99-002497RX
Consult Care, Inc. vs.
Agency For Health Care Administration
Status: Closed
DOAH Final Order on Tuesday, June 27, 2000.
DOAH Final Order on Tuesday, June 27, 2000.
1STATE OF FLORIDA
4DIVISION OF ADMINISTRATIVE HEARINGS
8CONSULT CARE, INC., )
12)
13Petitioner, )
15)
16vs. ) Case No. 99-2497RX
21)
22AGENCY FOR HEALTH CARE )
27ADMINISTRATION, )
29)
30Respondent. )
32___________________________________)
33FINAL ORDER
35Pursuant to notice, a formal hearing was conducted in this
45case on February 17, 2000, in Tampa, Florida, before Lawrence P.
56Stevenson, a duly-designated Administrative Law Judge of the
64Division of Administrative Hearings.
68APPEARANCES
69For Petitioner: Bruce Culpepper, Esquire
74Akerman, Senterfitt & Eidson, P.A.
79301 South Bronough Street, Suite 200
85Post Office Box 10555
89Tallahassee, Florida 32302-2555
92For Respondent: Moses E. Williams, Esquire
98Steven A. Grigas, Esquire
102Agency for Health Care Administration
1072727 Mahan Drive, Mail Stop 3
113Fort Knox Building 3, Suite 3431
119Tallahassee, Florida 32308-5403
122STATEMENT OF THE ISSUE
126The issue in this case is whether Rule 59G-4.010, Florida
136Administrative Code, including pages 1-5 and 1-6 of the Florida
146Medicaid Advanced Registered Nurse Practitioner Coverage and
153Limitations Handbook (the "ARNP Handbook"), which is incorporated
162in the rule by reference, is an invalid exercise of delegated
173legislative authority.
175PRELIMINARY STATEMENT
177Petitioner, Consult Care, Inc. ("CCI") challenges the
186amendment of the ARNP Handbook by the Agency for Health Care
197Administration ("AHCA"). The amendment to the ARNP Handbook was
208adopted by reference in Rule 59G-4.010, Florida Administrative
216Code. The challenge focuses on the ARNP Handbook's amended
225language regarding mobile ARNP units. CCI is a Medicaid provider
235offering health related services to the Medicaid community via a
245stationary office and two retrofitted recreational vehicles.
252AHCA published its notice of development of proposed rules
261in the December 4, 1998, issue of the Florida Administrative
271Weekly (vol. 24, no. 49, pp. 6616-6617). The agency conducted a
282rule development hearing on December 21, 1998. AHCA published
291its rule adoption notice in the February 19, 1999, issue of the
303Florida Administrative Weekly (vol. 25, no. 7, p. 702). The
313agency conducted a rule adoption hearing on March 18, 1999. CCI
324attended the adoption hearing and provided oral and documentary
333testimony regarding the proposed rule. On May 19, 1999, AHCA
343submitted its filing for final adoption to the Secretary of
353State. CCI filed its petition challenging the adopted rule on
363June 1, 1999. The final hearing was scheduled for June 29-30,
3741999, but was continued and then abated at the parties' request.
385The hearing was eventually rescheduled for and held on February
39517, 2000.
397At final hearing, Petitioner CCI called as witnesses Alan
406Strowd, program administrator in Medicaid program development;
413Jackie Manescala, co-owner of Albany Avenue ACLF, Inc.; Thomas J.
423McClusky of McClusky Enterprises; and JoAnna Mulder, president of
432CCI. Petitioner's Exhibits 1 and 2 were admitted into evidence.
442AHCA called as witnesses John A. Owens, bureau chief of the
453Medicaid Program Integrity Section of AHCA; Glen D. Stone, a
463medical program analyst in the Medicaid Program Integrity
471Section, accepted as an expert in Medicaid program integrity
480oversight functions; and Lynne Metz, physician services
487coordinator for AHCA, accepted as an expert in Medicaid program
497development and rule making. AHCA Exhibits 1 through 23 were
507admitted into evidence.
510The parties requested and were given 30 days from the filing
521of the transcript in which to file proposed final orders. The
532Transcript was filed on March 13, 2000, and parties filed
542Proposed Final Orders on April 12, 2000.
549FINDINGS OF FACT
552Based on the oral and documentary evidence adduced at the
562final hearing, and the entire record in this proceeding, the
572following findings of fact are made:
5781. Rule 59G-4.010, Florida Administrative Code, "applies to
586all advanced registered nurse practitioners enrolled in the
594Medicaid program for advanced registered nurse practitioner
601services under Section 409.906, F.S." It requires all ARNP
610service providers to comply with the "Florida Medicaid Advanced
619Registered Nurse Practitioner Coverage and Limitations Handbook,
626January 1999, which is incorporated by reference . . . ."
6372. The ARNP Handbook "explains covered services, their
645limits and who is eligible to receive them." The issue in this
657proceeding is Medicaid reimbursement for mobile ARNP units. The
666challenged language is found at pp. 1-5 and 1-6 of the ARNP
678Handbook, and reads as follows:
683Mobile ARNP Units
686Description
687A mobile ARNP unit is a fully operational
695vehicle, unit, trailer or office that travels
702to different locations for the provision of
709ARNP services and is not a stationary ARNP
717unit or office.
720Limitations and Exceptions
723Medicaid will not reimburse for any ARNP
730service rendered in a mobile unit regardless
737of the location with the following
743exceptions:
744Mobile ARNP unit owned or operated
750by the Department of Health
755complying with Medicaid's County
759Health Department (CHD) Clinic
763Services program specifications as
767a CHD provider;
770Mobile ARNP unit owned, operated
775by, or having a contractual
780arrangement with a Federally
784Qualified Health Center (FQHC),
788complying with Medicaid's Federally
792Qualified Health Center
795specifications as a FQHC provider;
800and
801Mobile ARNP unit certified as a
807mobile Rural Health Clinic (RHC)
812Contractual Arrangements with an FQHC
817Any contractual arrangement between a mobile
823ARNP unit and a FQHC for the provision of
832Medicaid ARNP services is subject to the
839following conditions:
841The services must be provided by a
848licensed ARNP on the premises;
853The services must be covered by the
860Medicaid ARNP services program and
865be subject to the same limitations
871and prior authorization
874requirements that apply to the ARNP
880services program;
882Medicaid reimbursement for ARNP
886services will only be to the FQHC,
893which is assigned a clinic group
899number to bill an encounter rate
905for clinic services. The treating
910practitioner who renders the
914services must enroll as a Medicaid
920provider affiliated with the FQHC
925clinic group provider number;
929The services must be provided at a
936mobile satellite clinic affiliated
940with the FQHC; and
944The services must be provided in
950accordance with the policy
954guidelines specified in the
958Federally Qualified Health Center
962Coverage and Limitations Handbook.
