15-003876MPI Agency For Health Care Administration vs. Lee Memorial Health System Gulf Coast Medical Center
 Status: Closed
Recommended Order on Tuesday, January 26, 2016.


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Summary: Sums paid on behalf of eligible aliens for emergency services provided by Respondent did not constitute an overpayment because the services were covered by Medicaid, as Petitioner had determined originally when it gave prior authorization to the claims.

1! ,'"'

4STATE OF FLORIDA :·_,·:;/;:::_

11AGENCY FOR HEALTH CARE ADMINISTRATION

162016 APR -'-1 P 2: 58

22STATE OF FLORIDA, AGENCY FOR

27HEALTH CARE ADMINISTRATION,

30DOAH CASE NO. 15-3876MPI

34Petitioner, C.l. NO. 11-2531-000

38v. PROVIDER NO. 011134100

42RENDITION NO.: "()'2,3Ci -FOI-MDO

47LEE MEMORIAL HEALTH SYSTEM

51GULF COAST MEDICAL CENTER,

55Respondent.

56-------------------------------- I

58FINAL ORDER

60This case was referred to the Division of Administrative Hearings (DOAH) where the

73assigned Administrative Law Judge (ALJ), John G. Van Laningham, issued a Recommended

85Order after conducting a formal hearing. At issue in this proceeding is whether the Agency for

101Health Care Administration ("Agency" or "AHCA") is entitled to recover alleged Medicaid

115overpayments from Respondent for claims the Agency paid to it during the period from January

1301, 2007 to December 31, 2007, relating to goods or services provided to undocumented aliens

145whom DCF had found eligible for Medicaid for the period of an emergency medical condition.

160The Recommended Order, dated January 26, 2016, is attached to this Final Order and

174incorporated herein by reference, except where noted infra.

182RULING ON EXCEPTIONS

185Petitioner filed exceptions to the Recommended Order, and Respondent filed a response

197to Petitioner's exceptions.

200In determining how to rule upon Petitioner's exceptions and whether to adopt the ALJ' s

215Recommended Order in whole or in part, the Agency must follow section 120.57(1)(1), Florida

229Statutes (20 15), which provides in pertinent part:

237The agency may adopt the recommended order as the final order of the agency.

251The agency in its final order may reject or modify the conclusions of law over

266which it has substantive jurisdiction and interpretation of administrative rules

276over which it has substantive jurisdiction. When rejecting or modifying such

287conclusion of law or interpretation of administrative rule, the agency must state

299with particularity its reasons for rejecting or modifying such conclusion of law or

312interpretation of administrative rule and must make a finding that its substituted

324conclusion of law or interpretation of administrative rule is as or more reasonable

337than that which was rejected or modified. Rejection or modification of

348conclusions of law may not form the basis for rejection or modification of

361findings of fact. The agency may not reject or modify the findings of fact unless

376the agency first determines from a review of the entire record, and states with

390particularity in the order, that the findings of fact were not based upon competent

404substantial evidence or that the proceedings on which the findings were based did

417not comply with essential requirements of law ....

425§ 120.57(1)(1), Fla. Stat. Additionally, "[t]he final order shall include an explicit ruling on each

440exception, but an agency need not rule on an exception that does not clearly identify the disputed

457portion of the recommended order by page number or paragraph, that does not identify the legal

473basis for the exception, or that does not include appropriate and specific citations to the record."

489§ 120.57(1 )(k), Fla. Stat. In accordance with these legal standards, the Agency makes the

504following rulings on Petitioner's exceptions:

509Exception I

511In Exception I, Petitioner takes exception to Paragraphs 11, 18, 51 (and by extension 52),

52653, 54, 55, 56, 57, 58, 60, 61, 62, 65, 95, 96, 97, 98, 99, 100, 101, 102, 103, 106, 107, and

548Endnote 12 of the Recommended Order, arguing the findings of fact and conclusions of law in

564these paragraphs "misinterpret and confuse the respective roles of the Department of Children

577and Families and the Agency for Health Care Administration in administering Florida's

589Medicaid Program." The Agency agrees. The ALJ in this case has blurred the lines between the

605agencies and, if not corrected, this will hamstring AHCA from performing its state and federally

620required duties.

622The Department of Children and Families ("DCF") is the state agency responsible for

637determining whether persons are eligible 1 to enroll in Medicaid. § 409.902, Fla. Stat. 2 DCF

653reviews applications for Medicaid enrollment submitted by or on behalf of individuals and

666families to determine whether they meet the income, asset, and categorical eligibility tests set

680forth in federal and state law such that they may be enrolled as Medicaid recipients.

695§ 409.902, Fla. Stat.; § 409.903, Fla. Stat.; § 409.904, Fla. Stat. In determining whether an

711applicant is categorically eligible to enroll in Medicaid based on a medical condition (such as

726pregnancy, age, blindness or other disability, or the need for certain services, including

739undocumented aliens in need of emergency medical services), DCF may consider any

751documentation submitted to it by or on behalf of the applicant.

762§ 409.902, Fla. Stat.;§ 409.903(5), (8), Fla. Stat.;§ 409.904(1), (2), (3), (4), (5), Fla. Stat. With

780respect to undocumented aliens, DCF must consider the application and supporting

791documentation to determine whether and when the alien had an emergency medical condition

804("EMC"), as such aliens are only Medicaid-eligible for the period of the EMC. See

820Respondent's Exhibit 27 at Pages 8-9; 42 U.S.C. § 1396b(v)(2); 42 C.P.R. § 440.255; § 409.902,

836Fla. Stat.; § 409.904(4), Fla. Stat.; Fla. Admin. CodeR. 65A-1.715(1). However, in making its

850eligibility determinations, DCF relies on the documentation provided to it, and does not

863necessarily receive and review any medical records. See Respondent's Exhibit 27 at Pages 33-

87734.

8781 Webster's Dictionary defines the term "eligible" as "able to be chosen for something; able to do or receive

897something; qualified to participate or be chosen." Merriam-Webster Dictionary, http://www.merriam­

907webster.com/dictionary/eligible (last visited March 21, 20 16).

9142 Unless otherwise stated, all statutory references from this point forward are to the 2006 and 2007 versions of the

934Florida Statutes, which were in effect during the period when the claims at issue in this case were submitted to

954AHCA for payment.

957In contrast, AHCA is "the single state agency authorized to make payments for medical

971assistance and related services under Title XIX of the Social Security Act," codified at 42 U.S.C.

987§ 1396a, et seq. § 409.902, Fla. Stat. AHCA contracts with health care providers to provide

1003medical goods and services to enrolled Medicaid recipients, receives and pays the claims health

1017care providers submit for goods and services furnished, conducts claims audits, and recovers any

1031overpayments for paid claims that it determines were not reimbursable.

1041§§ 409.903-.906, Fla. Stat.; § 409.907(1)-(3), (5)(a), (5)(b), (7)-(9), Fla. Stat.; § 409.908, Fla.

1055Stat.; § 409.913(1)(e), (2), (3), (5), (7), (9), (11), (15), (20)-(23), (27), Fla. Stat. As part of its

1073post-payment audits, AHCA requests and then reviews the provider's contemporaneous records,

1084including medical records, supporting each audited claim to determine whether the goods or

1097services billed for were rendered in accordance with the requirements of federal and state

1111Medicaid law, including whether they were "medically necessary" for the recipient, as

1123determined by a contracted, licensed physician or "peer"; if not, the claim is not payable by

1139Medicaid, and AHCA may refuse to pay it or require repayment. § 409.905, Fla. Stat.;§ 409.906,

1156Fla. Stat.; §409.913(l)(d), (7)(b), (7)(t), (9), (11), (15), (20)-(23), Fla. Stat.;§ 409.9131, Fla.

1170Stat.; Fla. Admin. CodeR. 59G-1.010(166). See also 42 C.F.R. § 440.230(d); Moore ex rel.

1184Moore v. Reese, 637 F.3d 1220, 1232-33 (11th Cir. 2011) ("Although the standard of "medical

1200necessity" is not explicitly denoted in the Medicaid Act, it has become a judicially accepted

1215component of the federal legislative scheme .... Accordingly, even if a category of medical

1229services or treatments is mandatory under the Medicaid Act, participating states must provide

1242those medical services or treatments for Medicaid recipients only if they are 'medically

1255necessary."'). With respect to undocumented aliens, AHCA must make the additional

1267determination whether the goods or services billed were necessary to treat an EMC, as

1281determined by a contracted, licensed physician or "peer" and based on the provider's supporting

1295medical records; if not, the claim is not payable. See 42 U.S.C. § 1396b(v)(2); 42 C.F.R. §

1312440.255; § 409.902, Fla. Stat.; § 409.904(4), Fla. Stat.; § 409.913(l)(d), (7), (9), (11), (15)(b)­

1327(d), Fla. Stat.;§ 409.9131, Fla. Stat.; Fla. Admin. CodeR. 590-1.010(166).

1338Indeed, for Medicaid payment purposes, a provider's claims must be "documented by

1350records made at the time the goods or services were provided, demonstrating the medical

1364necessity for the goods or services rendered. Medical goods or services are excessive or not

1379medically necessary unless both the medical basis and specific need for them are fully and

1394properly documented in the recipient's medical record." § 409.913(7)(f), Fla. Stat. In addition, a

1408Medicaid provider must "retain medical, professional, financial, and business records pertaining

1419to services and goods furnished to a Medicaid recipient and billed to Medicaid for a period of 5

1437years after the date of furnishing such services or goods." § 409.913(9), Fla. Stat. Section

1452409.913(1)(d), Florida Statutes, expressly provides: "For purposes of determining Medicaid

1462reimbursement, [AHCA] is the final arbiter of medical necessity. Determinations of medical

1474necessity must be made by a licensed physician or "peer" employed by or under contract with

1490[AHCA] and must be based upon information available at the time the goods or services are

1506provided." See§ 409.901, Fla. Stat.;§ 409.9131(2), (5)(b), Fla. Stat.

1516AHCA cannot refuse to make payments to a Medicaid provider on the basis that it

1531believes DCF erroneously determined the recipient was eligible for Medicaid, based on the

1544application submitted to DCF. § 409.907(5)(b), Fla. Stat. However, AHCA can and must

1557refuse to pay the provider or require repayment if it finds a claim is not supported by the

1575provider's contemporaneous records, including medical records, demonstrating that the goods or

1586services billed for were provided in accordance with the requirement of law and were "medically

1601necessary" for the recipient, as determined by AHCA's contracted, licensed physician or "peer."

1614§ 409.905, Fla. Stat.;§ 409.906, Fla. Stat.; §409.913(1)(d), (2), (7)(b), (7)(f), (9), (11), (15), (20)­

1630(23), Fla. Stat.;§ 409.9131, Fla. Stat.

1637The difference in the roles played by the agencies is made quite clear in the record of this

1655case. In Respondent's Exhibit 56 at Pages 23-24, Tracy Ryder, an investigator with AHCA's

1669Bureau of Medicaid Program Integrity, testified that DCF "is determining eligibility to receive

1682Medicaid, while the other determination as performed by AHCA is to determine whether or not­

1697to determine the duration of the emergency medical condition in terms of the medical

1711presentation and care and the patient's response to treatment. It is a medical review." In

1726Respondent's Exhibit 23 at Page 64, Shevaun Harris, an administrator for AHCA's Bureau of

1740Medicaid Services, stated that "DCF determines a from and through date of when someone is

1755eligible for Medicaid but that does not mean that that person is eligible - would have a condition

1773that requires [AHCA] to pay for services during that entire time frame." In Respondent's Exhibit

178824 at Page 57, Johnnie Shepherd, an administrator with AHCA's Bureau of Medicaid Program

1802Integrity, stated that "Department of Children and Families determines eligibility ... they do not

1816determine coverage." In Respondent's Exhibit 27 at Page 12, Dianna Laffey, the chief of

1830program policy for DCF, stated that "we just do the Medicaid eligibility piece, and then AHCA

1846is the one that pays claims in that. So from what I have always understood, they then determine

1864whether or not those services met that higher level, that higher threshold ... we don't determine

1880that because we don't get medical records." In Respondent's Exhibit 30 at Page 43, Beth

1895Kidder, AHCA's Deputy Secretary for Medicaid Operations, explained that "[e]ligibility and

1906coverage are two different things, and so I want to make that distinction that a span of eligibility

1924may be open but not all services would be covered for that person."

1937Thus, contra the ALJ's determinations, an application for Medicaid eligibility submitted

1948to DCF by or on behalf of a person seeking to enroll in the Medicaid program and a claim for

1968payment submitted to AHCA by a provider seeking reimbursement from Medicaid for a good or

1983service provided to an enrolled recipient have no meaningful overlap. The fact that DCF has

1998determined an undocumented alien is eligible for Medicaid due to an EMC based on the

2013documentation in the eligibility application does not mean that all claims submitted by a provider

2028for goods or services provided to the alien are payable by AHCA. The eligibility application and

2044claim are submitted to different agencies, by different persons, for different purposes, and require

2058different documentation and levels of documentation, i.e. type, detail, and completeness, in

2070support. The eligibility application reviewed by DCF may be accompanied by different

2082documentation, including medical records, than those maintained and supplied by the provider in

2095support of a claim for payment. For instance, this could occur if there was more than one

2112provider of goods or services, if the alien did not submit complete documentation to DCF, or if

2129the provider did not maintain and supply contemporaneous medical record supporting his or her

2143claims to AHCA upon request, as required by law.

