19-006584MPI Agency For Health Care Administration vs. Hour Bliss, Inc. Status: Closed Recommended Order on Monday, April 27, 2020.

Summary: Respondent was overpaid $237,802.50 for services that in whole or in part are not covered by Medicaid because the services were performed by providers who did not have the requisite education or work experience. Recommend repayment, sanctions, and costs.

S TATE OF F LORIDA

D IVISION OF A DMINISTRATIVE H EARINGS

A GENCY F OR H EALTH C ARE

A DMINISTRATION ,

Petitioner ,

Case No. 19 - 6584MPI

vs.

H OUR B LISS , I NC . ,

Respondent .

/

R ECOM MENDED O RDER

Pursuant to notice, a formal administrative hearing was conducted before

Administrative Law Judge Mary Li Creasy of the Division of Administrative

Hearings ( Ñ DOAH Ò ) on March 9, 2020, by video teleconference at sites located

in Miami and Tallah assee, Florida.

A PPEARANCES

For Petitioner: Susan Sapoznikoff, Esquire

Kimberly Murray, Esquire

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

For Respondent: Julio Cesar Perez - Del gado , pro se

Hour Bliss, Inc.

Apartment 406

888 Brickell Key Drive

Miami, Florida 33131

S TATEMENT OF T HE I SSUE S

Whether Respondent was overpaid $237,802.50 for services that in whole ,

or in part , are not covered by Medicaid becaus e the services were performed

by rendering providers who did not have the requisite education or work

experience to meet the eligibility requirements in the B ehavior A nalysis

Services Coverage Handbook (ÑBA HandbookÒ) to perform the services or for

whom do cumentation was insufficient to determine eligibility ; and , if so, the

amount of the overpayment to be repaid, t he amount of any fine to be

imposed against Respondent, and the amount of any investigative, legal, and

expert witness costs to be assessed agai nst Respondent.

P RELIMINARY S TATEMENT

Respondent, Hour Bliss, Inc., was a n entity that provided high quality

behavior a nalysis services , to families with children with developmental

disabilities and neurological condition s, for which Respondent received

r eimburse ment under the Florida Medicaid program.

In order for b eh a vior a nalysis services to be reimbursed by M edicai d, the

services must be provided by a Behav ior A ssistant (ÑBAÒ) who meets certain

educational, training , and experience requirements set fo rth in Section 3.2 of

the BA Handbook to work with the vulnerable target population (children

with medical and mental disabilities) .

Peti ti oner, FloridaÔs Agency for Health Care Administration (Ñ AHCA Ò)

performed an audit of RespondentÔs business records a nd Medicaid - related

records for the period of November 1, 2017, through December 31, 2018 , t o

determine if Respondent sufficient ly documented the qualifications of its

BAs .

AHCA issued the Final Audit Report (ÑFARÒ), dated July 19, 2019, that

constitutes the challenged agency action in this proceeding. The FAR

concluded that AHCA overpaid Respondent $905,838.36 for b ehavior a nalysis

services that, in whole or in part, were not covered by the Medicaid program.

Additionally, the FAR sought to impose a sancti on of $2,500.00 pursuant to

Florida Administrative Code Rule 59G - 9.070(7)(c), for failure to comply with

Medicaid rules, and costs of $1,280.00 inc urred as a result of the audit.

Respondent timely requested an administrative hearing pursuant to

sections 1 20.569 and 120.57(1), Florida Statutes, challenging the amounts

assessed and the findings in the FAR. In this proceeding, AHCA, as the party

seeking to establish a Medicaid overpayment, has the burden of proving the

allegation by a preponderance of the evi dence. Southpointe Phar m. v. Dep't of

H RS , 596 So. 2d 106, 109 (Fla. 1st DCA 1992). After an initial abeyance, the

matter was referred to DOAH to conduct a final hearing . The parties filed a

Joint Pre - Hearing S tipulation on March 2, 2020, including a state ment of

undisputed facts. To the extent that the stipulated facts are relevant, the

facts are adopted and incorporated herein as necessary. Based on additional

information received during the litigation process, AHCA reduced the

asserted overpayment to $23 7,802.50.

Despite repeated requests from AHCA prior to the filing of the Joint Pre -

Hearing S tipulation, Respondent failed to identify or provide any exhibits

upon which the business intended to rely . On March 5, 202 0 , four days prior

to the final hearing, Respondent provided AHCA with additional resumes

and training certificates for its BAs whose qualifications were in dispute.

AHCA repeatedly requested these documents from the outset of the audit and

through the discovery process in this proceeding. Respo ndentÔs owner,

Julio Perez - Delgado, previously insisted he did not have these records.

On March 9, 2020, the final hearing was held as scheduled . As a

preliminary matter, oral argument was held on AHCAÔs ÑMotion to

Strike/Exclude from Evidence Documents t hat Were Untimely Provided,

Previously Withheld, and/or Were Advised to be Non - Existent.Ò After hearing

from the parties, this motion was granted , holding that any document of

Respondent not provided to AHCA before March 5, 2020, was excluded.

AHCA offer ed Exhibits 1 through 11, which were admitted into evidence

without objection. Respondent offered no exhibits. AHCA presented

testimony of Ramona Stewart, AHCA Administrator, and Kathy Herold,

AHCA Senior Pharmacist. Respondent Ôs owner , Julio C. Perez - Delg ado,

testified on behalf of Respondent.

The one - volume Tr anscript of the final hear ing was filed on March 26,

2020. Both parties timely filed p roposed r ecommended o rder s that were

considered in the drafting of this Recommended Order. All references to

sta tutes refer to the 201 7 version unless otherwise specified.

F INDINGS OF F ACT

1. This case involves a Medicaid audit by AHCA of Respondent , which

relates to dates of service from November 1, 2017, through December 31,

2018 ("audit period").

2. During the a udit period, Respondent was an enrolled Medicaid provider

and had a valid Medicaid provider agreement with AHCA, Medicaid Provider

No . 017421300.

3. As an enrolled Medicaid provider, Respondent was subject to the duly -

enacted federal and state statutes, re gulations, rules, policy guidelines, and

Medicaid handbooks incorporated by reference into rule, which were in effect

during the audit period.

4. AHCA is designated as the single state agency authorized to make

payments for medical assistance and related s ervices under Title XIX of the

Social Security Act. This program of medical assistance is designated the

"Medicaid Program." See § 409.902, Fla. Stat. AHCA has the responsibility

for overseeing and administering the Medicaid Program for the State of

Florid a, pursuant to section 409.913, Florida Stat utes .

