STATE OF NORTH CAROLINA
COUNTY OF WAKE
IN THE OFFICE OF ADMINISTRATIVE HEARINGS
10 DHR 8735, 11 DHR 0691,
11 DHR 0762, 11 DHR 0763,
11 DHR 2021
1
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Geraldine Highsmith,
Pediatric Therapy Associates,
Petitioner,
vs.
North Carolina Department of Health and Human Services,
Respondent.
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DECISION
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THIS MATTER came on for hearing before Beecher R. Gray, Administrative Law Judge, on March 28, 2011, in Raleigh, North Carolina.
APPEARANCES
For Petitioner: Geraldine Highsmith, PT, DPT, appearing pro se
For Respondent: Iain Stauffer
Assistant Attorney General
North Carolina Department of Justice
ISSUE
Whether the Division of Medical Assistance’s action to recoup funds paid to Petitioner was proper.
STATUTES AND RULES
42 U.S.C. § 1396 et seq.
N. C. Gen. Stat. Ch. 108A, Article 2, Parts 1 and 6
N. C. State Plan for Medical Assistance
10 N.C.A.C. 22F
Division of Medical Assistance, Clinical Coverage Policy No.: 10A, Outpatient Specialized Therapies
EXHIBITS
Respondent's exhibits A1-A6, B7-B9, C11-C13, D15-D18, E20-E22 and 24-25 were admitted into evidence.
Petitioner’s exhibits P-1 and P-2 were admitted into evidence.
PRELIMINARY MATTERS
By Order dated and filed February 25, 2011, Chief Administrative Law Judge Julian Mann III, ordered that the following contested cases be consolidated for hearing: 10 DHR 8735; 11 DHR 0691; 11 DHR 0762; and 11 DHR 0763. Prior to hearing, 11 DHR 2021 also was consolidated with the other four cases for hearing.
BASED UPON careful consideration of the sworn testimony of the witnesses presented at the hearing, along with documents and exhibits received and admitted into evidence and the entire record in this proceeding, the undersigned makes the following Findings of Fact. In making the Findings of Fact, the undersigned has weighed all the evidence and has assessed the credibility of the witnesses by taking into account the appropriate factors for judging credibility, including but not limited to the demeanor of the witnesses, any interests, bias, or prejudice the witness may have, the opportunity of the witness to see, hear, know, or remember the facts or occurrences about which the witness testified, whether the testimony of the witness is reasonable, and whether the testimony is consistent with all other believable evidence in the case.
FINDINGS OF FACT
1. The parties received notice of hearing by certified mail more than 15 days prior to the hearing and each stipulated on the record that notice was proper.
2. Pediatric Therapy Associates (“Petitioner”) is an enrolled provider in the North Carolina Medicaid Program which entered into a North Carolina Medicaid Participation Agreement with the Division of Medical Assistance (“DMA”) to participate in this program.
3. By entering into the Medicaid Participation Agreement, Petitioner agreed to “operate and provide services in accordance with all federal and state laws, regulations and rules, and all policies, provider manuals, implementation updates, and bulletins published by the Department.”
4. By entering into the Medicaid Participation Agreement, Petitioner agreed to “[f]urnish upon request any and all documentation . . . including recipient records, supporting material, and information regarding payments claimed by the Provider.”
5. By entering into the Medicaid Participation Agreement, Petitioner further agreed to “[k]eep, maintain and make available complete and accurate medical and fiscal records in accordance with Department record-keeping requirements that fully justify and disclose the extent of the services . . . and claims submitted to the Department.”
6. The DMA has contracted with the Carolinas Center for Medical Excellence (“CCME”) to conduct post-payment reviews of Medicaid Outpatient Specialized Therapies providers.
7. Outpatient Specialized Therapies include speech therapy, occupational therapy, and physical therapy.
8. Division of Medical Assistance, Clinical Coverage Policy No. 10A, Outpatient Specialized Therapies, Revised Date May 1, 2007, and Revised Date December 1, 2009, promulgated medical coverage policies, were in effect at the time of the post-payment reviews.
10 DHR 8735
9. CCME issued a First Request letter to Petitioner on April 1, 2010 requesting documentation to conduct a post-payment review of Speech Therapy treatment for recipient J.H. for dates of service July 1, 2009 to November 30, 2009. The following documentation was requested: most recent evaluation/re-evaluation, including plan of care; order(s) covering services for the period specified; visit notes for the period specified; other documentation, if any, which substantiates the PA request for the time period specified; and any additional documentation necessary to support the need for this skilled intervention, including explanation of how this additional documentation supports the need for services.