966Contractual Arrangements with an RHC
971All services must be provided in accordance
978with the policy guidelines specified in the
985Medicaid Rural Health Clinic Services
990Coverage and Limitations Handbook.
9943. Federal law governs the provisions, requirements,
1001benefits, and service payments of Rural Health Clinics (RHCs),
1010Federally Qualified Health Centers (FQHCs), and County Health
1018Departments (CHDs) as they participate in the Medicaid program.
1027See Title 42 C.F.R. Parts 440.20 and 491 (RHCs), 491 (FQHCs), and
1039440.130 ( CHDs).
10424. CCI is a private corporation providing on-site community
1051based primary and behavioral health care services in
1059Hillsborough, Pinellas, Pasco, Polk, and Manatee counties. CCI
1067offers services through a stationary facility in Tampa and two
1077mobile units. The mobile units are retrofitted recreational
1085vehicles configured to have waiting areas, patient work-up areas,
1094lab areas, and private examination rooms. CCI has ceased
1103treating Medicaid patients in the mobile units since the adoption
1113of the challenged rule.
11175. CCI's client population consists of the developmentally
1125disabled, psychiatric disabled, and displaced frail elderly
1132living in congregate living facilities. CCI's group of health
1141care professionals includes physicians, ARNPs, and behavioral
1148care therapists.
11506. The genesis of the challenged rule was reports of
1160abusive practices by mobile dental units providing services to
1169children. In 1997, ACHA received reports that several such
1178units, all based in Miami, were trolling the state seeking large
1189concentrations of Medicaid-eligible children. These units would
1196stop in low-income housing projects and offer free diagnostic and
1206preventive services to children.
12107. Diagnostic and preventive services are especially
1217profitable for the provider, as they take comparatively little
1226time and are usually performed by auxiliary staff rather than the
1237dentist. AHCA found that some of these mobile units functioned
1247as mills, treating as many as 60 children per day.
12578. Problems began to arise when these children later
1266presented themselves to their regular dentists for treatment.
1274Medicaid places six month reimbursement limits per child for
1283items such as periodic exams and x-rays. The regular dentists,
1293unaware that their patients had used their eligibility in their
1303visits to the mobile units, performed these services and then
1313found their reimbursement denied due to the six month rule.
13239. AHCA also found problems with the treatment provided by
1333the nomadic mobile dental units. There could be no continuity of
1344care because the units moved on after the initial visit. Audits
1355of certain mobile providers found the mobile units dirty,
1364disorganized, and packed with waiting children. Up to 75% of the
1375x-rays taken in the audited units were not of diagnostic quality.
1386Obvious problems such as rotting teeth were ignored in the mobile
1397units, leaving these time consuming and less remunerative
1405procedures to be performed by the regular dentists.
141310. During the same time period, AHCA became aware of
1423billing discrepancies involving Vision Express, a mobile provider
1431of optometric services. AHCA found that Vision Express was
1440billing for services not covered by Medicaid, and was employing
1450misleading place of service codes on its claims.
145811. AHCA introduced several exhibits documenting its
1465investigation of Vision Express. The exhibits show that the
1474agency's concerns with Vision Express involved billing, not
1482quality of service. The exhibits also indicate that Vision
1491Express was the only mobile visual or optometric unit known to
1502have presented Medicaid billing problems for the agency.
151012. The conjunction of problems with dental and optometric
1519mobile units led the agency to conduct a review of its policies
1531and practices regarding mobile units overall. The agency's
1539traditional practice had been to deny reimbursement to mobile
1548service providers because a mobile unit was not termed a valid
"1559place of service" under the Medicaid billing codes. AHCA had no
1570written rule or policy regarding Medicaid reimbursement to mobile
1579service providers in any discipline.
158413. AHCA's review was intended to determine whether mobile
1593units should henceforth be reimbursed by Medicaid and, if so,
1603what restrictions should be placed on the activities of mobile
1613units to curb the potential for abuse.
162014. Lynne Metz, AHCA's expert in Medicaid program rule
1629making, testified that the agency's research revealed additional
1637problems with ARNPs, as well as the already acknowledged problems
1647with dental and optometric mobile units.
165315. Ms. Metz explained that Medicaid rules permit ARNPs to
1663treat a patient and bill Medicaid under their own provider
1673number, which reimburses the ARNP at 80% of the reimbursement
1683rate for physicians. ARNPs may also bill under the provider
1693number for their supervising physician and receive 100% of the
1703physician rate, but may do so only when the physician is
1714physically present and reviews, dates, and co-signs the medical
1723record. Ms. Metz testified that some ARNP mobile units were
1733found to have billed Medicaid at the higher rate even though the
1745supervising physician was not physically present on the mobile
1754unit.
175516. Alan Strowd, who was program administrator with the
1764practitioner services unit of Medicaid during the development of
1773this rule, testified that he recalled no complaints about ARNP
1783mobile units regarding the delivery of services, as opposed to
1793billing complaints.
179517. AHCA ultimately determined that mobile units have the
1804potential to increase the availability of and access to medical
1814services. However, the agency also determined that there is a
1824potential for abuse of services, potential lack of follow-up
1833care, and potential problems with management of patient records
1842involved with the provision of mobile unit services. The agency
1852decided to craft rules allowing Medicaid reimbursement for mobile
1861unit services, but also decided that some monitoring system
1870should be put in place to minimize the potential for abuse.
188118. Mr. Strowd admitted that the agency could address abuse
1891through the existing means of billing edits and the investigative
1901Medicaid Integrity Bureau, and that these means were attempted
1910prior to promulgation of the challenged rule. However, Mr.
1919Strowd testified that these were inefficient "pay and chase"
1928methods, meaning that Medicaid routinely pays the claims, then
1937investigates fraud and abuse after the fact. He testified that
1947these methods require the agency to sift through thousands of
1957providers to find the ones who are committing fraud.