5 . AHCA Ôs Bureau of Medicaid Program Integrity (MPI), pursuant to its

statutory authority, conducted an audit o f Respondent of paid Medicaid

claims for services to Medicaid recipients.

6 . Medicaid claims ar e paid under what is known as a Ñpay and chaseÒ

system. Claims are quickly paid under the presumption the provider is billing

in accordance with Medicaid law and rules. When paid claims are later

audited and AHCA finds non - compliant claims, the payments ar e deemed

overpayments and AHCA requests reimbursement.

7. Section 409.913 allows MPI to audit for fraud and abuse. Abuse

includes Ñ[p]rovider practices that are inconsistent with generally accepted

businessÈpractices and that result in an unnecessary cost to the Medicaid

program È. Ò See § 409.913(1)(a)1 . , Fla . Stat.

8. All Florida Medicaid providers are required to maintain, for at least five

years, Ñcontemporaneous documentation of entitlement to payment, including

employment eligibility, compliance with al l Medicaid Rules, regulations,

handbooks and policies.Ò This includes business records, Medicaid - related

records and medical records. See § 409.913(7)(e) and (f), Fla . Stat.

9. A providerÔs failure to document, in accordance with Medicaid

handbooks and the Provider Enrollment Agreement, whether its rendering

providers met the criteria to provide services, as stated in the promulgated

handbook, is inconsistent with generally accepted business practices.

10. Behavior analysis services are Ñhighly structured i nterventions,

strategies, and approaches provided to decrease maladaptive behaviors and

increase or reinforce appropriate behavior for persons with mental health

disorders, and developmental or intellectual disabilities.Ò 1 Medicaid coverage

for these servi ces is limited to children under the age of 21. B ehavior analysis

1 See Section 1.0 ÑIntroductionÒ of Florida Medicaid Behavior Analysis Services Coverage

Policy (October 2017); Fla. Admin. Code R. 59G - 4.125.

recipients are a vulnerable population, consisting of individuals that have

mental health disorders, and intellectual and developmental disabilities,

including , but not limited to , autism an d Down Syndrome. They often have

severe deficits in their abilities to complete self - care tasks and communicate

their wants and needs. These clients are at a heightened risk of abuse,

neglect, and exploitation because of their developmental disabilities an d

inability to self - preserve. For these reasons, persons entrusted to provided

critical services must meet the minimum qualifications.

11. To provide appropriate services to this vulnerable population, BA s are

required to meet the criteria set forth in Sec tion 3.2 of the BA Handbook ,

incorporated by reference in Florida Administrative Code Rule 59G - 4.125,

ÑBehavior Analysis Services , Ò as amende d , October 29, 2017 .

12. The BA Handbook requires a BA to have Ña bachelorÔs degree from an

accredited university or college in a related human service fieldÒ and an

agreement to become a Registered Behavior Technician (ÑRBTÒ) by 1/1/19; or,

alternatively: ( 1) be at least 18 years old; ( 2 ) have a high school diploma; ( 3 )

have Ñat least two years of experience providin g direct services to recipients

with mental health disorders, developmental or i ntellectual disabilitiesÒ; and

( 4 ) have at least Ñ20 hours of documented in - service training s in the

treatment of mental health, developmental or intellectual disabilities,

rec ipient rights, crisis management strategies and confidentiality . Ò

AHCAÔ S A UDIT

13 . This audit was opened in follow - up to AHCAÔs statewide review of

b ehavior a nalysis services. The assessment of these services revealed

rampa nt fraud and abuse within th e behavior analysis program including

more than twice as many providers as recipients, providers billing

unbelievable hours (such as more than 24 hours per day ) , and

unsubstantiated qualifications, meaning that patients were receiving BA

services from unqu alified providers .

1 4 . Based on information obtained in the s tatewide behavior analysis

review, AHCA issued a moratorium regarding new enrollments in Southeast

Florida and chose a number of providers for audits. Respondent was selected

for audit .

1 5 . Petitioner audited Respondent's records related to paid claims from

November 1, 2017, through D ecember 31, 2018 . This audit period was

selected because an updated Behavior Analysis Handbook was promulgated

and became effective October 29, 2017. 2

1 6 . AHCAÔs review of Respondent's records consisted of identifying the

rendering providers for whom Respondent provided insufficient or no

documentation to support t heir qualifications to render behavior analysis

services .

1 7 . The parties stipulated t hat none of the rendering providers at issue

had both a bachelorÔs degree Ñin a related human services fieldÒ and had

obtained their RBT by January 1, 2019. Respondent and AHCA also

stipulated that the records for each rendering provider indicate they were at

least 18 years old and had obtained at least a high school diploma or its

equivalent . The o nly questions that remained was did the BA provider have

the requisite two years of experience with the target population and did they

have 20 hours or more of t he required applicable in - service training .

1 8 . During the Audit Period, Respondent submitted claims for services

rendered by 169 rendering providers , for which Medicaid paid Respondent a

total of $3,999,828.65. Based on the audit, Petitioner initiall y determined

Respondent had been overpaid in the amount of $1,060,590.41. AHCA issued

a Preliminary Audit Report (ÑPARÒ) dated March 25, 2019, notifying

Respondent o f the rendering providers deemed not qualified and the amount

2 During the MPI audit period, Respondent was placed under pre - payment re view by a

different section of AHCA. Respondent stopped billing during the audit period and its

Medicaid provider number was terminated without cause in October 2018. As such, although

the audit period was from November 1, 2017, through December 31, 2018, the last claims

reviewed in the audit were for date of service March 28, 2018, as that was the date of the last

paid claim .

of the overpayment associated with each. Respondent was given the

opportunity to pay the PAR amount or submit additional records .

1 9 . In response to the PAR, Respondent submitted additional records.

Based on the those additional records, AHCA issued a FAR dated July 19,

2019, al leging Respondent was overpaid $905,838.36 for BA services it billed

for 41 BA rendering providers who did not meet the criteria specified in the

BA Handbook. In addition, the FAR informed Respondent that AHCA was

seeking to impose a sanction of $2,500.00 pursuant to r ule 59G - 9.070(7)(c),

and costs of $1,280.00 pursuant to section 409.913(23)(a). In sum, Petitioner

asserted in the FAR that Respondent owed a total of $909,618.36.

20 . Kathy Herold is a Senior Pharmacist with AHCAÔs MPI unit. In that

capa city she assists with MPI audits. She compiles and analyzes data;

applies appropriate rules, regulations, policies , and procedures to oversee the

activities of Florida Medicaid providers to detect fraudulent or abusive

behavior and minimize the neglect of recipients; recovers overpayments;

imposes sanctions; and makes referrals as appropriate to the Florida

Attorney GeneralÔs Medicaid Fraud Control Unit, the Florida Department of

Health , and the Florida Department of Business and Professional Regulation.

