Vol. 1 Antoine Dental Centers vs. THHSC, OIG - Dr. Tadlock

7/28/2019 Vol. 1 Antoine Dental Centers vs. THHSC, OIG - Dr. Tadlock

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800. 829. 6936 * 512. 472. 0880ken@kenowen. com * www. kenowen. com

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SOAH DOCKET NO. 529- 13- 0997HHSC- OI G CASE NO. : P20111316523848911

ANTOI NE DENTAL CENTER, ( BEFORE THE(

Pet i t i oner ((

vs. ( STATE OFFI CE OF(

TEXAS HEALTH AND HUMAN (SERVI CES COMMI SSI ON, (OFFI CE OF I NSPECTOR (GENERAL, (

(Respondent ( ADMI NI STRATI VE HEARI NGS

______________________________________

HEARI NG

VOLUME I

TUESDAY, MAY 28, 2013

______________________________________

BE I T REMEMBERED t hat on t hi s t he 28t h day of May,

2013, bet ween 9: 17 a. m. and 5: 07 p. m. , t he above- ent i t l ed

mat t er came f or hear i ng at t he St at e Of f i ce of

Admi ni st r at i ve Hear i ngs, Wi l l i am P. Cl ement s Bui l di ng, 300

West 15t h St r eet , Four t h Fl oor , Aust i n, Texas, bef or e t he

Honor abl e J udge Howard Sei t zman and Honor abl e J udge

Cather i ne Egan; and t he f ol l owi ng pr oceedi ngs were

r epor t ed by Renea Seggern, Cert i f i ed Shor t hand Repor t er .


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1 A P P E A R A N C E S2

3 ADMI NI STRATI VE LAW J UDGES:4 Honor abl e Howar d Sei t zman

Honorabl e Cather i ne Egan5 STATE OFFI CE OF ADMI NI STRATI VE HEARI NGSWi l l i am P. Cl ement s Bui l di ng

6 300 West 15t h St r eet , Sui t e 504Aust i n, Texas 78701

7

8 FOR THE PETI TI ONER:9 CANALES & SI MONSON, P. C.

Mr . J . A. "Tony" Canal es10 Mr . Hect or Canal es

2601 Mor gan Avenue11 Cor pus Chr i st i , Texas 78465

( 361) 883- 060112

13 ROBERT M. ANDERTON, D. D. S. , J . D.Mr . Rober t M. Ander t on

14 1909 Wal nut Pl zCar r ol l t on, Texas 75006

15 ( 972) 416- 525116

17 HI LDER & ASSOCI ATES, P. C.Mr . Phi l i p H. Hi l der

18 Mr . Wi l l i am B. Gr ahamMr . J ames G. Ryt t i ng

19 819 Lovet t Bl vd.Houst on, Texas 77006

20 ( 713) 655- 911121

22 BROWN MCCARROLL

Mr . Thomas Wat ki ns23 111 Congress Avenue

Sui t e 140024 Aust i n, Texas 78701

( 512) 703- 575225


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1 A P P E A R A N C E S

2

3 FOR THE RESPONDENT:

4 WATERS & KRAUS, L. L. P.Mr . Dan Hargrove

5 600 Navar r o, Sui t e 500San Ant oni o, Texas 78205

6 ( 210) 349- 0515

7

8 WATERS & KRAUS, L. L. P.Ms. Cai t l yn Si l han

9 3219 McKi nney AvenueDal l as, Texas 75204

10 ( 214) 357- 624411

12 MORI ARTY LEYENDECKER, P. C.Mr . J ames R. Mor i ar t y

13 4203 Mont r ose, Sui t e 150Houst on, Texas 77006

14 ( 713) 528- 0700

15

16

KHAROD LAW FI RM, P. C.Mr . Ketan Kharod17 P. O. Box 151677

Aust i n, Texas 7871518 ( 512) 293- 1556

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20 ATTORNEY GENERAL OF TEXASMr . Raymond C. Wi nt er , Chi ef

21 Ms. Mar gar et M. Moor e, Assi st ant At t or ney Gener alCI VI L MEDI CAI D FRAUD DI VI SI ON

22 P. O. Box 12548Aust i n, Texas 78711- 2548

23 ( 512) 936- 1709

24

25


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1 A P P E A R A N C E S2

3 FOR THE RESPONDENT:

4 HEALTH AND HUMAN SERVI CES COMMI SSI ON - OFFI CE OFI NSPECTOR GENERAL

5 Mr . Enr i que Var el aMr . J ohn R. Medl ock

6 11101 Met r i c Bl vd.Bui l di ng I

7 Aust i n, Texas 78708( 512) 491- 2000

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1 I N D E X - VOLUME I

2 Appear ances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Pr oceedi ngs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

4

WI TNESSES FOR RESPONDENT:5 LI NDA ALTENHOFF, D. D. S.

6 Di r ect Exami nat i on by Mr . Har gr ove. . . . . . . . . . . . . . . 42Cr oss- Exami nat i on by Mr . Canal es. . . . . . . . . . . . . . . . . 85

7 Exami nat i on by J udge Sei t zman. . . . . . . . . . . . . . . . . . . 112Exami nat i on by J udge Egan. . . . . . . . . . . . . . . . . . . . . . . 115

8 Redi r ect Exami nat i on by Mr . Har gr ove. . . . . . . . . . . . 116Recr oss- Exami nat i on by Mr . Canal es. . . . . . . . . . . . . . 118

9 Fur t her Redi r ect Exami nat i on by Mr . Har gr ove. . . . 120Fur t her Recr oss- Exami nat i on by Mr . Canal es. . . . . . 121

10

LARRY TADLOCK, D. D. S.11 Di r ect Exami nat i on by Mr . Har gr ove. . . . . . . . . . . . . . 126

Cr oss- Exami nat i on by Mr . Canal es. . . . . . . . . . . . . . . . 17812 Exami nat i on by J udge Egan. . . . . . . . . . . . . . . . . . . . . . . 228

Exami nat i on by J udge Sei t zman. . . . . . . . . . . . . . . . . . . 23113 Redi r ect Exami nat i on by Mr . Har gr ove. . . . . . . . . . . . 232

14 Repor t er ' s Cer t i f i cat e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

15 E X H I B I T I N D E X

FOR THE PETI TI ONER16 NO. DESCRI PTI ON PAGE

17 78 Texas Medi cai d Bul l et i n - J anuar y/ Febr uar y 2008 85

18 79 Texas Medi cai d Bul l et i n - J ul y/ August 2008 85

19 80 Benef i t I nf o. f or Cl i ent s wi t h Cl ef t Pal at es 85

20 81 Texas Medi cai d Bul l et i n - May/ J une 2012 85

21

E X H I B I T I N D E X22 FOR THE RESPONDENT

NO. DESCRI PTI ON PAGE23 1 Medi cai d Pr ovi der Enr ol l ment Appl i cat i on and 18

24 I nf or mat i on f or Dr . Behzad Nazar i

25 3 Cer t i f i ed Copy of TSBDE Agr eed Set t l ement Or der 18


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1 E X H I B I T I N D E X

2 FOR THE RESPONDENT

3 NO. DESCRI PTI ON PAGE

4 4 Cur r ent CV of Char l es W. Evans, D. D. S. 185 5 Repor t by Char l es W. Evans, D. D. S. 18

6 7 HLD Scor e Sheet s compl et ed by Dr . Evans 18

7 8 Cur r ent CV of Lar r y P. Tadl ock, D. D. S. 18

8 9 Repor t by Lar r y P. Tadl ock, D. D. S. 18

9 11 HLD Score Sheet s compl et ed by Dr . Tadl ock 18

10 12 Dent al Records f or 63 Pat i ent s 1811 13 ( I ndex st at es "Reserved") 18

12 14 THHSC 2008 TMHP Pr ocedur es Manual 18




16

18 Cur r ent CV of J ames W. Or r , D. D. S. 1817 29 Cur r ent CV of I r wi n K. Or ni sh, D. D. S. , M. S. 18

18 41 Amount s Pai d - Texas Medi cai d Or t hodont i c and 18Dent al Ser vi ces

19 49 Summar y of Vol umi nous Dat a pr epared by 167

20 Dr . Tadl ock

21 51 Bi r gi t Thi l ander Ar t i cl e 156

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1 P R O C E E D I N G S

2 J UDGE EGAN: We ar e conveni ng i n SOAH Docket

3 Number 529- 13- 0997, Ant oi ne Dent al Cent er , Pet i t i oner ,

4 ver sus Texas Heal t h and Human Servi ces Commi ss i on, Of f i ce

5 of I nspect or Gener al , Respondent . Today i s May 28t h,

6 2013, and we ar e i n t he Wi l l i am P. Cl ement s bui l di ng i n

7 Aust i n, Texas.

8 My name i s Cat her i ne Egan and I ' m one of t he

9 admi ni st r at i ve l aw j udges assi gned t o pr esi de over t hi s

10 hear i ng. Wi t h me as co- pr esi di ng ALJ i s Howard Sei t zman.11 Woul d you l i ke t o i nt r oduce your sel f ?

12 J UDGE SEI TZMAN: Hi . Howar d Sei t zman.

13 J UDGE EGAN: The proceedi ng wi l l be

14 conduct ed pur suant t o t he Admi ni st r at i ve Procedur e Act and

15 t he st at ut es and rul es t hat governs t he Heal t h and Human

16 Ser vi ces Commi ssi on, Of f i ce of I nspect or Gener al , and t he17 St at e Of f i ce of Admi ni st r at i ve Hear i ngs.

18 At t hi s poi nt , l et me have t he

19 r epr esent at i ves of t he par t i es i dent i f y t hemsel ves f or t he

20 r ecor d begi nni ng wi t h t he Pet i t i oner .

21 MR. CANALES: Yes, Your Honor .

22

J UDGE EGAN: And i f you coul d st and and gi ve23 your name and spel l i t and t hen al so any - - i nt r oduce t he

24 r est of t he at t or neys t hat ar e al so appear i ng i n t hi s

25 mat t er , t hat woul d be appr eci at ed.


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1 MR. CANALES: Yes, Your Honor . I ' m t he

2 at t or ney i n char ge f or Ant oi ne Dent al Cent er , my name i s

3 J . A. Tony Canal es, C- a- n- a- l - e- s. Assi st i ng i n t he case

4 wi l l be Mr . Hect or Canal es, al so wi l l be Mr . Phi l Hi l der

5 and Mr . J i m Ryt t i ng. Mr . Hi l der , Mr . Ryt t i ng and Mr . Bi l l

6 Gr aham wi l l al so be assi st i ng i n t he case. They wi l l be

7 pr esent i ng t o t he cour t Dr . Kanaan.