196619. John A. Owens, bureau chief of the Medicaid Program
1976Integrity Section, agreed that the standards were in place to
1986enforce compliance with the Medicaid program by mobile unit
1995providers prior to adoption of the rule. Mr. Owens stated that
2006the rule was desirable because it "places a control mechanism" on
2017the mobile unit providers, giving AHCA an entity it can look to
2029for assurance that proper medical records and quality of service
2039are maintained. Mr. Owens testified that AHCA is "at capacity"
2049in terms of the direct oversight it is able to provide.
206020. Ms. Metz testified that the agency sought some
2069mechanism to monitor the mobile unit providers that was less
2079onerous than the "pay and chase" method. After considering and
2089discarding the idea of carving out geographic regions to regulate
2099the mobile providers, the agency decided to examine programs that
2109were already working successfully at the county level. The
2118agency's registered nurse specialist for CHDs informed Ms. Metz
2127that federal law has already established mobile provider
2135guidelines for CHD, FQHC, and RHC programs. Ms. Metz testified
2145that "the system was almost handed to us . . . . Here was a
2160local control network . . . that had already been sitting there
2172for us to just turn on the allowance and put it into place."
218521. Mr. Strowd opined that he saw no distinction between
2195the activities of a mobile dental unit and a mobile ARNP unit in
2208terms of the potential for problems with continuity of care,
2218billing fraud, and sanitary conditions. No evidence was
2226presented that the agency performed an actual evaluation
2234comparing the services offered by a mobile dental unit to those
2245performed by a mobile ARNP unit. Mr. Strowd agreed that a mobile
2257unit could provide a valuable service, especially if it confined
2267its activity to a small geographic area or primarily serviced
2277rural areas.
227922. Thus, the agency decided to amend all twelve of its
2290practitioner handbooks, including the ARNP Handbook, to allow
2298reimbursement of mobile unit service providers, but only if they
2308were owned by or contractually affiliated with a CHD, FQHC, or
2319RHC. The agency determined that this was the least intrusive
2329method to allow the provision of mobile unit services while
2339ensuring quality and continuity of care and reducing the
2348potential for fraud and abuse in the Medicaid program.
235723. Mr. Strowd testified that this limitation would assure
2366that there would be oversight of the mobile unit providers at the
2378local level, thus eliminating the need for AHCA supervision at
2388the state level. Ms. Metz also stated that a main purpose of the
2401limitation was to provide for local control:
2408That's the basis of Medicaid, to make sure
2416recipients can get the services they need
2423when they need it, not just, okay, I need a
2433doctor but not five days from now. So that's
2442why we're trying to put this in the local
2451area and not have it regulated from up at the
2461Tallahassee headquarters office. We don't
2466need to be the ones regulating the policy.
2474It has to be in the local county level, FQHC
2484level or RHC level, where they know these
2492recipients are the ones who need the phone
2500pickup, the phone call, the mobile provider,
2507and say we need you to go out.
251524. However, Ms. Metz also stated that AHCA would allow a
2526mobile unit provider to provide services pursuant to a
2535contractual arrangement with any RHC, FQHC, or CHD, regardless of
2545the entity's location in the state. Ms. Metz testified that she
2556told Joanna Mulder, the president of CCI, that she did not have
2568to contract with an entity in her service area, that "she could
2580get a contract with anybody and do her services in this area."
2592Ms. Metz did not explain how an FQHC in Pensacola, for example,
2604could provide to a mobile unit provider in Tampa the kind of
2616local knowledge and control that she stated was a prime reason
2627for the limitation adopted by the challenged rule.
263525. Mr. Strowd conceded that the actual language adopted in
2645the ARNP Handbook, quoted above, appears to allow mobile ARNP
2655providers to contract with FQHCs and RHCs, but not with CHDs.
2666Mr. Strowd testified that this was an inadvertent omission, and
2676that the intent of the rule is to allow mobile ARNP providers to
2689affiliate contractually with any of the three named providers.
269826. Both Mr. Strowd and Ms. Metz conceded that the agency
2709conducted no inquiry as to the practical ability of mobile unit
2720providers to contract with RHCs, FQHCs, or CHDs, or as to legal
2732impediments to such contracts.
273627. Ms. Mulder of CCI testified that she has made several
2747efforts to contract with the listed entities. She contacted the
2757Hillsborough CHD and was told that it does not contract with
2768private entities and had no interest in offering additional
2777services. The Polk and Pasco CHDs also had no interest.
278728. Ms. Mulder stated that she spent five days trying to
2798contact FQHCs, and that most of them also showed no interest.
2809She was finally able to meet with Jeff Zimmerman, the chief
2820financial officer of Parrish Health Clinic, an FQHC. Mr.
2829Zimmerman told Ms. Mulder that reimbursement limitations in the
2838FQHC Handbook made it impossible for his FQHC to contract with
2849CCI in a way that would provide any financial benefit to the
2861FQHC.
286229. Mr. Strowd testified that he had assurances from Greg
2872Glass, president of the Florida Association of Community Health
2881Clinics, the statewide FQHC organization, that any of the 27
2891FQHCs in the state would be willing to discuss and enter into
2903contracts with private mobile service providers. However, Ms.
2911Mulder testified that Mr. Glass refused to discuss the issue with
2922her, and told her that she would have to contact the individual
2934FQHCs. Ms. Mulder stated that Mr. Glass could not or would not
2946provide her with a list of the FQHCs. He referred her to AHCA
2959for the list. AHCA promised to provide the list, but never did
2971so.
297230. Finally, Ms. Mulder stated that she could find only one
2983RHC, and that it never returned her calls. She did not believe a
2996contract with an RHC would be workable in any event, because not
3008all of her patients live in the rural areas to which RHCs are
3021limited in their provision of services.
302731. AHCA demonstrated that the amendment to Rule 59G-4.010,
3036Florida Administrative Code, was properly promulgated, and that
3044the procedures instituted for its adoption were proper. The
3053agency considered the rule's impact on small business, concluding
3062it was negligible.
306532. The federal Health Care Financing Administration
3072("HCFA") reviewed and approved the proposed amendment to Rule
308359G-4.010, Florida Administrative Code. AHCA conceded that no
3091federal statute or rule mandates the limitation of mobile unit
3101services to entities affiliated with RHCs, FQHCs, or CHDs, but
3111contended that there would be practical difficulties in obtaining
3120HCFA approval of further changes to the approved rule.