Sh e has over seventeen yearsÔ experience in administrative investigations.

She is a Certified Fraud Examiner.

2 1 . Ms. Herold re - reviewed the records provided by Respondent to

determine whether the rendering providers for whom behavior analysis

services were billed met the qualifications . AHCA did not place a ny

limitations on how Respondent documented the qualifications of its rendering

providers . AHCAÔs only concern was whether the criteria were met.

2 2 . During the audit, and through the discovery p rocess , Respondent

supplied AHCA with copies of employment applications, resumes, letters of

recommendation , and training certificates of the BAs in question. At the time

of the final hearin g, the qualifications of only 14 BAs remained in dispute

and the a mount sought in overpayment was calculated by AHCA as

$ 237,802.50. Based on the competent, substantial, and persuasive evidence,

AHCA demonstrated that the audit was properly conducted.

R ENDERING P ROVIDERS AT I SSUE

Eduardo Rodriguez

2 3 . The resu me for Eduardo Rodriguez lists work with Abreu Quality

(ÑAbreuÒ) from 2017 to Ñpresent.Ò It does not indicate a job title or reference

any work with the t arget population in that job. There is no contact

information that would have allowed Respondent the o pportunity to verify

the alleged work experience. The resume also lists ÑPrivate CaseÒ work with

a child with disabilities from 2010 - 2014 and 2016 - 2017. There is no contact

information that would have allowed Respondent the opportunity to verify

the allege d work experience.

2 4 . The application for Mr. Rodriguez, dated December 27, 2017,

Mr. Rodriguez lists BA work with Abreu from February 2017 to ÑpresentÒ

(December 27, 2017). While that listing (unlike the resume) contains contact

information that wou ld have allowed Respondent the opportunity to verify

the alleged work experience, that work, even if verified, did not meet the

r equisite work experience as it was at most ten months. The application also

lists two BA jobs for ÑPrivate Case.Ò There is no i nformation provided that

would have allowed Respondent the opportunity to verify the alleged work

experience met the r equisite work experience or the t arget population

requirements. One private job was from 2010 - 2014 and the other was from

2016 - 2017

2 5 . The documents submitted to AHCA by Respondent contain ed a letter

of recommendation by Felicia Noval. That letter makes no reference to work

with the t arget population . There is no indication who Ms. Noval is or how

she knows Mr. Rodriguez.

2 6 . The documents submitted to AHCA by Respondent contain ed a letter

of recommendation by Jose Chao. However, that letter contains no indication

of work with the t arget population . There is no indication of who Mr. Chao is

or how he knows Mr. Rodriguez.

2 7 . The documents submitted to AHCA by Respondent contain ed a

b ackground s creening requested by Respondent . The background screening

indicates that Mr. Rodriguez was not eligible to work with the t arget

population until April 2017. Because Respondent requeste d the screening , it

knew or should have known that Mr. Rodriguez did not ha v e the requisite

work experience .

2 8 . Based on conflicting information as to when Mr. Rodriguez worked at

Abreu, Ms. Herold reviewed documentation submitted by Abreu to AHCA .

This documentation indicates that Mr. Rodriguez only worked for them from

May 18, 2017 , to June 17, 2017.

2 9 . The documents submitted by Respondent to AHCA for Mr. Rodriguez

contain ed training certificates for both the 20 - hour BA cou rse and the 40 -

ho ur RBT course.

30 . Mr. Rodriguez began working for Respondent on February 8, 2018. The

last paid claim for Mr. Rodriguez was March 23, 2018 .

3 1 . Based on the documentation provided by Respondent , Mr. Rodriguez

did not have documented requisite wo rk experience at the time of hire, at the

beginning of the audit period, or by the end of the last paid claim in the audit

period.

3 2 . Despite Respondent ha ving documentation that Mr. Rodriguez

satisfied the t raining requirement , payments made by AHC A to Respondent

for services billed for him are an overpayment because he did not have the

r equisite work experience or there is insufficient documentation that he had

the requisite work experience .

Fanny Vargas

3 3 . The application for Fanny Varg as, dated March 1, 2017, lists work as a

BA / AHH for ChildrenÔs Home Services (ÑCHSÒ) from 2015 - 2017. There is no

indication of how long Ms. Vargas performed each function. There is no

indication of work with the t arget population in the job as an AHH. Ther e is

insufficient information to determine how long Ms. Vargas worked for CHS.

The application did not provide sufficient information regarding whether

Ms. Vargas had the r equisite work experience .

3 4 . The resume for Ms. Vargas only lists BA work with CHS from 2015 -

Ñstill workingÒ ( presumably March 1, 20 17, the date of the application) . There

is still insufficient information on the resume to determine when Ms. Vargas

began at CHS or if Ms. Vargas worked at CHS for over two years. The

resume also list s Ñprivate serviceÒ for children with special needs from 2012 -

2015. The Ñprivate serviceÒ job was not listed on the application. There is no

contact information listed on the resume for the Ñprivate serviceÒ job that

would have allowed anyone to verify it. The resume did not provide sufficient

information regarding whether Ms. Vargas had the r equisite work

experience .

3 5 . The documents submitted to AHCA by Respondent indicate

Ms. Vargas was not screened as a Medicaid Provider until January 14, 2017.

Sh e was enrolled as a Medicaid provider on April 4, 2017, effective January 9,

2017. She could not have provided services to the t arget population with CHS

before then.

3 6 . The date of service for the last paid claim for Ms. Vargas is

December 31, 2017.

3 7 . The documents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Ms. Vargas had the r equisite work

experience at the time of hire, at the beginning of the audit period or by the

end of the audit period , or that she satisfied the t raining requirement .

Javier Collazo Veloz

3 8 . The application for Javier Collazo Veloz , dated May 4, 2017, lists work

as Private Practice BA in Miami for Melissa Catano, from Ñ08/01/2016 Ï Ò

(presumably May 4, 2017) and BA work for Fe y Alegria in Ecuador from

March 9, 2015 Ï April 3, 2016. Combined , those jobs do not satisfy the

r equisite work experience .

3 9 . The resume for Mr. Collazo Veloz only lists work as a BA for Fe y

Alegria. However, on the resume the dates o f employment are listed as

July 1, 2013 Ï July 1, 2015. Those dates conflict with the information Mr.

Collazo Veloz listed on his application .

40 . Based on the conflict regarding the work with Fe y Alegria, Ms. Herold

attempted to verify it. She located a website for Fe y Alegria, but the website

makes no mention of work with the t arget population .