8 J UDGE EGAN: I t hought i t woul d be easi er i f

9 you i nt r oduced t hem, but I t hi nk i t ' s maki ng i t mor e - -

10 THE COURT REPORTER: I t ' s f i ne.11 J UDGE EGAN: Okay.

12 MR. CANALES: We al so have, of course, Dr .

13 Nazar i and we al so have Dr . Ander t on, who wi l l be

14 assi st i ng us i n our case. That ' s our t eam. Oh, I ' m

15 sor r y. Mr . Tom Wat ki ns f r om Br own McCar r ol l wi l l be

16 assi st i ng us, al so.17 J UDGE EGAN: Al l r i ght . And I ' l l r emi nd t he

18 par t i es, si nce t her e ar e so many at t or neys t hat ar e

19 pr esent t oday r epr esent i ng each si de, t hat when you st and

20 t o addr ess us, t hat you i dent i f y your sel f f or t he r ecor d

21 so i t ' s cl ear .

22

For Respondent .23 MR. HARGOVE: J udge Egan, good mor ni ng. My

24 name i s Dan Har gr ove, H- a- r - g- r - o- v- e, and we repr esent

25 t he St at e of Texas, Of f i ce of I nspect or Gener al . And on


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1 my t eam i s Mr . J i m Mor i ar t y, Mr . Ket an Khar od, Ms. Cai t l yn

2 Si l han. Di d I mi ss anybody?

3 And Raymond, woul d you i nt r oduce your t eam,

4 pl ease?

5 MR. WI NTER: Raymond Wi nt er , W- i - n- t - e- r ,

6 wi t h t he At t or ney Gener al ' s Of f i ce. Al so r epr esent i ng t he

7 St at e of Texas, and Margaret Moor e. And we al so have

8 r epr esent at i ves of t he HHSC- OI G wi t h us t oday.

9 MR. VARELA: Enr i que Varel a.

10 MR. MEDLOCK: And J ohn Medl ock.11 MR. HARGOVE: Thank you, J udge.

12 J UDGE EGAN: I wi l l al so r emi nd t he par t i es

13 t hat whi chever at t or ney begi ns a wi t ness wi l l have t o st ay

14 wi t h t hat wi t ness t hr oughout t he hear i ng, so we don' t

15 per mi t sever al at t or neys t o t ake one wi t ness. I - -

16 MR. HI LDER: J udge - -17 J UDGE EGAN: Yes?

18 J UDGE SEI TZMAN: Agai n, i f you wi l l i dent i f y

19 your sel f f or t he r ecor d.

20 MR. HI LDER: Phi l Hi l der . A housekeepi ng

21 mat t er , J udge. I bel i eve i n Or der Number 6 by t hi s cour t ,

22

t her e was an or der t hat no at t or ney may par t i ci pat e i n23 t hi s case wi t hout showi ng aut hor i t y.

24 We ar e j ust a bi t conf used. Mr . Khar od has

25 hi s own l aw f i r m, Kharod Law Fi r m. We don' t bel i eve t hat


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1 t her e i s aut hor i t y f or hi m t o appear . He doesn' t - - he' s

2 not under a cont r act wi t h t he At t or ney Gener al , t he

3 At t or ney Gener al ' s cont r act went t o Mr . Har gr ove and Mr .

4 Mor i ar t y, but doesn' t ext ent t o a t hi r d l aw f i r m. So we

5 bel i eve t hat i t woul d be i mpr oper f or hi m t o par t i ci pat e

6 i n t hese pr oceedi ngs.

7 J UDGE EGAN: Response.

8 MR. HARGOVE: J udge, he' s been r et ai ned by

9 OI G. He wor ks wi t h t he l aw f i r m of Wat er s & Kr aus, whi ch

10 i s my l aw f i r m.11 MR. HI LDER: J udge, j ust i n r esponse t o

12 t hat : The cont r act says t hat i f he i s cont r acted - - i f he

13 i s a subcont r act or , pur suant t o 9. 2, Assi gnment of OCC,

14 out si de counsel may not assi gn t hi s OCC or del egat e any

15 r i ght or dut y under t hi s OCC wi t hout pr i or wr i t t en

16 appr oval f r om t he Agency or t he Of f i ce of At t or ney17 General .

18 J UDGE EGAN: Al l r i ght . Wel l , si nce t hi s i s

19 t he f i r st t i me i t ' s been br ought t o our at t ent i on, we ar e

20 goi ng t o - - I wi l l hol d of f on t hat t o gi ve you t i me t o

21 obt ai n what ever aut hor i t y you have t o al l ow Mr . Khar od t o

22

r epr esent - -23 MR. HARGOVE: J udge, he' s named i n t he

24 cont r act and he works wi t h t he Law Fi r m of Wat er s & Kr aus.

25 J UDGE EGAN: I s he goi ng t o be t aki ng a


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1 wi t ness t hi s mor ni ng?

2 MR. HARGOVE: He i s not , Your Honor .

3 J UDGE EGAN: Then we wi l l t ake a l ook at i t

4 over t he l unch br eak.

5 J UDGE SEI TZMAN: He' s empl oyed, or I don' t

6 know i f he' s a par t ner - -

7 MR. HARGOVE: Cor r ect . He' s empl oyed by

8 Wat er s & Kr aus.

9 J UDGE EGAN: Al l r i ght . And my

10 under st andi ng i s al t hough Ant oi ne Dent al Cent er i s t he11 Pet i t i oner i n t hi s case, Texas Heal t h and Human Ser vi ces

12 Commi ssi on, whi ch we t ypi cal l y r ef er t o as HHSC, i s t he

13 par t y car r yi ng t he bur den of pr oof ; i s t hat cor r ect ?

14 MR. HARGOVE: That i s cor r ect , Your Honor .

15 J UDGE EGAN: Because of t hat , t he par t y

16 car r yi ng t he bur den of pr oof i s al l owed t o pr esent t hei r17 case f i r st , i s al l owed t o begi n t he openi ng and cl osi ng

18 f i r s t .

19 Addi t i onal l y, I under st and, Mr . Canal es,

20 t hat you asked t hat we i nvoke t he Rul e.


22

J UDGE EGAN: I s t hat st i l l a r equest ?23 MR. CANALES: Your Honor - -

24 J UDGE EGAN: Whatever makes you comf or t abl e.

25 MR. CANALES: I f t he Cour t ' s r ul i ng


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1 r egar di ng t he Rul e, t he 408 r ul i ng, r egar di ng whet her or

2 not Mr . St i ck can t est i f y as t o conver sat i ons of

3 set t l ement or of f er s of set t l ement i n t hat I nf or mal

4 Conf er ence Hear i ng. I f t he Cour t wi l l r ul e t hat i t cannot

5 commi t , t hen I ' m not goi ng t o cal l Mr . McCl endon.

6 I do need Mr . McCl endon as a wi t ness i n t hi s

7 case, whi ch wi l l be my r ebut t al wi t ness. And I cannot

8 r ecal l when I bel i eve t hat was ki nd of a yes or no or we

9 wer e goi ng t o car r y t hat mot i on, but I never got a

10 st r ai ght r ul i ng f r om t he Cour t , f or gi ve me. So i f St i ck11 cannot t est i f y or br i ng t he t opi c up of 408, t hen I ' m not

12 goi ng t o i nvoke t he Rul e. Of cour se, t hey can i nvoke t he

13 Rul e i f t hey wi sh, but I want t he Cour t t o under st and

14 wher e I ' m comi ng f r om. Mr . McCl endon i s i n t he cour t r oom

15 r i ght now.

16 J UDGE EGAN: I s t hat t he onl y - -17 MR. CANALES: That ' s t he onl y wi t ness, I

18 bel i eve, on bot h si des.

19 J UDGE EGAN: I bel i eve t hat J udge Sei t zman

20 was l eani ng t o excl udi ng t hat i nf or mat i on and I t hi nk he

21 st at ed l i ke a t r ee i n a hur r i cane, t hat ' s how f ar he was

22

l eani ng. My i ncl i nat i on i s t o pr ot ect any set t l ement23 conf er ence mat er i al , but I had not made rul i ng.


25 J UDGE EGAN: So i s t he onl y wi t ness - -


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1 because t here ar e a number of peopl e here and I don' t know

2 who bel ongs t o whom or whether or not t hey ar e wi t nesses.

3 Ar e t her e any ot her wi t nesses i n t he hear i ng r oom t hat ar e

4 not a par t y r epr esent at i ve?

5 MR. CANALES: Not t hat I know of , Your

6 Honor . They ar e al l ei t her exper t s or par t i es t o t he

7 l i t i gat i on.

8 MR. HARGOVE: Your Honor , we have Dr .

9 Al t enhof f and she wi l l be our f i r st wi t ness. The

10 gent l eman st andi ng up i s Dr . Tadl ock, who i s our exper t .11 J UDGE EGAN: My underst andi ng i s t here i s no

12 obj ect i on t o havi ng t he exper t s r emai n i n t he r oom.

13 MR. CANALES: Yes, Your Honor . And I al so

14 have Dr . Or r i n t he audi ence, so my under st andi ng i s t he

15 Rul e doesn' t appl y - -

16 J UDGE SEI TZMAN: The Rul e general l y appl i es17 t o f act wi t ness. I t get s a l i t t l e bi t di cey when you have

18 a mi x.

19 J UDGE EGAN: Mr . McCl endon - -

20 J UDGE SEI TZMAN: Let me j ust ask: Mr .

21 Har gr ove, ar e you st i l l pl anni ng on cal l i ng Mr . St i ck wi t h

22

t he pur pose of goi ng i nt o t he - -23 MR. MORI ARTY: J udge, I cl ear l y hear what

24 you say on t hat , and when t hat t r ee f ai l s t o bl ow over , we

25 wi l l cal l hi m. Ot her wi se, we wi l l not cal l J ack St i ck f or


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1 t hat pur pose.

2 J UDGE SEI TZMAN: Okay. Maybe what we can do

3 i s - - I r eal l y don' t want t o del ay any f ur t her t han we

4 al r eady ar e get t i ng, t i me i n t er ms of t he hear i ng, maybe

5 we can t ake up t he i ssue of Mr . St i ck r i ght bef or e t he

6 l unch br eak or dur i ng t he morni ng br eak and see i f we can

7 get t hat set t l ed wi t h r espect t o.

8 MR. MORI ARTY: Let me be more cl ear . I ' m

9 not cal l i ng J ack St i ck f or t hat pur pose. I hear what you

10 say and I hear what you say and we wi l l not of f er any11 t est i mony about t hi ngs t hat wer e sai d i n t hat conf er ence,

12 set t l ement conf er ence or not . We wi l l not t est i f y about

13 that.

14 J UDGE SEI TZMAN: Thank you, Mr . Mor i ar t y.

15 MR. CANALES: So I wi t hdr aw my i nvoki ng of

16 t he Rul e.17 J UDGE EGAN: So nei t her par t y want s t he Rul e

18 i nvoked; i s t hat cor r ect ?

19 MR. HARGOVE: That i s cor r ect .

20 J UDGE EGAN: Al l r i ght . One f i nal house

21 cl eani ng pr ocedur e, I ' m goi ng t o go t hr ough j ust what we

22

had admi t t ed so t hat i t ' s cl ear .23 Has somebody gi ven t he cour t r epor t er a l i st

24 of t hei r exhi bi t s bot h f r om t he Pet i t i oner and t he

25 Respondent ?


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1 MR. CANALES: I can make i t easi er f or t he

2 Cour t , Your Honor , i f I may. A t ot al of f i ve t hat we have

3 obj ect i ons t o, I t hi nk ever yt hi ng el se comes i n.