3129CONCLUSIONS OF LAW
313233. Section 120.56(1)(a), Florida Statutes (1999),
3138provides: "Any person substantially affected by a rule or a
3148proposed rule may seek an administrative determination of the
3157invalidity of the rule on the ground that the rule is an invalid
3170exercise of delegated legislative authority." An existing rule
3178is presumed valid, and the petitioner challenging the rule has
3188the burden of establishing that it is invalid. St. Johns River
3199Water Management District v. Consolidated -Tomoka Land Company ,
3207717 So. 2d 72, 76 (Fla. 1st DCA 1998).
321634. Rule 59G-4.010, Florida Administrative Code,
3222incorporates by reference the January 1999 edition of the ARNP
3232Handbook. Petitioner challenges only pages 1-5 and 1-6 of the
3242ARNP Handbook. Petitioner demonstrated at hearing that it is
3251substantially affected by the challenged portion of the rule and
3261accordingly has standing to bring this rule challenge.
3269Petitioner has alleged a real and sufficiently immediate injury
3278in fact, in that the rule has forced it to cease serving Medicaid
3291clients from its mobile unit. Petitioner's alleged injury is
3300within the zone of interest that is regulated by the Medicaid
3311statutes purportedly implemented by the challenged portion of the
3320rule. See Lanoue v. Florida Department of Law Enforcement , 751
3330So. 2d 94 (Fla. 1st DCA 1999), and cases cited therein regarding
3342the "substantially affected" test to establish standing in a rule
3352challenge proceeding.
335435. AHCA contends that Petitioner's "alleged injury does
3362not appear substantial given the availability of the exceptions
3371and alternatives afforded" by the challenged portion of the rule,
3381i.e., the ability to contract with RHCs, FQHCs, or CHDs. A party
3393is not required to comply with a rule at his peril in order to
3407obtain standing to challenge the rule. Ward v. Board of Trustees
3418of the Internal Improvement Trust Fund , 651 So. 2d 1236, 1238
3429(Fla. 4th DCA 1995); Professional Firefighters of Florida, Inc.
3438v. Department of Health and Rehabilitative Services , 396 So. 2d
34481194, 1195 (Fla. 1st DCA 1981). A logical corollary is that a
3460party's ability to comply with the challenged rule should not
3470stand as a barrier to the challenge.
347736. Section 120.52(8), Florida Statutes (1999), provides:
"3484Invalid exercise of delegated legislative
3489authority" means action which goes beyond the
3496powers, functions, and duties delegated by
3502the Legislature. A proposed or existing rule
3509is an invalid exercise of delegated
3515legislative authority if any one of the
3522following applies:
3524(a) The agency has materially failed to
3531follow the applicable rulemaking procedures
3536or requirements set forth in this chapter;
3543(b) The agency has exceeded its grant of
3551rulemaking authority, citation to which is
3557required by s. 120.54(3)(a)1.;
3561(c) The rule enlarges, modifies, or
3567contravenes the specific provisions of law
3573implemented, citation to which is required by
3580s. 120.54(3)(a)1.;
3582(d) The rule is vague, fails to establish
3590adequate standards for agency decisions, or
3596vests unbridled discretion in the agency;
3602(e) The rule is arbitrary or capricious;
3609(f) The rule is not supported by competent
3617substantial evidence; or
3620(g) The rule imposes regulatory costs on the
3628regulated person, county, or city which could
3635be reduced by the adoption of less costly
3643alternatives that substantially accomplish
3647the statutory objectives.
3650A grant of rulemaking authority is necessary
3657but not sufficient to allow an agency to
3665adopt a rule; a specific law to be
3673implemented is also required. An agency may
3680adopt only rules that implement or interpret
3687the specific powers and duties granted by the
3695enabling statute. No agency shall have
3701authority to adopt a rule only because it is
3710reasonably related to the purpose of the
3717enabling legislation and is not arbitrary and
3724capricious or is within the agency's class of
3732powers and duties, nor shall an agency have
3740the authority to implement statutory
3745provisions setting forth general legislative
3750intent or policy. Statutory language
3755granting rulemaking authority or generally
3760describing the powers and functions of an
3767agency shall be construed to extend no
3774further than implementing or interpreting the
3780specific powers and duties conferred by the
3787same statute.
378937. The specific authority cited by AHCA is Section
3798409.919, Florida Statutes (1999), which provides: "The agency
3806shall adopt any rules necessary to comply with or administer ss.
3817409.901 -409.920 and all r ules necessary to comply with federal
3828requirements." Petitioner concedes that this provision allows
3835AHCA to adopt rules relative to the disbursement of Medicaid
3845funds for the delivery of health services to qualified
3854recipients. However, Petitioner contends that the selection of
3862some ARNP mobile service providers for reimbursement, to the
3871exclusion of others, is not "necessary" for the conduct of the
3882Medicaid program and requires a more specific grant of authority.
389238. The laws implemented by Rule 59G-4.010, Florida
3900Administrative Code, as set forth in the agency's notice of
3910rulemaking, are Sections 409.905, 409.908, and 409.9081, Florida
3918Statutes.
391939. Section 409.905, Florida Statutes, titled "Mandatory
3926Medicaid services," provides in relevant part:
3932The agency may make payments for the
3939following services, which are required of the
3946state by Title XIX of the Social Security
3954Act, furnished by Medicaid providers to
3960recipients who are determined to be eligible
3967on the dates on which the services were
3975provided. Any service under this section
3981shall be provided only when medically
3987necessary and in accordance with state and
3994federal law. Nothing in this section shall
4001be construed to prevent or limit the agency
4009from adjusting fees, reimbursement rates,
4014lengths of stay, number of visits, number of
4022services, or any other adjustments necessary
4028to comply with the availability of moneys and
4036any limitations or directions provided for in
4043the General Appropriations Act or chapter
4049216.