4 1 . The last paid claim for Mr. Collazo Vel o z was February 16, 2018.

4 2 . The documents provided by Respondent to AHCA during the audit and

during li tigation did not substantiate that Mr. Collazo Veloz had the

documented r equisite work experience at the time of hire, at the beginning of

the audit period or by the end of the last paid claim in the audit period, or

that he satisfied the t raining requirem ent .

Jorge N. Bernal

4 3 . The application for Jorge N. Bernal, dated March 29, 2017 , lists work

as an x - ray technician from April 15 , 2015, to July 17, 20 15 . There is no

indication of work with the t arget population and the nature of that work

wou ld not contribute to the r equisite work experience . Overlapping with the

x - ray technician job, Mr. Bernal also lists he was a teacher at Jesus Para

Todos from December 1, 2012, to March 15, 2016 . The resume makes no

mention of work with the t arget populati on associated with that job and there

is no contact information on the application that Respondent could have used

to verify the alleged work experience.

4 4 . The resume for Mr. Bernal only lists the teacher job at Jesus Para

Todos, but there is no con tact information to verify the employment. The

resume indicates that job involved work with the t arget population .

4 5 . The documents submitted to AHCA by Respondent contain ed

numerous documents indicating Mr. Bernal was born June 16, 1993 . That

means that Mr. Bernal was purportedly ÑteachingÒ when he was only 17.

4 6 . The documents submitted to AHCA by Respondent also contain ed an

honor roll certificat e which indicates that Mr. Bernal was attending college

while purportedly Ñteaching.Ò

4 7 . The documents submitted to AHCA by Respondent post - PAR

contain ed a letter of reference from International Ministry of Jesus for All

(ÑJesus Para TodosÒ) dated March 19, 2019 . That letter does not clearly

corroborate that Mr. Bernal was teaching there. The letter from Jesus Para

Todos indicated it was a church, not a school. The letter further indicates

that Mr. Bernal Ñwas able to serve to the kid Ô s ministry and youth groups,

teaching kids and youth and serving in our community, and participate in

helping s pecial need kids in our church.Ò

4 8 . Mr. Bernal began w ork for Respondent on November 7, 2017 . The last

paid claim for Mr. Bernal is February 17, 2018 . Thus, not only could the

letter from Jesus Para Todos not have been used to verify work in the hir ing

process, it also was not created until after the audit period and almost one

year after the end of Mr. BernalÔs employment with Respondent .

4 9 . Given the conflicting information regarding Jesus Para Todos,

Ms. Herold attempted to verify the facili ty. She discovered there was no

online presence for the facility , and it was not listed in the StateÔs database of

private schools or licensed daycares .

50 . The documents provided by Respondent to AHCA during the audit and

during litigation did not su bstantiate that Mr. Bernal had the r equisite work

experience at the time of hire, at the beginning of the audit period or by the

end of the last paid claim in the audit period, or that he satisfied the t raining

requirement .

Leyanis Morffi

5 1 . T he application for Leyanis Morffi, dated June 30, 2017, lists two

cashier jobs. The nature of that work would not contribute to the r equisite

work experience . The application also lists work as a paid childcare worker at

Smiles Child c are from October 2014 to November 2016. However, there is no

mention of work with the t arget population at that job.

5 2 . The resume for Ms. Morffi lists the same work experience that was

listed on the application. Again, there is no reference to work with the t arget

popula tion at the childcare job. The resume further indicates that Ms. Morffi

Ñspecializes in homes for the elderly and youth detention facilities.Ò However,

there is no listing of that type of work on the application or resume.

5 3 . The documents submitted to AHCA by Respondent contain ed a

b ackground s creening requested by Respondent . The screening indicates that

Ms. Morffi was not eligible to work with the t arget population until

February 2017. Because Respondent requested the screening , it knew or

should have known that Ms. Morffi did not have the r equisite work

experience .

5 4 . Documents submitted to AHCA by Respondent contain ed a letter of

reference dated September 5, 2017, from Lazaro Noel Suarez. That letter is

dated post - hire and was provided to A HCA post - PAR. It references one year

of BA work. However, it provides no specific dates or date range, and contains

no contact information that could be used to verify the information. Neither

the application nor the resume indicates any BA work prior to R espondent to

which this letter could correlate.

5 5 . Documents submitted to AHCA by Respondent contain ed a letter of

reference dated July 30, 2017, from Doris Jimenez. That letter is dated post -

hire and was provided to AHCA post - PAR. It makes no refer ence to work

with the t arget population . It makes no mention of the relationship between

Ms. Morffi and Ms. Jimenez. The letter does not indicate where the work was

performed.

5 6 . Documents submitted to AHCA by Respondent contain a letter of

referenc e dated April 5, 2018. The author is unknown as the signature is

illegible. That letter is dated post - hire and was provided to AHCA post - PAR.

It references work at Smiles Child care from October 2014 to May 2017. While

the letter mentions work with the t arg et population , there is no way to

determine who wrote the letter or the authorÔs relationship to Ms. Morffi. The

letter contains no contact information that could be used to verify the

information. The dates of service in the letter conflict with the dates of

service listed by Ms. Morffi in her application and resume. The letter

indicates that Ms. Morffi was a volunteer, while her application indicates she

earned $10.00 per hour. While volunteer work would count toward requisite

work experience , t he conflic ting information undermines the credibility of

both this letter and the information provided by Ms. Morffi .

5 7 . Based on the conflicting information regarding Smiles Childcare ,

Ms. Herold attempted to verify the information. Smiles Childcare had no

in ternet website and was not listed by the State as a childcare facility.

5 8 . The last paid claim for Ms. Morffi is March 16, 2018. Not only could

the April 5, 2018, letter not have been used to verify work in the hiring

process, it also was not created until after the audit period and over

two weeks after the end of Ms. MorffiÔs employment with Respondent .

5 9 . The documents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Ms. Morffi had the documented

r equisite work experience at the time of hire, at the beginning of the audit

period or by the end of the last paid claim in the audit period, or that she

satisfied the t raining requirement .

Luig u i Melendez Tijerino

60 . The application for Luigui Melendez Tijerino, dated January 30, 2017,

lists overlapping work as a Pharmacy Tech at Walmart from June 2012 to

Ñ presentÒ ( presuma bly the date of the application) and as a food prepper at

WendyÔs from October 2013 to June 2014. There is no indication of work with

the t arget population and the nature of those jobs would not contribute to the

r equisite work experience . Overlapping with the Pharmacy technician job,

Mr. Melendez Tijerino also listed BA work with ABA Pro Support Services

(ÑABA Pro SupportÒ) f rom May 2015 to January 31, 2017.

