78(2) 79DEFINITIONS.80-81For purposes of this section, the term:88(a) 89“Active practice” means a physician must have regularly provided medical care and treatment to patients within the past 2 years.
109(b) 110“Medical necessity” or “medically necessary” 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. For purposes of determining Medicaid reimbursement, the agency is the final arbiter of medical necessity. In making determinations of medical necessity, the agency must, to the maximum extent possible, use a physician in active practice, either employed by or under contract with the agency, of the same specialty or subspecialty as the physician under review. Such determination must be based upon the information available at the time the goods or services were provided.
243(c) 244“Peer” means a Florida licensed physician who is, to the maximum extent possible, of the same specialty or subspecialty, licensed under the same chapter, and in active practice.
272(d) 273“Peer review” means an evaluation of the professional practices of a Medicaid physician provider by a peer or peers in order to assess the medical necessity, appropriateness, and quality of care provided, as such care is compared to that customarily furnished by the physician’s peers and to recognized health care standards, and, in cases involving determination of medical necessity, to determine whether the documentation in the physician’s records is adequate.
343(e) 344“Physician” means a person licensed to practice medicine under chapter 458 or a person licensed to practice osteopathic medicine under chapter 459.
366(f) 367“Professional services” means procedures provided to a Medicaid recipient, either directly by or under the supervision of a physician who is a registered provider for the Medicaid program.
554(5) 555DETERMINATIONS OF OVERPAYMENT.558-559In making a determination of overpayment to a physician, the agency must:571(a) 572Use accepted and valid auditing, accounting, analytical, statistical, or peer-review methods, or combinations thereof. Appropriate statistical methods may include, but are not limited to, sampling and extension to the population, parametric and nonparametric statistics, tests of hypotheses, other generally accepted statistical methods, review of medical records, and a consideration of the physician’s client case mix. Before performing a review of the physician’s Medicaid records, however, the agency shall make every effort to consider the physician’s patient case mix, including, but not limited to, patient age and whether individual patients are clients of the Children’s Medical Services Network established in chapter 391. In meeting its burden of proof in any administrative or court proceeding, the agency may introduce the results of such statistical methods and its other audit findings as evidence of overpayment.
704(b) 705Refer all physician service claims for peer review when the agency’s preliminary analysis indicates that an evaluation of the medical necessity, appropriateness, and quality of care needs to be undertaken to determine a potential overpayment, and before any formal proceedings are initiated against the physician, except as required by s. 755409.913756. 757(6) 758COST REPORTS.760-761For any Medicaid provider submitting a cost report to the agency by any method, and in addition to any other certification, the following statement must immediately precede the dated signature of the provider’s administrator or chief financial officer on such cost report:803“I certify that I am familiar with the laws and regulations regarding the provision of health care services under the Florida Medicaid program, including the laws and regulations relating to claims for Medicaid reimbursements and payments, and that the services identified in this cost report were provided in compliance with such laws and regulations.”