4050(1) Advanced registered nurse practitioner
4055services. - - The agency shall pay for services
4064provided to a recipient by a licensed
4071advanced registered nurse practitioner who
4076has a valid collaboration agreement with a
4083licensed physician on file with the
4089Department of Health or who provides
4095anesthesia services in accordance with
4100established protocol required by state law
4106and approved by the medical staff of the
4114facility in which the anesthetic service is
4121performed. Reimbursement for such services
4126must be provided in an amount that equals not
4135less than 80 percent of the reimbursement to
4143a physician who provides the same services,
4150unless otherwise provided for in the General
4157Appropriations Act. (Emphasis added)
416140. The underscored portion of Section 409.905 provides the
4170agency with authority to make reimbursement adjustments, but
4178limits that authority to those "adjustments necessary to comply
4187with the availability of moneys" and any limitations set forth by
4198the Legislature in the General Appropriations Act or in Chapter
4208216, Florida Statutes, which governs agency planning and
4216budgeting.
421741. Petitioner contends that this language provides no
4225authority for AHCA to differentiate between qualified Medicaid
4233providers or selectively allow reimbursement to one qualified
4241provider over another in the provision of ARNP services.
4250Petitioner contends that Section 409.905 provides for
4257reimbursement determinations "across the board," to be applied
4265evenly to every ARNP, without a distinction as to whether the
4276ARNP is employed by a private company, an RHC, an FQHC, or a CHD.
429042. Petitioner's contention has merit, under the
4297circumstances presented by this case. Section 409.905(1)
4304establishes that ARNP services are reimbursable, and provides no
4313basis for distinguishing between ARNP services provided by
4321private corporations and those provided by government affiliated
4329entities. The italicized statutory language is plainly aimed at
4338providing the agency flexibility in performing its legislatively
4346defined duties within budgetary constraints; it does not give the
4356agency authority to redefine its duties. The "adjustments" set
4365forth in the statute are in the nature of accounting or budgetary
4377adjustments, as opposed to substantive changes in the
4385reimbursable services enumerated below the underscored language,
4392including those for ARNPs. For example, the statute allows AHCA
4402to adjust the number of visits or services to comply with budget
4414constraints, but does not of itself allow the agency to adjust
4425the kind of services that are reimbursable. Similarly, the
4434statute allows AHCA to adjust reimbursement rates , but does not
4444of itself give the agency authority to declare some otherwise
4454qualified providers ineligible for reimbursement.
445943. It is concluded that the challenged portions of Rule
446959G-4.010, Florida Administrative Code, improperly enlarge or
4476modify the provisions of Section 409.905, Florida Statutes.
448444. Section 409.908, Florida Statutes, titled
"4490Reimbursement of Medicaid providers," provides in relevant part:
4498Subject to specific appropriations, the
4503agency shall reimburse Medicaid providers, in
4509accordance with state and federal law,
4515according to methodologies set forth in the
4522rules of the agency and in policy manuals and
4531handbooks incorporated by reference therein.
4536These methodologies may include fee
4541schedules, reimbursement methods based on
4546cost reporting, negotiated fees, competitive
4551bidding pursuant to s. 287.057, and other
4558mechanisms the agency considers efficient and
4564effective for purchasing services or goods on
4571behalf of recipients. Payment for Medicaid
4577compensable services made on behalf of
4583Medicaid eligible persons is subject to the
4590availability of moneys and any limitations or
4597directions provided for in the General
4603Appropriations Act or chapter 216. Further,
4609nothing in this section shall be construed to
4617prevent or limit the agency from adjusting
4624fees, reimbursement rates, lengths of stay,
4630number of visits, or number of services, or
4638making any other adjustments necessary to
4644comply with the availability of moneys and
4651any limitations or directions provided for in
4658the General Appropriations Act, provided the
4664adjustment is consistent with legislative
4669intent .
4671* * *
4674(3) Subject to any limitations or directions
4681provided for in the General Appropriations
4687Act, the following Medicaid services and
4693goods may be reimbursed on a fee -for -service
4702basis. For each allowable service or goods
4709furnished in accordance with Medicaid rules,
4715policy manuals, handbooks, and state and
4721federal law, the payment shall be the amount
4729billed by the provider, the provider's usual
4736and customary charge, or the maximum
4742allowable fee established by the agency,
4748whichever amount is less, with the exception
4755of those services or goods for which the
4763agency makes payment using a methodology
4769based on capitation rates, average costs, or
4776negotiated fees.
4778(a) Advanced registered nurse practitioner
4783services.
478445. The underscored language in Section 409.908, Florida
4792Statutes, is virtually identical to that discussed above in
4801Section 409.905, Florida Statutes. For the reasons discussed
4809above, it is concluded that the challenged portions of Rule 59G-
48204.010, Florida Administrative Code, improperly enlarge or modify
4828the provisions of Section 409.908, Florida Statutes. The
4836analysis is not affected by the fact that Section 409.908(3)
4846provides that allowable services or goods must be furnished in
4856accordance with Medicaid policy manuals and handbooks. The
4864policy manuals and handbooks are adopted by reference as rules,
4874and rules must comport with the specific provisions of law they
4885purport to implement.
488846. Section 409.90 81, Florida Statutes, titled
"4895Copayments," provides in relevant part:
4900(1) The agency shall require, subject to
4907federal regulations and limitations, each
4912Medicaid recipient to pay at the time of
4920service a nominal copayment for the following
4927Medicaid services:
4929(a) Hospital outpatient services: up to $3
4936for each hospital outpatient visit.
4941(b) Physician services: up to $2 copayment
4948for each visit with a physician licensed
4955under chapter 458, chapter 459, chapter 460,
4962chapter 461, or chapter 463.
4967(2) The agency shall, subject to federal
4974regulations and any directions or limitations
4980provided for in the General Appropriations
4986Act, require copayments for the following
4992additional services: hospital inpatient,
4996laboratory and X -ray services, transportation
5002services, home health care services,
5007community mental health services, rural
5012health services, federally qualified health
5017clinic services, and nurse practitioner
5022services. The agency may only establish
5028copayments for prescribed drugs or for any
5035other federally authorized service if such
5041copayment is specifically provided for in the
5048General Appropriations Act or other law.
505447. Section 409.9081, Florida Statutes, relates exclusively
5061to co-payments. On its face, it appears not to be implemented by
5073or related to the challenged portions of Rule 59G-4.010, Florida
5083Administrative Code. AHCA offered no evidence for or explanation
5092of any connection between this statute and the challenged
5101portions of the rule.
510548. At the final hearing and in its proposed final order,
5116AHCA contended that two other provisions of the governing
5125statutes are implemented by the challenged provisions of Rule
513459G-4.010, Florida Administrative Code. Those provisions are
5141Section 409.912(13)(a) and 409.913, Florida Statutes.