6 1 . The resume for Mr. Melendez Tijerino lists the same jobs as indicated

on the application and also lists work as a server at ÑThe ChelseaÒ from

April 2011 to September 2013. There is no indication of work with the t arget

population and the nature of that job would not contribute to the r equisite

work experience .

6 2 . Documents submitted to AHCA by Respondent contain a b ackground

s creening requested by Respondent . The screening indicates that Mr.

Melendez Tijerin o was not eligible to work with the t arget population until

October 2016. Because Respondent requested the screening , it knew or

should have known that Mr. Melendez Tijerino did not have the r equisite

work experience .

6 3 . Documents submitted to AHCA b y Respondent contain an undated

letter of reference from Xochilt Povsic . 3 That letter was provided to AHCA

post - PAR. That letter references work with the t arget population , but it does

not mention any dates that would allow anyone to determine if it satisf ied the

r equisite work experience . The letter does not mention where the BA services

were allegedly performed, and the only indication of BA work on

Mr. Melendez TijerinoÔs application and resume was at ABA Pro Support .

6 4 . Based on the conflicting in formation regarding work at ABA Pro

Support, Ms. Herold looked further into the matter. In response to the letter

sent to ABA Pro Support for the BA statewide review, ABA Pro Support

advised th at Mr. Melendez Tijerino was never an employee. That informatio n

was provided to AHCA on January 12, 2018.

3 Ms. Povsic is another rendering provider at issue in the audit. Ms. Povsic may be or may

have been related to Mr. Melendez Tijerin o as the documents submitted by Respondent for

her indicate she used to be called Xochilt Tijerino.

6 5 . Documents submitted to AHCA by Respondent contain a letter of

reference dated September 23, 2016, from Walmart, that was provided to

AHCA post - PAR. That letter does not reference work with the t arget

pop ulation and the nature of the job would not contribute to the r equisite

work experience .

6 6 . Mr. Melendez Tijerino began working for Respondent on November 1,

2017. The last paid claim for Mr. Melendez Tijerino was January 27, 2018.

6 7 . The docum ents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Mr. Melendez Tijerino had the

r equisite work experience at the time of hire, at the beginning of the audit

period or by the end of the last paid claim in t he audit period, or that he

satisfied the t raining requirement .

Maria Oduber

6 8 . The application for Maria Oduber, dated November 29, 2017, lists

Ñyoung care workerÒ with ÑLoyal Resource/CHSÒ from August 2015 to

March 2017. There is no mention of work with the t arget population

associated with that job. Overlapping with that job, the application lists work

as client support with HOPWA Housing from March 2010 to January 2017.

The application also lists work as an ESOL (English for Speakers of Other

Languages) teacher at Greystone Elementary School and as a theater teacher

in ÑCaracas.Ò There is no indication of work with the t arget population and

the nature of those jobs would not contribute to the r equisite work

experience .

6 9 . The resume for Ms. Oduber listed the same jobs as listed on the

application. There was still no mention of work with the t arget population for

any of those jobs.

70 . Ms. Oduber began working for Respondent on January 2, 2018. The

last paid claim for Ms. Oduber was March 17, 2018.

7 1 . The documents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Ms. Oduber had the r equisite work

experience at the time of hire, at the beginning of the audit period or by the

end of the last paid claim in the audit period, or that she satisfied the

t raining requirement .

Mey Weiss Rodriquez

7 2 . The application for Mey Weiss Rodriguez is dated October 4, 2017, on

the front and October 10, 2017, on the back. The application lis ts work as an

assistant at Eliseo Reyes School in ÑS. Spiritus, Cuba,Ò from September 2010

to December 2014. There is no mention of work with the t arget population

associated with the job. The application also lists work at Provincial

Veterinary Laboratory from August 1997 to August 2010. There is no

indication of work with the t arget population and the nature of that job

would not contribute to the r equisite work experience .

7 3 . The resume submitted for Ms. Weiss Rodriguez lists the same work on

the application, but with less specific information regarding dates, and no

information regarding location or contact information. Contrary to the

application, work with the t arget population is listed for Eliseo Reyes S chool.

The resume also claims that Ms. W eiss Rodriguez is an RBT even though

Respondent stipulated that none of the rendering providers at issue obtained

an RBT by January 1, 2019.

7 4 . The documents submitted to AHCA by Respondent contain ed a letter

of recommendation dated October 4, 2017, from Carmen Yebra. The letter

was provided to AHCA post - PAR and makes no mention of work with the

t arget population .

7 5 . Due to the conflict regarding whether there was work with the t arget

population , and the fact there was no documentation of indep endent

verification of that matter, Ms. Herold attempted to verify the work

experience. No search engine provi ded a listing for Eliseo Reyes S chool and

Google Maps, while providing detailed information on Sancti Spiritus, Cuba,

indicated the address listed on the application does not exist.

7 6 . The last paid claim for Ms. Weis s Rodriguez was March 17, 2018.

7 7 . The documents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Ms. Weiss Rodriguez had the

r equisite work experience at the time of hire, at the beginning of the audit

period , or by the end of the last paid claim in the audit period, or that she

satisfied the t raining requirement .

Sorelys Ferros

7 8 . On her application dated March 14, 2017, Sorelys Ferros lists work as

an RBT with MHB Consultants Group (ÑMHBÒ) beginning in December 2015

with no end date listed. However, Respondent stipulated that none of the

rendering providers at issue obtained an RBT by January 1, 2019.

7 9 . The r esume for Ms. Ferros lists the job at MHB and also lists work at

Respondent from March 2017 to present. On her resume , Ms. Ferros also

indicates that she obtained her RBT certification in December 2015.

However, as indicated above, Respondent stipulated th at none of the

rendering providers at issue obtained an RBT by January 1, 2019.

80 . Documents submitted to AHCA by Respondent contain a b ackground

s creening requested by Respondent . The screening indicates that Ms. Ferros

was not eligible to work with the t arget population until June 2016. As such,

she could not have obtained her RBT certification by December 2015.

Because Respondent requested the screening , it knew or should have known

that Ms. Ferros did not have the r equisite work experience and tha t she was

not actually an RBT .

8 1 . The last paid claim for Ms. Ferros was February 2, 2018.

8 2 . The documents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Ms. Ferros had the r equisite work

experi ence at the time of hire, at the beginning of the audit period , or by the

end of the last paid claim in the audit period, or that she satisfied the

t raining requirement .