2152Further, even assuming the same documentation is submitted in support of both an

2165application for Medicaid eligibility and a provider's claim for payment, DCF's eligibility

21771 determination is not the equivalent of AHCA's medical necessity determination. AHCA utilizes

2190a contracted, licensed physician to conduct a medical review of claims and supporting

2203documentation; DCF's review of eligibility applications utilizes no such personnel and includes

2215no such component. Also, a provider may submit a bill to AHCA for goods or services that were

2233not provided in accordance with the requirements of law, were not medically necessary, or were

2248provided to treat some condition other than the EMC. The legislature has specified that AHCA is

2264the final arbiter of "medical necessity" for Medicaid payment purposes. § 409. 913( 1 )(d), Fla.

2280Stat.

2281For all of the aforementioned reasons and also for the reasons stated in AHCA's rulings

2296on its Exceptions II through VI, which are hereby incorporated by reference, the Agency hereby

2311rules on Petitioner's Exception I, as follows:

2318Paragraph 11 of the Recommended Order contains findings of fact that are not based on

2333competent, substantial evidence. As Dianna Laffey stated, DCF relies on the documentation

2345provided by the hospital in determining whether an EMC exists. See Respondent's Exhibit 27 at

2360Page 8-9. Therefore, the Agency grants Petitioner's Exception I to the extent that it modifies

2375Paragraph 11 of the Recommended Order as follows:

238311. When an alien applies for Medicaid assistance, DCF, considers

2393the application and supporting documentation to determine

2400whether and when the alien had an EMC, as such aliens are only

2413Medicaid-eligible for the period of the EMC.follov1ing its rules,

2422turns to the health care provider for an opinion as to •.vheilier an

2435EMC exists and, if so, for an estimate regarding the length of time

2448th:e EMC will last. DCF relies on the documentation provided to it,

2460and does not necessarily receive and review any medical

2469records.generally accepts ilie provider's judgement on these

2476matters.

2477The findings of fact at Paragraph 18 of the Recommended Order are supported by

2491competent, substantial evidence. See generally Respondent's Exhibit 27. The Agency is not free

2504to reject or modify the ALJ's findings in this paragraph. See § 120.57(1)(1), Fla. Stat. (2015);

2520Heifetz v. Dep't of Bus. Reg., 475 So. 2d 1277, 1281 (Fla. 1st DCA 1985) (holding an agency

"2538may not reject the hearing officer's finding [of fact] unless there is no competent, substantial

2553evidence from which the finding could reasonably be inferred"). Therefore, the Agency must

2567deny Petitioner's Exception I as it pertains to Paragraph 18 ofthe Recommended Order.

2580Paragraph 51 of the Recommended Order consists solely of erroneous conclusions of law

2593that highlight the ALJ's misconceptions about the role AHCA plays in this matter. The Agency

2608finds that it has substantive jurisdiction over the conclusions of law in Paragraph 51 of the

2624Recommended Order because it is the single state agency in charge of administering Florida's

2638Medicaid program, and that it can substitute conclusions of law that are as or more reasonable

2654than those of the ALJ. Therefore, the Agency grants Petitioner's Exception I in-part and rejects

2669the conclusions oflaw in Paragraph 51 of the Recommended Order in their entirety.

2682The first two sentences of Paragraph 52 of the Recommended Order are erroneous

2695conclusions of law that highlight the ALJ's misconceptions about the role AHCA plays in this

2710matter. The Agency finds that it has substantive jurisdiction over the conclusions of law in the

2726first two sentences of Paragraph 52 of the Recommended Order because it is the single state

2742agency in charge of administering Florida's Medicaid program, and that it can substitute

2755conclusions of law that are as or more reasonable than those of the ALJ. Therefore, the Agency

2772grants Petitioner's Exception I in-part and modifies the conclusions of law in the first two

2787sentences ofParagraph 52 ofthe Recommended Order as follows:

279552. To thread the needle, AHCA's solution is to change the subject

2807from "eligibility" to "compensability." This is canny, fur the two

2817concepts really are distinct, as AHCt\\ observes, and the application

2827of coverage provisions and exclusions is AHC'\\'s responsibility,

2835unlike the determination of eligibility, \\Nhich is not. AHCA's

2844position in regard to its authority to conduct the audit at issue in

2857this case is summed up in the following paragraph from its

2868Proposed Recommended Order:

287118. Although DCF is initially responsible for

2878deciding whether a person is eligible to enroll in

2887Medicaid, only AHCA has statutory authority to

2894determine the compensability of a Medicaid service

2901(and, consequently, whether a Medicaid provider

2907was entitled to receive Medicaid payment for a

2915service). Those two roles may appear to overlap

2923where undocumented aliens are involved due to the

2931similarity of DCF's legal standard for enrollment

2938eligibility to AHCA's legal standard for service

2945payment compensability, however they are distinct

2951processes: each are performed by different (and

2958differently qualified) employees, who are reviewing

2964different documentation, for different purposes,

2969each applying separate and distinct legal standards

2976in light of the dissimilar role that they perform.

2985AHCA's PRO at 16.

2989Paragraph 53 of the Recommended Order contains erroneous conclusions of law

3000concerning the way that the audit at issue was conducted. Alternatively, it contains findings of

3015fact that are not supported by the record. The record of this case clearly demonstrates that the

3032Agency conducted the audit at issue in accordance with the provisions of section 409.913,

3046Florida Statutes, because it reviewed the claims to determine whether the services Respondent

3059provided to undocumented aliens were "medically necessary" to treat an EMC. See § 409.905,

3073Fla. Stat.; § 409.906, Fla. Stat.; §409.913(1)(d), (2), (7)(b), (7)(f), (9), (11), (15), (20)-(23), Fla.

3088Stat. The ALJ made two mistakes in reaching the conclusions of law in this paragraph. First, the

3105ALJ erred by concluding that none of the claims at issue were for services Respondent provided

3121to undocumented aliens for the treatment of a condition other than an EMC. Indeed, AHCA's

3136contracted physician reviewers found Respondent had billed for services that were not necessary

3149to treat an EMC. See Respondent's Exhibit 28 at Pages 12-13; Respondent's Exhibit 30 at Page

316517; Respondent's Exhibit 31 at Pages 41 and 42-43; Respondent's Exhibit 32 at Pages 33-34 and

318182. Second, the ALJ erred by concluding that Petitioner made its determinations about each

3195claim based on the date of "alleviation" instead of whether the services billed for were

"3210medically necessary" to treat an EMC. While the date of alleviation is an important part of

3226determining the medical necessity of each claim at issue, AHCA's overall focus was clearly on

3241whether the services Respondent billed for were medically necessary to treat an EMC. See

3255Respondent's Exhibit 28 at Pages 8, 10, 15-16. 18, 21, 26, 38-40 and 60-62; Respondent's

3270Exhibit 29 at Page 22; Respondent's Exhibit 31 at Pages 34-35, 46-47 and 50; Respondent's

3285Exhibit 32 at Page 36. The Agency finds that it has substantive jurisdiction over the conclusions

3301of law in Paragraph 53 of the Recommended Order because it is the single state agency in charge

3319of administering Florida's Medicaid program, and that it can substitute conclusions of law that

3333are as or more reasonable than those of the ALJ. Therefore, the Agency grants Petitioner's

3348Exception I to the extent that it modifies Paragraph 53 of the Recommended Order as follows:

336453. This argument starts from premises which are true, in the

3375abstract, but it quickly begs the question by assuming, rather than

3386shovv'§ing, that In other words, AHCA is merely determining the

3396compensability of a service as opposed to the eligibility of a

3407person. In- The fact, that none of the claims at issue involves

3419particular services which AHCA alleges were not medically

3427necessary, for example, or were provided to treat some condition

3437other than the recipient's emergency medical condition is

3445irrelevant. Rather, tfor each claim at issue, AHCA is denying

3455demanded repayment from Respondent of monies AHCA paid to

3464Respondent, categorically, for aU-services Respondent rendered to

3471an undocumented alien that were not for the purpose of treating an

3483EMC. AHCA did so by determining whether the services provided

3493were for the treatment of an EMC, and, if so, when the EMC had

3507been "alleviated".after the so called "date of alleviation" on the

3518grounds that all such services, \\Vhatever they 'Here (for it does not

3530matter), constituted nonemergency or post "alleviation" care. To

3538repeat for emphasis, AHCA has reached this conclusion, in e'v'ery

3548instance, not based upon a determination about any particular

3557service, for the actual services truly are irrelevant to AHCA's

3567argument; but based on a determination about the recipient, namely

3577that this particular person's EMC, if he had one, ended or w:as

3589at least alleviated on a particular date.

3596Most of Paragraph 54 of the Recommended Order is legal argument taken directly from

3610Petitioner's Proposed Recommended Order. However, the last sentence of the paragraph is an

3623erroneous conclusion of law made by the ALJ based on the legal argument in Petitioner's

3638Proposed Recommended Order. The Agency finds that it has substantive jurisdiction over the

3651conclusion of law in the last sentence of Paragraph 54 of the Recommended Order because it is

3668the single state agency in charge of administering Florida's Medicaid program, and that it can

3683substitute a conclusion of law that is as or more reasonable than that of the ALJ. Therefore, the

3701Agency grants Petitioner's Exception I to the extent that the last sentence of Paragraph 54 of the

3718Recommended Order is modified as follows:

372454. In this connection, AHCA asserts that it "has the authority and

3736legal obligation to ensure that state funds are not used to provide

3748medical services to undocumented aliens unless the services are

3757necessary to treat an emergency [medical] condition.' See §

3766409.902(2)(b), Fla. Stat." AHCA's PRO at 16. Thus, on the

3776authority of section 409.902(2)(b), AHCA claims the power to

3785refuse recoup monies it paid to Medicaid providers who provided

3795medical assistance on behalf of alien recipients for both

3804nonemergency services and services to treat alleviated

3811emergencies, alike.

3813Paragraph 55 of the Recommended Order contains conclusions of law concemmg

3824Petitioner's interpretation of section 409.902(2)(b), Florida Statutes. 3 The Agency must agree

3836with the ALJ's conclusions of law in this paragraph. Section 409.902(2)(b), Florida Statutes,

3849does not give the Agency the authority to recoup monies for claims it paid to Medicaid providers

3866who provided services to undocumented aliens. Instead, the authority for such action comes

3879from section 409.913.

3882Indeed, the preamble to section 409.913 requires the Agency to "operate a program to

3896oversee the activities of Florida Medicaid recipients, and providers and their representatives, to

3909ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum

39233 Petitioner's argument concerning this section was erroneously raised because section 409.902(2)(b) is not

3937applicable to this case since it was not in existence at the times the claims at issue were submitted to AHCA for

3959payment. However, the Agency disagrees with the ALJ's conclusion that section 409.902(2)(b) is solely about

3974eligibility. The subsection addresses the use of state funds, which is clearly under AHCA's jurisdiction.

3989Nevertheless, because section 409.902(2)(b) was not enacted until after the time period at issue and is therefore

4006irrelevant to this matter, the Agency will not disturb Paragraph 55 of the Recommended Order as it pertains to this

4026case.

4027extent possible, and to recover overpayments and impose sanctions as appropriate." Section

4039409.913(11), requires the Agency to "deny payment or require repayment for inappropriate,

4051medically unnecessary, or excessive goods or services from the person furnishing them, the

4064person under whose supervision they were furnished, or the person causing them to be

4078furnished." Section 409.913(2), requires the Agency to "conduct, or cause to be conducted by

4092contract or otherwise, reviews, investigations, analyses, audits, or any combination thereof, to

4104determine possible fraud, abuse, overpayment, or recipient neglect in the Medicaid program and

4117shall report the findings of any overpayments in audit reports as appropriate." An

"4130overpayment" is defined by section 409.913(1)(e), Florida Statutes, as "any amount that is not

4144authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper

4161cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake." Together,

4172these subsections authorize AHCA to conduct audits of provider claims, determine whether

4184goods or services rendered to an undocumented alien were medical necessary to treat an EMC

4199and, if not, to deny payment or require repayment.

4208Thus, Petitioner erred by arguing that it is section 409.902(2)(b), Florida Statutes, that

4221gives the Agency the authority to recoup monies it paid to Medicaid providers for services

4236rendered to undocumented aliens that were not for the treatment of an emergency medical

4250condition, rather than section 409.913, and the Agency must deny Petitioner's Exception I as it

4265pertains to Paragraph 55 of the Recommended Order.

4273Paragraph 56 of the Recommended Order also contains erroneous conclusions of law

4285concerning the respective roles of DCF and the Agency. Specifically, the ALJ concluded that

4299DCF decides whether an undocumented alien has an EMC, and, if so, what is the duration of the

4317EMC. As the ALJ correctly concluded in the first sentence of the paragraph, DCF determines

4332eligibility for services. However, as explained above, AHCA, not DCF, is the final arbiter on the

4348question of whether services rendered by a provider to an undocumented alien were "medically

4362necessary" to treat an EMC such that provider's claim should be paid. § 409.905, Fla. Stat.; §

4379409.906, Fla. Stat.; §409.913(l)(d), (l)(e), (7)(b), (7)(±), (9), (11), (15), (20)-(23), Fla. Stat.; Fla.