514749. Section 409.91 2(13)(a), Florida Statutes, provides:
5154The agency shall identify health care
5160utilization and price patterns within the
5166Medicaid program which are not cost -effective
5173or medically appropriate and assess the
5179effectiveness of new or alternate methods of
5186providing and monitoring service, and may
5192implement such methods as it considers
5198appropriate. Such methods may include
5203disease management initiatives, an integrated
5208and systematic approach for managing the
5214health care needs of recipients who are at
5222risk of or diagnosed with a specific disease
5230by using best practices, prevention
5235strategies, clinical -practice improvement,
5239clinical interventions and protocols,
5243outcomes research, information technology,
5247and other tools and resources to reduce
5254overall costs and improve measurable
5259outcomes.
526050. Section 409.913, Florida Statutes, provides the
5267following preliminary statement:
5270The agency shall operate a program to oversee
5278the activities of Florida Medicaid
5283recipients, and providers and their
5288representatives, to ensure that fraudulent
5293and abusive behavior and neglect of
5299recipients occur to the minimum extent
5305possible, and to recover overpayments and
5311impose sanctions as appropriate.
531551. Section 409.913 goes on to define the terms "abuse,"
"5325fraud," and "overpayment," then to list in detail the agency's
5335powers to curb those activities. Those powers include the
5344conduct of reviews, investigations, analyses and audits of
5352Medicaid providers; prepayment review of provider claims;
5359reporting of criminal violations to the Attorney General's
5367Medicaid Fraud Control Unit; peer review of Medicaid providers;
5376provider certification of submitted claims; provider retention of
5384records for five years and free agency access to those records;
5395provider repayment of for inappropriate, medically unnecessary or
5403excessive services; administrative remedies, including fine,
5409suspension, and termination of participation in the Medicaid
5417program; follow-up reviews of providers with a history of
5426overpayments; and the withholding of payments upon receipt of
5435reliable evidence of fraud or willful misrepresentation by the
5444provider.
544552. Putting aside the question of the agency's authority to
5455rely on statutory provisions not set forth as "specific
5464provisions of law implemented" in the rule, these late-cited
5473statutes are not properly implemented by the challenged portions
5482of Rule 59G-4.010, Florida Administrative Code.
548853. Section 409.912(13)(a), Florida Statutes, requires AHCA
5495to identify cost-ineffective and medically inappropriate health
5502care utilization and price patterns in the Medicaid program, and
5512permits the agency to implement "new or alternate methods of
5522providing and monitoring service." While the accompanying list
5530of methods is not exclusive, it does indicate a legislative
5540intent that the methods to be employed should be in the nature of
5553improvements in practice management techniques in utilization or
5561price patterns shown not to be cost effective or medically
5571appropriate as currently practiced.
557554. No persuasive evidence was presented at hearing that
5584the utilization or price patterns of ARNP mobile unit providers
5594are not cost-effective or medically necessary, or that the agency
5604conducted a review specific to mobile ARNP providers to determine
5614their utilization or price patterns. AHCA had in hand some
5624anecdotal evidence of utilization problems with mobile dental
5632units. Rather than treating these as problems related to such
5642services as dental examinations, which may be performed quickly
5651on many patients and thus invite abuse by unscrupulous providers,
5661the agency simply assumed that these problems were generic to all
5672mobile providers, including ARNPs. Even assuming that Section
5680409.912(13)(a) could be implemented by the rule at issue, AHCA
5690failed to meet the statutory condition precedent to introducing a
"5700new or alternate method of providing and monitoring service:"
5709it failed to identify utilization or price pattern problems that
5719would justify the restrictions placed on ARNP mobile unit
5728providers by the challenged portions of the rule.
573655. Section 409.913, Florida Statutes, requires the agency
5744to operate a program of Medicaid oversight designed to minimize
5754fraudulent and abusive behavior and to recover overpayments and
5763impose sanctions where appropriate. This requirement, and the
5771powers granted to the agency to meet it, substantially embody the
"5782pay and chase" concept that ACHA's witnesses derided at the
5792hearing as an inefficient, ineffective way to combat fraud and
5802abuse.
580356. AHCA is granted some authority to take preemptive
5812action to deny or withhold claims, but only as to individual
5823providers suspected of wrongdoing or known to have committed
5832violations in the past. Section 409.913, Florida Statutes,
5840provides no authority to take preemptive "fraud and abuse"
5849control measures against entire classes of providers, or to
5858subject a subclass of ARNPs to special "fraud and abuse"
5868controls, absent any evidence that the class or subclass has
5878engaged in fraudulent or abusive activities. To the extent AHCA
5888may rely on a statute not expressly cited in its rule as a
"5901specific provision of law implemented," the challenged portions
5909of Rule 59G-4.010, Florida Administrative Code, enlarge and
5917modify the provisions of Section 409.913, Florida Statutes.
592557. Section 409.913, Florida Statutes, provides that the
5933agency shall operate a program to oversee the Florida Medicaid
5943program to minimize fraudulent and abusive behavior and neglect
5952of recipients. The statute makes no provision for delegation of
5962the agency's authority to other entities. The challenged
5970portions of Rule 59G-4.010, Florida Administrative Code, allow
5978private ARNP mobile unit providers to participate in the Medicaid
5988program only through contractual arrangements with RHCs, FQHCs,
5996and CHDs. However, the rule does not require those entities to
6007contract with ARNPs, meaning that AHCA has delegated to those
6017entities the power to prevent private ARNP mobile unit providers
6027from participating in the Medicaid program at all. The agency's
6037witnesses made it clear that this delegation was a prime
6047motivation for drafting the rule as it did. In this respect, the
6059challenged portions of the rule contravene the provisions of
6068Section 409.913, Florida Statutes.
607258. AHCA argues that the rule is justified by the overall
6083goals of the Medicaid program: efficiency, economy, and quality
6092care. AHCA argues that it is the best judge of the means by
6105which those goals are to be achieved, quoting a recent federal
6116decision: "A general and undefined requirement of efficiency and
6125economy for the Medicaid program as a whole is a concept for
6137policy makers, not for the courts." Florida Pharmacy Association
6146v. Cook , 17 F.Supp. 3d 1293, 1301 (N.D. Fla. 1998).