4 J UDGE EGAN: What f i ve do you have

5 obj ect i ons t o?

6 MR. CANALES: R- 2, whi ch was t he one - - t he

7 CD- ROM, we coul d never open i t . R- 6, R- 10, R- 33 - - and

8 R- 33 i s t hat r epor t f r om Dr . Tadl ock t hat was

9 post - deposi t i on - - and R- 45 has t hat set t l ement , t he

10 t hi r d- par t y set t l ement i n t her e.11 J UDGE EGAN: And I bel i eve t hey sai d t hey

12 wer e wi t hdr awi ng t hat por t i on. I t was i nadver t ent l y

13 i ncl uded i n our 45. So you ar e wi t hdr awi ng al l your ot her

14 obj ect i ons?

15 MR. CANALES: Not wi t hdr awi ng t hem; I ' m j ust

16 sayi ng t hat t hose wi t h t he ones we made obj ect i ons17 r egar di ng, f or exampl e, al l t hese r epor t s. I t hi nk t he

18 Cour t over r ul ed t hose l ast week. I made obj ect i ons on - -

19 J UDGE SEI TZMAN: We coul dn' t r ul e on R- 2,

20 because we coul dn' t get i t open. I have i t . I was abl e

21 t o open t hr ee. One of t hem - - R- 2 had a separ at e code

22

f r om 6 t o 10, I bel i eve.23 THE REPORTER: J udge, you are goi ng t o have

24 t o speak up f or me j ust a l i t t l e bi t .

25 J UDGE SEI TZMAN: Okay. We di dn' t r ul e on


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1 R- 2 because we coul dn' t get i t open l ast week. Mr .

2 Hargr ove sent out t he code, t her e was a separate code f or

3 R- 2 and a common code t hen f or 6 and 10.

4 Mr . Canal es, you wer en' t abl e t o open R- 2?

5 MR. CANALES: That i s t he so- cal l ed RNS and

6 cl ai ms dat a?

7 J UDGE SEI TZMAN: Yeah. I have i t open, i f

8 you woul d l i ke t o see i t .

9 J UDGE EGAN: He' s si nce been abl e t o open

10 i t ; i s t hat cor r ect ?11 MR. CANALES: I have not . I t ' s ki nd of l i ke

12 a spr eadsheet .

13 MR. KHAROD: Your Honor , t hi s coul d make i t

14 easi er . What t he RNS dat a i s, i s r aw dat a whi ch shows t he

15 pat i ent number and i t ' s basi cal l y a summary of t he amount s

16 pai d t o Ant oi ne Dent al , f our di f f er ent pat i ent s. I t hi nk17 we coul d cl ear t hi s up by - - and we can di scuss

18 st i pul at i ons l at er and I don' t want t o put Pet i t i oner on

19 t he spot her e, but basi cal l y, t hat woul d be evi dence t hat

20 Ant oi ne di d get pai d f or cl ai ms t hey submi t t ed.

21 I f we can wor k out a st i pul at i on t hat , yes,

22

we got pai d; t he amount pai d i s not r eal l y an i ssue i n23 t hi s hear i ng. So t hat ' s al l i t woul d be used f or .

24 MR. CANALES: Maybe t hey can gi ve i t t o me

25 dur i ng t he l unch hour and we can see i t at t hat t i me.


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1 J UDGE EGAN: Al l r i ght . Gi ven what ' s j ust

2 been sai d, l et me go back t hr ough what I bel i eve have been

3 admi t t ed, and cor r ect me i f I ' m wr ong.

4 R- 1, R- 3, R- 4, R- 5, R- 7, R- 8, R- 9, R- 11,

5 R- 12, R- 13, R- 14, R- 15, R- 16, R- 17, R- 18 - - t her e wer e a

6 number of exhi bi t s bei ng of f ered f or i mpeachment so we ar e

7 r eserved r ul i ng on t hose - - R- 29 and R- 41; does ever yone

8 agr ee t hat t hose have been admi t t ed f or t he r ecor d?

9 ( Respondent ' s Exhi bi t s 1, 3, 4, 5, 7, 8, 9,

10 11, 12, 13, 14, 15, 16, 17, 18, 29, 41 admi t t ed. )11 MR. HI LDER: J udge, I woul d ask t hat R- 3 be

12 hel d i n abeyance f or r i ght now. I t woul d depend i f t hat

13 comes i n under 404( b) , whether t hose count s i n t he

14 compl ai nt i n Par agr aphs 1, st ay or i f t hey ar e abandoned

15 or st r i cken by t he Cour t .

16 J UDGE EGAN: We had over r ul ed. We i ndi cat ed17 i t di dn' t go t o t he admi ssi bi l i t y but t o t he wei ght . But

18 my r ecol l ect i on i s t hat R- 3 has been admi t t ed. We

19 cer t ai nl y dr aw our at t ent i on - - we have r ead i t and not ed

20 t hat t he st at ement t hat your cl i ent has not admi t t ed t he

21 t r ut h or t he accur acy of t he f i ndi ngs of f act , but i t i s a

22

pr i or Boar d or der . Any ot her s t hat wer e - - anybody23 bel i eves were admi t t ed t hat we have not ment i oned?

24 MR. MORI ARTY: I want t o br i ng your

25 at t ent i on on t he exhi bi t s t hat I t hi nk wi l l need t o be


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1 deal t wi t h. Fr ankl y, i t ' s a cl ean- up i ssue. The exhi bi t s

2 t hat Mr . Canal es of f er ed i nt o evi dence t hat you ar e about

3 i n t he pr ocess t o admi t , have t he pat i ent s' names on t hem,

4 pat i ent i dent i f yi ng i nf or mat i on and i nf or mat i on l i ke t hat .

5 I woul d hol d up on accept i ng t hose exhi bi t s unt i l t hat ' s

6 been cl eaned up. We have gone i n and r edact ed al l t hat

7 i nf or mat i on and we have r enumber ed t hose, but we haven' t

8 had t i me t o cl ean up t hose exhi bi t s.

9 J UDGE EGAN: You are t al ki ng about

10 Pet i t i oner ' s exhi bi t s?11 MR. MORI ARTY: The Pet i t i oner ' s exhi bi t l i st

12 vi ol at es t hi s Cour t ' s rul es by di scl osi ng t he pr i vat e

13 HI PAA i nf or mat i on of al l of t hose pat i ent s, and I woul d

14 encour age t he Cour t t o hol d of f on admi t t i ng t he

15 Pet i t i oner ' s exhi bi t s unt i l we have pr oper l y - - unt i l t hey

16 have proper l y r enamed them.17 We have t hose exhi bi t s i n t hi s housekeepi ng

18 deal , but I want t o put you on not i ce what you are about

19 t o do i s t o di scl ose t he HI PAA i nf or mat i on on t hose 63

20 pat i ent s.

21 J UDGE SEI TZMAN: Wel l , what we had di scussed

22

at t he f i nal pr et r i al , because t her e was al so i n t he23 mat er i al s t hat came f r om t he Respondent , t her e wer e

24 pi ct ur es of i ndi vi dual s' f aces and st uf f , and so I t hought

25 what we had agr eed t o do was we woul d admi t t hem, but gi ve


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1 t he par t i es l eave t o subst i t ut e a r edact ed copy f or t he

2 r ecor d copy.

3 MR. MORI ARTY: That ' s f i ne. And we have

4 done t hat and we have now done a - - we had r edact ed al l of

5 t he i dent i f yi ng dat a, name and bi r t hday and st uf f l i ke

6 t hat , and we have al so gone i n and put bl anks over t he

7 f aces. So we wi l l wor k wi t h t he Pet i t i oner on t hat .

8 MR. CANALES: My par al egal i nf or ms me t hat

9 we have done t hat . We go by i ni t i al s.

10 J UDGE SEI TZMAN: I t hi nk we were al l i n11 agr eement l ast week t hat j ust - - because we ar e goi ng to

12 f i nd st uf f , I mean, you j ust t r y and cat ch ever yt hi ng, but

13 you don' t al ways cat ch everyt hi ng. And so as we go al ong

14 and bot h par t i es cat ch somet hi ng, l et ' s j ust - - whosever

15 exhi bi t i t i s, we wi l l agr ee t o r edact i t , and by t he end

16 of hear i ng, we shoul d have a cl ean r ecor d copy, whi ch i s17 t he copy we ar e concer ned about . We can dest r oy our

18 copi es.

19 So Mr . Canal es - -

20 MR. CANALES: We wi l l do i t . J udge Egan,

21 f or gi ve me. R- 6 and 10, t hat i s what i s cal l ed t he

22

At t achment A. We obj ect ed t o t hose l ast t i me.23 J UDGE EGAN: We have not admi t t ed - -

24 MR. CANALES: Okay. Very wel l .

25 J UDGE SEI TZMAN: Because we coul dn' t open


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1 t hem. Those wher e t he r esumes; were t hey not ?

2 MR. CANALES: No, t he At t achment A.

3 J UDGE EGAN: I di d not admi t R- 2, R- 6 or

4 R- 10.

5 MR. CANALES: Ri ght .

6 J UDGE EGAN: J ust make sure t he cour t

7 r epor t er has a copy of t he exhi bi t l i st .

8 MR. KHAROD: Your honor , I ' m not cl ear f or

9 R- 2, i s t her e an obj ect i on or i s i t t hat t hey can' t open

10 t he f i l e? Because we gave - - al ong wi t h gi vi ng t hem t he11 Cour t t he password, we gave t he password t o t he ot her si de

12 f or t hat one, t oo. So I ' m not sur e whet her i t ' s a

13 t echni cal i ssue or whet her i t ' s an obj ect i on.

14 MR. CANALES: Bot h.

15 J UDGE EGAN: I bel i eve at t hi s poi nt , he' s

16 not had a chance t o see t he exhi bi t ; i s t hat cor r ect , you17 coul d not open i t ?

18 MR. CANALES: Wel l , what t hey have descr i bed

19 t o me, i t ' s hear say and i t was not pr epar ed by any

20 par t i cul ar wi t ness, and i t i s somet hi ng made f or t he

21 pur pose of l i t i gat i on and we obj ect t o i t . 8036, Your

22

Honor .23 J UDGE EGAN: Okay. We wi l l deal wi t h t hose.

24 I t hi nk you pr obabl y need t o l ook at i t and open i t bef or e

25 you pr oceed wi t h an obj ect i on, t ake a l ook at i t and see


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1 i f you r eal l y obj ect t o i t .

2 MR. HI LDER: I f I may j ust r evi si t t he i ssue

3 wi t h R- 3, I woul d ask t hat t he Cour t t o al l ow us t o r enew

4 our obj ect i on t o R- 3 i f , i n f act , par t Number 1 of t he

5 pet i t i on i s somehow not pr oved or wi t hdr awn or di smi ssed.

6 Because t hen t he 404( b) does not become appl i cabl e t o even

7 al l ow t hat i nt o evi dence. So wi t h t hat , I want ed t o r ai se

8 my concer ns.

9 J UDGE EGAN: When i t i s of f ered, you can

10 r e- r ai se your obj ect i on.11 MR. HI LDER: Thank you.