4393Admin. CodeR. 59G-1.010(166). The Agency finds that it has substantive jurisdiction over the

4406conclusions of law in Paragraph 56 of the Recommended Order because it is the single state

4422agency in charge of administering Florida's Medicaid program, and that it can substitute

4435conclusions of law that are as or more reasonable than those of the ALJ. Therefore, Petitioner

4451Exception I is granted to the extent that Paragraph 56 of the Recommended Order is modified to

4468state:

446956. This matters because DCF, not AHCA, is responsible for

4479Medicaid eligibility determinations. § 409.902(1), Fla. Stat.

4486However, AHCA, not DCF, determine§ the eligibility of an alien

4496applicant, DCF whether a provider correctly billed Medicaid for

"4505medically necessary" goods or services rendered to an

4513undocumented alien for the treatment of an EMC. § 409.905, Fla.

4524Stat.; § 409.906, Fla. Stat.; §409.913(7)(b), (7)(f), (9), (11), (15),

4534(20)-(23), Fla. Stat.; Fla. Admin. CodeR. 59G-1.010(166). mHSt

4542make several findings of ultimate fact, including ·.vhether the

4551applicant has an emergency medical condition. If DCF determines

4560that the applicant does not ha-ve an EMC, then the applicant is

4572ineligible, and state funds may not be used to provide him

4583medical services. If, however, DCF determines that the applicant

4592does, in fact, have an EMC, then he is eligible to receive medical

4605assistance for all services necessary to treat that EMC (provided he

4616meets the other eligibility criteria as ·.vell) for the duration of the

4628EMC, which DCF must also determine. This obviously requires

4637DCF to decide, as a matter of fact, when the EMC was reduced to a

4652nonemergency condition, ending the period of the emergency

4660and with it, the recipient's eligibility.

4666Paragraph 57 of the Recommended Order also contains erroneous conclusions of law

4678concerning the Agency's authority. As explained above, the Agency has the authority to

4691determine whether goods or services rendered to an undocumented alien were "medically

4703necessary" to treat an EMC under section 409.913. To make this determination, AHCA must

4717look at whether the undocumented alien had an EMC that made the rendering of the services

4733billed "medically necessary." Thus, the ALJ erred in reaching a contrary conclusion of law. The

4748Agency finds that it has substantive jurisdiction over the conclusions of law in Paragraph 57 of

4764the Recommended Order because it is the single state agency in charge of administering

4778Florida's Medicaid program, and that it can substitute conclusions of law that are as or more

4794reasonable than those of the ALJ. Therefore, Petitioner Exception I is granted to the extent that

4810Paragraph 57 ofthe Recommended Order is modified to state:

481957. Indeed, AHCA is the final arbiter of "medical necessity" for

4830purposes of determining Medicaid reimbursement (section

4836409.913(1)(d), Florida Statutes), which would include determining

4843whether services rendered were medically necessary to treat an

4852EMC when the recipient at issue is an undocumented alien.There is

4863no provision 81l)"Nhere in ehapter 4 09 that gives AHCA the

4875authority to deeide for itself v.rhether the reeipient had an EMC.

4886AHCA has no more authority to do that than it does to determine

4899for itself whether the reeipient met all applieable teelmieal

4908(ineluding resideney) and finaneial requirements for a Medieaid

4916eoverage group or any other faetor upon •.vhieh eligibility rests.

4926AHCA's assigned role is to determine the eompensability of the

4936serviees rendered to treat the EMC upon v.rhieh DCF based the

4947reeipient' s eligibility.

4950Paragraph 58 of the Recommended Order also contains erroneous conclusions of law

4962concerning the respective roles of DCF and the Agency. The Agency finds that it has

4977substantive jurisdiction over the conclusions of law in Paragraph 58 of the Recommended Order

4991because it is the single state agency in charge of administering Florida's Medicaid program, and

5006that it can substitute conclusions of law that are as or more reasonable than those of the ALJ.

5024Therefore, the Agency grants Petitioner's Exception I to the extent that Paragraph 58 of the

5039Recommended Order is modified to state:

504558. Consequently, it is appropriate for AHCA to determine

5054whether, for example, the goods or services for which payment is

5065sought were necessary: to treat the EMC. In carrying

5074out thisits responsibility, however, AHCA fffilSt need not accept

5083DCF's finding that the recipient's condition was an EMC and its

5094determination of the duration of the EMC, which are made for

5105eligibility purposes only, as they may have been based on different

5116or incomplete information and documentation and were made

5124without the benefit of a medical review by a contracted physician. ,

5135just as AHCA must accept all of DCF's other findings in support of

5148eligibility, including the duration of the EMC. It would be absurd

5159if, after DCF determined an alien applicant was eligible on the

5170basis of an EMC, AHCA could make a contrary finding of fact to

5183re•rerse that determination and refuse all medical assistance.

5191Paragraph 60 of the Recommended Order also contains erroneous conclusions of law

5203concerning the respective roles of DCF and the Agency. The Agency finds that it has

5218substantive jurisdiction over the conclusions of law in Paragraph 60 of the Recommended Order

5232because it is the single state agency in charge of administering Florida's Medicaid program, and

5247that it can substitute conclusions of law that are as or more reasonable than those of the ALJ.

5265Therefore, the Agency grants Petitioner's Exception I to the extent that Paragraph 60 of the

5280Recommended Order is modified to state:

528660. Indeed, this is such a basic proposition that it is set forth in the

5301definition of the "Medicaid program" found m section

5309409.901(16), which, again, states:

5313(16) "Medicaid program" means the program .

5320which provides for payments for medical items or

5328services, or both, on behalf of any person who is

5338determined by the Department of Children and

5345Families ... to be eligible on the date of service for

5356Medicaid assistance.

5358Every "good" or "service" that AHCA currently alleges resulted in

5368an overpayment to Gulf Coast was rendered to a person whom

5379DCF had determined to be eligible on the date of service for

5391Medicaid assistance because DCF had found accepted the

5399documentation submitted by or on behalf of the applicant

5408supporting that the recipient applicant had an EMC on that date

5419and thus met the requirements of subsection (2) of section 409.902,

5430without having a physician conduct a medical review. AHCA is

5440attempting to deny payment for these required repayment of the

5450monies it paid Respondent for goods or services,--net because it has

5462found any of them to have been excessive, medically unnecessary,

5472or provided to treat some complaint other than the condition which

5483DCF had found to be an EMC, but because it has determined that

5496the recipient of such services, contrary to DCF's finding, did not

5507have an EMC en the date 9} sen:ice and therefore, contrary to

5519DCF's finding, did not meet the eligibility requirements of section

5529409.902(2) en t.ltte date ofsenice has determined through a review

5539by a contracted physician that the contemporaneous documentation

5547submitted by Respondent in support of its claims is insufficient to

5558establish that the goods or services were "medically necessary" to

5568treat an EMC for Medicaid payment purposes. AHCA has this

5578authority under section 409.913, Florida Statutes.

5584Paragraph 61 of the Recommended Order also contains erroneous conclusions of law

5596concerning the respective roles of DCF and the Agency. The Agency finds that it has

5611substantive jurisdiction over the conclusions of law in Paragraph 61 of the Recommended Order

5625because it is the single state agency in charge of administering Florida's Medicaid program, and

5640that it can substitute conclusions of law that are as or more reasonable than those of the ALJ.

5658Therefore, the Agency grants Petitioner's Exception I to the extent that Paragraph 61 of the

5673Recommended Order is modified to state:

567961. Simply put, AHCA is not shortening the period of the

5690emergency for each recipient, relative to DCF's determination of

5699that same period, to deny payment for medically necessary services

5709provided to recipients who were in fact, by virtue of DCF's prior

5721exercise of its exclusive power to grant Medicaid eligibility,

5730legally entitled to receive Medicaid assistance on the dates of

5740service. Instead, AHCA is reviewing the claims for payment to

5750ensure that the contemporaneous records, including medical

5757records, submitted by the Respondent support that the goods or

5767services billed for were provided in accordance with the

5776requirements of law and were "medically necessary" to treat an

5786EMC.There are no "separate and distinct legal standards" for

5795deciding "service payment compensability" questions at vrork here,

5803just the one and only definition of "emergency medical condition"

5813as applied to the historical facts of each recipient's ease to ascertain

5825v1hether, as DCF feHnd, the recipient had an EMC on the dates of

5838service. Every alleged overpayment in this ease reflects a

5847disagreement v1ith DCF as to the existence of an EMC on a

5859particular date based upon a de novo review of the recipient's

5870medical record.

5872The second sentence of Paragraph 62 of the Recommended Order contains an erroneous

5885conclusion of law regarding the respective roles of DCF and the Agency. The Agency finds that

5901it has substantive jurisdiction over the conclusion of law in the second sentence of Paragraph 62

5917of the Recommended Order because it is the single state agency in charge of administering

5932Florida's Medicaid program, and that it can substitute a conclusion of law that is as or more

5949reasonable than that of the ALJ. Therefore, the Agency grants Petitioner's Exception I to the

5964extent that Paragraph 62 of the Recommended Order is modified to state:

597662. As we have seen, an alien who does not have an EMC on a

5991particular date is not eligible for Medicaid assistance on that date.

6002AHCA's intended agency action here is tantamount to not the

6012retroactive revocation of each recipient's eligibility before the date

6021his or her eligibility expired automatically pursuant to DCF's

6030determination regarding the duration of the recipient's EMC.

6038Rather, AHCA is simply carrying out its statutory duty to audit

6049claims and determine whether Respondent correctly billed

6056Medicaid only for those goods or services that were provided in

6067accordance with the requirements of law and were medically

6076necessary to treat the Medicaid-eligible undocumented alien's

6083EMC, as supported by the Respondent's contemporaneous records,

6091including medical records, and determined by AHCA's contracted

6099physician.

6100Paragraph 65 of the Recommended Order contains erroneous conclusions of law

6111concerning the respective roles of DCF and the Agency. As stated above in the ruling on

6127Exception I as it pertains to Paragraphs 55 and 56 of the Recommended Order, the Agency

6143reviewed the claims at issue in order to determine whether Respondent had correctly billed

6157Medicaid for services provided to undocumented aliens for the treatment of an EMC. The

6171Agency has the authority to make such a determination under section 409.913. Thus, the Agency

6186finds that it has substantive jurisdiction of the conclusions of law in Paragraph 65 of the

6202Recommended Order because it is the single state agency in charge of administering Florida's

6216Medicaid program, and that it can substitute conclusions of law that are as or more reasonable

6232than those of the ALJ. Therefore, the Agency grants Petitioner's Exception I to the extent that

6248Paragraph 65 of the Recommended Order is modified to state:

625865. In substance and effect, AHCA is determining whether

6267Respondent correctly billed Medicaid only for those goods or

6276services that were provided in accordance with the requirements of

6286law and to treat the Medicaid-eligible undocumented alien's EMC,

6295as supported by the Respondent's contemporaneous records,

6302including medical records, and determined by its contracted

6310physician.when a recipient's eligibility enabling EMC was reduced

6318to an eligibility ending nonemergency medical condition, using the

6327malleable term "alleviation" to create the plausible appearance that

6336something else is going on. Nothing else is. AHCA's Respondent's

6346insistence to the contrary notwithstanding, the Undocumented

6353Alien Project is not an effort to re-determine eligibility.

6362Paragraphs 95-103 of the Recommended Order contain erroneous conclusions of law

6373concermng the respective roles of DCF and the Agency. As explained above, DCF only

6387determines eligibility for services. Respondent still has the affirmative duty to only bill

6400Medicaid for services rendered to undocumented aliens for the treatment of an EMC, and the

6415Agency has the responsibility to determine whether Respondent fulfilled its duty. DCF's

6427eligibility determinations in no way, shape, or form prohibit the Agency from reviewing

6440Respondent's claims for payment in order to determine whether Respondent complied with the

6453law. The ALJ's conclusion that AHCA is collaterally attacking DCF's eligibility determinations

6465is without merit and further demonstrates his lack of understanding in regard to difference

6479between the roles DCF and AHCA play in regard to the Medicaid program. While the ALJ is

6496correct that AHCA cannot dispute DCF's eligibility determinations, those determinations do not

6508bar AHCA from carrying out its duty to ensure that it only pays providers for goods or services

6526that are medically necessary to treat an undocumented alien's EMC. § 409.905, Fla. Stat.; §

6541409.906, Fla. Stat.; §409.913(l)(d), (l)(e), (7)(b), (7)(f), (9), (11), (15), (20)-(23), Fla. Stat.; Fla.

6555Admin. Code R. 59G-1.010(166). Thus, the Agency finds that it has substantive jurisdiction

6568over the conclusions of law in Paragraphs 95-103 of the Recommended Order because it is the

6584single state agency charged with administering Florida's Medicaid program, and that it can

6597substitute conclusions of law that are as or more reasonable than those of the ALJ. Therefore,

6613the Agency grants Exception I to the extent that it modifies the conclusions of law in Paragraphs

663095-103 of the Recommended Order to state:

663795. Assuming, however, Neither administrative finality nor section

6645409.905(5)(a) operates as a bar to this action,.!. there are alternate

6657grounds for denying Further, Respondent's argument that AHCA's

6665demand for repayment, vihich from the fact that, in reality,

6675AHCA is attempting to re-determine eligibility is also without

6684merit.