615659. This argument is unpersuasive. For purposes of this
6165rule challenge proceeding, the ultimate "policy maker" is the
6174Legislature. The agency's policy decisions must be premised upon
6183specific statutory authority. In the Florida Pharmacy case, the
6192plaintiffs were attempting to challenge the ACHA's implementation
6200of a Medicaid pharmacy fee schedule that was expressly mandated
6210by the Legislature itself. In the instant case, ACHA pointed to
6221no persuasive legislative authorization for the challenged
6228portions of Rule 59G-4.010, Florida Administrative Code. The
6236general goals of efficiency, economy, and quality care do not
6246substitute for the specific authority required by Section
6254120.52(8)(b)&(c), Florida Statutes.
625760. Finally, the challenged portions of Rule 59G-4.010,
6265Florida Administrative Code, are arbitrary and capricious. An
"6273arbitrary" decision is one not supported by facts or logic, or
6284despotic. A "capricious" decision is one taken irrationally, or
6293without thought or reason. Board of Clinical Laboratory
6301Personnel v. Florida Association of Blood Banks , 721 So. 2d 317,
6312318 (Fla. 1st DCA 1998); Board of Trustees of the Internal
6323Improvement Trust Fund v. Levy , 656 So. 2d 1359, 1362 (Fla. 1st
6335DCA 1995). In undertaking this analysis, the undersigned is
6344mindful that these definitions
6348add color and flavor to our traditionally dry
6356legal vocabulary, but do not assist an
6363objective legal analysis. If an
6368administrative decision is justifiable under
6373any analysis that a reasonable person would
6380use to reach a decision of similar
6387importance, it would seem that the decision
6394is neither arbitrary nor capricious.
6399Dravo Basic Materials Company, Inc. v. Department of
6407Transportation , 602 So. 2d 632, 634 n.3 (Fla. 2d DCA 1992).
641861. Under any of the standards provided by the cited cases,
6429the challenged portion of Rule 59G-4.010 is arbitrary and
6438capricious. Having received anecdotal complaints of abuses by
6446mobile dental units, the agency leaped to the conclusion that
6456mobile units generally presented a fraud and abuse problem, and
6466crafted a rule that prohibits private ARNPs from providing mobile
6476unit services unless they are able to establish contractual
6485affiliations with RHCs, FQHCs, or CHDs. As noted above, the rule
6496does not require those entities to enter contracts with the
6506ARNPs, or even to negotiate with them. The evidence at hearing
6517established that CCI made substantial efforts to contract with
6526one of the named entities, and was uniformly rebuffed. The
6536practical effect of the rule has been to prohibit CCI from
6547providing ARNP mobile unit services to Medicaid recipients,
6555because the agency discovered abuses by mobile dental units.
6564There is no rational connection between the cause and effect of
6575the rule.
657762. AHCA promulgated the rule without making inquiry as to
6587the willingness or ability of RHCs, FQHCs, or CHDs to contract
6598with private ARNPs. Neither was evidence provided that the
6607agency chose those entities based on their ability to deliver the
6618ARNP mobile unit services differently or better than private
6627providers. The agency's stated reason for choosing these
6635entities was not their capacity for delivering services but their
6645ability to provide local oversight of the ARNPs' activities.
6654However, Ms. Metz testified that the rule would allow an ARNP to
6666contract with an RHC, FQHC, or CHD anywhere in the state, thus
6678rendering irrational the purported local control purpose.
668563. The evidence e stablished that ACHA promulgated the
6694challenged portions of the rule as part of a blanket amendment to
6706its practitioner handbooks, without thought for ARNP services in
6715particular. The agency conceded there was no evidence that ARNP
6725mobile unit providers were engaging in the abusive practices
6734found in the dental field, and provided no evidence as to the
6746pervasiveness of the abusive practices even among dental
6754providers. The agency provided no evidence that it even
6763considered whether the nature of ARNP services carries the
6772potential for such "Medicaid patient mill" abuses as it found in
6783certain mobile dental units. These factors further indicate that
6792the rule is arbitrary and capricious.
679864. In conclusion, Petitioner established, and Respondent
6805failed to refute, that the challenged portions of Rule 59G-4.010,
6815Florida Administrative Code, enlarge, modify, or contravene the
6823specific provisions of law implemented, and are arbitrary and
6832capricious.
6833ORDER
6834Based upon the foregoing Findings of Fact and Conclusio ns of
6845Law, it is ORDERED that pages 1-5 and 1-6 of the ARNP Handbook,
6858adopted by reference in Rule 59G-4.010, Florida Administrative
6866Code, constitute an invalid exercise of delegated legislative
6874authority within the meaning of Sections 120.52(8)(c)&(e),
6881Florida Statutes.
6883DONE AND ORDERED this 27th day of June, 2000, in
6893Tallahassee, Leon County, Florida.
6897___________________________________
6898LAWRENCE P. STEVENSON
6901Administrative Law Judge
6904Division of Administrative Hearings
6908The DeSoto Building
69111230 Apalachee Parkway
6914Tallahassee, Florida 32399-3060
6917(850) 488-9675 SUNCOM 278-9675
6921Fax Filing (850) 921-6847
6925www.doah.state.fl.us
6926Filed with the Clerk of the
6932Division of Administrative Hearings
6936this 27th day of June, 2000.
6942COPIES FURNISHED:
6944Bruce Culpepper, Esquire
6947Ackerman, Senterfitt & Eidson, P.A.
6952301 South Bronough Street, Suite 200
6958Post Office Box 10555
6962Tallahassee, Florida 32302-2555
6965Moses E. Williams, Senior Attorney
6970Agency for Health Care Administration
69752727 Mahan Drive, Mail Stop 3
6981Fort Knox Building Three, Suite 3431
6987Tallahassee, Florida 32308
6990Sam Power, Agency Clerk
6994Agency for Health Care Administration
69992727 Mahan Drive
7002Fort Knox Building Three, Suite 3431
7008Tallahassee, Florida 32308
7011Julie Gallagher, General Counsel
7015Agency for Health Care Administration
70202727 Mahan Drive
7023Fort Knox Building Three, Suite 3431
7029Tallahassee, Florida 32308
7032NOTICE OF RIGHT TO JUDICIAL REVIEW
7038A party who is adversely affected by this Final Order is entitled
7050to judicial review pursuant to Section 120.68, Florida Statutes.
