protocol for identifying claims that do not meet the

requirements for codes 2391 and 239 2 is consi stent with the

requirements of Florida Medicaid Handbooks and is credited.

There are, however, instances where Dr. Kuhl made downward

adjustments for claims when, according to the requirements of the

Dental Handbook, the claims should not have been paid .

Recipient 8

6 7 . For recipient 8, Dr. Kuhl determined that RespondentÓs

dental record for this patient does not support the use of either

CDT code 2391 or 2392 for claims 6 through 11. This opinion is

credited. Dr. Kuhl erred , however , in adjusting thes e claims to

CDT code 1351 because the teeth involved in these claims (A, J,

K, L, S, and T) are deciduous teeth that are not eligible for

reimbursement when sealants are applied. In accordance with the

Dental H andbook , these claims should be denied.

Recip ient 13

6 8 . For recipient 13, Dr. Kuhl determined that RespondentÓs

dental record for this patient does not support the use of either

CDT code 2391 or 2392 for claims 8 through 13, 18, 20, 21, and 24

through 26. This opinion is credited. Dr. Kuhl erred , however ,

in adjusting claims 8, 9, 12, 13, and 24 through 26 to CDT code

1351 because the teeth involved in these claims (A, I, J, K, S,

and T) are deciduous teeth that are not eligible for

reimbursement when sealants are applied. In accordance with the

Dental Handbook , these claims should be denied. As for claims

10, 11, 18, 20, and 21, Dr. Kuhl correctly adjusted these claims

downward to CDT code 1351 because the permanent teeth involved in

these claims are eligible for reimbursement when sealants are

applied under appropriate circumstances.

Recipient 19

6 9 . For recipient 19, Dr. Kuhl determined that RespondentÓs

dental record for this patient does not support the use of either

CDT code 2391 or 2392 for claims 1 through 5. This opinion is

credited. Dr. Kuhl erred , however , in adjusting these claims to

CDT code 1351 because the teeth involved in these claims (A, B,

J, K, and T) are deciduous teeth that are not eligible for

reimbursement when sealants are applied. In accordance with the

Dental Handb ook , these claims should be denied.

Recipient 22

70 . For recipient 22, Dr. Kuhl determined that RespondentÓs

dental record for this patient does not support the use of either

CDT code D2391 or D2392 for claims 10, 11, 13, 15, and 16. This

opinion is cre dited. As for claims 10, 11, 13, and 16, Dr. Kuhl

correctly adjusted these claims downward to CDT code 1351 because

the permanent teeth involved in these claims are eligible for

reimbursement when sealants are applied under appropriate

circumstances. Cla im 15 involved tooth 20 , which is not

identified in the Dental Handbook as a tooth that is eligible for

reimbursement when a sealant is applied. Accordingly, claim 15

should be denied.

Recipient 23

71 . For recipient 23, Dr. Kuhl determined that Responde ntÓs

dental record for this patient does not support the use of either

CDT code D2391 or D2392 for claims 13 through 15, and 17. This

opinion is credited. Dr. Kuhl erred , however , in adjusting these

claims to CDT code 1351 because the teeth involved in t hese

claims (K, L, S, and T) are deciduous teeth that are not eligible

for reimbursement when sealants are applied. In accordance with

the Dental Handbook , these claims should be denied.

Recipient 24

7 2 . For recipient 24, Dr. Kuhl determined that Respon dentÓs

dental record for this patient does not support the use of either

CDT code 2391 or 2392 for claims 13, 17, and 21. This opinion is

credited. Dr. Kuhl erred , however , in adjusting claims 13 and 17

to CDT code 1351 because the teeth involved in thes e claims (A

and J) are deciduous teeth that are not eligible for

reimbursement when sealants are applied. In accordance with the

Dental Handbook , these claims should be denied. As for claim 21,

Dr. Kuhl correctly adjusted this claim downward from CDT cod e

2392 to CDT code D2940 because the patient record reflects that a

sedative fil l ing was applied and not a resin - based composite

restoration as billed.

Recipient 26

7 3 . For recipient 26, Dr. Kuhl determined that RespondentÓs

dental record for this patie nt does not support the use of either

CDT code 2391 or 2392 for claims 9 through 11. This opinion is

credited. Dr. Kuhl erred , however , in adjusting these claims to

CDT code 1351 because the teeth involved (K, L, and T) are

deciduous teeth that are not e ligible for reimbursement when

sealants are applied. In accordance with the Dental H andbook ,

these claims should be denied.

Recipient 28

7 4 . For recipient 28, Dr. Kuhl determined that RespondentÓs

dental record for this patient does not support the use of either

CDT code 2391 or 2392 for claims 8, 9, and 11. This opinion is

credited. Dr. Kuhl correctly adjusted these claims downward to

CDT code 1351 because the permanent teeth involved (3, 14,

and 30) are eligible for reimbursement when sealants are a pplied

under appropriate circumstances.