668596. To begin with a brief review, the bottom line is that under the

6699Undocumented Alien Project, AHCA is determining whether

6706Respondent correctly billed Medicaid only for those goods or

6715services that were provided in accordance with the requirements of

6725law and were medically necessary to treat the Medicaid-eligible

6734undocumented alien's EMC, as supported by the Respondent's

6742contemporaneous records, including medical records, and

6748determined by AHCA's contracted physician.for itself (i) vihether

6756each alien recipient actually had an eligibility enabling EMC, and

6766(ii) with respect to each such EMC recognized, the date upon

6777vihich the recipient's complaint went from being an EMC to an

6788eligibility ending nonemergency medical condition. These very

6795questions, as v1e have seen, were previously and conclusively

6804resolved by DCF, the only agency having the authority to

6814determine Medicaid eligibility. See § 409.902(1), Fla. Stat. DCF

6823necessarily found as a matter of ultimate fact that each recipient

6834had a qualifying EMC and that the EMC lasted for a specific

6846period of time comprising the dates of the recipient's eligibility.

6856These findings were part and parcel of the final agency action

6867taken on each recipient's application for medical assistance. Under

6876the doctrine of administrative finality, discussed above, DCF

6884cannot revisit and re-determine its decisions respecting the

6892eligibility of these recipients.

689697. However, DCF's eligibility determinations do not relieve

6904Respondent of its duty to correctly bill Medicaid for "medically

6914necessary" goods or services rendered to an undocumented alien

6923for the treatment of an EMC. § 409.905, Fla. Stat.; § 409.906, Fla.

6936Stat.; §409.913(7)(b), (7)(0, (9), (11), (15), (20)-(23), Fla. Stat.;

6945Fla. Admin. CodeR. 590-1.010(166). AHCA is now trying to do

6955vihat DCF itself could not accomplish. Unlike DCF, however,

6964AHCA does not even have jurisdiction to define or decide

6974eligibility. Booker Creek Pres., Inc. v. Sw. Fla. '.Vater Mgmt. Dist.,

6985534 So. 2d 419, 424 (Fla. 5th DCA 1988)(0ne agency may not

6997exercise jurisdiction that has been delegated to another state

7006agency). Such a lack of jurisdiction could not be cured by a rule,

7019for A.HCA cannot confer regulatory jurisdiction upon itself. See

7028Saddlebrook Resorts v. Wiregrass Ranch, 630 So. 2d 1123, 1128

7038(Fla. 2d DCA 1993)("A,n agency cannot enlarge, reduce, or modify

7050its jurisdiction its ovm action .... Since an agency car.not

7060confer jurisdiction upon itself, the adoption of an agency rule

7070should have no effect upon jurisdiction."), affd, 645 So. 2d 374

7082(Fla. 1994). AHCA does not ha§.¥e the authority, therefore, to

7092recover as an overpayment amounts paid for medically necessary

7101emergencygoods or services provided to an alien recipient that

7110were not provided in accordance with the requirements of law or

7121medically necessary to treat an EMC even though the alien

7131recipientwhe, according to DCF, was eligible on the dates of

7141service for Medicaid assistance.

714598. Respondent's argument !hat AHCA is attempting to exercise

7154jurisdiction it does not possess is seen most easilyseems plausible

7164in relation to R3, R16, R19, and R20, the recipients who, by

7176A.HCA's lights, never had an EMC, according to AHCA's

7185contracted physician reviewer. Having an emergency medical

7192condition is should be a sine qua non for alien eligibility. However,

7204Therefore, AHCA:' s position that these recipients never had EMCs

7214is in direct and irreconcilable conflict with DCF's eligibility

7223determinations, which necessarily held that each of them did have

7233an EMC, may have been based on different or incomplete

7243information and medical documentation and were made without

7251the medical expertise of a physician. Agreeing with AHCA weuld

7261be is not tantamount to reversing DCF's eligibility determinations

7270and retroactively deeming R3, R16, R19, and R20 ineligible for

7280assistance. Clearly that cannot be done. ≻⵹, the Agency's

7289demand for repayment of the $24,819.61 paid to Gulf Coast for

7301providing services to these recipients is based on its determination

7311that Respondent billed Medicaid for goods or services that were

7321not provided in accordance with the requirements of law and

7331medically necessary to treat the Medicaid-eligible undocumented

7338alien's EMC, as supported by the Respondent's contemporaneous

7346records, including medical records, and the medical review

7354conducted by AHCA's contracted physicianpatently ultra vires.

736199. With respect to the remaining recipients, AHCA's re

7370determination of eligibility is somevihat more difficult to observe,

7379due to the alle-viation smokescreen. A.s explained above, however,

7388·.vhen it comes to it, all AHCA is doing is not re-defining these

7401recipients' respective eligibility periods by deciding they had

7409nonemergency conditions as of their "dates of alleviation."

7417Agreeing with AHCA would not reverse DCF's decisions that Rl,

7427R4, R15, R18, and R23 were eligible, but-it nor would !Lin effect_,_

7440retroactively revoke the eligibility of each of these recipients,

7449leaving them with fewer days of eligibility than DCF had granted.

7460That, too, would be ultra vires.

7466100. Viewing AHCA's proposed agency action from a slightly

7475different angle, it cannot fairly be characterized as a collateral

7485attack on the final actions taken by DCF in granting the recipients'

7497applications for medical assistance. This is because AHCA's

7505position does not necessarily impliesy that DCF erred (i) in

7515determining that R3, R16, R19, and R20 had EMCs and (ii) in

7527determining that the periods of Rl, R4, R15, R18, and R23's

7538emergencies lasted as long as DCF found they did because DCF's

7549determinations may have been based on different or incomplete

7558information and documentation than AHCA reviewed in

7565conducting the audit at issue, and were not made by a physician.

7577Neither AHCA nor this Administrative La'.v Judge, howe-ver, has

"7586collateral review power over final agency action taken after

7595regular proceedings under other provisions of the [Administrative

7603Procedure] Act." Dep't of HR8 v. Barr, 359 8o. 2d 503, 505 (Fla.

76161st DCA 1978). Thus, AHCA's intended action cannot lawfully be

7626implemented.

76271 01. This common law arrest of collateral action is codified in

7639409.907(5)(b), \\vhich states that AHCA is "prohibited

7646from demanding repayment from the provider in any instance in

7656which the Medicaid overpayment is attributable to agency error in

7666the determination of eligibility of a recipient." Here, DCF

7675determined that Rl, R3, R4, R15, R16, R18, R19, R20, and R23

7687were each eligible for Medicaid assistance on the dates that Gulf

7698Coast treated them. However, 409.907(5)(b) does not

7705assures providers such as Gulf Coast that they can rely upon

7716DCF' s eligibility determinations when billing Medicaid for the

7725goods or services they provide. Providers still have an affirmative

7735duty to bill true and accurate claims for goods and services that are

7748medically necessary and were provided in accordance with the

7757applicable Medicaid rules, regulations, handbooks, and policies,

7764and federal, state, and local laws. § 409.913(7)(b), (e), Fla. Stat.;

7775see also Florida Medicaid Provider General Handbook at 5-4.

7784Providers also have an affirmative have a duty to maintain

7794contemporaneous records, including medical records, in support of

7802their claims, and to supply those records to AHCA when requested.

7813§ 409.913(7), (9), Fla. Stat.

7818102. AHCA is demanding that Gulf Coast repay an alleged

7828overpayment for goods or services that were not provided to treat

7839that 'tvould be, if AHCA's theory of the case were credited,

7850attributable to findings establishing (retroactively) that R1, R3, R4,

7859R15, R16, R18, R19, R20, and R23's EMCs.vrere not eligible on

7870the dates of service after all, contrary to DCF's determinations,

7880which could only mean that DCF had erred. Section 409.907(5)(b)

7890prohibits the Agency from recouping such an overpayment and

7899thus forecloses this action.

7903103. If this proceeding 'Nere not doomed to fail for one or more of

7917the multiple grounds set forth above, however, thenThus, the

7926question for decision--presented de novo--would be whether

7933the claims at issue were authorized to be paid by Medicaid. To

7945arrive at an alternative ratio decidendia final determination, the

7954undersigned will examine this question.

7959Paragraphs 1 06 and 107 of the Recommended Order contain erroneous conclusions of

7972law concerning the respective roles of DCF and the Agency. The Agency finds that it has

7988substantive jurisdiction over the conclusions of law in Paragraphs 106 and 107 of the

8002Recommended Order because it is the single state agency in charge of administering Florida's

8016Medicaid program, and that it can substitute conclusions of law that are as or more reasonable

8032than those of the ALJ. Therefore, the Agency grants Exception I to the extent that Paragraphs

8048106 and 107 of the Recommended Order are modified to state:

8059106. As for the second question, "services [which] are necessary to

8070treat an emergency medical condition" fall within the scope of

8080Medicaid's coverage. § 409.902(2)(b), Fla. Stat. The Agency will

8089only pay for these goods and services, and not for any goods or

8102services rendered to an undocumented alien after the EMC has

8112been alleviated, as determined by its contracted physician after

8121reviewing the provider's contemporaneous records, including

8127medical records, supporting the claim(s). See Page 2-7 of the

8137Florida Hospital Services Coverage and Limitations Handbook

8144(incorporated by reference into Rule 590-4.160(2), Florida

8151Administrative Code). Having an "emergency medical condition"

8158as that term is defined in section 409.901(10)(a) is a necessary

8169condition of Medicaid eligibility for aliens. An alien can have an

8180EMC and not be eligible, but he cannot be eligible and not have an

8194EMC. Thus, the undisputed fact that each recipient was eligible on

8205the date of each service conclusively establishes that each recipient

8215had an emergency medical condition on the date of each service.

8226107. AHCA has neither alleged nor attempted to proven that any-ef

8237the goods or services in question were not provided to treat a

8249complaint other than an EMC. the condition which DCF

8258determined '.vas sufficient to satisfy the EMC requirement for alien

8268eligibility. While AHCA concedes, moreover, that all of the

8277services were medically necessary,. Thus, not all of the services at

8289issue were medically necessary to treat an EMC. The second

8299question must be answered ¥E-SNO, and the third question does

8309not apply.

8311Endnote 12 of the Recommended Order is an erroneous conclusion oflaw concerning the

8324Agency's substantive jurisdiction. Contrary to the ALJ's conclusion, sections 409.902(2) and

8335409.904(4), Florida Statutes, are within the Agency's substantive jurisdiction because the

8346Agency is the single state agency in charge of administering Florida's Medicaid program. The

8360Agency finds that it has substantive jurisdiction over the conclusion of law in Endnote 12 of the

8377Recommended Order because it is the single state agency in charge of administering Florida's

8391Medicaid program, and that it can substitute a conclusion of law that is as or more reasonable

8408than that of the ALJ. Therefore, the Agency grants Exception I to the extent that it rejects

8425Endnote 12 of the Recommended Order in its entirety.

8434Exception II

8436In Exception II, Petitioner takes exception to Paragraphs 32, 34, 35, 37, 38, 39, 40, 41,

845243, 45, 46, 48, 49, 50, 51, 64, 88, 108, and Endnote 10 ofthe Recommended Order, arguing that

8470the ALJ's conclusions of law in these paragraphs misinterpret the Agency's rules with regard to

8485what the term "alleviate" means. This specific issue was previously litigated in Bayfront

8498Medical Center et al. v. Agency for Health Care Administration, DOAH Case No. 12-2757RU

8512(Fla. Div. Admin. Hrgs. Dec. 21, 2012) ("Bayfront I") and Bayfront Medical Center et al. v.

8530Agency for Health Care Administration, DOAH Case No. 14-4758RU (Fla. Div. Admin. Hrgs.

8543Apr. 20, 2015) ("Bayfront II"). The ALJ's interpretation of the Agency's rules is in direct

8560conflict with Bayfront II. In Bayfront II, the ALJ concluded:

"8570Alleviate" has a plain and ordinary meaning ... The Medicaid

8580Program statutes use "alleviate" frequently without explication.

8587§ 409.913(1)(d), Fla. Stat. (defining "medical necessity"

8594as "goods or services necessary to palliate the effects of a terminal

8606condition, or to prevent, diagnose, correct, cure, alleviate, or

8615preclude deterioration of a condition that threatens life, causes pain

8625or suffering, or results in illness or infirmity, which goods or

8636services are provided in accordance with generally accepted

8644standards of medical practice") (emphasis added); § 409.906(1)(a),

8653Fla. Stat. (authorizing AHCA to pay for "medically necessary,

8662emergency dental procedures to alleviate pain or infection")

8671(emphasis added); § 409.9131(2)(b), Fla. Stat. (defining "medical

8679necessity" or "medically necessary" as "any goods or services

8688necessary to palliate the effects of a terminal condition or to

8699prevent, diagnose, correct, cure, alleviate, or preclude deterioration

8707of a condition that threatens life, causes pain or suffering, or results

8719in illness or infirmity, which goods or services are provided in

8730accordance with generally accepted standards of medical

8737practice"). (emphasis added). The Hospitals' contention that

8745Agency representatives Harris and Shepherd cannot explain the

8753meaning of "alleviate" is not supported by the citations to their

8764deposition transcripts. The questioning cited involved repeated

8771efforts to tie the representatives to the "stabilization" standard

8780rejected as an unadopted rule. When the meaning of "alleviated"

8790was not tied to the Agency's previous position, the witnesses were

8801consistent that the dictionary meaning should apply.