12 J UDGE EGAN: Ar e we r eady t o proceed t o

13 openi ng st at ement s?

14 MR. HARGOVE: Yes, Your Honor .

15 J UDGE EGAN: Ar e t here any quest i ons bef ore

16 we pr oceed?17 MR. CANALES: Yes, Your Honor . Respondent

18 t oday, at t hi s poi nt , at 8: 35 f i l ed somet hi ng t hey cal l ed

19 a Tr i al Suppl ement t o Respondent ' s Compl ai nt .

20 J UDGE EGAN: We r ecei ved t hose and we

21 wi l l - - J udge Sei t zman and I wi l l r evi ew bot h t he r equest

22

and t he r esponse dur i ng t he l unch hour and make a rul i ng23 when we come back.

24 MR. CANALES: So how does thi s pl ay

25 r egardi ng openi ng st at ement ?


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1 J UDGE EGAN: Accor di ng t o t he Respondent ,

2 t hey have not added anyt hi ng t o t hi s, so I woul dn' t

3 i magi ne i t woul d af f ect i t at al l . But i f t hey go out si de

4 t hei r pl eadi ngs, I ' m sur e you wi l l obj ect .

5 MR. CANALES: Wel l , t hey are goi ng out si de

6 t hei r pl eadi ngs.

7 J UDGE EGAN: They haven' t made t hei r openi ng

8 st at ement .

9 MR. CANALES: I want t o be sur e I ' m not

10 agr eei ng t o t he so- cal l ed suppl ement , what ever i t i s. We11 obj ect t o i t .

12 J UDGE EGAN: I under st and t he obj ect i on.

13 And at t hi s poi nt , t he onl y t hi ng we ar e headi ng t o i s t he

14 openi ng st at ement s, and i f - - I wi l l r emi nd you, openi ng

15 st at ement s ar e not evi dence, and i f we agr ee wi t h you,

16 t hen we wi l l - - i f t her e' s anyt hi ng i n t hei r openi ng17 st at ement t hat per t ai ns t o t he new mat er i al or what you

18 bel i eve i s new mat er i al , we wi l l cer t ai nl y not consi der

19 i t .

20 Go ahead and proceed, Mr . Har grove.

21 MR. HARGOVE: Dan Har grove f or OI G. J udge

22

Egan, J udge Sei t zman, di d Ant oi ne Dent al Cent er commi t23 Medi cai d f r aud? Di d Dr . Nazar i and hi s cl i ni cs, di d t hey

24 use poor Texas ki ds t o commi t Medi cai d f r aud? Di d t hey

25 st eal mi l l i ons of dol l ar s f r om t he Medi cai d pr ogr am? Al l


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1 of t hat i s not r el evant f or our pur poses t oday. That ' s

2 not why we ar e her e. That f i ght i s f or anot her day. That

3 f i ght i s f or anot her pr oceedi ng at t he over payment

4 hear i ng. We t hi nk when t hat t i me comes, t he evi dence wi l l

5 over whel mi ngl y show yes t o al l t hose quest i ons.

6 Our pur pose i s a di f f er ent mat t er , our

7 pur pose i s t o show i f t her e' s a l egal basi s t o mai nt ai n a

8 payment hol d because i t ' s not Ant oi ne' s money. I t ' s t he

9 t axpayer ' s money, i t ' s t he St at e of Texas' money. And al l

10 we have t o do i s det er mi ne i f t her e' s pr i ma f aci e evi dence11 t o mai nt ai n t he payment hol d.

12 So what we must show t oday i s i f t here' s

13 pr i ma f aci a evi dence of ei t her a wi l l f ul mi sr epr esent at i on

14 i nvol vi ng a r ei mbur sement cl ai m or pr ogr am vi ol at i ons.

15 Some of t he pr ogr am vi ol at i ons i n quest i on ar e submi t t i ng

16 or causi ng t o be submi t t ed a f al se cl ai m, up- codi ng,17 bi l l i ng f or nonr ei mbur sabl e ser vi ces, f ai l ur e t o compl y

18 wi t h t he Medi cai d r ul es, f ai l ur e t o compl y wi t h Dr . Nazar i

19 and hi s cl i ni c' s pr ovi der agr eement - - whi ch you wi l l see

20 shor t l y - - mi sr epr esent at i on on a pr i or aut hor i zat i on - -

21 and we wi l l t al k about what a pr i or aut hor i zat i on i s - -

22

and submi t t i ng or causi ng t o be submi t t ed a f al se23 st at ement .

24 So t hi s i s what we have t o pr ove i n order

25 f or t hi s t r i bunal t o mai nt ai n t he payment hol d. That ' s


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1 al l we ar e t aki ng about , i s mai nt ai ni ng t he payment hol d

2 ei t her , A, a wi l l f ul mi sr epr esent at i on, or Medi cai d

3 pr ogr am vi ol at i ons.

4 Dr . Al t enhof f wi l l t al k about what t hose

5 pr ogr am vi ol at i ons ar e. So t he st andar d i s ext r emel y

6 i mpor t ant t o us. I t ' s a ver y l ow st andar d of pr oof f or

7 t hi s pr oceedi ng.

8 So what i s t he St at e' s bur den of pr oof ?

9 J udge, i t ' s pr i ma f aci a. Pr i ma f aci a. And l et me r ead t o

10 you what t hat st andar d means under t he l aw. The pr i ma11 f aci a st andar d r equi r es onl y t he mi ni mum quant um of

12 evi dence necessary t o suppor t a r at i onal i nf er ence t hat

13 t he al l egat i on of f act i s t r ue.

14 The mi ni mum quant um of evi dence necessar y t o

15 suppor t a r at i onal i nf er ence t hat t he al l egat i on of f act

16 i s t r ue.17 So i f t hi s wer e a cr i mi nal cour t , we woul d

18 be up her e at r easonabl e doubt , but we ar e not . I f t hi s

19 wer e a di f f er ent pr oceedi ng, we mi ght be at cl ear and

20 convi nci ng evi dence, but we are not . We are not even at a

21 ci vi l case where we have t o show pr eponderance of t he

22

evi dence, we are not even at t he pr obabl e cause st age. We23 are one st ep bel ow t hat , bet ween r easonabl e suspi ci on and

24 pr obabl e cause.

25 So as you eval uat e t he evi dence and come t o


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1 a det er mi nat i on i n t hi s case, i t ' s cr i t i cal t o under st and

2 what t he St at e' s bur den of pr oof i s, and t hat i s pr i ma

3 f aci a.

4 Thi s i s a messy sl i de, l et me wal k you

5 t hr ough i t , t he pr ogr am vi ol at i ons t hat ar e goi ng t o come

6 out over t he next coupl e of days. So l et me t ake you t o

7 St ep 1.

8 St ep 1 - - here i s how we ar e goi ng t o show

9 what happened, and t he r ecor ds, most i mpor t ant l y, ar e

10 goi ng t o show t hi s.11 St ep 1, a pat i ent r epor t s t o Ant oi ne Dent al

12 Cent er . The pat i ent i s exami ned, and you wi l l hear about

13 t hi s HLD score sheet and Ant oi ne scores t he pat i ent on t he

14 HLD scor e sheet ; t hey t ake x- r ays and model s. So Ant oi ne

15 Dent al Cent er does al l t hi s. Some of t he pr ogr am

16 vi ol at i ons come i n at t hat st age when t hey have t he chi l d17 t her e i n t he chai r and t he pr ovi der , t he dent i st i s

18 scor i ng t he ki d or whoever i s scor i ng t he chi l d on t he HLD

19 scor e sheet . I t ' s at t hi s st age wher e some of t he pr ogr am

20 vi ol at i ons come i n, wher e we have mi sr epr esent at i ons, we

21 have a f al se pr i or aut hor i zat i on, and t he f i r st st eps

22

t owar ds a f al se cl ai m.23 Because what happens t hen i s t he ADC

24 packages up mat er i al , i nf or mat i on, evi dence, t hat t hey

25 si gn t o and t hey shi p i t of f t o TMHP, whi ch i s t he


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1 cont r act or t hat r ecei ves t hese r equest s f or pr i or

2 aut hor i zat i on f or br aces and t hey l ook at i t and t hey

3 det er mi ne whet her t her e' s suf f i ci ent medi cal evi dence t o

4 put br aces on a Medi cai d benef i ci ar y.

5 So when Ant oi ne shi ps t hat of f t o TMHP, t he

6 mere submi ssi on of t hose document s at t hat st age i nvol ves

7 sever al pr ogr am vi ol at i ons t hat you wi l l see i n t he

8 r ecor ds.

9 Then TMHP approves t he cl ai m, whet her t hat

10 i s r i ght or wr ong i s not r el evant t oday. And t hen t hey11 aut hor i ze Ant oi ne t o pl ace br aces. Ant oi ne t hen pl aces

12 br aces, and t hen t hey pl ace br aces and t hey submi t a cl ai m

13 f or r ei mbur sement . Agai n, we have anot her st age where

14 pr ogr am vi ol at i ons ar e commi t t ed. Thr oughout t hi s, we

15 have wi l l f ul mi sr epr esent at i ons.

16 So we have pr ogr am vi ol at i ons i nvol vi ng17 noncompl i ance wi t h t he pr ogr am, bi l l i ng f or

18 nonr ei mbur sabl e servi ces, mi sr epr esent at i on,

19 mi sr epr esent at i on, mi sr epr esent at i on, f al se cl ai m when

20 t hey r ecei ve t he money.

21 So l et ' s tal k a l i t t l e bi t - - you ar e goi ng

22

t o hear some of t hi s f r om Dr . Al t enhof f , we wi l l det ai l23 t hat and pul l out t he manual , i t ' s i mpor t ant t o under st and

24 t he pr ocess t hat a Medi cai d benef i ci ar y goes t hr ough t o

25 get br aces.


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1 So t he Medi cai d cri t er i a f or br aces. I t ' s a

2 deci si on t r ee, basi cal l y. Ar e br aces per mi t t ed under t he

3 Medi cai d pr ogr am f or cosmet i c pur poses? I f t hey want t o

4 do i t f or cosmet i c pur poses, no; Medi cai d won' t pay f or

5 cosmet i c pur poses.

6 Does t he chi l d have baby t eet h? There are a

7 coupl e of except i ons we wi l l addr ess. I f t he chi l d has

8 baby t eet h, can' t get br aces i f t he chi l d has not had baby

9 t eet h; t hey ar e cal l ed pr i mar y t eet h. Then does t he chi l d

10 need br aces? I n ot her wor ds, i s t her e a medi cal necessi t y11 t o pl ace br aces on t hat chi l d?

12 I f t he answer i s, yes, t her e i s a medi cal

13 necessi t y t o pl ace br aces on t he chi l d, t hen we go t o t he

14 next par t of t he deci si on t r ee. And her e i s t he t hi ng,

15 does t hat chi l d have a sever e handi cappi ng mal occl usi on?

16 A sever e handi cappi ng mal occl usi on. I s t he chi l d17 dysf unct i onal ? Can t hat chi l d chew or eat ? That i s what

18 t he pr ogr am i s desi gned f or , f or chi l dr en who ar e

19 dysf unct i onal . I t i s not desi gned t o make ki ds l ook

20 pr et t y. I t i s not desi gned t o have ki ds wi t h st r ai ght

21 t eet h.