Recipient 29

7 5 . For recipient 29, Dr. Kuhl determined that RespondentÓs

dental record for this patient does not support the use of either

CDT code 2391 or 2392 for claims 4, 5, 8, and 10. This opinion

is credited . Dr. Kuhl erred , however , in adjusting claims 8

and 10 to CDT code 1351 because the teeth involved in these

claims (K and T) are deciduous teeth that are not eligible for

reimbursement when sealants are applied. In accordance with the

Dental Handbook , these claims should be denied. As for claims

4 and 5, Dr. Kuhl correctly adjusted these claims downward to CDT

code 1351 because the permanent teeth involved in these claims

(3 and 19) are eligible for reimbursement when sealants are

applied under appro priate circumstances.

Recipient 32

7 6 . For recipient 32, Dr. Kuhl determined that RespondentÓs

dental record for this patient does not support the use of either

CDT code 2391 or 2392 for claims 9 through 12, 28, 30, and 32.

This opinion is credited. Dr . Kuhl erred however in adjusting

claims 11 and 32 to CDT code 1351 because the teeth involved in

these claims (J and S) are deciduous teeth that are not eligible

for reimbursement when sealants are applied. In accordance with

the Dental Handbook , these c laims should be denied. As for

claims 12 and 28, Dr. Kuhl correctly adjusted these claims

downward to CDT code 1351 because the permanent teeth involved in

these claims (14 and 30) are eligible for reimbursement when

sealants are applied under appropriate circumstances. As for

claim 30, Dr. Kuhl erred in adjusting this claim downward to CDT

code 1351 because it involves tooth 30 which was addressed in

claim 12. The Handbook provides that Ð[s]ealants may be

reimbursed once per three years, per tooth.Ñ Th e date of service

for claim 12 is October 19, 2010, and the date of service for

claim 30 is March 28, 2012. Claim 30 was not submitted more than

three years after claim 12 , and it should therefore be denied.

E. Duplicate Claims

7 7 . Certain claims were denied by Petitioner as being

duplicates of other claims. These claims relate to FAR finding

No. 4 , which involves CDT Codes 2391, 2392, and 1351.

Recipient 8

7 8 . For recipient 8, claims 12 and 13 were billed and

reimbursed under CDT code 2391 for teet h K and T. As previously

noted, Dr. Kuhl correctly opined that Respondent improperly used

CDT code 2391 for services related to these teeth. Because

tooth K was addressed in claim 8 (as previously discussed) and

tooth T was addressed in claim 11 (as pre viously discussed),

Dr. Kuhl correctly opined that claims 12 and 13 are duplicate

claims that should be denied.

Recipient 13

7 9 . For recipient 13, claims 14 through 17, and 19, were

billed and reimbursed under CDT code 2391 for teeth K, T,

3 and 30. A s previously noted, Dr. Kuhl correctly opined that

Respondent improperly used CDT code 2391 for services related to

these teeth. Because tooth K was addressed in claim 12 (as

previously discussed) , tooth T was addressed in claim 13 (as

previously discusse d), tooth 3 was addressed in claim 18 (as

previously discussed), and tooth 30 was addressed in claim 11 (as

previously discussed), Dr. Kuhl correctly opined that claims 14

through 17, and 19 are duplicate claims that should be denied.

Recipient 19

80 . Fo r recipient 19, claim 6 was billed and reimbursed

under CDT code 2391 for tooth K. As previously noted, Dr. Kuhl

correctly opined that Respondent improperly used CDT code 2391

for services related to this tooth. Because tooth K was

addressed in claim 8 ( as previously discussed) , Dr. Kuhl

correctly opined that this claim is a duplicate claim that should

be denied.

Recipient 22

81 . For recipient 22, claims 12 and 14 were billed and

reimbursed under CDT code 2392 for teeth 14 and 15. As

previously noted, Dr. Kuhl correctly opined that Respondent

improperly used CDT code 2391 for services related to these

teeth. Because the patient record does not support the use of

code 2391, it also does not support the use of code 2392.

Because tooth 14 was addressed i n claim 11 (as previously

discussed) and tooth 15 was addressed in claim 13 (as previously

discussed), Dr. Kuhl correctly opined that claims 12 and 14 are

duplicates that should be denied.

Recipient 23

8 2 . For recipient 23, claim 16 was billed and reimbu rsed

under CDT code 2391 for tooth T. As previously noted, Dr. Kuhl

correctly opined that Respondent improperly used CDT code 2391

for services related to this tooth. Because tooth T was

addressed in claim 15 (as previously discussed), Dr. Kuhl

correctly opined that this claim is a duplicate that should be

denied.