8808Bayfront II at Pages 37-38. The ALJ in this case failed to even acknowledge the existence of the

8826final order in Bayfront II, much less offer any explanation for why he disagreed with its

8842reasoning. The Agency, however, will follow and hereby adopts by reference the precedent of

8856Bayfront II, which held that the Agency's use of the plain and ordinary meaning of "alleviate"

8872for determining whether services rendered to an undocumented alien were "medically necessary"

8884to treat an EMC for claims payment purposes is lawful.

8894For the above-stated reasons and also for the reasons set forth in AHCA's rulings on

8909Exceptions I, and III through VI, which are hereby incorporated by reference, the Agency finds

8924that it has substantive jurisdiction over the conclusions of law in these paragraphs because it is

8940the single state agency in charge of administering Florida's Medicaid program, and that it can

8955substitute conclusions of law that are as or more reasonable than those of the ALJ. Therefore,

8971Petitioner's Exception II is denied as it pertains to Paragraph 45 of the Recommended Order, and

8987is granted to the extent that the Agency rejects Paragraphs 35, 37, 38, 40, 41, 46, 48 (and, by

9006extension, Endnote 11), 51, 88 4 , 108 and Endnote 10 of the Recommended Order in their

9022entirety, and modifies Paragraphs 32, 34, 39, 43, 49, 50, and 64 of the Recommended Order to

9039state:

904032. The focus on "alleviation" as a critical moment in the course of

9053an EMC was inspired by is taken from the Handbook provisions

9064comprising the Statement on the Eligibility of Aliens for Services,

9074or SEAS, introduced above. Under the Undocumented Alien

9082Project, 8EA8 acquired a new, aggressively prescriptive quality, as

9091AHCA conceived the theoryapplied the Handbook provisions and

9099determined that medical items goods or services furnished to an

9109alien recipient after his EMC has been "alleviated" are not

9119authorized to be paid under Medicaid. As support for this

9129proposition, AHCA makes mention of sections 409.902(2)(b) and

9137409.904(4), but mainly it relies on SEAS.

914434. AHCA has not publicly either defined the term "alleviation,"

9154or specified the criteria to be applied in determining the point at

9166which a recipient's EMC was "alleviated," for the purposes of

9176SEAS. To the contrary, i\\HCA has eschevled making a clear

9186statement concerning its construction of this supposed exclusion,

9194with the result that there is, in fact, no official agency

9205interpretation to '.vhich a court could defer v1ere it inclined to do

9217S&.-According to AHCA, no authoritative interpretation is needed

9225because the word "alleviation" is plain and unambiguous. Thus,

9234AHCA claims that its physician peer reviewers are asked only to

9245apply SEAS according to the common "dictionary definition" of

9254the crucial term as they understand it in the context of an EMC and

9268using their medical knowledge, background, expertise, and

9275training.

92764 Paragraph 88 is also addressed in the ruling on Petitioner's Exception IV.

928939. Looking to capitalize on the term's elasticity, tihe Agency

9299argues that the alleviation of an emergency condition can occur

9309anytime, regardless of when, even including after, the EMC ends.

9319This, clearly, goes too far. Logically, the point of alleviation must

9330occur at or before the recipient's condition ceases to be an EMC

9342meeting the statutory criteria, because once a medical condition

9351has improved to the point that it stops being an "emergency

9362medical condition" within the statutory definition, it can no longer

9372be alleviated as such.8/ Still, a term broad enough to describe

9383something that literally can happen anytime, indeed multiple times,

9392during the existence of an EMC is not a benchmark but a license.

940543. If the point at which an emergency medical condition was

"9416alleviated" is to be used as the basis for excluding from otherwise

9428payable claims amounts for medically necessary emergency

9435services, as AHCA urges, then the undersigned must find, for each

9446recipient, the date upon which his or her EMC was alleviated,

9457since that is a matter of ultimate fact. In this fact finder's

9469estimation, the dictionary definition of "alleviate" Vt'ill not cut the

9479mustard as a standard fur decision. 8EA8 must be interpreted or at

9491least explicated.

949349. The Agency directs its peer reviewers to use the common

"9504dictionary definition" of alleviation, as they understand it, and

9513their medical knowledge, background, expertise, and training to

9521determine whether a provider's claim for goods or services

9530provided to an undocumented alien were "medically necessary to

9539treat an EMChis, actually, is vihat the Agency covertly understands

95498EA8 to mean, as it occasionally reveals, although this truth is

9560always well attended by a bodyguard of disclaimers. Ms. Ryder

9570testified, for example, as follows:

9575Q. How would you get a uniform decision amongst

9584peer reviewers if you're not telling them how much

9593it has--an emergency medical condition has to be

9601lessened for it to be alleviated?

9607A. Well, [to be alleviated,] the--[emergency

9614medical condition] would have to be lessened to the

9623point that it wouldn't--! would assume it would

9631no longer be considered an emergency condition. I

9639mean, you know, what I'm saying is I really can't

9649answer that question because I'm not a medically

9657trained doctor.

9659Tr. 191:8-14 (emphasis added). Or, as AHCA's counsel put it:

9669[W]e don't want to compare alleviate to the end of

9679an emergency medical condition because that's not

9686how our rule is written. The only reason why we're

9696answering that question in as direct a way as

9705possible is because you're asking us to . . . and I

9717think as you read through these [deposition]

9724transcripts, most of the peer reviewers when pressed

9732on cross-examination [to answer the question:] ["I]s

9740the alleviation point the same point as--that the

9748emergency medical condition no longer exists[?,"]

9755most of them, for the facts they're reviewing, that's

9764what they--most of them eventually come to that

9772point when pushed hard enough on cross­

9779examination. But all of them, I think, along with the

9789corporate--the Agency representative ... , [a]ll

9794we're trying to say is [that] that's not what we were

9805doing because we're trying to apply the common,

9813ordinary meaning of the terms in our rule.

9821Tr. 71 :25-73:2 (emphasis added).

982650. In truth, although they had to be "pushed hard" to say so, the

9840peer reviewers did look forconsider the end of the emergency

9850medical condition in forming their opinions about when an

9859emergency was alleviated, a fact which becomes reasonably clear

9868upon reviewing their Case Detail Reports, and is evident

9877notwithstanding the strong resistance all put up against admitting

9886as much when questioned under oath. Given that, the question

9896naturally arises: '.Vhy is the Agency so reluctant to acknowledge

9906the obvious, namely that in this context "alleviated" means, as it

9917can only mean, rethtced te tl nenemergency· medictJl cenditien?

992664. AHCA relies upon SEAS as authority for disallowing payment

9936for services after the date of alleviation, arguing that SEAS

9946imposes an exclusion from coverage that resembles, but is distinct

9956from, the eligibility restriction which limits alien recipient

9964eligibility to the period of the emergency. AHCA's reliance upon

99748EA8 is misplaced, however, because (i) the plain and

9983unambigHoHs language of 8EA8 can reasonably be Hnderstood in

9992only one sense, i.e., as a description of the requirements for, and

10004the temporal limitation on, Medicaid eligibility for aliens; and, (ii)

10014to the eJttent 8EA8 is SHsceptible of more than one reasonable

10025interpretation and hence ambigHoHs, it mHst be construed as a

10035description of the conditions of eligibility to avoid a conflict with

10046federallavr that would implicate the Supremacy Clause.

10053Exception III

10055In Exception III, Petitioner takes exception to Paragraphs 42, 43, 69, 70, 71, 111, and 112

10071of the Recommended Order, arguing that the ALJ's decision that the testimony of Petitioner's

10085peer reviewers should be rejected because the ALJ's perceived vagueness of the "alleviation"

10098standard they used is erroneous and not supported by the record of the case. Indeed, there is no

10116competent, substantial evidence to support the ALJ' s finding that "the peer reviewers' opinions

10130as to when the alleviation points were reached are necessarily based on undisclosed subjective

10144principles." The competent, substantial evidence of this case instead demonstrates that the peer

10157reviewers' are licensed physicians whose opinions as to when the alleviation points were reached

10171were based on their review of Respondent's medical records provided in support of each claim

10186for payment, as well as their education, training and experience, and were made with a

10201reasonable degree of medical certainty. See Respondent's Exhibit 28 at Pages 8, 10, 13-14, 15-

1021616, 18, 19, 21, 26, 27, 52, 56 and 76-78; Respondent's Exhibit 29 at Pages 15-17 and 21-22;

10234Respondent's Exhibit 30 at Page 16; Respondent's Exhibit 31 at Pages 38-39, 40-41, 46-47 and

1024967-68; Respondent's Exhibit 32 at Pages 14, 36. Respondent was given the opportunity to cross­

10264examine each peer reviewer as well as present its own expert testimony, which it did not do. The

10282ALJ departed from the essential requirements of law by brushing the peer reviewers' testimony

10296aside as unsupported dogmatic statements (or "ipse dixits" as he called them) instead of

10310weighing their testimony against the other evidence presented in this matter. Thus, to the extent

10325that these paragraphs contain findings of fact, the Agency concludes after a review of the entire

10341record that the proceedings on which the findings of fact are based did not comply with the

10358essential requirements of law such that the Agency is permitted to reject or modify these findings

10374of fact. See§ 120.57(1)(1), Fla. Stat. (2015) To the extent these paragraphs contain conclusions

10388of law, the Agency finds that it has substantive jurisdiction over the conclusions of law because

10404it is the single state agency charged with administering Florida's Medicaid program, and that it

10419can substitute conclusions of law that are as or more reasonable than those of the ALJ.

10435Therefore, for these reasons, and also for the reasons stated in AHCA's rulings on its Exceptions

10451I, II, and IV through VI, which are hereby incorporated by reference, the Agency grants

10466Petitioner's Exception III to the extent that it rejects Paragraph Ill ofthe Recommended Order,

10480and modifies Paragraphs 42, 69, 70, 71 and 112 of the Recommended Order as follows:

1049542. What this means is that, lacking a uniform foundation of

10506neutral principles prescribing authoritatively for everyone affected

10513precisely how much relief or whtlt degree of lessening of the

10524severity of an EMC constitutes "alleviation,"The unrebutted

10532evidence of this case shows that the peer reviewers' opinions as to

10544when the alleviation points were reached are necessarilywere based

10553upon their education, training and experience, as well as a review

10564of Respondent's medical records for the claims at issue. Further,

10574they constitute the only testimony as to the dates of alleviation of

10586the EMCs, as demonstrated in the medical records supporting each

10596of Respondent's claims for payment, in this matter.undisclosed

10604subjective principles, making them the mere ipse dixits of

10613credentialed v1itnesses, which AHCA e)cpects will simply be

10621accepted unconditionally as valid. Indeed, the Agency's

10628representative, Tracy Ryder, admitted as much Vtrhen she testified

10637at hearing as follows:

10641Q. Okay. How much was the emergency medical

10649condition to be lessened to be--how much was it

10658required to be lessened for it to be alleviated?

10667A. That would be for a peer reviewer to determine.

10677T r. 191 :3-7. To the undersigned, v.rhose responsibility as the trier

10689of fact in this de novo proceeding is to determine, vlhere relevant,

10701such facts as the "dates of alleviation," the peer re'vievrers' opinions

10712are practically worthless because they rest almost entirely on the

10722authority of the respective witnesses and cannot be independently

10731verified or falsified.

1073469. The opinions ofthe peer reviewers that R3, R16, R19, and R20

10746never had an emergency medical condition for purposes of the

10756claims at issue, and as supported by the provider's

10765contemporaneous documentation, are unrebuttedrejected as

10770irrelevant because DCF determined that each of these recipients

10779did have an EMC that made it possible for him or her to be eligible

10794for Medicaid assistance during the period of his or her emergency.

10805Accordingly, each of these recipients met the requirements of

10814section 409.902(2)(b), and state funds could be used to provide

10824them medical services, as AHCA found when it pre authorized for

10835payment all of Gulf Coast's claims for the services it rendered to

10847these recipients. NThus, AHCA has demonstrated that it overpaid

10856Respondent for the claims it submitted for recipients yment \\Vas

10866shown to htvre been made on beha:lfofR3, R16, R19, or R20.

1087770. The opinions of the peer reviewers that Rl, R4, R15, R18, and

10890R23 received post-"alleviation" treatment are also

10897unrebuttedrejected as irrelevant because (i) DCF determined that

10905each of these recipients had an EMC that made it possible for him

10918or her to be eligible for Medicaid assistance during the entire

10929period of his or her emergency, which period in each case

10940e)ctended, by order of DCF, beyond the recipient's "date of

10950alleviation" as identified much later by AHCA; and (ii) all of the

10962alleged post "alleviation" services were provided to a recipient

10971who had been determined by DCF to be eligible on the date of

10984service for Medicaid assistance.

1098871. Accordingly, Rl, R4, Rl5, Rl8, and R23 met the requirements

10999of sections 409.902(2)(b) and 409.904(4), and state funds could be

11009used to provide them medical services, as AHCA found vrhen it

11020pre authorized for payment all of Gulf Coast's claims for the

11031services it rendered to these recipients. No Thus, AHCA has

11041demonstrated that it overpaid Respondent for claims Respondent

11049billed AHCA for services provided to yment was shovm to have

11060been made on behalf of R1, R4, Rl5, R18, or R23.

