[Indistinct conversation continues]
JUDGE TEATE: All right, ma’am, if you’ll come up here and if you would, before you take the seat up
here, if you would raise your right hand?
WYLENE MOORE: Sure.
JUDGE TEATE: Do you solemnly affirm the testimony you’re about to give is the whole truth and nothing but the truth, so help you God?
WYLENE MOORE: Yes.
JUDGE TEATE: All right. Please be seated and state your name for the record.
WYLENE MOORE: My name is Wylene Moore, Registered Nurse.
TARA DICKERSON: Ms. Moore, could you tell the Court how you’re currently employed?
WYLENE MOORE: I’m currently employed at Department of Community Health, Medicaid.
TARA DICKERSON: And what’s your job title?
WYLENE MOORE: I am a Compliance Auditor and Monitor.
TARA DICKERSON: And how long have you held that position?
WYLENE MOORE: I’ve held that position for three years.
TARA DICKERSON: And in the course of your duties and responsibilities, could you tell the Court what you do with regard to being a compliance auditor?
WYLENE MOORE: Yes. Basically, what I do is I
audit and monitor providers throughout the state of Georgia and review to make sure that they’re in compliance with the Medicaid policy as well – as well as federal policies.
TARA DICKERSON: Okay. And with regard to actual audits, in the course of your work, how – approximately how many provider audits would you say you’ve actually done?
WYLENE MOORE: I’ve completed 14 audits and assisted with 12.
TARA DICKERSON: Okay. And when you talk about providers, are you talking about a large volume of records?
WYLENE MOORE: Oh, yes, large volume.
TARA DICKERSON: Okay. And in the course of your duties and responsibilities, did you come in contact with Old National Gynecological?
WYLENE MOORE: I did.
TARA DICKERSON: And with regard to that, uh, particular location, who is the doctor at that location? Who owns that location?
WYLENE MOORE: Dr. Tyrone Malloy.
TARA DICKERSON: All right. And could you tell the Court, um, what you did with regard to going out and conducting an audit?
WYLENE MOORE: What I did was I notified the office on January 25, 2010, that I would be coming out to perform an onsite.
TARA DICKERSON: And how did you notify them?
WYLENE MOORE: I note – I note – notified them by way of fax as well as mailing the letter.
TARA DICKERSON: Okay. And what did you do thereafter?
WYLENE MOORE: I then arrived on the morning of the 27th, identified myself as well as my team, gave them a bus – a business card, and the officer manager took us back to their waiting area for us to set up our equipment.
TARA DICKERSON: And with regard to setting up your equipment, what equipment did you have?
WYLENE MOORE: I had my laptop and my scanner and a list.
TARA DICKERSON: And could you tell the Court what you did as it relates to your scanner?
WYLENE MOORE: Yes. I set up my scanner, connected to the computer, and I scanned all of the records that I had on my list that I [overlapping conversation].
TARA DICKERSON: And what time frame were you looking at with regard to the actual audit?
WYLENE MOORE: I was looking at, um, I believe it was January – just a second; I’ll let you know.
TARA DICKERSON: Would that information have been in the letter that you [overlapping conversation]?
WYLENE MOORE: Yes, it would have. Yes. I was looking at October 2008 through January 15, 2010.
TARA DICKERSON: Okay. And about how many member records did you actually scan or copy at this location?
WYLENE MOORE: Seventy-two.
TARA DICKERSON: All right. What else did you do besides the copying of the records?
WYLENE MOORE: I also interviewed the employees who were present, and I also took a tour of the facility.
TARA DICKERSON: And, based upon your interview, first tell the Court who all did you, in fact, interview?
WYLENE MOORE: I interviewed the Officer Manager, Cathy Warner. I also interviewed the medical – the Certified Medical Assistant, Britney Fields, and the Medical Assistant Supervisor, Quin – Quintetta[phonetic] Clemson.
TARA DICKERSON: Okay. And with regard to the interviews, what did you conclude was the business at
this location?
WYLENE MOORE: I concluded that it was an abortion clinic.
TARA DICKERSON: Okay. And why did you make that conclusion?
WYLENE MOORE: Because that was what I was told, that that’s the only procedure that is done there.