Teresita Rodriguez

8 3 . The application for Teresita Rodriguez, dated Augus t 10, 2017, lists

two jobs as an HHA - BA , 4 one with Gifted Health Group, Inc. (ÑGiftedÒ) , from

January 2010 to February 2014, and the other with NoryÔs Home Services,

Inc. (ÑNoryÔs Ò ) , from February 2014 to April 2015. There is no indication of

how long Ms. Rodriguez worked in the capacity of an HHA versus as a BA at

either job. There is no indication of work with the t arget population in the

HHA job at Gifted or NoryÔs. The application also listed work as an HHA at

Homecare for Neighborhood Home Health (ÑNei ghborhoodÒ) from April 2015

to ÑactualÒ (presumably, the date of the application, August 10, 2017). There

is no mention of work with the t arget population in the job with

Neighborhood.

8 4 . The resume for Ms. Rodriguez, lists the same jobs listed on th e

application ; however, the work with Neighborhood is listed on the resume as

HHA - BA , and not HHA Homecare. The resume provides more description for

each job , and only the job at Gifted describes work with the t arget population .

8 5 . Documents submitt ed to AHCA by Respondent contain a b ackground

s c reening requested by Respondent . The screening indicates that Ms.

Rodriguez was not eligible to work with the t arget population until

September 2015. Based on the screening, Ms. Rodriguez could not have

worke d with the t arget population at NoryÔs, Neighborhood , or Gifted before

then. Because Respondent requested the screening , it knew or should have

known that Ms. Rodriguez did not have the r equisite work experience .

8 6 . The documents submitted to AHCA b y Respondent contain ed an

undated letter of reference from Josie Vallejo. That letter does not reference

any work with the t arget population but specifically mentions work with Ms.

VallejoÔs mother, a senior, although it does not provide any dates. The let ter

mentioned that Ms. Vallejo had been a friend of Ms. Rodriguez for six years.

4 Presumably, ÑHHAÒ as used in applications and on resumes of rendering providers stands

for Home Health Aide .

8 7 . The documents submitted to AHCA by Respondent contain an undated

letter of refer ence from Danitza Montero. The letter from Ms. Montero states

Ms. Rodriguez cared for Ms. MonteroÔs son, but does not indicate the son was

a member of the t arget population .

8 8 . Ms. Rodriguez began working for Respondent on December 26, 2017.

There is no documentation indicating that Ms. Rodriguez worked for Gifted

past August 10, 201 7. The last paid claim for Ms. Rodriguez was March 17,

2018.

8 9 . The documents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Ms. Rodriguez had the r equisite

work experience at the time of hire, at the beginning of the audit period , or by

the end of the last paid claim in the audit period, or that she satisfied the

t raining requirement .

Xochilt Povsic

90 . The application for Xochilt Povsic, dated January 31, 2017, states she

worked as a member ship coordinator for SamÔs Club, and a dietary aide at

Bentley Commons at Paragon Village in New Jersey. There is no indication of

work with the t arget population at either job , and the nature of those jobs

would not contribute to the r equisite work experi ence . Overlapping the

dietary aide job, on her application Ms. Povsic also indicates work as a BA at

two private practice/personal care jobs. Ms. Povsic states she worked for

Maria Mora from August 2013 to June 2015 and that she worked for Miriam

Ponzano f rom September 2014 to December 2015.

9 1 . The resume for Ms. Povsic listed the same jobs and dates as listed on

the application and also listed another dietary aide job with Fellowship

Village in New Jersey. The resume contains descriptions of the typ e of work

performed at each job. There is no mention of work with the t arget population

at either dietary aide job or in the job at SamÔs Club, and those jobs would not

be of the type to contribute to the r equisite work experience . The work for

Ms. Mora wa s described by Ms. Povsic as providing BA services from

August 2013 to June 2015 to a Ñ3 - 4 [year old child]Ò with autism, ADHD , and

behavior disorders. The work for Ms. Ponzano was described by Ms. Povsic as

providing BA services from September 2014 to Dec ember 2015 to twin boys,

Ñ1 - 2 years oldÒ with behavior disorders and ADHD.

9 2 . The documents submitted to AHCA by Respondent contain ed a letter

from Miriam Ponzano that is not dated and was provided to AHCA post - PAR.

While Ms. Ponzano confirms that Ms . Povsic cared for her boys, there is no

indication that the children were part of the t arget population or that any

work performed contributed to the r equisite work experience . In addition, the

dates of service listed by Ms. Ponzano conflict with the date s listed by Ms.

Povsic. Ms. Ponzano indicated the Ms. Povsic cared for her sons from

November 2015 to March 2016, not September 2014 to December 2015, as

had been asserted by Ms. Povsic on her application and resume.

9 3 . The documents submitted to AH CA by Respondent also contain ed a

letter from Maria Mor a , that is not dated , and was provided to AHCA post -

PAR. Ms. Mora did not confirm that Ms. Povsic had cared for her 3 to 4 - year -

old son with autism, ADHD , and behavior disorders, as Ms. Povsic had

indi cated. Rather, Ms. MoraÔs letter indicates that Ms. Povsic was her

caretaker, performing personal tasks such as picking up medicines and

buying groceries. Ms. Mora does not indicate that she is part of the t arget

population and the services listed are not of the type to contribute to the

r equisite work experience . In addition, the dates of service listed by Ms. Mora

conflict with the dates listed by Ms. Povsic. Ms. Mora indicates that Ms.

Povsic cared for her during the winter of 2014 to 2015 (even mentioni ng that

Ms. Povsic shoveled snow for her), not August 2013 to June 2015, as had been

indicated by Ms. Povsic on her application and resume.

9 4 . The documents submitted to AHCA by Respondent contain ed a letter

from Maydelis Cruz. The letter is not date d and was provided to AHCA post -

PAR. Ms. Cruz indicates she has known Ms. Povsic for 20 years. Ms. Cruz

indicates that Ms. Povsic assisted with her son, who has Down Syndrome,

from November 2011 to March 2013. Ms. Povsic would only have been

17 years old a t that time.

9 5 . The last paid claim for Ms. Povsic was March 17, 2018.

9 6 . The documents provided by Respondent to AHCA during the audit and

during litigation did not substantiate that Xochilt Povsic had the r equisite

work experience at the time of hire, at the beginning of the audit period , or by

the end of the last paid claim in the audit period, or that she satisfied the

t raining requirement .

Yaima Alvarez

9 7 . The application for Yaima Alvarez, dated August 10, 2017, listed two

overl apping HHA jobs: ÑFaith,Ò from July 2016 to ÑpresentÒ (presumably

August 10, 2017, the date of the application) ; and Home Health Solutions,

from June 2017 to present (August 10, 2017). There is no indication of work

with the t arget population for either jo b.