22

Then t he i ssue i s, i f t her e i s a sever e23 handi capped mal occl usi on, whi ch i s a ver y hi gh st andar d,

24 t hen we go t o t he next st age. Yes, t hen t hey submi t pr i or

25 aut hor i zat i on f or r ei mbur sement . I f pr i or aut hor i zat i on


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1 i s appr oved, t hen t he benef i t i s i ssued.

2 Thi s i s j ust one exampl e of a pat i ent . You

3 ar e goi ng t o see qui t e a f ew of t hem, especi al l y over t he

4 next coupl e of days. Thi s i s f r om Ant oi ne' s own r ecor ds.

5 Thi s i s a chi l d who pr esent ed and t hese ar e bef or e

6 phot ogr aphs, t hi s i s how a chi l d pr esent ed t o Ant oi ne.

7 And as you see, t hese phot ogr aphs over t he next coupl e of

8 days, ask your sel f , t hi nk about i t , does t hi s chi l d have a

9 sever e handi cappi ng mal occl usi on? I s t hi s chi l d

10 dysf unct i onal wi t h her or al heal t h?11 So what we have here - - and l et me j ust ki nd

12 of wal k you t hr ough here. We have phot ogr aphs f r om

13 Ant oi ne' s r ecor ds, you have - - t her e ar e HLD scor e sheet s.

14 You ar e goi ng t o see some of t hese, and t hi s i s what an

15 HLD score sheet l ooks l i ke. And t hen her e i s how t he

16 pr ovi der scor es t he HLD scor e sheet . Bot t om l i ne i s, i f17 you get 26 poi nt s, t hat i s what t hey ar e l ooki ng f or .

18 They want t o get t o 26 poi nt s because t hat i s t hei r t i cket

19 t o t he Medi cai d dol l ar .

20 And her e i s wher e t hey scor e i t . Ther e ar e

21 cer t ai n f unct i ons. I f you can' t see i t , we wi l l wai t f or

22

Dr . Al t enhof f t o t al k about i t , but her e i s wher e you ar e23 goi ng t o see a l ot of t hese r ecor ds. And I ' m not goi ng t o

24 go i nt o det ai l r i ght now, but t he t eet h i n quest i on ar e

25 t he f r ont t eet h, not t he back t eet h.


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1 Do you have a t oot h t hat i s ect opi cal l y

2 er upt ed? We ar e t al ki ng about t he 12 f r ont t eet h. And

3 t hi s i s wher e Ant oi ne - - and Dr . Nazar i scor ed t hi s one,

4 wher e he i s sayi ng, t hi s young gi r l , ever y si ngl e one of

5 her f r ont t eet h i s ect opi cal l y er upt ed. And t hen he si gns

6 i t , t he exami ner says her e, Dr . Nazar i , pr ovi der ' s

7 si gnat ur e, Dr . Nazar i , pl ease submi t t hi s scor e sheet wi t h

8 your r ecor ds. He scor ed i t 36 poi nt s. He sends i t of f t o

9 TMHP.

10 And t hen we have t he rul e here . 1671( a) ,11 submi t t i ng or causi ng to be submi t t ed a mi sr epr esent at i on

12 or omi t t i ng pert i nent f act s when cl ai mi ng payment under

13 Medi cai d or when suppl yi ng i nf or mat i on used t o det er mi ne

14 t he r i ght t o payment under Medi cai d or ot her Heal t h and

15 Human Ser vi ces pr ogr am.

16 So when t hey send t hat of f , i t ' s f al se17 i nf or mat i on. That ' s a pr ogr am vi ol at i on. I t ser ves as

18 t he basi s t o mai nt ai n t hi s payment hol d unt i l we get t o

19 t he next pr oceedi ng t o get t he St ate' s money back.

20 Now, you don' t have t o be a Medi cai d

21 pr ovi der . Dr . Nazar i , hi s pr ovi der s, t hey vol unt ar i l y

22

enr ol l ed i n t he Medi cai d pr ogr am. What you wi l l see l at er23 i s you wi l l see hi s pr ovi der enr ol l ment appl i cat i on. And

24 i n t hat appl i cat i on, he comes t o t he St at e, he t el l s t he

25 St at e, I want t o do busi ness wi t h you, Gover nment , I want


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1 t o be a Medi cai d pr ovi der , I want t o get on t hi s syst em.

2 And he enr ol l ed back i n 2000 and per i odi cal l y re- enr ol l ed,

3 and t hi s i s f r om hi s 2008 appl i cat i on.

4 So t hi s f or m i s r equi r ed f or al l appl i cant s.

5 Par t I , pr ovi der i nf or mat i on, Behzad Nazar i ; t her e i s hi s

6 addr ess, 6206 Ant oi ne Dr i ve; and t her e i s hi s si gnat ur e

7 dat ed J anuar y 9, 2008. Let ' s pul l out a coupl e par t s of

8 t hi s.

9 Dr . Nazar i cer t i f i ed t o be t r ut hf ul . I n

10 Par t I I , i t says, agr eement s and cer t i f i cat i ons: I n11 consi der at i on of t he payment s aut hor i zed under t hi s

12 agr eement - - i t ' s a cont r act he has wi t h t he St at e - - t he

13 pr ovi der i dent i f i ed i n Par t I of t hi s agr eement agr ees or

14 cer t i f i es t o become f ami l i ar - - what t hi s says i s he' s

15 goi ng t o f ol l ow t he r ul es and become f ami l i ar wi t h t he

16 r ul es and he' s goi ng t o st ay up- t o- dat e wi t h t he r ul es.17 And Dr . Al t enhof f wi l l t al k about t hat .

18 Her e i s t he ki cker , i n Subpar agr aph E, i t

19 says, he cer t i f i es - - Dr . Nazar i - - t hat al l i nf or mat i on

20 cont ai ned i n al l cl ai ms or encount er ed dat a submi t t ed by

21 or on behal f of t he pr ovi der i s t r ue, compl et e and

22

accur at e, and can be ver i f i ed by ref er ence t o sour ce23 document at i on mai nt ai ned by pr ovi der i n accor dance wi t h

24 t he manual , whi ch i s goi ng t o be t hi s document r i ght her e

25 whi ch you wi l l hear about . Thi s i s t he Texas Medi cai d


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1 Pr ovi der Pr ocedur es Manual . You wi l l hear a l ot about

2 t hat . Maybe t oo much.

3 So he' s cer t i f i ed he' s goi ng t o be t r ue

4 compl et e and accur at e. The pr ovi der wi l l pr ovi de ser vi ces

5 f or Medi cai d r eci pi ent s i n t he same manner by t he same

6 met hods and t he same l evel of qual i t y pr ovi ded t o t he

7 gener al publ i c.

8 I n ot her wor ds, we don' t have t wo di f f er ent

9 st andar ds of car e. We don' t have a st andar d of car e f or

10 t he Medi cai d popul at i on f or poor ki ds and a st andar d of11 car e f or ki ds who ar e not on Medi cai d.

12 Tr ue, compl et e and accur at e, t hat ' s what

13 t hi s case i s about . Was he t r ut hf ul ? Was he compl et e?

14 Was he accur at e? And as you go t hrough t he next coupl e

15 days, you wi l l get mor e of t hi s, and l at er on i n t hi s

16 af t er noon. Ar e t hese sever e handi cappi ng mal occl usi on?17 These ar e f our phot ographs. These ar e how ki ds pr esent ed

18 t o Dr . Nazar i .

19 Thank you, J udges.

20 MR. CANALES: May I pr oceed?

21 J UDGE EGAN: Yes, Mr . Canal es.

22

MR. CANALES: You wi l l hear t est i mony f r om23 Dr . Nazar i and Dr . Kanaan, our t wo exper t s - -

24 THE REPORTER: I ' m sor r y. Who?

25 MR. CANALES: Dr . Nazar i , Dr . Kanaan and Dr .


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1 Or r . Al l of t hem wi l l say t hat t hi s def i ni t i on of what

2 const i t ut es t he ect opi c er upt i on i s a ver y subj ect i ve

3 mat t er . You wi l l see peopl e who ar e doct or s i n t hi s

4 pr of essi on who ar e al l over t he pl ace i n t he gr adi ng of

5 i t . The quest i on has now ar i sen as t o whet her or not a

6 di sput e and a pr of essi onal opi ni on r i ses t o t he l evel of

7 some t ype of f r aud. That i s what t hey ar e cont endi ng.

8 MR. HARGOVE: Your Honor , I don' t want t o

9 obj ect , but we have made i t cl ear we are not havi ng t o

10 pr ove f r aud i n t hi s pr oceedi ng.11 J UDGE EGAN: I under st and. Thi s i s openi ng.

12 MR. CANALES: I submi t t hat t hey have t o

13 pr ove f r aud or wi l l f ul mi sr epr esent at i on or some t ype of a

14 f al se st at ement . But you have t o l ook as t o, how di d we

15 get her e. And we got her e because some t i me, and t he

16 t est i mony wi l l be f r om ot her par t i es, t hat t her e was a17 t el evi si on st at i on, WFAA out of Dal l as, who r an a ser i es

18 of st or i es. And i n t hi s ser i es of st or i es al l had t o do

19 wi t h cr i t i ci zi ng t he HHSC agency f or spendi ng a l ot of

20 money i n t he t r eat i ng of Medi cai d pat i ent s.

21 As a r esul t of t hat , OI G deci des t o

22

i nvest i gat e, aut omat i cal l y audi t t he t op 25 pr ovi der s i n23 t he St at e. Dr . Nazar i f el l i n t hat cat egor y. So t her e

24 was no pr obabl e cause, t here was no suspi ci on, t here was

25 not hi ng except we are goi ng t o conduct an audi t . When


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1 t hey conduct ed t hi s audi t , t hey st ar t ed a campai gn at t hat

2 t i me of what i s cal l ed not i f yi ng ever ybody about payment

3 hol ds. So t hey gi ve a payment hol d not i ce and t hey come

4 over and pi ck up your r ecor ds. And I say t hey, OI G pi cks

5 up t he r ecor ds. And t hey st ar t doi ng t hese st udi es,

6 anal ys i s of t he f i l es.

7 The f i l es ar e al l i n t he r ecor d. We have

8 phot ogr aphs, t he phot ogr aph he showed you was onl y par t of

9 t he phot ogr aph. You wi l l see t he ent i r e par agr aph. You

10 are goi ng t o see so many t eet h i n t he next coupl e of days,11 you are goi ng t o be sayi ng, oh, my God. And you are goi ng

12 t o be seei ng some di spar i t i es, wher e t he chi l dr en' s t eet h

13 ar e comi ng out f r om t he t op. They ar e t er r i bl e t eet h.

14 And not one t i me di d Dr . Evans, out of t he 63 pat i ent s,

15 not one t i me di d Dr . Evans appr ove a si ngl e one. Not one.

16 Out of t he 63 pat i ent s, onl y one pat i ent17 passed t he HLD scor e accor di ng t o Dr . Tadl ock. Why i s

18 t hat di spar i t y? I t ' s because of t he def i ni t i on. Dr .