TARA DICKERSON: Okay. And with regard to, um, your records that you reviewed, did your records that you actually reviewed uphold that conclusion?
WYLENE MOORE: Yes.
TARA DICKERSON: Okay. Now once you, uh, reviewed the records, what, if anything, did you note with regard to this particular location? What was the results of your review?
WYLENE MOORE: The results is that upon a client coming in or calling to set up an appointment to, um, be seen there, that they were requesting to terminate their pregnancy. And so when they came in, everything was done on the same day.
TARA DICKERSON: And did that cause you any concern?
WYLENE MOORE: It did.
TARA DICKERSON: How so?
WYLENE MOORE: Uh, based on the policy for
Medicaid, is that any services associated with an abortion will not be paid for.
TARA DICKERSON: And what particular services did you deem to be associated with an abortion?
WYLENE MOORE: Abdominal ultrasound, transvaginal ultrasound, um, he – hemoglobin and urine test, and then, of course, the office visit.
TARA DICKERSON: Okay. And with regard to the actual abortion, um, did you – first of all, did you review any billing related to the member records that you scanned and reviewed?
WYLENE MOORE: I reviewed the claims data prior to going out - -
TARA DICKERSON: Okay.
WYLENE MOORE: - - saw that everyone had the same billing pattern.
TARA DICKERSON: And what pattern did you find?
WYLENE MOORE: I found that every one of those clients were billed the same, exact five charges.
TARA DICKERSON: All right. And do you have a copy of the billing? (Let me give you a copy [indistinct] give the Court.) Dr. Malloy, the billing is those two [indistinct] Part I and Part II.
DR. MALLOY: Okay.
[Indistinct conversation and noise in background]
TARA DICKERSON: And are these in any alphabetical order or anything? Are they just - -
WYLENE MOORE: They’re just random. They’re not in alphabetical order.
TARA DICKERSON: All right. [Indistinct; background noise] Part I [indistinct] 48 [indistinct], 47, 48.
JUDGE TEATE: Forty-seven and what?
TARA DICKERSON: Forty-eight, Part I and Part II. It’s a fiscal billing. [Indistinct] And we didn’t – we can put these together [indistinct]. And they’re on the disk [indistinct]. And we’re not gonna go through all of those, Your Honor. [Writing] And they’re not in alphabetical order.
DR. MALLOY: I don’t think [indistinct].
TARA DICKERSON: With regard to this billing, did you find, um – hmm, did you find, um, member AA in that section? Go to – just go to one of the [indistinct] ones that you’ve got [indistinct].
WYLENE MOORE: Okay. All right.
JUDGE TEATE: [Indistinct] the first ones.
TARA DICKERSON: And you can just tell the Court the number.
WYLENE MOORE: Okay. The number is Exhibit ZZ.
TARA DICKERSON: Okay. And could you tell the
Court the name of that particular individual?
WYLENE MOORE: Kay Gray is the name.
TARA DICKERSON: Okay. So if you go to ZZ, and is this a Medicaid member?
WYLENE MOORE: It is.
TARA DICKERSON: And what did you find on this particular record?
WYLENE MOORE: I found that this person was billed for an abdominal ultrasound, transvaginal ultrasound, office visit-new patient, hemoglobin and urine pregnancy test.
TARA DICKERSON: Okay. And, based upon your records, did you find out the date that these particular services were rendered?
WYLENE MOORE: Yes.
TARA DICKERSON: And were – wasn’t a – was a termination or an abortion also rendered on that date?
WYLENE MOORE: Yes, it was.
TARA DICKERSON: Now did you find the type of billing for an actual abortion billed to Medicaid?
WYLENE MOORE: No, I did not.
TARA DICKERSON: Okay. Do you have that, Your Honor?
JUDGE TEATE: I’m just now getting to that.
TARA DICKERSON: ZZ.
JUDGE TEATE: [Indistinct; pages shuffling] This is – oh, I thought that was 22. Sorry, ZZ.
TARA DICKERSON: I’m sorry.
JUDGE TEATE: That’s all right.
TARA DICKERSON: I just want to make sure it’s the same one. What’s her name?