10. On April 12, 2010, in response to the CCME’s request, Petitioner submitted visit notes, a physician’s order, and a speech and language progress report for recipient J.H.
11. CCME identified an overpayment amount to Petitioner of $1,221.00 for services provided when the records failed to document the duration of the treatment session.
12. A Medicaid provider for outpatient specialized therapies must maintain documentation for each recipient that shows “[t]he duration of service (i.e., length of assessment and/or treatment session in minutes).” Division of Medical Assistance, Clinical Coverage Policy No.: 10A, Outpatient Specialized Therapies, sec. 7.1.e., Revised Date May 1, 2007. (Emphasis in original).
13. Petitioner requested a reconsideration review from the DMA. The North Carolina Department of Health and Human Services Hearing Office conducted the reconsideration review and issued a decision on October 12, 2010 which upheld the recoupment amount of $1,221.00. For the reconsideration review, Petitioner submitted the same records as submitted to CCME but also used its Tiger/Mysis system records containing information on the duration of the treatment sessions to add documentation of the session length in minutes on each of the visit notes.
14. The visit notes for services provided from July 1, 2009 through November 30, 2009 submitted to CCME failed to document the duration of the treatment session in minutes.
15. Petitioner submitted claims for payment to DMA for recipient J.H. without documenting the duration of the treatment session in minutes for the following dates of service in 2009: July 1, 15, 22, 29; August 5; September 1, 8, 15, 22; October 1, 8, 13, 27; and November 3, 10, 17, and 24.
11 DHR 0691
16. CCME issued a First Request letter to Petitioner on October 1, 2010 requesting documentation to conduct a post-payment review of Physical Therapy services for recipient Z.F. for dates of service from March 5, 2010 to April 16, 2010. CCME requested the following documentation: most recent evaluation/re-evaluation, including plan of care; order(s) covering services for the period specified; visit notes for the period specified; other documentation, if any, which substantiates the PA request for the time period specified; and any additional documentation necessary to support the need for this skilled intervention, including explanation of how this additional documentation supports the need for services.
17. On October 15, 2010, in response to the CCME’s request, Petitioner submitted progress notes, a physician’s order, and a plan of care for recipient Z.F.
18. CCME identified an overpayment to Petitioner in the amount of $280.44 because documentation did not provide service dates and services were provided without a valid physician’s order. CCME notified Petitioner of this overpayment by notice dated December 15, 2010.
19. Prior to the hearing, after further review of the documentation presented, the DMA reduced the overpayment amount in 11 DHR 0691 from $280.44 to $140.22. The remaining overpayment amount of $140.22 was due to the lack of a physician’s order.
20. A requirement for coverage of this treatment is that “a written order must be obtained for services prior to the start of the services.” Division of Medical Assistance, Clinical Coverage Policy No.: 10A, Outpatient Specialized Therapies, sec. 5.1.e., Revised Date December 1, 2009.
21. The physician’s order submitted by Petitioner for recipient Z.F. was dated March 5, 2010 and provided for a frequency of two treatments per week for four weeks. This physician’s order was valid for services provided on March 12, 15, and 19, 2010.
22. Petitioner submitted claims for payment to DMA for recipient Z.F. without a physician’s order authorizing treatment for the following dates of service in 2010: April 5, 9, and 16.
11 DHR 0762
23. CCME issued a First Request letter to Petitioner on October 1, 2010 requesting documentation to conduct a post-payment review of Physical Therapy services for recipient I.A. for dates of service from December 1, 2009 to April 28, 2010. CCME requested the following documentation: most recent evaluation/re-evaluation, including plan of care; order(s) covering services for the period specified; visit notes for the period specified; other documentation, if any, which substantiates the PA request for the time period specified; and any additional documentation necessary to support the need for this skilled intervention, including explanation of how this additional documentation supports the need for services.
24. On October 4, 2010, in response to the CCME’s request, Petitioner submitted a physician’s order, a document titled “Initial Evaluation,” and treatment notes for recipient I.A.
25. CCME identified an overpayment amount to Petitioner of $771.21 for the failure to document a plan of care that included the specific content of services. CCME notified Petitioner of this overpayment by notice dated December 15, 2010.