19 Tadl ock - - we wi l l show you, t hat Dr . Tadl ock and Dr .

20 Evans ar e i nsi st i ng on appl yi ng a def i ni t i on t hat ' s

21 out si de t he manual .

22

Now, t o us, I t hi nk we have of f er ed i nt o23 evi dence t he opi ni ons - - t he Agency' s deci si on or t he

24 Agency' s adopt i on of t he def i ni t i on by J udge Feket y. She

25 says I ' m t he Agency, I adopt t he f i ndi ngs of J udge


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1 Ki l gor e, and her e t hey ar e. And she f l at out says, t hi s

2 i s t he Agency' s def i ni t i on; not t he expanded ver si on, not

3 a cl ar i f i cat i on, but a ver se t hat says, an unusual pat t er n

4 of er upt i on such as hi gh l abi al cuspi ds or t eet h t hat ar e

5 gr ossl y out of t he l ong axi s of t he al veol ar r i dge. That

6 has been t he def i ni t i on, by t he way, t hat t hese doct or s,

7 my cl i ent s, have operated on si nce Day 1, si nce t hey came

8 i nt o t he pr ogr am.

9 And when t hey came i nt o t he pr ogr am, TMHP

10 appr oved al l t hese pat i ent s. Year s l at er , now t hey ar e11 comi ng back t o r edef i ne t he def i ni t i on. The quest i on i s:

12 Where i s Dr . Fel kner? Where i s TMHP? Where i s t he

13 pr ogr am vi ol at i ons? Wher e i s t hat ot her si de of coi n?

14 You wi l l never see i t . What you wi l l see i s

15 t hat TM - - t hat OI G i s pr esent l y under a Feder al - - i s

16 pr esent l y under a Feder al - - t he Of f i ce of I nspect or17 General , Heal t h and Human Servi ces Commi ss i on audi t , f or

18 t hem t o be abl e t o expl ai n whet her or not t hi s so- cal l ed

19 pr i or aut hor i zat i on pr ogr am was wor ki ng or not . As a

20 r esponse t o t hat , we ar e her e t oday. Ther e i s an i nt er nal

21 audi t t hat you wi l l see i n evi dence came out i n 2008 where

22

St at e OI G conduct s an audi t of TMHP r egardi ng t he pr i or23 aut hor i zat i ons. And t hey say, we ar e conduct i ng t he pr i or

24 aut hor i zat i ons under t hi s st andar d. Nobody compl ai ned;

25 everyt hi ng st ayed t he same.


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1 Dr . Al t enhof f wi l l t est i f y, because we have

2 her deposi t i on, I ' m sur e she' s not goi ng t o change i t ,

3 t hat she was ki nd of l i ke a consul t ant f or HHSC and t hat

4 she had t hese doct or s - - t hey cal l t hem shar ehol der

5 meet i ngs. And not one di d she ever speak wi t h TMHP, and

6 not one t i me di d she t el l t he doct or s, you ar e doi ng i t

7 wr ong; you ar e r eadi ng t he def i ni t i on wr ong. So I submi t

8 t o t he Cour t t hat now, whi l e t hey don' t want t o admi t i t ,

9 at l east Dr . Tadl ock says, t hat he i s appl yi ng a di f f er ent

10 def i ni t i on. He i s goi ng out of t he manual .11 Now, none of t he doct ors made t he rul e, none

12 of t he doct or s can change t he r ul e. Al l of t he doct or s

13 have t o appl y by t he r ul es. Those r ul es ar e put out i n

14 t he manual . You wi l l see t hat t he manual ' s def i ni t i on

15 di dn' t change al l unt i l about l at e 2011; t hat ' s wher e t hey

16 changed t he def i ni t i ons.17 Now, al l t hese doct or s ar e goi ng t o t est i f y

18 t hat pur suant t o t hat ol d def i ni t i on, t hei r onl y

19 def i ni t i on of ect opi c er upt i on, t hat t hese doct or s made a

20 cl ear , l ogi s t i c, f ai r , dent al di agnos i s i n t r eat i ng t he

21 pat i ent s. Al l of t hem; not a pr obl em at al l .

22

So t oday, what we have here i s not hi ng but23 an at t empt by OI G t o t r y and r ecoup some money by pul l i ng

24 out ever y t ype of possi bl e post - what ever audi t vi ol at i on

25 t hat t hey can dr eam of t o see because i t woul d of f set


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1 St at e dol l ar s goi ng t o t he Feds.

2 Now t hese - - al l t hese pat i ent s, by t he way,

3 wer e al l seen, t hey al l exi st , t her e' s no f ake pat i ent s,

4 al l t he ser vi ces wer e del i ver ed, i t ' s al l t her e. The

5 quest i on i n al l of t hem i s whet her or not t hese pat i ent s

6 qual i f y.

7 I n t he case of t he Har l i ngen case, J udge

8 Ki l gor e sai d t he i ssue i s t he appl i cat i on of t he HLD

9 score. J udge, when t he mat t er went over t o t he Agency,

10 and t he opi ni on i s al so cor r ect , J udge Feket y sai d t he11 same t hi ng. She went so f ar t o say, oh, my God, t hese

12 wi t nesses' exper t s t hi s OI G br ought i n. Dr . Evans, Evans

13 has never been a Medi cai d pr ovi der , he has never done a

14 Medi cai d pat i ent , and hi s t est i mony was deemed by t he

15 Agency as not cr edi bl e.

16 The t est i mony you wi l l hear f r om Dr . Tadl ock17 i s si mi l ar ; never seen a Medi cai d pat i ent , has never

18 submi t t ed a Medi cai d bi l l , t ot al l y f or ei gn t o t he Medi cai d

19 r ol e. They ar e hi r ed guns t o be abl e t o gi ve you an

20 opi ni on. And we underst and t he busi ness; we underst and

21 t he busi ness, you hi r e exper t s t o gi ve you t hei r si de of

22

case. But t her e has t o be some l ogi c t o i t .23 So what Dr . Tadl ock has done, he' s gone al l

24 over t he dent al wor l d t o t r y and expand t he def i ni t i on of

25 ect opi c er upt i on. t he Agency' s own posi t i on, and t he


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1 i r ony of t he whol e t hi ng i s t hey ar e at t acki ng. OI G i s

2 at t acki ng t he f i ndi ngs of i t s par ent of HHSC' s f i ndi ngs,

3 whi ch makes i t ver y unusual f or OI G t o be at t acki ng t he

4 f i ndi ngs of HHSC. HHSC has made a deci si on; t hey have

5 made a f i ndi ng. And t hey say i n t he f i ndi ng what t he

6 evi dence has been.

7 That ' s why we f i l ed our mot i on f or

8 col l at er al est oppel . So t he quest i on her e t oday i s

9 whet her or not t he def i ni t i on appl i es t hat i t ' s been al l

10 t hese year s. We submi t t ed t o you t hat i t does; i t hasn' t11 changed at al l . So how - - whet her or not t he t est i mony of

12 t hese t wo doct or s, of Tadl ock and Evans, has any bear i ng,

13 I ' l l submi t t o you t hat i t cannot .

14 J udge Feket y sai d, once an agency ref er s a

15 cont est ed case t o SOAH, t he SOAH ALJ st ands i n t he shoes

16 of t he Agency and may make any f i ndi ngs necessary t o17 r esol ve l egal i ssues i n t he case. And t hat ' s what t hey

18 di d her e. And t hey i ssued t he aut hor i t y, t hey i ssued t he

19 r ul i ngs t hat t hese - - t hat makes t he f i ndi ngs of f act .

20 We submi t t o you t hat t hese t wo doct or s ar e

21 i ncor r ect l y i nt er pr et i ng t he def i ni t i on of ect opi c

22

er upt i on, t hat ' s what t hi s case i s al l about . Not hi ng23 el se. J ust ect opi c er upt i on. We do i t pur suant t o t he

24 manual , and you wi l l see phot ogr aphs t hat ar e goi ng t o

25 shock you, I bel i eve.


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1 He showed you one phot ogr aph; you di dn' t see

2 t he whol e si de of i t . But our doct or s al l honest doct or s,

3 t hey ar e al l har d- wor ki ng peopl e, t hey have been subj ect ed

4 t o t hi s par t i cul ar i nqui r y. And Dr . Nazar i wi l l expl ai n

5 each and ever y one of t hese cases. We don' t have any

6 pr obl em at al l def endi ng i t . We don' t have any pr obl em at

7 al l bei ng subj ect ed t o cr oss- exami nat i on.

8 So t he quest i on i s: Does the f act t hat

9 doct or s di sagr ee on t he scor e sheet , does t hat ar i se t o

10 t he l evel - - does t hat aut omat i cal l y r i se t o t he l evel of11 some t ype of f r aud, wi l l f ul mi sr epr esent at i on? Does not

12 t o word of t he act ual doct or wor k? So we don' t have her e

13 a case wher e, oh, my God, t hese wer e f i ct i t i ous pat i ent s;

14 we don' t have a si ngl e one of t hat .

15 We i nqui r ed, by t he way, of Dr . Evans and

16 Dr . Tadl ock, whet her t hey ar e al l egi ng t hat we have done17 anyt hi ng wr ong f r audul ent l y or f al sel y. He says - - bot h

18 of t hem sai d, no, al l we got hi r ed t o do was t o pass t he

19 scor e, l ook at t he HLD scor e, t hat ' s al l we got hi r ed t o

20 do. Dr . Tadl ock says i t and Dr . Evans says i t .

21 So al l of a sudden, we ar e now f aci ng t hi s

22

t r emendous amount of l egal i nqui r y t o our abi l i t y, wher e23 basi cal l y cal l ed f r aud, f r audul ent doct or s, we ar e cal l ed

24 cr ooks. And I submi t t o you t hat you ar e not goi ng t o

25 hear any t est i mony of t hat whatsoever .


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1 Thank you.

2 J UDGE EGAN: Woul d you l i ke t o proceed wi t h

3 your di r ect case?

4 MR. WATKI NS: Your Honor , as a r esul t of

5 what Mr . Canal es j ust sai d, I woul d f i l e a mot i on t o

6 di smi ss. The evi dence i s cl ear i n t hi s case t hat t he hol d

7 l et t er , whi ch was sent out and dat ed Apr i l 4t h, 2012, t hat

8 i s t he l et t er whi ch put s i t on hol d. The evi dence t hen

9 has t o be i s what i s t he pr i ma f aci a evi dence or t he

10 r easonabl e al l egat i on of f r aud t hat exi st ed as of t hat11 dat e, Apr i l 4t h, 2012.

12 Dr . Tadl ock was not hi r ed unt i l J une of

13 2012, t her e i s no way t hat hi s t est i mony i s r el evant t o

14 anyt hi ng havi ng t o do wi t h t he j ust i f i cat i on wi t h t he

15 pr i mar y hol d put on t hi s case. The St at e doesn' t get t o

16 put on a hol d and see i f t hey can come up and j ust i f y i t .17 They have got t o show t hat at t he t i me t hat t hey i ssued

18 t hei r l et t er on Apr i l 4, 2012, t hey had a r easonabl e

19 al l egat i on of f r aud, or as t hey put i t , a pr i ma f aci a

20 cl ai m at t hat poi nt .