JUDGE TEATE: Um - -
WYLENE MOORE: Gray.
TARA DICKERSON: Gray.
JUDGE TEATE: - - Gray.
TARA DICKERSON: Thank you. [Indistinct] So with regard to this particular member – and the records indicate that she came in on the actual date of 5/15/09, and then the services were billed based upon the billing sheet that you have, and could you tell the Court what number you’re on on that billing sheet? What is the actual number by that name?
WYLENE MOORE: Okay, 1162.
TARA DICKERSON: 1162?
WYLENE MOORE: Uh-huh.
TARA DICKERSON: See, the numbers are right here on the end?
DR. MALLOY: Oh.
TARA DICKERSON: [Indistinct] look back
[indistinct] 11 - -
DR. MALLOY: Oh, I got you.
TARA DICKERSON: - - and there’s 62 [indistinct] right there.
DR. MALLOY: Got you, thank you.
JUDGE TEATE: Oh, could you identify - -
TARA DICKERSON: You see?
JUDGE TEATE: - - where that’s at?
TARA DICKERSON: These are all of the numbers and then, if you go through 11, [indistinct] 600 and [indistinct]. I may have given you the first [indistinct].
JUDGE TEATE: All right.
TARA DICKERSON: But the second set, let me give you part [indistinct]. Yeah, 1162, correct?
WYLENE MOORE: Yes. [Sighing]
TARA DICKERSON: I’m gonna just set this section aside. I guess start with #1 and then go down to 1162.
JUDGE TEATE: Okay, I have it now.
TARA DICKERSON: Thank you, your Honor. And with regrad(sic) – gard(sic) – to this member, and this billing reflects what was submitted and paid for Medicaid, correct?
WYLENE MOORE: Correct.
TARA DICKERSON: Okay. Could you tell us the
next, just the, um, number for the next person that you have on your list? It doesn’t matter.
WYLENE MOORE: Doesn’t matter?
TARA DICKERSON: Uh-uh.
WYLENE MOORE: Just one that I’ve marked? [Indistinct] Okay.
TARA DICKERSON: Just tell the Court the number.
WYLENE MOORE: Okay. It is exit(sic), um, Exhibit 00, and the number is 1,438.
TARA DICKERSON: That’s gonna be - -
WYLENE MOORE: 1438.
TARA DICKERSON: - - OO?
WYLENE MOORE: OO? Thank you.
TARA DICKERSON: If we look at OO, and this would be a Medicaid member, correct?
WYLENE MOORE: Correct.
TARA DICKERSON: As a matter of fact, all of the billing that you show with regard to what we’re looking at, does that reflect Medicaid members?
WYLENE MOORE: It does.
TARA DICKERSON: Because you wouldn’t receive billing but for someone submitting something for Medicaid reimbursement, correct?
WYLENE MOORE: Yes.
TARA DICKERSON: Okay. So if we go to OO
[indistinct] - -
WYLENE MOORE: And that’s your – we’re gonna start with one, um, 1439 - -
TARA DICKERSON: Okay.
WYLENE MOORE: - - to be consistent with the dates.
TARA DICKERSON: All right. And, on that particular bill, what are you showing the actual services that were billed?
WYLENE MOORE: The actual services billed for that particular day – let me make sure I have this correct; hold on just a second. Okay, let’s – let’s go up, because there’s two sets for the same person.
TARA DICKERSON: Okay.
WYLENE MOORE: Okay? So let’s move up to 1434.
TARA DICKERSON: Okay.
WYLENE MOORE: Okay? [Clearing throat; pages shuffling] And what I see here is ab – abdominal ultrasound, transvaginal ultrasound, office visit-new, hemoglobin and urine pregnancy test.
TARA DICKERSON: And if we actually look at the records for OO for that particular member, those are the tests that were, in fact, formed – performed – back on 2/8 – 8/29/09, correct?
WYLENE MOORE: 8/29/09? Yes, all but the office
visit, because there’s two sets of data for the same person.
TARA DICKERSON: Okay.
WYLENE MOORE: So, for August 29th - -
TARA DICKERSON: Uh-huh?
WYLENE MOORE: - - the same – same, um, procedures were billed except the office visit-new, because they had been there prior to.