11071112. Because the sequence of answers is YES-¥ES-NO-N/ANG, it

11080is concluded that the amounts in question were not authorized to be

11092paid by Medicaid, and AHCA has failed to proven the alleged

11103overpayment.

11104The Agency will make no further modifications to Paragraph 43 of the Recommended Order

11118beyond those enumerated in the ruling on Petitioner's Exception II supra.

11129Exception IV

11131In Exception IV, Petitioner takes exception to Paragraphs 16, 17, 19, 20, 27, 30, 63, 80,

1114781, 82, 83, 84, 86, 88, 89, and Endnotes 7 and 15 of the Recommended Order, arguing that the

11166ALJ's findings of fact and conclusions oflaw that the Agency's prior authorization ofthe claims

11180at issue constituted an administrative adjudication of these claims, made their payment akin to a

11195final order, and barred the Agency from recovering overpayments on those claims under the

11209doctrine of administrative finality, is erroneous. The Agency agrees with Petitioner.

11220Florida Medicaid requires providers to receive "prior authorization" from AHCA or its

11232contracted agent, here KePRO, to deliver certain goods and services to a Medicaid recipient prior

11247to delivering the good or service or prior to submitting a claim to AHCA for payment. See §

11265409.905(4)(a), (5)(a), (23), Fla. Stat.; 409.908(2)(a)2., (18), Fla. Stat.; § 409.912, Fla. Stat.; §

11279409.9128, Fla. Stat.; § 409.913(15)(d), (15)(i), (16)(c), Fla. Stat.; Fla. Admin. Code R. 590-

112931.01 0(226). A request for prior authorization must be reviewed by a contracted, licensed

11307physician, who makes a preliminary determination, based on the documentation submitted with

11319the request, that the requested good or service is medically necessary for the recipient. See

11334Medicaid Provider Reimbursement Handbook, UB-92 (April 2004) at Pages 2-2, 2-5, 2-9, 2-

1134714and 2-18, incorporated by reference in Rule 590-4.160, Florida Administrative Code;

11358Medicaid Provider Reimbursement Provider Handbook, UB-04 (May 2007) at Pages 2-2, 2-3, 2-

113717,2-17 and 2-20, incorporated by reference in 590-4.003, Florida Administrative Code. Ifprior

11384authorization is granted, the provider may provide the goods or services and then submit a claim

11400to AHCA, which will be paid if supported by contemporaneous medical records demonstrating

11413the good or service was provided in accordance with the requirements of law, including medical

11428records demonstrating it was "medically necessary" for the recipient. See § 409.913(7), Fla.

11441Stat. If prior authorization is denied, the Medicaid recipient may seek review through a

11455Medicaid fair hearing before a DCF, Office of Appeal Hearings' hearing officer, governed by the

11470procedures set forth at Chapter 28-106 and Rule 65-2.042, et seq., of the Florida Administrative

11485Code. 42 U.S.C. § 1396a(a)(3); 42 C.F.R. § 431.200(a), (b); 42 C.F.R. § 431.220; 42 C.F.R. §

11502438.400(a)(l); 42 C.P.R. § 438.402(a); Fla. Admin. Code R. 590-1.010(85) (defining "fair

11514hearing"); Fla. Admin. CodeR. 65-2.042(3). Cf. 42 C.P.R.§ 431.205(b)(1) (requiring a state's

11527fair hearing system to provide for a hearing before the state Medicaid agency); 42 C.P.R. §

11543431.206( d) (permitting a state Medicaid agency to delegate its authority to conduct fair

11557hearings). Only if DCF affirms the decision to deny prior authorization after a fair hearing will

11573the denial become final agency action subject to review by an appropriate District Court of

11588Appeal. § 120.68(1), Fla. Stat.; Fla. Admin. Code R. 65-2.066(4), (7); see also 42 C.P.R. §

11604431.245. The prior authorization of a provider's request to provide goods or services to a

11619Medicaid recipient, as described above, should not be confused with pre- or post-payment review

11633of a provider's Medicaid claims for payment for those goods or services. Compare the above

11648with§ 409.913, Fla. Stat.;§ 409.9131, Fla. Stat.; Medicaid Provider Reimbursement Handbook,

11660UB-92 (April 2004) at Pages 2-2, incorporated by reference in Rule 590-4.160, Florida

11673Administrative Code; Medicaid Provider Reimbursement Provider Handbook, UB-04 at Page 2-

116842 (May 2007), incorporated by reference in 590-4.003, Florida Administrative Code.

11695In reaching his findings of fact and conclusions of law, the ALJ made key mistakes.

11710Specifically, he erroneously considered the prior authorization process to be a final agency action

11724with respect to the provider's right to payment, when it is not. Even if the Agency or its agent

11743grants prior authorization for a Medicaid recipient to receive a good or service, the provider must

11759still provide the service (if it has not already been provided) and then submit the claim for

11776payment, in accordance with the requirements of section 409.913(7), Florida Statutes. See also

11789Florida Medicaid Provider General Handbook at 5-4; Respondent's Exhibit 31 at Pages 34-35. If

11803AHCA pays the claim, it is still subject to post-payment audit via the procedures described above

11819and must be repaid if not supported by contemporaneous records, including medical records, that

11833were provided to AHCA upon request and demonstrate that the good or service was provided in

11849accordance with the requirements of law and medically necessary to treat an EMC of the

11864undocumented alien whom DCF has determined to be Medicaid-eligible, as determined by

11876AHCA's contracted, licensed physician or "peer." See§ 409.913(7)(f), Fla. Stat. Therefore, the

11888ALJ's conclusion that KePRO's prior authorization approval was a final adjudication of a claim

11902is patently incorrect; indeed, no claim even existed at the time KePRO made its prior

11917authorization decision.

11919Second, the ALJ considered the KePRO's contracted physician's medical review of the

11931documentation submitted in support of the request for prior authorization to be equivalent to

11945AHCA's contracted, licensed physician's medical review of the records supporting the paid

11957claim, which it is not. A request for prior authorization is submitted for a different purpose and

11974may be accompanied by different documentation, including different medical records, than those

11986maintained and supplied by the provider in support of a claim for payment. Further, the record

12002of this case shows that the KePRO prior authorization review was, in fact, markedly different

12017from the post-payment audit of Respondent's claims. As Shevaun Harris stated, KePRO was

12030reviewing Respondent's requests for prior authorization in order to determine whether the

12042inpatient hospital services for a recipient were medically necessary. See Respondent's Exhibit

1205431 at Pages 12-13. More importantly, at the time KePRO did the prior authorization review it

"12070would not have known whether or not the person was [an] undocumented alien." Respondent's

12084Exhibit 31 at Page 14. In contrast, the post-payment audit of Respondent's claims was for the

12100purpose of determining whether the services Respondent provided to undocumented aliens were

12112medically necessary to treat an EMC. Since the two reviews are markedly different,

12125administrative finality has no application here.

12131In essence, the ALl's conclusions of law violate the principals of statutory construction.

"12144[I]t is ... an axiom of statutory construction that an interpretation of a statute which relates to an

12162unreasonable or ridiculous conclusion or a result obviously not designed by the Legislature will

12176not be adopted." Allied Fid. Ins. Co. v. State, 415 So. 2d 109, 110-11 (Fla. 3d DCA 1982). The

12195ALl's interpretation of the statutes and rules regarding prior authorization review would lead to

12209an absurd result if it were allowed to stand. This is highlighted by the case of Agency for Health

12228Care Administration v. Florida Hospital Orlando, 11-2892MPI (AHCA 2012), which also dealt

12240with the issue of whether services rendered to undocumented aliens were medically necessary to

12254treat an EMC, and which AHCA hereby adopts and incorporates by reference. In the Florida

12269Hospital Orlando case, the ALJ concluded

12275Prior approval by KeP[RO] does not estop AHCA from pursuing

12285overpayment claims when an audit does not support the charges

12295and services billed to Medicaid. AHCA has the daunting task of

12306chasing monies already paid to providers who may or may not

12317have submitted accurate or truthful information to KeP[RO]. Prior

12326approval does not justify payment when contrary to law. AHCA

12336must always protect the Medicaid funds it is challenged to

12346conserve so that bona fide recipients receive the medical care they

12357reqmre.

12358Recommended Order at Page 11. The ALJ in this case did not even acknowledge the reasoning

12374set forth in Florida Hospital Orlando on this issue, much less offer a valid explanation as to why

12392he disagreed with it. Were the Agency to allow the ALJ's findings of fact and conclusions of

12409law to stand, it would prevent the Agency from fulfilling its responsibilities under state and

12424federal law since it would not be able to audit any prior authorized claims.

12438Thus, to the extent Paragraphs 16, 17, 19, 20, 27, 30, 63, 80, 81, 82, 83, 84, 86, 88, 89,

12458and Endnotes 7 and 15 of the Recommended Order are findings of fact, the findings of fact are

12476not based on competent, substantial evidence as noted above. To the extent the paragraphs are

12491conclusions of law, the Agency finds that it has substantive jurisdiction over the conclusions of

12506law in Paragraphs 16, 17, 19, 20, 27, 30, 63, 80, 81, 82, 83, 84, 86, 88, 89, and Endnotes 7 and

1252815 of the Recommended Order because it is the single state agency in charge of administering

12544Florida's Medicaid program, and that it can substitute conclusions of law that are as or more

12560reasonable than those of the ALJ. Therefore, for these reasons, and also for the reasons stated in

12577AHCA's rulings on its Exceptions I through III, V, and VI, which are hereby incorporated by

12593reference, Petitioner's Exception IV is granted to the extent that the Agency rejects Paragraphs

1260781, 82, 83, 84, 86, 88, 89, and Endnotes 7 and 15 of the Recommended Order in their entirety

12626(and by extension Paragraph 85 and Endnotes 16 through 19 of the Recommended Order), and

12641modifies Paragraphs 16, 17, 19, 20, 27, 30, 63 and 80 ofthe Recommended Order as follows:

1265716. Prior authorization is an administrative adjudication the

12665determination made by AHCA or its contractor that a provider may

12676deliver certain goods or services to a Medicaid recipient, here an

12687undocumented alien determined by DCF to be eligible for

12696Medicaid due to an EMC. Prior authorization does not relieve the

12707hospital provider of its affirmative duty to bill true and accurate

12718claims for goods and services that are medically necessary and

12728were provided in accordance with the applicable Medicaid rules,

12737regulations, handbooks, and policies, and federal, state, and local

12746laws. § 409.913(7)(b), (e), CO, Fla. Stat.; see also Florida Medicaid

12757Provider General Handbook at 5-4. of the compensability of a

12767claim, vffiich determines the hospital's substantial interests. Denial

12775or reduction of a claim entitles the hospital to a hearing which, if

12788requested, results in a final order. Payment in full of a previously

12800authorized claim is the equivalent of a final order because AHCA,

12811signaling the consummation of its decision making process, binds

12820itself to a course of action, which, being neither tentative nor

12831interlocutory, affords the hospital complete satisfaction, depriving

12838the payee of any opportunity or reason to protect its substantial

12849interests at a later date.7/

1285417. Pursuant to the prior authorization program, AHCA examined

12863each claim at issue in this case and prior authorized Respondent to

12875deliver each good or service.determined that it ·.vas authorized to

12885be paid by the Medicaid program before the claim Vfa:S presented

12896for payment. Thereafter AHCA paid each pre-approvedprior

12903authorized claim upon submission, on the dates, in the amounts,

12913and for the days of hospitalization shown in the following table:

12924[TABLE NOT INCLUDED BUT ADOPTED UNCHANGED]

1293019. An alien recipient is entitled to eligible to receive medical

12941assistance for emergency care and services that are compensable

12950under Medicaid and are provided during the period of the

12960emergency comprising the dates established by DCF in its final

12970agency action, for the recipient is Medicaid-eligible on those dates

12980of service, as a matter of Florida law. Medicaid providers who

12991render services necessary to treat the EMC upon which DCF based

13002the recipient's eligibility may present a claim to AHCA for

13012payment under the Medicaid program. Under section 409.913,

13020Florida Statutes, AHCA is responsible for adjudicating conducting

13028audits of claims paid in order to determine whether the provider's

13039claim is authorized to be paid by the Medicaid program, and

13050AHCA takes final agency action determining the provider's

13058substantial interests in this regard.

1306320. If the provider is a hospital, it may receive prior authorization

13075from AHCA to deliver a good or service to a Medicaid recipient.

13087Prior authorization is not equivalent to a determination that the

13097claim subsequently submitted by the hospital should be

13105paid.AHCA determines prospectively whether the claim is

13112authorized to be paid, pursuant to the prior authorization program

13122described above. For other providers not subject to prior

13131authorization requirements, AHCA determines compensability _gf

13137claims retroactively, after and audits of previously

13144paid claims. '.Vhether the adjudication is prospective or

13152retrospective, hov<'ever, ahca's="" retrospective="" audits="">

13154considered to be final agency action culminates that may be

13164challenged by a provider whose substantial interests have been

13173affected in an administrative process having two parties, i.e.,

13182AHCA and the provider.

