Zen Group, Inc. v. State of Florida Agency for Health Care Administration

CourtDistrict Court, S.D. Florida
DecidedSeptember 28, 2021
Docket1:20-cv-23218
StatusUnknown

This text of Zen Group, Inc. v. State of Florida Agency for Health Care Administration (Zen Group, Inc. v. State of Florida Agency for Health Care Administration) is published on Counsel Stack Legal Research, covering District Court, S.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Zen Group, Inc. v. State of Florida Agency for Health Care Administration, (S.D. Fla. 2021).

Opinion

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF FLORIDA

Case No.: 1:20-cv-23218-GAYLES/OTAZO-REYES ZEN GROUP, INC., and CARLOS OTAMENDI,

Plaintiffs,

v.

SHEVAUN HARRIS, Acting Secretary, State of Florida, Agency for Health Care Administration, in her official capacity, and KELLY A. BENNETT, individually and in her official capacity as Chief of the Office of Medicaid Program Integrity within the State of Florida, Agency for Health Care Administration,

Defendants. ______________________________________/

ORDER THIS CAUSE comes before the Court on Defendants’ Renewed Motion to Transfer Venue and Motion to Dismiss Amended Complaint for its Failure to State a Claim (the “Motion”) [ECF No. 20]. The Court has reviewed the Motion and the record and is otherwise fully advised. For the reasons that follow, the Motion is granted in part. I. BACKGROUND1 Zen Group, Inc. (“Zen Group”), provided behavior analysis services to developmentally disabled Medicaid recipients, with its principal place of business in Miami-Dade County, Florida. In 2017, the State of Florida’s Agency for Health Care Administration (“AHCA” or “Agency”)

1 As the Court is proceeding on a Motion to Dismiss, it takes Plaintiffs’ allegations in the Amended Complaint as true. See Brooks v. Blue Cross & Blue Shield of Fla., Inc., 116 F.3d 1364, 1369 (11th Cir. 1997). implemented a Behavior Analysis Services Program. Under the program, the Agency paid behavioral services providers, such as Zen Group, for providing services to Medicaid recipients. On February 14, 2019, the Agency issued a Final Audit Report (“Report”) in which it claimed that Zen Group was overpaid $1,376,226.46 for services not covered by Medicaid.

Specifically, the Report claimed that the services Zen Group provided to Medicaid recipients were “rendered by an individual determined not to meet the qualifications or for whom documentation was insufficient to determine eligibility.” Pursuant to the language of the Report, the Report itself constituted a probable cause determination that Zen Group was overpaid by the Medicaid program. Consequently, the Agency demanded that Zen Group repay the Agency $1,644,402.69 (the “Demand”). Under Florida Statute §§ 120.569 and 120.57, Zen Group had the right to request an administrative hearing to challenge the Demand. Accordingly, on March 7, 2019, Zen Group sought administrative review of the Demand pursuant to the First and Fourteenth Amendments to the United States Constitution. During the pendency of the administrative action, the Agency withheld $737,000.00 in

payments to Zen Group for services it rendered to Medicaid patients, which were unrelated to the claims set forth in the Report. Zen Group’s administrative hearing was set for October 29–31, 2019, but on August 15, 2019, the hearing was rescheduled for January 14–16, 2020. On October 15, 2019, Zen Group moved for sanctions, pursuant to Florida Statute § 120.57, alleging that the Agency wholly mismanaged the Behavior Analysis Services Program from the outset and attempted to use the Report to retroactively adopt a non-rule policy and impose it on Zen Group. Shortly after Zen Group’s Motion for Sanctions, the parties engaged in settlement discussions where the parties agreed that the Agency would retain approximately $70,000 of the money it withheld from Zen Group and it would pay back over $665,000 to Zen Group. Moreover, the parties agreed that the money retained by the Agency would not be characterized as “an overpayment” and the Agency would remove any fines or sanctions. As a part of settlement discussions, Zen Group requested the inclusion of a non-retaliation provision in the settlement agreement, whereby the Agency would not take any adverse actions against Zen Group based on

the settlement, its terms, or any of the conduct underlying this case. The Agency refused to agree to a non-retaliation clause, noting that “such relief is not available.” Nonetheless, the parties executed the settlement agreement. On January 9, 2020, the Agency paid Zen Group the amount due under the settlement agreement. The next day, the Agency suspended Medicaid payments to Zen Group pursuant to 42 C.F.R. § 455.23, which provides that a state Medicaid agency may suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending. In connection with this suspension, the Agency issued a letter noting that there were general allegations against Zen Group for billing for services not rendered. Defendant Kelly A. Bennett, Chief of the Agency’s Office of Medicaid Program Integrity (“MPI”), signed-

off on the suspension. Zen Group later learned that it was being investigated by the Medicaid Fraud Control Unit (“MFCU”). Zen Group fully complied with the investigation by sharing information with the MFCU investigator but maintained that it did not commit any fraud. On January 28, 2020, Zen Group sent Bennett the materials it prepared for the MFCU investigator and requested that Bennett confirm which patient was the subject of the investigation. Bennett responded, “I can’t comment on this investigation.” [ECF No. 17 ¶ 52]. Bennett refused to provide further information by telephone, as well. Further, Bennett never responded to Zen Group’s request to terminate the payment suspension and never corresponded with Zen Group or its counsel after January 28, 2020. Around January 29, 2020, the MFCU investigator provided Zen Group with an update on the investigation and stated that he found evidence verifying that the billings in dispute were correct. He further explained that uncontroverted evidence did not support the Agency’s allegations of fraud. On February 18, 2020, the MFCU Investigator updated Zen Group about his

intention to close the investigation for lack of evidence. However, he had to wait for approval from Hagerenesh Ketema Simmons, the Regional Chief Assistant Attorney General for the MFCU in Miami, Florida. During the week of March 16, 2020, the MFCU received two packages from the MPI— each referring a purported allegation of fraud by Zen Group. Bennett was responsible for the MPI referrals to the MFCU. One of the referrals related to the very same alleged overpayment allegation previously brought by the Agency which was settled. The other referral related to Zen Group’s billing regarding services rendered and billed in 2017 for one patient. On April 9, 2020, almost three full months after the Agency suspended Medicaid payments to Zen Group, Zen Group informed Assistant Attorney General Jose Marti, who acted in an

investigatory capacity in this case, that due to the payment suspension, the company is in a dire financial condition and is at risk of closing. Zen Group offered to assist in the investigation in any way and noted that time is of the essence. On April 13, 2020, Zen Group emailed the Assistant Attorney General again explaining that Zen Group was suspending services on April 15, 2021. After May 5, 2020, Zen Group received no further updates on the investigation. On August 3, 2020, Plaintiffs Zen Group and its owner, Carlos Otamendi, commenced this lawsuit raising various federal and state claims against the AHCA; Mary C. Mayhew, former Secretary of the AHCA; and Bennett. [ECF No. 1]. On August 21, 2020, Bennett sent a letter to Zen Group, stating the payment suspension had been lifted. Defendants moved to transfer venue and dismiss the Complaint on September 25, 2020. [ECF No. 12]. On October 23, 2020, Plaintiffs filed their Amended Complaint bringing six counts against Bennett and Secretary Mayhew2: 42 U.S.C.

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