TARA DICKERSON: All right.
WYLENE MOORE: Or with the - -
TARA DICKERSON: And there is no deal as indicated for an actual abortion, correct?
WYLENE MOORE: No.
TARA DICKERSON: So if we go and look at the actual records for Client OO, based upon the Old National GYN Laboratory Report Physical Examination, oper – Operative Summary page, we’ll see that that date corresponds to 8/29/09 as well?
WYLENE MOORE: Yes. Yes.
TARA DICKERSON: Okay. And did you see this throughout these records that you reviewed?
WYLENE MOORE: I did.
TARA DICKERSON: Okay. And what did this cause you to believe?
WYLENE MOORE: Uh, it caused me to believe that
there was some type of misrepresentation or fraud or something of that nature.
TARA DICKERSON: And why did you conclude that?
WYLENE MOORE: Because every, single person is being the same – billed the same – exact procedure codes. And when – when you review the records, everything was billed on the same date as the abortion.
TARA DICKERSON: Okay. And the only thing that wasn’t billed was the abortion, is that correct?
WYLENE MOORE: Correct.
TARA DICKERSON: And that is because the abortion did not meet the constraints of what Medicaid would pay for, is that correct?
WYLENE MOORE: Correct.
TARA DICKERSON: No other questions, Your Honor.
JUDGE TEATE: All right. Cross-examination?
DR. MALLOY: Yes. [Indistinct] good morning, Ms. Moore.
WYLENE MOORE: Good morning.
DR. MALLOY: Um, [indistinct] have you – have we ever met before? I’m not sure.
WYLENE MOORE: I don’t think so.
DR. MALLOY: Okay. Um, and – and – and – I’ll –
I’ll be brief. Uh, you stated that you have been a
Compliance Monitor and Auditor for approximately three years?
WYLENE MOORE: Yes.
DR. MALLOY: Could you tell us what the – what you did before that?
WYLENE MOORE: Yes. I worked for Department of Human Resources, and I was a Perinatal Nurse Consultant for the State of Georgia.
DR. MALLOY: Uh-huh. Okay. [Clearing throat; coughing] You stated that you’ve done approximately 14 audits and you assisted with approximately 12 audits?
WYLENE MOORE: Correct.
DR. MALLOY: Um, of those 14 audits, how many (if you can recall) were GYN practices?
WYLENE MOORE: None, other than yours.
DR. MALLOY: Okay.
WYLENE MOORE: Uh-huh.
DR. MALLOY: So mine was the first GYN office?
WYLENE MOORE: Right.
DR. MALLOY: Okay.
WYLENE MOORE: Well, I take that back, sir. I have completed one more. It’s in the process. It’s not to the end.
DR. MALLOY: Okay. [Overlapping conversation]
WYLENE MOORE: It’s in the process.
DR. MALLOY: Okay.
WYLENE MOORE: Yes.
DR. MALLOY: All right.
WYLENE MOORE: I’m sorry.
DR. MALLOY: Okay. That’s fine.
WYLENE MOORE: Uh-huh. [Chuckling]
DR. MALLOY: Well, then I – my second question then [indistinct] okay.
WYLENE MOORE: Okay.
DR. MALLOY: Uh, and you also stated that you notified us by fax and mail January 25th and that the audit was con – then conducted – January 27th.
WYLENE MOORE: Correct.
DR. MALLOY: Okay. With – with your team. Okay. Um, was I present at that audit on January 27th?
WYLENE MOORE: No, you were not.
DR. MALLOY: Okay. And it was – again you – well, okay. Um, are you aware that, um – well, did, on January 27th, were you interested, or anybody from your team, in speaking with me, um, during this audit?
WYLENE MOORE: I did ask were you going to be present. I was told that you were not going to be there that day because no patients were being seen.
DR. MALLOY: Okay. And were you aware that they
stated that I was - -
TARA DICKERSON: Objection, Your Honor, hearsay.
DR. MALLOY: No, I’m asking her was she aware. I’m - -
JUDGE TEATE: Let him finish the statement; then [indistinct] the objection if necessary.
DR. MALLOY: Okay. My – my – my question was: Were you aware that I would be available at another time?