9 8 . The resume for Ms. Alvarez lists no work experience, but has listings

under ÑProfessional AffiliationsÒ that appear to be a work history. Faith

Health Care, Inc. , is listed with dates that correspond to the listing for Faith

on the application. There is no mention of a job title or work with the t arget

population regarding Faith Health Care, Inc. Solutions Group, Inc. , is also

listed under ÑProfessional Affiliations.Ò As with Faith Health Care, Inc., there

is no mention of her job title or work with the t arget population . That listing

does not appear to be the same job that is listed as Home Health Solutions on

the resume as the dates do not correspond. There is no indication of work

with the t arget population for Faith Health Care, Inc. , or Solu tions Group,

Inc. There is also a listing for ÑL.G. (R.B.T. patient).Ò However, as indicated

before, Respondent stipulated that none of the rendering providers at issue

obtained an RBT by January 1, 2019 .

9 9 . Ms. Alvarez began working for Respondent o n December 12, 2017. The

last paid claim for Ms. Alvarez was February 8, 2018.

100 . The documents provided by Respondent to AHCA during the audit

and during litigation did not substantiate that Ms. Alvarez had the r equisite

work experience at the time of hire, at the beginning of the audit period or by

the end of the last paid claim in the audit period, or that she satisfied the

t raining requirement .

Yudisley Garces

10 1 . The application for Yudisley Garces, dated April 20, 2017, lists

overlap ping CNA (Certified Nursing Assistant) jobs. One was with AAA

Home Health Service (ÑAAAÒ) from June 2014 to today (April 20, 2017) and

the other is with Alma Care, Inc. (ÑAlma CareÒ) , from August 2015 to ÑtodayÒ

(presumably the date of the application, Apr il 20, 2017). There is no

indication of work with the t arget population for either job.

10 2 . The resume for Ms. Garces only lists the job for AAA. However, the

dates listed on the resume for that job (beginning June 2014) conflict with the

dates liste d on the application (beginning February 2014). There is no

indication of work with the target population associated with that job. The

resume also listed two jobs (one at a hospital in Cuba and the other at a

hospital in Venezuela) performing puncture asp iration biopsies and cervical

cancer diagnoses. There is no mention of work with the t arget population at

either of those hospital jobs, and those jobs would not be of the type to

contribute to the requisite work experience .

10 3 . The last paid claim f or Ms. Garces was March 17, 2018.

10 4 . The documents provided by Respondent to AHCA during the audit

and during litiga tion did not substantiate that Ms. Garces had the r equisite

work experience at the time of hire, at the beginning of the audit period , or by

the end of the last paid claim in the audit period, or that she satisfied the

t raining requirement .

Zerelys Lauzerique

10 5 . The resume for Zerelys Lauzerique lists work with ÑLenin &

DaughterÒ and Ignite Christian Academy (ÑIgniteÒ). There is no indication of

work with the target population regarding the job at Ignite. It also lists work

as a fitness coach with Beach Body, as a Youth Pastor at Cross Church, and

as an Assistant Director at Flames of Fire Bible School (ÑFlames of FireÒ) ,

that is not listed on the application. The Beach Body work overlaps the BA

work with Lenin & Daughter. There is no indication of working with the

t arget population associated with the jobs at Beach Body , Cross Church , or

Flames of Fire, and those jobs would no t be of the type to contribute to the

r equisite work experience .

10 6 . The application for Ms. Lauzerique, dated December 4, 2017, lists

work as a BA with Lenin & Daughter from December 2016 to ÑcurrentÒ

(presumably the date of the application, Decembe r 4, 2017) and as a Teacher

Assistant with Ignite from August 2014 to August 2015. There is no mention

of work with the t arget population regarding the job at Ignite.

10 7 . The documents submitted to AHCA by Respondent contain ed a letter

of reference d ated December 5, 2016, from Melanie Reyes, a Ñclose friend.Ò

The letter from Ms. Reyes does not indicate any work with the t arget

population and instead pertains to Ms. La uzeriqueÔs work at Beach Body.

10 8 . The documents submitted to AHCA by Responde nt also contain ed a

letter of reference dated December 2016 from Reverend Abram Gomez of

Cross Church. The letter indicates that he worked with Ms. Lauzerique for

two years, but does not indicate any work with the t arget population .

10 9 . Ms. Lauzeriq ue began working for Respondent on December 11, 2017.

The last paid claim for Ms. Lauzerique was January 6, 2018.

1 10 . The documents submitted by Respondent to AHCA for Ms.

Lauzerique contain ed training certificates for both the 20 - hour BA course and

the 40 - hour RBT course.

11 1 . The documents provided by Respondent to AHCA during the audit

and during litigation d id not substantiate that Ms. Lauzerique had the

requisite work experience at the time of hire, at the beginning of the audit

period , or by the end of the last paid claim in the audit period.

Respondent's Response

11 2 . The owner of Hour Bliss, Inc., Mr. Perez - Delgado, testified on behalf

of Respondent. He is a Board - Certified Behavior Analyst, has a masterÔs

certification in addiction , and is a Licensed Mental Health Counselor.

Mr. Perez - Delgado testified that Respondent served populations in Miami

that no other company would because of the crime.

11 3 . Mr. Perez - Delgado said that when he enrolled Respondent as a BA

provider, many of the rendering providers he hired had worked at other

companies where he had also worked , and because of this, he believed they

met the qualifications required to serve as BAs .

11 4 . Mr. Perez - Delgado testified that he provided records he thought wer e

relevant to the Medicaid investigation beginning in August 2017, and again

in January 2018 and April 2019. If there had been a proble m , he would have

liked AHCA to institute a corrective action plan. However, he alleges the next

communication from AHCA w as terminating his Medicaid provider number

without cause. Later, he received notice of the audit . Much of the testimony

from Mr. Perez - Delgado concerned events that occurred prior to the audit

beginning in November 2018, and the issuance of the PAR and FA R in 2019.

These events are obviously related to the pre - payment review or other

matters with AHCA, and not the audit.

11 5 . Mr. Perez - Delgado testified that several of his rendering providers

were parents of children with autism or ADHD. Accordingly, they had more

than the requisite experience with the target population. However, he did not

document that in the files provided to the Agency . Nor did he timely provide

recor d s demonstrating that these same workers met the training

requirement. Mr. Perez - D elgado offered no information regarding how or

whether he verified prior work experience of these BAs in question.

U LTIMATE F INDING S OF F ACT

11 6 . In this case, AHCA presented credible, persuasive evidence

establishing that the audit giving rise to this pro ceeding wa s properly

conducted. AHCA obtained and reviewed records from Respondent , issued a

PAR, reviewed additional records submitted after the PAR, issued the FAR,

and even then continued to review records and consider evidenced that, by

giving Responde nt the benefit of the doubt whenever possible, further

reduced the overpayment.