Recipient 26

8 3 . For recipient 26, claims 13 and 14 were billed and

reimbursed under CDT code 2391 for teeth K and T. As previously

noted, Dr. Kuhl correctly opined that Respondent improperly used

CDT code 2391 for services related to these teeth. Because

tooth K was addressed in claim 9 (as previously discussed) and

tooth T was addressed in claim 10 (as previously discussed),

Dr. Kuhl correctly opined that claims 13 and 14 are duplicates

t hat should be denied.

Recipient 28

8 4 . For recipient 28, claim 10 was billed and reimbursed

under CDT code 2391 for tooth 3. As previously noted, Dr. Kuhl

correctly opined that Respondent improperly used CDT code 2391

for services related to this tooth. Because tooth 3 was

addressed in claim 8 (as previously discussed), Dr. Kuhl

correctly opined that this claim is a duplicate that should be

denied.

Recipient 29

8 5 . For recipient 29, claims 6 and 7 were billed and

reimbursed under CDT code 2392 for tee th 3 and 14. As previously

noted, Dr. Kuhl correctly opined that Respondent improperly used

CDT code 2391 for services related to these teeth. Because the

patient record does not support the use of CDT code 2391, it also

does not support the use of CDT c ode 2392. Because tooth 3 was

addressed in claim 4 (as previously discussed) and tooth 14 was

addressed in claim 15 (as previously discussed), Dr. Kuhl

correctly opined that claims 6 and 7 are duplicates that should

be denied.

Recipient 32

8 6 . For recip ient 32, claims 13 and 31 were billed and

reimbursed under CDT code 2391 for teeth 19 and 30, and claim 29

was billed and reimbursed under CDT code 2392 for tooth 14. As

previously noted, Dr. Kuhl correctly opined that Respondent

improperly used CDT code 2391 and 2392 for services related to

these teeth. Because tooth 14 was addressed in claim 28 (as

previously discussed) tooth 19 was addressed in claim 10 (as

previously discussed), and tooth 30 was addressed in claims 12

and 30 (as previously discussed), Dr. Kuhl correctly opined that

claims 13, 29, and 31 are duplicates that should be denied.

CONCLUSIONS OF LAW

8 7 . The Division of Administrative Hearings has

jurisdiction over the subject matter. §§ 120.569, 120.57(1)

and 409.913(31), Fla. Stat. (2016). 2 /

8 8 . As the party asserting the overpayment, Petitioner

bears the burden of proof to establish the alleged overpayment by

a preponderance of the evidence. See Southpointe Pharmacy v.

Dep't of HRS , 596 So. 2d 106, 109 (Fla. 1st DCA 1992);

S. Med . Serv s. v. Ag. for Health Care Admin. , 653 So. 2d 440, 441

(Fla. 3d DCA 1995) (per curiam).

8 9 . The statutes, rules, and the Medical Provider Handbooks

in effect during the period for which the services were provided

govern the outcome of the dispute. Toma v . Ag. for Health Care

Admin. , Case No. 95 - 2419 (Fla. DOAH July 26, 1996; Fla. AHCA

Sept. 24, 1996).

90 . The Medicaid program is the federal - state medical

assistance program authorized by Title XIX of the Federal Social

Security Act, pursuant to which the State of Florida provides

medical goods and services to eligible indigent recipients.

§ 409.901(15) , Fla. Stat .

91 . Petitioner is the State of Florida agency designated to

administer the Medicaid program in the State of Florida.

§§ 20.42 ; 409.901(2) , (14) ; and 409.902, Fla. Stat.

9 2 . Among other statutory duties, Petitioner oversees the

activities of Medicaid providers; conducts reviews,

investigations, and audits of Medicaid providers to identify

fraud, abuse, and overpayments; issues audit reports with

Medicaid overpayment determinations; recovers Medicaid

overpayments; and imposes sanctions upon Medicaid providers for

fraud, abuse, and overpayments. § 409.913 , Fla. Stat .

9 3 . Petitioner is authorized to seek repayment of

overpayments that it may have made for goods or services

reimbursed under the Medicaid program. § 409.913(10), (11)(a),

(15)(j) and (30) , Fla. Stat.

9 4 . Section 409.913(7)(e) and (f) requires providers to

present claims for reimbursement in accordance with all Medicaid

rules, regulations, and handbooks and appropriately document

goods and services supplied by them.

9 5 . Section 409.913(20) provides that "[w]hen making a

determination that an overpayment has occurred, the agency shall

prepare and issue an audit report to the pr ovider showing the

calculation of overpayments."