WYLENE MOORE: Yes, I was made available – I mean, I was told that while I was there, yes.
DR. MALLOY: And, as a matter of fact, I was going to be available on the next day, the 28th?
WYLENE MOORE: Yes.
DR. MALLOY: Um, were you told – well, did someone from your office or yourself state that it wasn’t necessary to see me on the 28th?
WYLENE MOORE: Yes.
DR. MALLOY: Okay. So I was [indistinct], um, you were aware that I was going to be available - -
WYLENE MOORE: Yes.
DR. MALLOY: - - and you stated that, on the 27th, you did want to speak with me, but then, on the 28th, you said it wasn’t necessary?
WYLENE MOORE: Correct.
DR. MALLOY: Okay. Just – all right. Um, now, you made reference to my private practice as an abortion clinic. And since you worked for the Department of Human Resources, then you are well aware that there is a specific definition and regulatory body that governs abortion clinics. Um, Department of Human Resources, where you were previously employed, regulates abortion clinics. Um, are you aware of Department of Human Resources regulating my office?
WYLENE MOORE: Not that I know of.
DR. MALLOY: Okay. And that’s because I am not an abortion clinic.
WYLENE MOORE: Okay.
DR. MALLOY: I am a private practice facility.
WYLENE MOORE: Okay.
DR. MALLOY: Um - -
JUDGE TEATE: All right, sir, let me just caution at this time you’re not sworn and it’s not the time to present testimony.
DR. MALLOY: Oh, I’m sorry.
JUDGE TEATE: Okay.
DR. MALLOY: Sorry. I’m sorry. Um, uh, also you stated that – and I – and I didn’t object to the hearsay [indistinct; pages shuffling] but you said that patients call and want an abortion. You made
that as a general statement.
WYLENE MOORE: I was told by your staff that people call in to make an appointment to terminate their pregnancy.
DR. MALLOY: Okay. I’m sorry, ‘cause I – I – the way – the way Ms. Dickerson phrased, it made it seem like that’s what they – that everyone who calls, calls and wants an abortion. So that some patients will call for an abortion, okay. All right. Um, and then you made a comment about because of the pattern of charges that you saw, that it appeared to be some fraud or misrepresentation, um, because it was like done on the same day that an abortion procedure was done.
WYLENE MOORE: Yes.
DR. MALLOY: So if – would you interpret it to be fraud and misrepresentation if, let’s say, the patient had those charges but they had the abortion on another day? Would – would it still be fraud and misrepresentation?
WYLENE MOORE: I would say no.
DR. MALLOY: Okay. So it’s fraud and misrepresentation because the patient decides that to not make it – because the patient decides to undergo the abortion the same day that they find out that they’re pregnant? Okay. Is that what you’re – that – that that makes it fraud and misrepresentation?
WYLENE MOORE: Possibly, but I’m also looking at the pattern.
DR. MALLOY: Okay. But I’m just saying you – you just said earlier - -
WYLENE MOORE: Uh-huh.
DR. MALLOY: - - that if they had it on another day, you would not consider it fraud and misrepresentation, but because the patient has elected to have the abortion that day, it becomes fraud and misrepresentation?
WYLENE MOORE: Possibly.
DR. MALLOY: Okay. [Indistinct]
WYLENE MOORE: Based on policy.
DR. MALLOY: Okay. So it – it is or it isn’t. I – I mean, I - -
WYLENE MOORE: Based on policy, it would be.
DR. MALLOY: It – oh, would be? Okay. All right. Okay. That, that’s all my questions for this witness.
JUDGE TEATE: Anything on redirect?
TARA DICKERSON: Nothing, Your Honor.
JUDGE TEATE: All right. You can step down,
ma’am. Your next witness, Ms. Dickerson?
TARA DICKERSON: Thank you, Your Honor. [Indistinct conversation in background]
SHIRLEY BENSON: [Indistinct] finish that up. [Indistinct conversation] Yes, thank you.
TARA DICKERSON: [Indistinct] step up.
JUDGE TEATE: Ma’am, if you’ll come up and, if you would before you take your seat, go ahead and raise your right hand. Do you solemnly swear that the testimony you’re about to give is the whole truth and nothing but the truth, so help you God?