11 7 . In this audit, AHCA examined the records provided by Respondent to

determine if it maintained business records and Medicaid - related records

establishing that its renderin g providers met the qualifications set forth in

the BA Handbook. The BA Handbook required no special documentation.

Respondent , as are all providers who contract to provide Medicaid services,

was required to keep contemporaneous records regarding entitleme nt to

payment, including employment eligibility, an d compliance with all Medicaid

r ules, regulations, handbooks , and policies.

11 8 . Respondent failed to provide AHCA with documentation that its

rendering providers met the qualifications set forth in the B A Handbook . Of

the 14 BA providers in dispute, 12 lacked any documentation of the requisite

work experience with the target population and meeting the training

requirement. Only two BAs, Mr. Rodriguez and Ms. Lazerique, met the

training requirements , but d id not meet the required work experience with

the target population.

C ONCLUSIONS OF L AW

11 9 . The Division of Administrative Hearings has jurisdiction over the

parties to and the subject matter of this proceeding. §§ 120.569 and 120.57,

Fla. Stat.

1 20 . T he burden of proof is on Petitioner to prove the material allegations

by a preponderance of the evidence. See e.g., S. Med. Servs., Inc. v. Ag. for

Health Care Admin. , 653 So. 2d 440, 441 (Fla. 3d DCA 1995); Southpointe

Pharm. v. Dep't of HRS , 596 So. 2d 1 06, 109 (Fla. 1st DCA 1992).

1 21 . Pursuant to section 409.913, Petitioner is authorized to recover

Medicaid overpayments from Medicaid providers . Under section

409.913 (1)(e), an ÑoverpaymentÒ is defined as Ñany amount that is not

authorized to be paid by t he Medicaid program whether paid as a result of

inaccurate or improper cost reporting, improper claiming, unacceptable

practices, fraud, abuse, or mistake.Ò Under section 409.913(1)(a), ÑabuseÒ is

defined, in pertinent part, as Ñ[p]rovider practices that a re inconsistent with

generally accepted businessÈpractices and that result in an unnecessary cost

to the Medicaid programÈ.Ò

12 2 . The failure of a Medicaid provider to document that its employees

meet the applicable qualifications to provide services in ac cordance with the

applicable Medicaid handbooks and the Provider Enrollment Agreement is

inconsistent with generally accepted business practices. See Ag. For Health

Care Admin. v. Zenith Psych. Ser v s . , Case No. 19 - 3666MPI ( Fla. DOAH

Jan. 14, 2020, p. 12, ¶ 28; Fla. AHCA Feb. 12, 2020).

12 3 . AHCA is authorized to impose sanctions on a provider, including

administrative fines. § 409.913(16), Fla. Stat. To impose an administrative

fine, AHCA must establish by clear and convincing evidence the factual

grounds f or doing so. Dep't of Banking & Fin., Div. of Sec. & Investor Prot. v.

Osborne Stern & Co. , 670 So. 2d 932, 935 (Fla.1996); Dep't of Child. & Fams.

v. Davis Fam. Day Care Home , 160 So. 3d 854, 857 (Fla. 2015).

12 4 . Sections 409.913(7) (e) and (f), require providers to present claims for

reimbursement in accordance with all Medicaid rules, regulations, and

handbooks, and to appropriately document all good s and services provided.

The Medicaid rules and handbooks applicable to all Medicaid providers, and

the N on - Institutional Medicaid Provider Agreement signed by Respondent

set forth the type of documentation required to be kept. No specialized

documentation was required by the BA Handbook or requested in this audit.

12 5 . In this case, AHCA presented credible, persuasive evidence

establishing that the audit giving rise to this proceeding was prop erly

conducted. AHCA presented documentary and testimonial evidence that

supports the denial of the claims at issue in this proceeding. Respondent was

required to keep c ontemporaneous records regarding entitlement to payment,

including employment eligibility, and compliance with all Medicaid Rules,

regulations, handbooks , and policies. Respondent failed to provide AHCA

with documentation that its rendering providers met t he qualifications set

forth in the BA Handbook.

12 6 . Based on these standards and the foregoing Findings of Fact, AHCA

proved, by a preponderance of the evidence, that Respondent was overpaid a

total of $237,802.50 for claims that failed to comply with the laws, rules, and

regulations governing Medicaid providers .

12 7 . AHCA presented unrefuted, competent , and substantial testimony

that Respondent provided additional documentation after the PAR was

issued. AHCA demonstrated its entitlement to sanctions by clear and

convincing evidence in this proceeding. AHCA is entitled to a sanction of

$2,500.00 pursuant to r ule 59G - 9.070(7)(c) .

12 8 . Pursuant to section 409.913(23), as the prevailing party in this

proceeding, AHCA is entitled to recover, as costs, all investigative, legal, and

expert witness costs. At the time AHCA issued the FAR, it was seeking costs

in the amount of $1,280.00. Additional costs were incurred in preparing for

and attending the final hearing and filing post - hearing submittals.

R EC OMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is

R ECOMMENDED tha t the Agency for Health Care Administration enter a final

order incorporating the terms of this Recommended Order as follows:

1. AHCA overpaid Respondent the s um of $237,802.50 for BA services and

Respondent must reimburse the Agency for those payments.

2. AHCA is entitled to an administrative sanction in the amount of

$2,500.00.

3. AHCA , as the prevailing party in this proceeding , is entitled to recover,

from R espondent, costs inclu ding all investigative, legal, and expert witness

costs .

D ONE A ND E NTERED this 27 th day of April , 2020 , in Tallahassee, Leon

County, Florida.

S

M ARY L I C REASY

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 27th day of April , 2020 .

C OPIES F URNISHED :

Julio Cesar P erez - Delgado

Hour Bliss, Inc.

Apartment 406

888 Brickell Key Drive

Miami, Florida 33131

(eServed)

Susan Sapoznikoff, Esquire

Agency for Health Care Administration

2727 Mahan Drive , Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Kimberly Murray, Esqu ire

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Richard J. Shoop, Agency Clerk

A gency for H ealth C are A dministration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Stefan Grow, General Counsel

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Mary C. Mayhew, Secretary

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 1

Tallahassee, Florida 32308

(eSer ved)

Shena L. Grantham, Esquire

Agency for Health Care Administration

Building 3, Room 3407B

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Thomas M. Hoeler, Esquire

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

N OTICE OF R IGHT T O S UBMIT E XCEPTIONS

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 w ill issue the Final Order in this

case.