Court Backs State In Doctor Overpayment Dispute

Sep 1, 2016

An appeals court Wednesday sided with the state Agency for Health Care Administration in a dispute about whether a pediatrician is required to repay more than $1 million to the Medicaid program.

The decision by a panel of the 3rd District Court of Appeal was rooted in an audit of claims for Medicaid reimbursement by physician Alfred Ivan Murciano.

As part of the process, AHCA used another physician, Keith O'Hern, to conduct a "peer review" of documents submitted by Murciano. AHCA later contended that Medicaid had overpaid Murciano by $1.05 million, according to Wednesday's ruling.

The agency sought repayment of nearly $1.266 million, including fines and audit costs. Murciano challenged the agency, at least in part arguing that O'Hern did not meet the legal definition of a "peer" --- an argument backed by an administrative law judge.

Murciano specializes in pediatrics with a subspecialty in infectious diseases and provides services at hospital intensive-care units in Miami-Dade, Broward and Palm Beach counties, Wednesday's ruling said.

O'Hern did not have the same subspecialty as Murciano. But the appeals court said the same subspecialty was not required by state law.

"We do not ignore Dr. Murciano's argument that a peer who is both a board certified specialist in pediatrics and a board certified subspecialist in infectious diseases might be more desirable as a peer reviewer for Dr. Murciano," said the 14-page ruling, written by Judge Kevin Emas and joined by judges Barbara Lagoa and Thomas Logue. "And while the statute would permit the use of a peer reviewer who is of the same specialty and subspecialty, the statute does not require it."