21 Now, t he onl y ot her evi dence t hat t hey have

22

submi t t ed, t hat ' s i n t he evi dence t hat t hi s Cour t has23 r ecei ved, i s t hat of Dr . Evans. He st ands i n t he shoes - -

24 t he pr evi ous SOAH J udge st ands i n t he shoes of t he Agency.

25 And t hat agency has made a f i ndi ng t hat Dr . Evans'


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1 t est i mony i s not cr edi bl e. So t her ef or e, i t shoul d not be

2 admi t t ed.

3 So as of Apr i l 4, 2012, t he onl y t hi ng t hey

4 have got t o show t hat t hi s doct or has done anyt hi ng wr ong

5 i s a doct or t hat t he Agency has a f act f i ndi ng, whi ch i s

6 bi ndi ng on i t , t hat hi s t est i mony i s not credi bl e and

7 anot her doct or t hat t hey went out af t er Apr i l 4t h, 2012,

8 t o hi r e t o come i n and pr ovi de t est i mony t o t r y t o shor e

9 up a case whi ch was f al l i ng apar t .

10 We t hi nk t hat based upon t hat , we shoul d11 di smi ss t hi s case at t hi s poi nt and we f eel ver y st r ongl y

12 about t hat .

13 Now, i f you- al l deci de t o go f or war d, we at

14 l east t hi nk t hat Dr . Tadl ock' s t est i mony shoul d be mot i on

15 i n l i mi ne' ed out and excl uded because i t i s not r el evant

16 t o t he quest i on of t he dat e when t he hol d was put on Dr .17 Nazar i , what was t he reasonabl e al l egat i on or t he pr i ma

18 f aci a case. So we move t o di smi ss t he case or , i n t he

19 al t er nat i ve, t o excl ude ever yt hi ng Dr . Tadl ock says.

20 J UDGE EGAN: Response?

21 MR. MORI ARTY: Y' al l set a r ul e t hat we have

22

t r i ed t o l i ve wi t h, t hat al l di sposi t i ve mot i ons wer e t o23 be f i l ed on or bef or e Apr i l 29t h. I l ooked at my

24 cal endar , Apr i l 29t h was awhi l e ago. That mot i on i s not

25 t i mel y and i s not pr oper .


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1 J UDGE EGAN: The mot i on i s over r ul ed.

2 MR. HARGOVE: I ' m sor r y, J udge. I t hought

3 you wer e st i l l conf er r i ng. We coul d cal l Dr . Al t enhof f .

4 J UDGE EGAN: You may pr oceed.

5 LI NDA ALTENHOFF, D. D. S. ,

6 havi ng been f i r st dul y swor n, t est i f i ed as f ol l ows:

7 DI RECT EXAMI NATI ON

8 BY MR. HARGROVE:

9 Q Dr . Al t enhof f , wi l l you pl ease st at e your f ul l

10 name.11 A Li nda Mar i e J ackson Mor r i s Al t enhof f .

12 Q And t hank you f or bei ng here t oday; we appr eci at e

13 your t est i mony.

14 What i s your pr of essi on?

15 A I ' m a doct or of dent al sur ger y.

16 Q And what do you do f or a l i vi ng r i ght now?17 A Cur r ent l y, I ' m a pol i cy exper t f or t he Depar t ment

18 of St at e Heal t h Ser vi ces f or dent al pol i cy, not onl y f or

19 Medi cai d, but al so f or ot her publ i c heal t h dent al pr ogr ams

20 f or t he St at e.

21 Q I t hi nk i t ' s i mpor t ant t hat t he J udges hear a

22

l i t t l e bi t about your backgr ound, so l et ' s t al k a l i t t l e23 bi t about your educat i onal backgr ound and what you' ve been

24 doi ng f or t he St at e over t he past f ew year s.

25 A Okay. I am a 1984 gr aduat e of t he Uni ver si t y of


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1 Texas Heal t h Sci ence Cent er Dent al School i n San Ant oni o.

2 I was i n pr i vat e pr act i ce i n San Mar cos, Texas begi nni ng

3 - - shor t l y af t er my gr aduat i on. And dur i ng t hat t i me, I

4 served as a Medi cai d dent al pr ovi der f or t he St at e of

5 Texas. I n 1998, I came t o wor k f or - - at t hat t i me, t he

6 Texas Depart ment of Heal t h, ser vi ng as a r egi onal dent al

7 di r ect or based out of San Ant oni o, Texas.

8 And dur i ng t he cour se of t hat t i me, I

9 over saw t he Texas Heal t h St eps Medi cai d Dent al Progr am and

10 Medi cal Pr ogr am f or t he St at e of Texas, as wel l as ot her11 Medi cai d- r el at ed pr ogr ams and t he publ i c heal t h pr ogr am

12 f or t he 28 count i es cover ed under Heal t h Ser vi ce Regi on 8.

13 I n 2001, I was r equest ed t o come t o t he

14 cent r al of f i ce i n Aust i n as an i nt er i m di vi si on di r ect or

15 f or t he Texas Heal t h St eps Medi cal Progr am.

16 Q So what i s t he Texas Heal t h St eps Medi cal17 Pr ogr am?

18 A Texas Heal t h St eps i s t he Texas pr ogr am t hat ' s

19 obl i gat e - - or mandat ed under t he Soci al Secur i t y Act , and

20 i n par t i cul ar , t he ear l y and per i odi c screeni ng, di agnosi s

21 and t r eat ment pl an as mandat ed by the Feder al Government .

22

Q And you wer e t he di r ect or of - - t he pol i cy23 di r ect or f or t hat ?

24 A I was t he di r ect or of t he medi cal si de of Texas

25 Heal t h St eps begi nni ng i n Apr i l of 2001.


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1 Q Okay. Cont i nue on.

2 A I n t he cour se of t hat , I over saw t he pol i cy

3 devel opment f or medi cal pol i cy f or t he pr event i ve medi cal

4 ser vi ces f or Texas Heal t h St eps r eci pi ent s, whi ch ar e poor

5 and under ser ved chi l dr en who ar e el i gi bl e f or Medi cai d,

6 bi r t h t hr ough age 20, i n t he St at e of Texas. And pr ovi ded

7 gui dance t o st af f , pr of essi onal st af f wi t hi n Texas Heal t h

8 St eps Medi cal wi t h r egar ds t o medi cal pol i cy f or t he

9 chi l dr en f or t hei r pr event i ve heal t h car e vi si t s.

10 And al so pr ovi ded addi t i onal pol i cy,11 di r ect i on f or t he Medi cal Tr anspor t at i on Pr ogr am, as wel l .

12 Q And what about t he dent al servi ces i n quest i on,

13 what ki nd of pol i cy gui dance di d you pr ovi de?

14 A Begi nni ng i n 2004, I st epped i n as t he i nt er i m

15 st at e dent al di r ect or over t he Texas Heal t h St eps Dent al

16 Pr ogr am, as wel l and t ook on t he r esponsi bi l i t i es of17 par t i ci pat i ng i n t he devel opment of dent al pol i cy f or t he

18 Texas Heal t h St eps Dent al Pr ogram. I have al so ser ved i n

19 t he capaci t y f or t he Heal t h and Human Servi ces Commi ss i on

20 as t he consul t ant f or Medi cai d dent al pol i ci es f or

21 chi l dr en, but al so f or t he Chi l dr en' s Heal t h I nsur ance

22

Pr ogr am dent al pol i cy.23 I n my capaci t y wi t h t he Depar t ment of St at e

24 Heal t h Ser vi ces wher e I ' m cur r ent l y empl oyed, and have

25 been si nce t he t r ansi t i on f r om t he Texas Depar t ment of


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1 Heal t h t o t he Depar t ment of St at e Heal t h Ser vi ces. I have

2 al so ser ved i n t he capaci t y as a subj ect mat t er exper t

3 wi t h r egar ds t o dent al pol i cy f or t he Chi l dr en Wi t h

4 Speci al Heal t h Car e Needs Progr am, as wel l as t he Ti t l e V,

5 Mat er nal and Chi l d Heal t h Pr ogr am, and our publ i c

6 heal t h - - pr i mar y heal t h car e pr ogr am wi t hi n our agency.

7 Q And i s t hi s most l y i n t he cont ext of t he Medi cai d

8 pr ogr am?

9 A The maj or i t y of i t , yes, i s associ at ed wi t h t he

10 Medi cai d pr ogr am, but i s al so i s associ at ed wi t h11 l ow- i ncome chi l dr en who do not qual i f y f or Medi cai d or

12 ot her Feder al assi st ance ot her t han t he Ti t l e V, Mat er nal

13 and Chi l d Heal t h Progr am.

14 Q And t el l us, Medi cai d i s a st at e pr ogr am, r i ght ?

15 A Medi cai d i s f unded by St at e and Feder al . I t i s a

16 par t nershi p bet ween t he St at e and t he Federal Government17 and i s f unded i n t hat manner bet ween t he St at e and t he

18 Feder al Government .

19 Q As i t r el at es t o dent al pol i cy of t he Texas

20 Medi cai d pr ogr am, t el l us about t hat , what your r ol e has

21 been?

22

A My r ol e has been t o ser ve as a consul t ant t o t he23 Heal t h and Human Ser vi ces Commi ssi on as a dent al subj ect

24 mat t er exper t wi t h r egar ds t o Medi cai d dent al pol i cy, not

25 onl y i n t he devel opment , but i n t he revi ew and updat i ng of


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1 t hat pol i cy. Al so as ser vi ng i n t hat capaci t y, I was

2 asked by t he Heal t h and Human Ser vi ces Commi ssi on t o

3 f aci l i t at e quar t er l y st akehol der meet i ngs i n whi ch we had

4 r epr esent at i ves f r om t he Medi cai d pr ovi der gr oups acr oss

5 t he St at e come t o Aust i n and meet wi t h us on a quart er l y

6 basi s.

7 The meet i ngs wer e hel d i n J anuar y, Apr i l ,

8 J ul y and Oct ober of t he year s st ar t i ng i n Oct ober 2004 i n

9 whi ch we pr oact i vel y sought t hei r i nput wi t h r egar ds t o

10 changes t hat we wer e consi der i ng t o t ake pl ace wi t hi n t he11 Medi cai d dent al pol i cy, t o get a sense f r om t hose

12 pr ovi der s, what i mpact t hat woul d have f or t hem, what t hey

13 wer e seei ng wi t hi n t hei r pr act i ces and wi t hi n t he pat i ent s

14 t hat t hey wer e t r eat i ng.

15 But we al so i nvi t ed and had r epr esent at i ves

16 f r om t he t hr ee dent al school s i n t he St at e of Texas17 because we want ed t o know what was bei ng t aught

18 academi cal l y wi t hi n t hose i nst i t ut i ons t o not onl y t he

19 dent al st udent s, but al so i n t he gr aduat e pr ogr ams wi t h

20 r egar ds t o dent al ser vi ces t hat t hese chi l dr en woul d be

21 accessi ng.