9 6 . Section 409.913(21) provides that "[t]he audit report,

supported by agency work papers, showing an overpayment to a

provider constitutes evidence of the overpayment." Consistent

with this language, Pe titioner can establish a prima facie case

by proffering a properly supported audit report, which must be

received in evidence. Colonial Cut - Rate Drugs v. AHCA , Case

No. 03 - 1547MPI (Fla. DOAH Mar. 14, 2005; Fla. AHCA May 27, 2005).

9 7 . To be eligible for coverage by Medicaid, a service must

be Ðmedically necessary,Ñ which is defined in section

409.913(1)(d) as follows:

ÐMedical necessityÑ or Ðmedically necessaryÑ

means any goods or services necessary to

palliate the effects of a terminal condition,

or to prevent, diagnose, correct, cure,

alleviate, or preclude deterioration of a

condition that threatens life, causes pain or

suffering, or results in illness or

infirmity, which goods or services are

provided in accordance with generally

accepted standards of medical practice.

9 8 . For the purposes of determining Medicaid reimbursement,

Petitioner is the final arbiter of medical necessity.

§ 409.913(1)(d) , Fla. Stat.

9 9 . PetitionerÓs interpretation of its administrative rules

and incorporated handbooks i s entitled to great deference.

Colonnade Med . Ctr ., Inc. v. Ag. for Health Care Admin . , 847 So.

2d 540 (Fla. 4th DCA 2003). Even if the AgencyÓs interpretation

of its own rules and incorporated handbooks is merely one of

several reasonable alternatives, the interpretation must stand

even though it may not appear as reasonable as some other

alternative. Duke's Steakhouse Ft. Myers, Inc. v. G5 Properties,

LLC , 106 So. 3d 12 (Fla. 2d DCA 2013). The AgencyÓs

interpretation of its statutes and rules only nee ds to be a

permissible one and should not be overturned unless clearly

erroneous. Id.

100 . As determined in the Findings of Facts, Petitioner met

its burden of proof and established for those claims identified

herein that Respondent was paid for claims that failed to comply

with the laws, rules, and regulations governing Medicaid

providers.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that Petitioner, Agency for Health Care

Administration, enter a final order that:

1. Revises the Final Audit Report consistent with the

Findings of Fact and Conclusions of Law set forth herein;

2. Recalculates the total overpayment consistent with the

Findings of Fact and Conclusions of Law set forth herein;

3. Requir es Respondent to pay interest at the statutorily

mandated rate on the recalculated overpayment; and

4. Requires Respondent to pay a fine in the amount of

20 percent of the recalculated overpayment.

Pursuant to section 409.913(23)(a), Petitioner is enti tled to

recover all investigative, legal and expert witness costs.

Petitioner has documented costs of $2,223.64 , but advises that

Ð[a]dditional costs have been incurred in preparing for and

attending the final hearing.Ñ Jurisdiction is retained to

determ ine the amount of appropriate costs, if the parties are

unable to agree. Within 30 days after entry of the final order,

either party may file a request for a hearing on the amount.

Failure to request a hearing within 30 days after entry of the

final order shall be deemed to indicate that the issue of costs

has been resolved.

DONE AND ENTERED this 29th day of August , 2017 , in

Tallahassee, Leon County, Florida.

S

LINZIE F. BOGAN

Administrative Law Judge

Division of Adminis trative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 29th day of August , 2017 .

END NOTE S

1/ Mr. Livingston is still counsel of record in this proceeding.

However, it appears as though Mr. Livingston is now with a

different agency. Based on his e S erve registration, a copy of

this Recommended Order is provided to Mr. Livingston at his new

address.

2 / All subsequent references to Florida Statutes will be to 2016,

unless otherwise indicated.

COPIES FURNISHED:

Christopher Edward Brown, Esquire

The Health Law Firm

1101 Douglas Avenue

Altamonte Springs, Florida 32714

(eServed)

Kevin D ouglas Dewar, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Ephraim Durand Livingston, Esquire

Office of Financial Regulation

Suite 615

1313 Tampa Street

Tampa, Florida 33602

(eServed)

Do uglas James Lomonico, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Gregory L. Pitt, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Lance O. Leider, Esquire

The Health Law Firm

1101 Douglas Avenue

Altamonte Springs, Florida 32714

(eServed)

Michelle Bedoya, Esquire

The Health Law Firm

1101 Douglas Avenue

Altamonte Springs, Florida 32714

(eServed)

William Roberts, Acting General Counsel

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Richard J. Shoop, Agency Clerk

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed )

Justin Senior, Secretary

Agency for Health Care Administration

Mail Stop 1

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Shena L. Grantham, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Thomas M. Hoeler, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days fro m 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.