SHIRLEY BENSON: Yes.
JUDGE TEATE: All right. Please be seated and state your name for the record.
SHIRLEY BENSON: Name is Shirley Benson.
JUDGE TEATE: All right, Ms. Dickerson.
TARA DICKERSON: Ms. Benson, could you tell the Court your current employment?
SHIRLEY BENSON: Um, Georgia Department of Community Health.
TARA DICKERSON: And, um, what’s your current title?
SHIRLEY BENSON: I am Program Director of - -
TARA DICKERSON: Of what?
SHIRLEY BENSON: - - Program Integrity.
TARA DICKERSON: And what is Program Integrity?
Could you share that with the Court?
SHIRLEY BENSON: Program Integrity is a unit that was formed to be in compliance with the federal government to monitor all money paid that receive federal funds.
TARA DICKERSON: Okay. And with regard to this particular Program Integrity Director, how long have you held that position?
SHIRLEY BENSON: Since ’95. No, 2005.
TARA DICKERSON: 2005. And with regard to your duties and responsibilities, share with the Court what your particular duties and responsibilities are.
SHIRLEY BENSON: Basically, it’s to oversee the program to make sure every –we are in compliance with the federal regs. I review, advise, supervise, and monitor all processes.
TARA DICKERSON: Okay. And in the review and, uh, supervision, do you have any contact with those who actually go out and do audits of providers?
SHIRLEY BENSON: Yes, I do.
TARA DICKERSON: What would your contact be with them?
SHIRLEY BENSON: Most of the times, a lot of ‘em will come in, depending on the cases that they’ve been assigned, they will come in and sit down and discuss
the cases with me.
TARA DICKERSON: And in the course of your oper – your active – your action as a Program Director, did you come in contact with Old National Gynecological?
SHIRLEY BENSON: Yes. It was discussed during [indistinct] review.
TARA DICKERSON: Okay. And I’m gonna show you what’s already been marked as Exhibit B. That’s gonna be Exhibit B of B, um, Part I, [indistinct] not Part – no, that’s B. Part I would be in that section.
DR. MALLOY: Oh, sorry.
TARA DICKERSON: Do you have your Exhibit List [indistinct]?
DR. MALLOY: Yeah. Okay.
TARA DICKERSON: Uh-huh.
DR. MALLOY: [Chuckling]
TARA DICKERSON: I’m gonna show you what’s, um, already been marked as Exhibit B. [Pages shuffling; indistinct] Could you look at that and tell the Court if you recognize that?
SHIRLEY BENSON: Yes, I do.
TARA DICKERSON: Could you tell the Court what that is, please?
SHIRLEY BENSON: It’s a letter notifying Dr.
Malloy that his, um, he’s been put on – his provider
number has been put on withhold.
TARA DICKERSON: And what does that mean to actually put a provider number on withhold?
SHIRLEY BENSON: Basically, saying that he can continue to file claims, continue to bill, but he will receive all his checks will go – be withheld by the Department.
TARA DICKERSON: And what was the purpose in your letter of withholding his checks?
SHIRLEY BENSON: Withholding of the payments and the creation of procedural [indistinct] basically based on abortions in accordance with the federal regulation of a recent Congressionally-enacted revision of the Hyde Amendment. The Division will reimburse for abortions performed on Medicaid-eligible patients if the life of the mother will be in danger if the fetus will be carried to term or if the victim – mother’s a victim – of rape and incest.
TARA DICKERSON: Okay. And with regard to this particular case, what did you find that caused you to withhold the payments?
SHIRLEY BENSON: Basically, after reviewing the documents which came in from the onsite review, there appears to be whereas the provider was billing for abortion-related services. Abortion-related services,
by the Department, are non-covered.
TARA DICKERSON: Under – are they covered under any circumstances?
SHIRLEY BENSON: No.
TARA DICKERSON: And with regard to the exceptions - -
SHIRLEY BENSON: [Indistinct]
TARA DICKERSON: - - and tell the Court what those exceptions are.
SHIRLEY BENSON: Exception is basically for rape or incest or life endangerment of the mother.