22

Q You' ve been a dent i st bef or e, r i ght ?23 A Yes, I am cur r ent l y a dent i st , as wel l .

24 Q And are you on t he f acul t y of any dent al school s

25 i n Texas?


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1 A I am. I am adj unct f acul t y i n t he Depar t ment of

2 Communi t y Dent i st r y, i t ' s now been changed t o

3 Compr ehensi ve Dent i st r y at t he Uni ver si t y of Texas Heal t h

4 Sci ence Cent er i n San Ant oni o, t hei r dent al school . And

5 al so an assi st ant cl i ni cal pr of essor i n pedi at r i cs at t he

6 Bayl or Col l ege of Dent i st r y i n Dal l as.

7 Q And have you assi st ed t he Depart ment of J ust i ce

8 i n any Medi cai d dent al f r aud cases?

9 A I have. I have been and ser ved as a f act wi t ness

10 f or t he Depar t ment of J ust i ce i n a Medi cai d f r aud case11 t hat was - - t he pr ovi der was f r om Br ownwood, Texas and t he

12 case was hear d i n San Angel o. I have al so been an i nvi t ed

13 f acul t y t o t he Medi cai d I nt egr i t y I nst i t ut e, whi ch i s r un

14 by t he Depar t ment of J ust i ce, as wel l as t he cent er s f or

15 Medi cai d and Medi care ser vi ces.

16 Q What was t hat ?17 A The Medi cai d I nt egr i t y I nst i t ut e.

18 Q The Medi cai d I nt egr i t y I nst i t ut e, what i s t hat ?

19 A I t i s a t r ai ni ng pr ogr am f or Medi cai d f r aud

20 i nvest i gat or s and ot her i ndi vi dual s wi t hi n St at e Medi cai d

21 pr ogr ams t hat i s r un by t he Depar t ment of J ust i ce i n

22

col l abor at i on wi t h t he cent er s f or Medi car e and Medi cai d23 ser vi ces. I t i s housed at t he Uni ver si t y of Sout h

24 Car ol i na i n Col umbi a, Sout h Car ol i na.

25 Q Okay. Let ' s t r ansi t i on her e. Let ' s t al k about


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1 t he Texas Medi cai d Dent al Progr am. You have t al ked about

2 Medi cai d, t hat i t ' s a j oi nt pr ogr am bet ween t he Feds and

3 t he St at e. And t her e' s a benef i t pr ovi ded f or or t hodont i c

4 ser vi ces, cor r ect ?

5 A Ther e i s, yes.

6 Q Now, bef or e we get t o t hat , l et ' s t al k about

7 Medi cai d i n gener al . I s i t a heal t h i nsur ance pr ogr am or

8 i s i t ent i t l ement ?

9 A Medi cai d i s an ent i t l ement pr ogr am. I t i s gear ed

10 t o pr ovi de heal t h car e ser vi ces t o t he poor est and most11 vul ner abl e i ndi vi dual s wi t hi n a St at e. That - - and t he

12 dent al benef i t i n t he St at e of Texas i s l i mi t ed t o

13 chi l dr en. So i t i s chi l dr en bi r t h t hr ough 20 year s of age

14 and f or t he most poor - - t hose poor est and most vul ner abl e

15 of t hose chi l dr en.

16 Q Now, I know i n pr i vat e i nsur ance t her e' s a copay,17 i s t her e a copay wi t h t hi s ent i t l ement Medi cai d?

18 A Medi cai d does not f or chi l dr en. For t he bi r t h

19 t hr ough 20 years of age gr oup does not al l ow f or copayment

20 t o be made. I bel i eve i t i s f el t t hat woul d pot ent i al l y

21 l i mi t t he access f or t hese chi l dr en because t he f ami l i es

22

ar e j uggl i ng, t hey have ver y l i t t l e f i nanci al r esour ces.23 Q They ar e poor ?

24 A They ar e ver y poor . A f ami l y of f our , i ncome and

25 asset s, about $42, 000 a year f or a f ami l y of f our . So


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1 t hat i s not a l ot of money, and f or t he most par t , t hose

2 i ndi vi dual s, t hose par ent s of t hose chi l dr en ar e usi ng

3 t hose r esour ces t o pr ovi de shel t er and f ood and cl ot hi ng

4 f or t hei r chi l dr en.

5 Q Now, goi ng back t o t he copay. So Medi cai d - - a

6 chi l d on Medi cai d, t her e i s no f i nanci al ski n i n t he game,

7 so t o speak?

8 A They do not have any f i nanci al r esponsi bi l i t i es

9 f or t he ser vi ces t hat ar e cover ed and al l owed under t he

10 Medi cai d progr am.11 Q Who pays t he pr ovi der ? I s i t a

12 r ei mbur sement - t ype syst em?

13 A I t i s. I t i s pai d usi ng Feder al and St at e t ax

14 dol l ar s, and cur r ent l y, i n t he St at e of Texas, as has been

15 done f or sever al year s, t he St at e has cont r act ed wi t h

16 ent i t i es - - out si de ent i t i es t o pr ovi de t hat17 admi ni st r at i on, t hat cl ai ms admi ni st er i ng. So not onl y do

18 t hey go t hr ough t he pr ocesses of t he pr i or aut hor i zat i on

19 f or ser vi ces, f or any ser vi ces t hat r equi r e t hat , but as a

20 pr ovi der submi t t i ng cl ai ms, t hey ar e r esponsi bl e f or

21 payi ng f or t hose cl ai ms and mai nt ai ni ng t he syst em t hat

22

goes t hr ough t o pr ocess t he cl ai ms.23 Q We wi l l t al k about t he pr ovi der s obl i gat i ons and

24 dut i es and cer t i f i cat i ons i n a mi nut e her e. What ' s t he

25 t ot al Medi cai d budget i n Texas r i ght now?


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1 A For t he 2012- 2000 bi enni um, t he expendi t ur es and

2 budget as of J anuar y of t hi s year was $40 bi l l i on.

3 Q And how many Texas ki ds ar e enr ol l ed i n Medi cai d

4 on aver age?

5 A On t he average f or any gi ven mont h of t he year ,

6 i t ' s about 2. 6 mi l l i on chi l dr en. However , as f ar as t he

7 t ot al undupl i cat ed number of chi l dr en per year t hat ar e

8 enr ol l ed and have at l east a si ngl e day of el i gi bi l i t y and

9 par t i ci pat i on i n t he pr ogr am, i t ' s about 3. 4 mi l l i on

10 chi l dr en.11 Q And what ' s t he - - about t he aver age - - what

12 per cent age of our chi l d popul at i on i n Texas i s enr ol l ed i n

13 Medi cai d?

14 A I ' m gi ven - - t he number s t hat I have seen most

15 r ecent l y, over hal f of t he chi l dr en i n t he St at e of Texas

16 bet ween t he ages of bi r t h and 18 t o 19 years of age are at17 any gi ven t i me on Medi cai d i n the St at e of Texas.

18 Q Over hal f ?

19 A Over hal f .

20 Q Al l r i ght . So bef or e we get t o t al k about how a

21 pr ovi der such as Dr . Nazar i becomes a Medi cai d pr ovi der , a

22

cont r act or wi t h t he St at e, l et ' s t al k about j ust br i ef l y23 t he r ul es appl i cabl e t o t he Texas Medi cai d pr ogr am. Go

24 sl ow, but j ust br i ef l y t el l us what t he appl i cabl e r ul es

25 are t o t he Texas Medi cai d pr ogr am.


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1 So, f or exampl e, you have t he Texas

2 Admi ni st r at i ve Code?

3 A Yes, whi ch i s based of f t he Feder al r egul at i ons

4 associ at ed wi t h t he ear l y and per i odi c scr eeni ng di agnosi s

5 and t r eat ment pr ogr am. So we have t he Admi ni st r at i ve Code

6 t hat set s out pr ogr am r ul es wi t hi n - - f r om t her e wi t hi n

7 pol i cy devel opment f or t he Texas Medi cai d pr ogr am. We

8 t hen t ake t hose rul es wi t hi n t he Texas Admi ni st r at i ve Code

9 and devel op pol i cy t o appl y t hat . That pol i cy i s

10 publ i shed wi t hi n t he Texas Medi cai d Pr ovi der Pr ocedur es11 Manual , and as any - - and t hat manual i s publ i shed once a

12 year . I t ' s t r adi t i onal l y been publ i shed once a year .

13 And dur i ng t he cour se of t i me f r om - - up

14 unt i l r ecent l y wi t hi n t he past year , t hat ' s wher e t he

15 pr i mary publ i shi ng was, on an annual basi s. However ,

16 ever y t wo mont hs, t here was a bul l et i n t hat woul d be17 i ssued, and t hat bul l et i n woul d cont ai n any updat es t o t he

18 manual t hat had occur r ed i n t he i nt er i m t i me f r ame.

19 As we woul d prepar e t he manual f or t he

20 subsequent year , we woul d t ake everyt hi ng t hat was

21 publ i shed wi t hi n t he bul l et i ns and we woul d i ncor por at e

22

t hem i nt o t he manual so t hat t he manual i n t he subsequent23 year woul d cont ai n al l t he updat es.

24 Q I was hopi ng t o show you up on t he scr een, but I

25 can' t f i nd t he r i ght s l i de. So f or t he J udges, t el l t he


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1 J udges what t hat i s.

2 A What Mr . Har gr ove i s hol di ng t her e i s t he 2009

3 ver si on of t he Texas Medi cai d Pr ovi der Procedur es Manual .

4 Q What does i t do as i t r el at es t o pr ovi der s?

5 A I t gi ves pr ovi der s an over al l gui dance as t o not

6 onl y what t hei r r esponsi bi l i t i es ar e t o become a pr ovi der ,

7 but al so i n t r eat i ng of pat i ent s, how t o submi t cl ai ms,

8 how t o submi t pr i or aut hor i zat i ons, what ser vi ces ar e

9 benef i t s of t he pr ogr am, what l i mi t at i ons t her e ar e,

10 whet her t hose l i mi t at i ons ar e age or coul d be al so who was11 qual i f yi ng f or i t , f or t he ser vi ces t hat ar e bei ng

12 pr ovi ded. So i t r eal l y gi ves a gui dance t o t he pr ovi der s

13 as t o what t he pr ogr am i s encompassi ng.

14 Q So you have t he Texas Medi cai d Pr ovi der

15 Pr ocedur es Manual , so f or t he rest of t he day, I want t o

16 cal l i t t he manual .17 A Al l r i ght .

18 Q And i n addi t i on t o t he manual , do you have

19 pol i ci es, r i ght ? Tel l us what t hose pol i ci es ar e.

20 A Pol i ci es ar e an over vi ew of what t he benef i t i s.

21 I t i s what t he payment i s goi ng t o be when t he ser vi ce has

22

been pr ovi ded. I t wi l l l i s t i n i t , agai n, any23 l i mi t at i ons, whet her i t ' s age l i mi t at i ons, maybe t he t oot h

24 speci f i cal l y t hat t hat par t i cul ar ser vi ce can be pr ovi ded

25 t o or f or . I t has i n t her e wi t hi n t he pol i cy t he


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