26. A requirement for coverage of this treatment is that “[e]ach plan must include a specific content . . . of services for each therapeutic discipline.” Division of Medical Assistance, Clinical Coverage Policy No.: 10A, Outpatient Specialized Therapies, sec. 5.1.d., Revised Date December 1, 2009. Specific content of services includes the planned modalities, therapeutic interventions, and/or the treatment approaches that require the skill of a licensed therapist and which target the achievement of the stated goals.
27. The documentation submitted did not contain a plan of care that included the specific content of services for recipient I.A.
28. Petitioner submitted claims for payment to DMA for recipient I.A. without a plan of care that included the specific content of services for the following dates of service in 2009: December 1, 15, 22, and 29; and for the following dates of service in 2010: January 5, 19; February 2, 9; March 2, 9; and April 6.
11 DHR 0763
29. CCME issued a First Request letter to Petitioner on August 2, 2010 requesting documentation to conduct a post-payment review of Occupational Therapy services for recipient T.M. for dates of service December 1, 2009 to February 19, 2010. CCME requested the following documentation: most recent evaluation/re-evaluation, including plan of care; order(s) covering services for the period specified; visit notes for the period specified; other documentation, if any, which substantiates the PA request for the time period specified; and any additional documentation necessary to support the need for this skilled intervention, including explanation of how this additional documentation supports the need for services.
30. On August 2, 2010, in response to the CCME’s request, Petitioner submitted a physician’s order, a document titled Initial Evaluation, and service or treatment notes for recipient T.M.
31. CCME identified an overpayment amount to Petitioner of $221.31 for the failure to document a plan of care that included the specific content of services and for the failure to document the interventions that supported the nature and intensity of the skilled services billed. CCME notified Petitioner of this overpayment by notice dated October 26, 2010.
32. Petitioner requested a reconsideration review from the DMA. The North Carolina Department of Health and Human Services Hearing Office conducted the reconsideration review and issued a decision on December 13, 2010 which upheld the recoupment amount of $221.31.
33. A Medicaid provider for outpatient specialized therapies must maintain documentation for each recipient that shows the “[d]escription of services (intervention and outcome/client response) performed and dates of service.” Division of Medical Assistance, Clinical Coverage Policy No.: 10A, Outpatient Specialized Therapies, sec. 7.2.d., Revised Date December 1, 2009.
34. The documentation submitted by Petitioner failed to document the specific content of services for recipient T.M. and the service or treatment notes failed to document the interventions that supported the nature and intensity of the skilled services billed to Medicaid.
35. Petitioner submitted claims for payment to DMA for recipient T.M. without a plan of care that included the specific content of services and without documenting the interventions that supported the nature and intensity of the skilled services billed for the following dates of service in 2009: December 2, 16; and in 2010: January 13.
11 DHR 2021
36. CCME issued a First Request letter to Petitioner on December 1, 2010 requesting documentation to conduct a post-payment review of Occupational Therapy services for recipient J.S. for dates of service January 5, 2010 to June 23, 2010. CCME requested the following documentation: most recent evaluation/re-evaluation, including plan of care; order(s) covering services for the period specified; visit notes for the period specified; other documentation, if any, which substantiates the PA request for the time period specified; and any additional documentation necessary to support the need for this skilled intervention, including explanation of how this additional documentation supports the need for services.
37. On December 14, 2010, in response to the CCME’s request, Petitioner submitted a physician’s order, a document titled “Occupational Therapy Re-Evaluation,” and service or treatment notes for recipient J.S.
38. CCME identified an overpayment amount to Petitioner of $295.08 for the failure to document a plan of care that included the specific content of services. CCME notified Petitioner of this overpayment by notice dated February 15, 2011.
39. The documentation submitted did not contain a plan of care that included the specific content of services for recipient J.S.
40. Petitioner submitted claims for payment to DMA for recipient J.S. without a plan of care that included the specific content of services for the following dates of service in 2010: January 6, 20; February 3; March 3; and May 26.
41. The DMA sought recoupment of a total of $2,648.82.
42. The DMA paid Petitioner for all the claims for which the DMA is seeking recoupment.
43. Under 10A N.C.A.C. 22F .0103(b)(5), DMA “shall institute methods and procedures to recoup improperly paid claims.”
44. Under 10A N.C.A.C. 22F .00601(a), DMA “will seek full restitution of any and all improper payments made to providers by the Medicaid Program.”