TARA DICKERSON: Okay. And so, in this particular case, did you actually look at any documents that showed Dr. Malloy was billing for an actual abortion?
SHIRLEY BENSON: [No audible response]
TARA DICKERSON: Did he bill for an abortion procedure?
SHIRLEY BENSON: No, he didn’t. He billed for abortion-related services.
TARA DICKERSON: And you are saying the services are abortion-related because of what?
SHIRLEY BENSON: Because of the actual abortion procedure being performed.
TARA DICKERSON: And it was performed, as you
stated, on the same date as - -
SHIRLEY BENSON: As - -
TARA DICKERSON: - - the actual abortion services?
SHIRLEY BENSON: - - correct, correct.
TARA DICKERSON: Okay. Now, in response to that, did you hear – did you receive any notice or any, uh, correspondence from Dr. Malloy?
SHIRLEY BENSON: Yes, we did receive a request for administrative review.
TARA DICKERSON: And, um, could you look at, um, Exhibit C?
SHIRLEY BENSON: Yes.
TARA DICKERSON: And would that have been his request for an administrative review?
SHIRLEY BENSON: Yes.
TARA DICKERSON: Okay. And there’s also an attachment with that particular request, isn’t that correct?
SHIRLEY BENSON: Correct.
TARA DICKERSON: And what is that attachment? Could you tell the Court what that is?
SHIRLEY BENSON: That is the, uh, Pregnancy Verification Form.
TARA DICKERSON: And with regard to the services
listed on that particular form, are those the services that you are speaking of that Dr. Malloy actually billed Medicaid for?
SHIRLEY BENSON: Correct.
TARA DICKERSON: Okay. Now, once you received his request for an administrative review, did you take any additional action or did you change your previous decision?
SHIRLEY BENSON: No, basically, sent a letter out informing him that the decision remained the same.
TARA DICKERSON: And what particular policy, um, were you looking at to uphold that decision?
SHIRLEY BENSON: Looking at the, um, DCH policy, um, and the physician services [indistinct] in § 904.2.
TARA DICKERSON: Okay. And could you share the Court – uh, share with the Court – what that particular policy indicates?
SHIRLEY BENSON: Okay. Starting - -
TARA DICKERSON: Right there.
SHIRLEY BENSON: - - okay. In accordance with federal regulations and a recent Congressionally-enacted revision of the Hyde Amendment, the Division will reimburse for abortions performed by Medicaid – on Medicaid-eligible – members if the life of the mother will be in danger if the fetus were carried to term or if the mother was a victim of rape or incest.
TARA DICKERSON: Okay. Now could you also look at Part I – Policies and Procedures?
SHIRLEY BENSON: [Pages shuffling; indistinct] section.
TARA DICKERSON: Could you look at Part I – Policy and Procedures? There’s Chapter 100 – General Provisions.
SHIRLEY BENSON: Right.
TARA DICKERSON: Could you look at § 103? What does § 103 state?
SHIRLEY BENSON: The provider or(sic) the Department agrees that, in the event of a disagreement regarding, arising out of or related to policy language interpretation, the Department’s interpretation of this policy language in dispute shall control and govern. The Department’s interpretation of the contract language in dispute will not be subject to appeal under any circumstances.
TARA DICKERSON: Now, as it relates to a provider, once you become a provider in the state of Georgia for Medicaid services, aren’t you agreeing to comply with the policy and procedures as set out by
the Department of Community Health?
SHIRLEY BENSON: Yes, that’s correct.
TARA DICKERSON: And those policies and procedures are found in the Policies and Procedures Manuals for the particular services we want to provide, correct?
SHIRLEY BENSON: Correct.
TARA DICKERSON: Okay. Let’s look at another section. [Pages shuffling; indistinct] Could you go to § 408, please?
DR. MALLOY: Okay, can I, um - -
TARA DICKERSON: That’s the same Part I – Policy and Procedures Manual, § 408. [Indistinct] it’s just a [indistinct]. Okay.
JUDGE TEATE: I think it would be R-K.
TARA DICKERSON: Yes, Your Honor.
DR. MALLOY: [Indistinct]
TARA DICKERSON: Here.
DR. MALLOY: Okay.