1318627. As for recouping overpayments from providers, while AHCA

13195has the authority under section 409.913, Florida Statutes, to

13204determine whether claims are authorized to be paid by the Florida

13215Medicaid program, and to recover overpayments and impose

13223sanctions as appropriate.the power to "re determine" a previously

13232adjudicated claim is another matter entirely, one which is a

13242question of state law. And state law, as will be seen, does not

13255casually permit "do overs" with respect to final agency actions

13265which determine substantial interests.

1326930. The Undocumented Alien Project is a program which entails

13279the retrospective review of hospitals' Medicaid claims, in that the

13289reason for carrying it out is to adjudicate determine the

13299compensability of claims that have already been paid. Ex post

13309facto audits of paid Medicaid claims are authorized under section

13319409.913, Florida Statutes.commonplace, to be s\\:lfe, but unlike the

13328typical retrospective review, this project involves the attempted re

13337adjudication of claims that were already authorized once before, on

13347a prospective basis. The point has been made, but it bears

13358repeating: Because of the prior authorization program for hospital

13367inpatient services, the compensability of each claim selected for

13376re\\'iew p'l:lfsuant to the Undocumented Alien Project, including

13384every claim at issue in this case, had already been determined on

13396the merits by AHCA, \\Vhose decision that the claim was payable

13407became final agency action upon payment. In effect, then, the

13417UndocUfllented Alien Project is AHCA's blueprint for revisiting its

13426mvn prior decisions.

1342963. This is a good place to pause for a review of the foregoing

13443findings relating to the Undocumented Alien Project. Purportedly

13451acting under the aegis of Following a review by CMS, AHCA has

13463undertaken a comprehensive audit of all previously adjudicated

13471paid claims for emergency services received by alien recipients

13480between mid-2005 and mid-20 10, to make fresh findings as to (i)

13492'.vhether, as DCF found, each recipient had an EMC; and, for each

13504one who in AHCA='s judgment did, (ii) the emergency was

"13514alleviated" sometime during the DCF determined "period of the

13523emergency." The purpose of this retrospective review is to recoup,

13533as overpayments, amounts disbursed for any and all goods or

13543services provided (i) to aliens who, in AHCA's view, never had an

13555EMC or (ii) after a recipient's AHCA-determined "date of

13564alleviation."

1356580. As may be recalled, AHCA implemented a prior authorization

13575program for hospital inpatient services in 2002 and, pursuant to

13585that program, reviewed preliminarily determined that Respondent

13592was allowed to provide the goods or services and submit and

13603determined the compensability of every claim at issue in this case

13614prospective!)', i.e., before it was presented to AHCA for payment.

13624Respondent still had an affirmative duty to bill true and accurate

13635claims for goods and services that are medically necessary and

13645were provided in accordance with the applicable Medicaid rules,

13654regulations, handbooks, and policies, and federal, state, and local

13663laws. § 409.913(7)(b), (e), Fla. Stat.; see also Florida Medicaid

13673Provider General Handbook at 5-4. As it happened, the Agency

13683found on the merits, years before bringing this action, that all of

13695the amounts for which Gulf Coast sought compensation were

13704authorized to be paid by Medicaid. Each prior authorization of a

13715claim constituted agency action. § 120.52(2), Fla. Stat. When the

13725Agency actually paid the pre approved claim, as it did every one of

13738the claims at issue here, that agency action became final, because

13749AHCA bound itself to a course of action which determined both

13760parties' rights and obligations, consummating a free form decision

13769making process.15/ See Save Our Creeks & Envtl. Confed'n of Sw.

13780Fla. v. Fish & 'Nildlife Conser. Comm'n, 112 So. 3d 128, 130 (Fla.

137931st DCA 2013); cf. Bennett v. Spear, 520 U.S. 154, 177 78, 117 S.

13807Ct. 1154, 1168, 137 L. Ed. 2d 281, 305 (1997).

13817Exception V

13819In Exception V, Petitioner takes exception to Paragraphs 90 through 94 of the

13832Recommended Order, arguing that the ALJ erred in concluding that the "plain language" of

13846section 409.905(5)(a), Florida Statutes, barred the Agency from conducting the audit at issue in

13860this case. Instead, Petitioner argues that section 409.905(5)(a), Florida Statutes, does not apply

13873to this matter because the "review" referenced in that section is different from the review

13888Petitioner conducted in this matter. The Agency agrees with Petitioner. As stated in the ruling

13903on Exception IV supra, there is a universal rule that a statutory provision will not be construed in

13921such a way that it renders meaningless or absurd any other statutory provision. See Amente v.

13937Newman, 653 So. 2d 1030 (Fla. 1995). The ALJ has violated that universal rule by interpreting

13953the language in the last sentence of section 409.905(5)(a), Florida Statutes, to prohibit the

13967Agency from conducting audits like the one at issue in this case.

13979The Legislature has authorized AHCA and/or its contractor to conduct both pre-payment

13991reviews of providers' Medicaid claims to ensure they are billed in accordance with state and

14006federal Medicaid law and retrospective reviews and/or audits of providers' paid Medicaid claims

14019to identify any overpayments. § 409.913(2), (3), (5), Fla. Stat. "'Overpayment' includes any

14032amount that is not authorized to be paid by the Medicaid program whether paid as a result of

14050inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse,

14061or mistake." § 409.913(l)(e), Fla. Stat. AHCA "shall" deny payment or require repayment of

14075any overpayment for services not provided and billed for in accordance with federal and state

14090Medicaid law. § 409.913(l)(e), (7), (11), (15), (27), Fla. Stat. Federal law requires state

14104Medicaid agencies to provide procedures for post-payment claims review in order to ensure a

14118provider's compliance with Medicaid law. See 42 U.S.C. § 1396a(a)(37)(B); 42 C.F.R.

14130§ 447.253(g) (stating "[t]he Medicaid agency must provide for periodic audits of the financial

14144and statistical records of participating providers"). These utilization reviews/audits of Medicaid

14156providers are performed retrospectively. § 409.913(2), Fla. Stat.; see also Goldstar Med. Servs.,

14169Inc. v. Dep't of Social Servs., 955 A. 2d 15, 26 (Conn. 2008) (recognizing that Medicaid

" 14185[a ]udits, by their inherent nature, are retrospective; they determine the accuracy of claims

14199submitted and payments made after the fact"). If section 409.905(5)(a), Florida Statutes, was a

14214bar to the Agency performing audits like the one at issue in this case, it would result in a

14233violation of federal law, which requires the Agency to conduct such audits.

14245For these reasons, and also for the reasons stated in AHCA's rulings on its Exceptions I

14261through IV and VI, which are hereby incorporated by reference, the Agency finds that it does

14277have substantive jurisdiction over the conclusions of law in Paragraphs 90 through 94 of the

14292Recommended Order because it is the single state agency in charge of administering Florida's

14306Medicaid program, and that it can substitute conclusions of law that are as or more reasonable

14322than those of the ALJ. Therefore, the Agency grants Petitioner's Exception V and rejects the

14337conclusions oflaw in Paragraphs 90 through 94 of the Recommended Order in their entirety.

14351Exception VI

14353In Exception VI, Petitioner takes exception to Paragraphs 46, 47, 59, 64, 96, 109, 110,

14368and 114 of the Recommended Order, arguing that the ALJ departed from the essential

14382requirements of law by making the findings of fact and conclusions of law in these paragraphs

14398because they pertained to issues that neither party had raised in this case. The Agency agrees.

14414Generally, section 120.57(1)(b), Florida Statutes, states that "[a]ll parties shall have an

14426opportunity to respond, to present evidence and argument on all issues involved" in a case.

14441Here, the ALJ raised the following issues sua sponte after the hearing had concluded, such that

14457AHCA had no meaningful "opportunity to respond, present evidence and argument" on these

14470Issues:

14471• The constitutionality Issue discussed m Paragraphs 46 and 4 7 of the

14484Recommended Order;

14486• The issue whether an application for medical assistance under the Medicaid

14498program is analogous to a licensure application in Paragraph 59 of the

14510Recommended Order; and

14513• The issue of the application of case law governing the interpretation of insurance

14527policies to this case that the ALJ raised in Paragraphs 1 09 and 11 0 of the

14544Recommended Order.

14546Indeed, neither Respondent's Amended Petition nor the parties' Joint Pre-Hearing Stipulation

14557raises these issues, nor were they addressed at the hearing. Further, DOAH is an administrative

14572agency; therefore, the ALJ lacked the authority to rule on constitutionality issue that he raised

14587raised in Paragraphs 46 and 47 of the Recommended Order. See, e.g., Gulf Pines Mem'l Park,

14603Inc. v. Oaklawn Mem'l Park, Inc., 361 So. 2d 695, 700 (Fla. 1978); Fla. Hosp. v. Ag. for Health

14622Care Admin., 823 So. 2d 844, 849 (Fla. 1st DCA 2002). As such, the ALJ departed from the

14640essential requirements of law by raising and addressing these issues for the first time in its

14656Recommended Order.

14658AHCA asserts it has the authority to modify both findings of fact and conclusions of law

14674when there is a lack of compliance with the essential requirements of law, although the phrase

"14690did not comply with the essential requirements of law" is contained in the sentence of section

14706120.57(1 )(/), Florida Statutes, that pertains to the rejection or modification of findings of fact.

14721Quite simply, AHCA cannot allow a conclusion of law that was entered without compliance with

14736- and thus in violation of- the essential requirements of law to stand.

14749For these reasons, and also for the reasons stated in AHCA's rulings on its Exceptions I

14765through V, which are hereby incorporated by reference, the Agency grants Petitioner's Exception

14778VI to the extent that it rejects Paragraphs 46, 47, 109 and 110 of the Recommended Order (and

14796by extension Endnote 20 of the Recommended Order) in their entirety, and modifies Paragraphs

1481059 and 114 ofthe Recommended Order to state:

1481859. It is important to recognize that when DCF approves an

14829individual alien's application for medical assistance and issues that

14838person a Medicaid card or other notice signifying that the person is

14850a recipient, DCF is conferring a legal status upon that person which

14862entitles him to receive benefits from providers for which Medicaid

14872must pay. The application for medical assistance initiates a

14881transaction between the applicant and DCF to which no one else is

14893a party--not AHCA, not the providers. The determination of

14902eligibility of an individual alien, however, is separate and distinct

14912from AHCA's review of claims for payment by hospital providers

14922for services provided to that alien, which may only be approved if

14934the services provided are covered by Medicaid.In this respect, the

14944application for medical assistance is analogous to an application

14953for licensure, and the issuance of a Medicaid card or other notice

14965of approval is somevihat akin to the issuance of a license. The

14977point is that once DCF confers recipient S{atus on an applicant,

14988AHCA (and the providers) must respect and accept that status, juS{

14999as AHCA (and the providers) must respect and accept other legal

15010credentials, such as professional licenses, vihich are conferred by

15019governmental authorities having the power to issue them.

15027114. This is an interesting and close question of first impression,

15038and it would be useful to have an authoritative decision on the

15050subject. The undersigned has elected to punt the issue this time,

15061however, inasmuch as he would rather address the question in a

15072case where there are not a half-dozen or so other, potential separate

15084grounds for finding the provider not liable as alleged.

15093The Agency will make no further modifications to Paragraph 64 of the Recommended Order

15107beyond those enumerated in the ruling on Petitioner's Exception II supra. The Agency will make

15122no further modifications to Paragraph 96 of the Recommended Order beyond those enumerated

15135in the ruling on Petitioner's Exception I supra.

15143FINDINGS OF FACT

15146The Agency adopts the findings of fact set forth in the Recommended Order, except

15160where noted supra. 5

15164CONCLUSIONS OF LAW

15167The Agency adopts the conclusions of law set forth in the Recommended Order, except

15181where noted supra.

15184IT IS THEREFORE ADJUDGED THAT:

15189Respondent is hereby required to repay $46,901.85 in overpayments, plus interest at a

15203rate of ten (1 0) percent per annum as required by Section 409 .913(25)( c), Florida Statutes, to the

15222Agency. Respondent shall make full payment of the overpayment to the Agency for Health Care

15237Administration within 30 days of the rendition date of this Final Order unless other payment

15252arrangements have been agreed to by the parties. Respondent shall pay by check payable to the

15268Agency for Health Care Administration and mailed to the Agency for Health Care

15281Administration, Office of Finance and Accounting, 2727 Mahan Drive, Mail Stop 14,

15293Tallahassee, Florida 32308.

152965 The Agency does not agree with the finding of fact in the last sentence of Paragraph 29 of the Recommended

15317Order, but will leave it unchanged since Petitioner failed to take exception to it.

,

15331DONE and ORDERED this 4 day of 2016, in Tallahassee,

15341Florida.

15342UDEK, SECRET A

15345HEALTH CARE ADMINISTRATION

15348NOTICE OF RIGHT T DICIAL REVIEW

15354A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO

15367JUDICIAL REVIEW, WHICH SHALL BE INSTITUTED BY FILING THE ORIGINAL

15377NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A COPY ALONG

15390WITH THE FILING FEE PRESCRIBED BY LAW WITH THE DISTRICT COURT OF

15402APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS

15412HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL

15421BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE

15431NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF THE RENDITION OF THE

15445ORDER TO BE REVIEWED.

15449CERTIFICATE OF SERVICE

15452I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has

15467been furnished by U.S. or interoffice mail to the persons named below on this

15481ftl ,2016.

15483RICHARD J. SHOOP, Agency Clerk

15488Agency for Health Care Administration

154932727 Mahan Drive, MS #3

15498Tallahassee, Florida 32308

15501(850) 412-3630

15503COPIES FURNISHED TO:

15506Honorable John G. Van Laningham

15511Administrative Law Judge

15514Division of Administrative Hearings

15518The DeSoto Building

155211230 Apalachee Parkway

15524Tallahassee, Florida 32399-3060

15527(via electronic filing)

15530Joseph M. Goldstein, Esquire

15534Jacqueline Howe, Esquire

15537Shutts and Bowen LLP

15541200 East Broward Boulevard, Suite 21 00

15548Fort Lauderdale, Florida 33301

15552(via U.S. Mail)

15555Daniel Elden Nordby, Esquire

15559Shutts and Bowen LLP

15563215 South Monroe Street, Suite 804

15569Tallahassee, Florida 32301

15572(via U.S. Mail)

15575Joanne Barbara Erde, Esquire

15579Donna Holshouser Stinson, Esquire

15583Duane Morris LLP

15586200 South Biscayne Boulevard, Suite 3400

15592Miami, Florida 33131

15595(via U.S. Mail)

15598Medicaid Program Integrity

15601Office of the Inspector General

15606Medicaid Accounts Receivable

15609Finance & Accounting

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PDF
Date
Proceedings
PDF:
Date: 04/06/2016
Proceedings: Agency for Health Care Administration's Exceptions to Recommended Order filed.
PDF:
Date: 04/06/2016
Proceedings: Agency Final Order filed.
PDF:
Date: 04/04/2016
Proceedings: Agency Final Order
PDF:
Date: 03/11/2016
Proceedings: Order Unsealing File.
PDF:
Date: 03/04/2016
Proceedings: Letter to Judge Van Laningham from Joanne Erde regarding Judge Creasy's ruling on Respondent's request to unseal filed.
PDF:
Date: 03/03/2016
Proceedings: Petitioner's Letter Response to Judge Van Laningham Regarding Respondent's Public Record Exemption filed.
PDF:
Date: 02/26/2016
Proceedings: (Respondent's) Public Record Exemption filed.
PDF:
Date: 01/26/2016
Proceedings: Recommended Order
PDF:
Date: 01/26/2016
Proceedings: Recommended Order (hearing held November 2, 2015). CASE CLOSED.
PDF:
Date: 01/26/2016
Proceedings: Recommended Order cover letter identifying the hearing record referred to the Agency.
PDF:
Date: 01/13/2016
Proceedings: Notice of Correction of Ministerial Error filed.
PDF:
Date: 12/21/2015
Proceedings: Agency for Health Care Administration's Proposed Recommended Order filed.
PDF:
Date: 12/21/2015
Proceedings: Respondent's Proposed Recommended Order filed.
PDF:
Date: 12/11/2015
Proceedings: Order Granting Enlargement of Time.
PDF:
Date: 12/10/2015
Proceedings: Respondent's Unopposed Motion for Extension to File Proposed Recommended Order filed.
PDF:
Date: 11/23/2015
Proceedings: Petitioner's Objections and Notice of Counter-Designations filed.
Date: 11/17/2015
Proceedings: Transcript of Proceedings (not available for viewing) filed.
PDF:
Date: 11/12/2015
Proceedings: Petitioners Notice of Designation filed.
PDF:
Date: 11/12/2015
Proceedings: Petitioners Amended Notice of Filing Complete Depostion Transcript of Steve Beiser filed.
Date: 11/10/2015
Proceedings: Notice of Filing Respondents Exhibit R-59 filed. (not available for viewing)  Confidential document; not available for viewing.
PDF:
Date: 11/10/2015
Proceedings: Notice of Designation filed.
Date: 11/02/2015
Proceedings: CASE STATUS: Hearing Held.
PDF:
Date: 11/02/2015
Proceedings: Amended Notice of Hearing (hearing set for November 2, 2015; 9:00 a.m.; Tallahassee, FL; amended as to in-person hearing).
PDF:
Date: 11/02/2015
Proceedings: Joint Pre-hearing Stipulation filed.
PDF:
Date: 10/30/2015
Proceedings: Order Granting Leave to Amend.
PDF:
Date: 10/30/2015
Proceedings: Respondent's Notice of Filing Affidavit of Corporate Representative filed.
Date: 10/30/2015
Proceedings: Respondent's Proposed Exhibits filed (exhibits not available for viewing).
PDF:
Date: 10/30/2015
Proceedings: Respondent's Exhibit List to Joint Prehearing Stipulation filed.
Date: 10/30/2015
Proceedings: Petitioner's Proposed Exhibits filed (exhibits not available for viewing).
PDF:
Date: 10/30/2015
Proceedings: Petitioner, Agency for Health Care Administration's Exhibit List to Joint Prehearing Stipulattion filed.
Date: 10/30/2015
Proceedings: Respondent's Notice of Filing Affidavit of Corporate Representative filed. (not available for viewing)  Confidential document; not available for viewing.
PDF:
Date: 10/29/2015
Proceedings: Notice of Filing Respondent's Proposed Exhibits for Final Hearing filed.
Date: 10/29/2015
Proceedings: Petitioner, Agency for Health Care Administration's Notice of Filing Deposition Transcript filed.  Confidential document; not available for viewing.
PDF:
Date: 10/29/2015
Proceedings: Petitioner, Agency for Health Care Administration's Notice of Filing Deposition Transcript filed.
PDF:
Date: 10/28/2015
Proceedings: (Respondent's) Notice of Filing filed.
PDF:
Date: 10/27/2015
Proceedings: Order Enlarging Time to File Pre-hearing Stipulation.
PDF:
Date: 10/27/2015
Proceedings: Respondent's Motion to File an Amended Petition filed.
PDF:
Date: 10/27/2015
Proceedings: Second Amended Notice of Deposition of Agency Representative Duces Tecum filed.
PDF:
Date: 10/27/2015
Proceedings: Petitioner, Agency for Health Care Administration's Notice of Filing Deposition Transcript (of Jocelyne David) filed.
PDF:
Date: 10/27/2015
Proceedings: Petitioner, Agency for Health Care Administration's Notice of Filing Deposition Transcript (of Thomas Wells) filed.
PDF:
Date: 10/26/2015
Proceedings: Joint Motion for Enlargement of Time to File Joint Prehearing Stipulation filed.
PDF:
Date: 10/26/2015
Proceedings: Notice of Taking Deposition of Sonya Graves filed.
PDF:
Date: 10/26/2015
Proceedings: Petitioner, Agency for Health Care Administration's Amended Notice of Filing Deposition Transcript (Naveen Gande) filed.
PDF:
Date: 10/26/2015
Proceedings: Amended Notice of Deposition of Agency Representative Duces Tecum filed.
PDF:
Date: 10/26/2015
Proceedings: Cross-Notice of Taking Deposition of Thomas Wells filed.
PDF:
Date: 10/26/2015
Proceedings: Second Amended Notice of Taking Deposition (Thomas Wells) filed.
PDF:
Date: 10/23/2015
Proceedings: Amended Notice of Taking Deposition (of Thomas Wells) filed.
PDF:
Date: 10/23/2015
Proceedings: Petitioner, Agency for Health Care Administration's Notice of Filing Deposition Transcript (of Naveen Gande) filed.
PDF:
Date: 10/23/2015
Proceedings: Petitioner, Agency for Health Care Administration's Notice of Filing Deposition Transcript (of Michael Phillips) filed.
PDF:
Date: 10/23/2015
Proceedings: Petitioner, Agency for Health Care Administration's Notice of Filing Deposition Transcript (of Steve Beiser) filed.
PDF:
Date: 10/23/2015
Proceedings: Notice of Taking Deposition (of Patricia Baumann) filed.
PDF:
Date: 10/22/2015
Proceedings: Notice of Taking Deposition (of Jocelyne David) filed.
PDF:
Date: 10/22/2015
Proceedings: Order Re-scheduling Hearing by Video Teleconference (hearing set for November 2, 2015; 9:00 a.m.; Miami, FL).
PDF:
Date: 10/22/2015
Proceedings: Order on Motion to Reinstate Hearing Date.
PDF:
Date: 10/21/2015
Proceedings: Notice of Cancellation of Taking Deposition (of Jocelyne David) filed.
PDF:
Date: 10/21/2015
Proceedings: Petitioner's Response to Respondent's Request to Withdraw its Motion to Dismiss and to Reinstate the Final Hearing on November 2, 2015 filed.
PDF:
Date: 10/21/2015
Proceedings: Notice of Cancellation of October 22, 2015 Deposition of Agency Representative Duces Tecum filed.
PDF:
Date: 10/16/2015
Proceedings: Respondent's Request to Withdraw its Motion to Dismiss and to Reinstate the Final Hearing on November 2, 2015, the Originally Scheduled Date filed.
PDF:
Date: 10/16/2015
Proceedings: Order Granting Continuance (parties to advise status by October 23, 2015).
PDF:
Date: 10/16/2015
Proceedings: Notice of Conversion.
PDF:
Date: 10/13/2015
Proceedings: Cross-notice of Taking Deposition (of Jocelyne David) filed.
PDF:
Date: 10/13/2015
Proceedings: Notice of Taking Deposition (of Jocelyne David) filed.
PDF:
Date: 10/09/2015
Proceedings: Cross-notice of Taking Deposition (of Naveen Gande) filed.
PDF:
Date: 10/08/2015
Proceedings: Petitioner's Response in Opposition to Respondent's Motion to Dismiss filed.
PDF:
Date: 10/08/2015
Proceedings: Notice of Deposition of Agency Representative Duces Tecum filed.
PDF:
Date: 10/07/2015
Proceedings: Amended Cross-notice of Taking Deposition (of Michael Phillips, as to Location) filed.
PDF:
Date: 10/07/2015
Proceedings: Cross-notice of Taking Deposition (of Michael Phillips) filed.
PDF:
Date: 10/05/2015
Proceedings: Notice of Cancellation of Deposition (of Jocelyne David) filed.
PDF:
Date: 10/02/2015
Proceedings: Order Enlarging Time.
PDF:
Date: 10/01/2015
Proceedings: Petitioners Unopposed Motion for Extension of Time to Respond to Respondents Motion to Dismiss filed.
PDF:
Date: 09/30/2015
Proceedings: Respondent's Opposition to Petitioner's Motion for Continuance of Final Hearing filed.
PDF:
Date: 09/30/2015
Proceedings: Petitioner's Motion for Continuance of Final Hearing filed.
Date: 09/24/2015
Proceedings: Respondent's Motion to Dismiss filed. (not available for viewing)  Confidential document; not available for viewing.
PDF:
Date: 09/18/2015
Proceedings: Amended Notice of Taking Deposition (of Naveen Gande) filed.
PDF:
Date: 09/18/2015
Proceedings: Notice of Taking Deposition (of Michael Phillips) filed.
PDF:
Date: 09/18/2015
Proceedings: Notice of Taking Deposition (of Jocelyne David) filed.
PDF:
Date: 09/18/2015
Proceedings: Re-notice of Taking Deposition (of Steve Beiser) filed.
PDF:
Date: 09/17/2015
Proceedings: Notice of Appearance (Daniel Nordby) filed.
PDF:
Date: 09/02/2015
Proceedings: Notice of Taking Deposition (of Naveen Gande) filed.
PDF:
Date: 09/02/2015
Proceedings: Notice of Taking Deposition (of Steve Beiser) filed.
PDF:
Date: 08/26/2015
Proceedings: Notice of Withdrawal of Counsel for the Agency filed.
PDF:
Date: 08/14/2015
Proceedings: Notice of Substitution of Counsel (Joseph Goldstein) filed.
PDF:
Date: 08/14/2015
Proceedings: Notice of Appearance (Jacqueline Howe) filed.
PDF:
Date: 07/21/2015
Proceedings: Amended Notice of Hearing by Video Teleconference (hearing set for November 2, 2015; 9:00 a.m.; Miami and Tallahassee, FL; amended as to hearing date ).
PDF:
Date: 07/21/2015
Proceedings: Order of Pre-hearing Instructions.
PDF:
Date: 07/21/2015
Proceedings: Notice of Hearing by Video Teleconference (hearing set for November 11, 2015; 9:00 a.m.; Miami and Tallahassee, FL).
PDF:
Date: 07/21/2015
Proceedings: Notice of Transfer.
PDF:
Date: 07/17/2015
Proceedings: Joint Response to Initial Order and Petitioner's Motion for Enlargement of Time to Schedule Hearing filed.
PDF:
Date: 07/13/2015
Proceedings: Initial Order.
PDF:
Date: 07/13/2015
Proceedings: Petition for Formal Administrative Hearing filed.
PDF:
Date: 07/13/2015
Proceedings: Final Audit Report filed.
PDF:
Date: 07/13/2015
Proceedings: Notice (of Agency referral) filed.
PDF:
Date: 07/13/2015
Proceedings: Agency referral (request case be sealed) filed.

Case Information

Judge:
JOHN G. VAN LANINGHAM
Date Filed:
07/13/2015
Date Assignment:
07/21/2015
Last Docket Entry:
04/06/2016
Location:
Tallahassee, Florida
District:
Northern
Agency:
Other
Suffix:
MPI
 

Counsels

Related DOAH Cases(s) (3):

Related Florida Statute(s) (19):

Related Florida Rule(s) (4):