7059Review proceedings are governed by the Florida Rules of Appellate
7069Procedure. Such proceedings are commenced by filing one copy of
7079a notice of appeal with the Clerk of the Division of
7090Administrative Hearings and a second copy, accompanied by filing
7099fees prescribed by law, with the District Court of Appeal, First
7110District, or with the District Court of Appeal in the Appellate
7121District where the party resides. The notice of appeal must be
7132filed within 30 days of rendition of the order to be reviewed.
- Date
- Proceedings
- Date: 11/27/2001
- Proceedings: Record Returned from the District Court of Appeal filed.
- Date: 10/05/2000
- Proceedings: Index, Record, Certificate of Record sent out.
- Date: 10/04/2000
- Proceedings: Received payment in the amount of $157.00 for Record received.
- Date: 10/02/2000
- Proceedings: Amended Index sent out.
- Date: 09/25/2000
- Proceedings: Letter to G. Blake from M. Williams In re: missing exhibits filed.
- Date: 09/20/2000
- Proceedings: Invoiced in the amount of $157.00 sent out.
- Date: 09/18/2000
- Proceedings: Index sent out.
- Date: 08/25/2000
- Proceedings: Petition for Attorney`s Fees filed. (DOAH Case No. 00-3528F extablished)
- Date: 08/25/2000
- Proceedings: Certificate of Service to be attached to Petition for Cost and Attorney`s Fees (filed via facsimile).
- Date: 08/04/2000
- Proceedings: Notice of Filing (conformed copy of the order of the lower tribunal with the 1st DCA) filed.
- Date: 07/31/2000
- Proceedings: Letter to DOAH from the District Court of Appeal filed. DCA Case No. 1D00-2922.
- Date: 07/28/2000
- Proceedings: Certified copy of Appeal (1st DCA) sent out.
- Date: 07/28/2000
- Proceedings: Notice of Appeal filed. (Filed by S. Grigas)
- PDF:
- Date: 06/27/2000
- Proceedings: Final Order sent out. CASE CLOSED. Hearing held February 17, 2000.
- Date: 04/12/2000
- Proceedings: Agency for Health Care Administration`s Proposed Final Order filed.
- Date: 04/12/2000
- Proceedings: Proposed Order Submitted by Consult Care, Inc. (For Judge Signature) filed.
- Date: 03/30/2000
- Proceedings: Joint Motion for Extension of Time to File Proposed Final Orders filed.
- Date: 03/13/2000
- Proceedings: Transcript filed.
- Date: 02/17/2000
- Proceedings: CASE STATUS: Hearing Held.
- Date: 02/14/2000
- Proceedings: Petitioner`s Notice of Taking Deposition of John Owens (filed via facsimile).
- Date: 02/14/2000
- Proceedings: Fax Civer Sheet to L. Davis from S. Rhymer Re: Request for subpoenas (filed via facsimile).
- Date: 02/14/2000
- Proceedings: (Petitioner) Objection to Respondent`s Motion to Amend Witness List (filed via facsimile).
- Date: 02/14/2000
- Proceedings: (Respondent) Motion to Amend Witness List as Stated in AHCA`s Unilateral Response to Order of Pre-Hearing Instructions filed.
- Date: 02/08/2000
- Proceedings: AHCA`s Response to June 15, 1999 Order of Pre-Hearing Instructions filed.
- Date: 02/07/2000
- Proceedings: Petitioner`s Response to Pretrial Instructions filed.
- Date: 01/10/2000
- Proceedings: (Respondent) Notice of Hearing (1/13/00; 1:00 p.m.) filed.
- Date: 01/03/2000
- Proceedings: AHCA`s Motion for Official Recognition w/exhibits filed.
- Date: 11/29/1999
- Proceedings: Agreed Motion for Continuance (filed via facsimile).
- Date: 11/23/1999
- Proceedings: Amended Notice of Hearing sent out. (hearing set for February 17 and 18, 2000; 9:00 a.m.; Tampa, FL; amended as to location only.)
- Date: 11/17/1999
- Proceedings: AHCA`s Motion for a Continuance filed.
- Date: 11/10/1999
- Proceedings: (Petitioner) Response to First Request for Production of Documents; Notice of Filing Petitioner`s First Set of Answers to AHCA`s of Interrogatories filed.
- Date: 10/29/1999
- Proceedings: (Respondent) Motion to Deem Admitted AHCA`s First Request for Admissions filed.
- Date: 10/26/1999
- Proceedings: (Bruce Culpepper) Notice of Change of Street Address filed.
- Date: 10/22/1999
- Proceedings: Petitioner`s Response to AHCA`s First Request for Admissions filed.
- Date: 10/12/1999
- Proceedings: AHCA`s Answer to the Petition filed.
- Date: 10/08/1999
- Proceedings: Amended Notice of Hearing sent out. (hearing set for December 14 and 15, 1999; 9:00 a.m.; Tampa, FL)
- Date: 10/04/1999
- Proceedings: Notice of Hearing sent out. (hearing set for December 14, 1999; 9:00 a.m.; Tampa, FL)
- Date: 09/20/1999
- Proceedings: AHCA`s Response to Petitioner`s Status Report (filed via facsimile).
- Date: 09/13/1999
- Proceedings: Petitioner`s Status Report (filed via facsimile).
- Date: 07/28/1999
- Proceedings: Petitioner`s Notice of Taking Depositions of Alan Strowd and Lynne Metz filed.
- Date: 07/13/1999
- Proceedings: Order of Abatement sent out. (Parties to advise status by 09/13/1999)
- Date: 07/12/1999
- Proceedings: Petitionre`s Response to Respondent`s Motion to Quash (filed via facsimile).
- Date: 07/12/1999
- Proceedings: AHCA`s Motion to Quash and Objections to Subpoenas Duces Tecum (filed via facsimile).
- Date: 07/09/1999
- Proceedings: Petitioner`s Motion to Produce to Respondent filed.
- Date: 07/09/1999
- Proceedings: Joint Stipulation for Abatement filed.
- Date: 06/25/1999
- Proceedings: Order Continuing Hearing sent out. (Video Hearing set for 1:00pm; Tampa & Talla; 7/12/99)
- Date: 06/15/1999
- Proceedings: (M. Williams, B. Culpepper) Stipulation for Consinuance and Hearing Date; (M. Williams) Notice of Appearance (filed via facsimile).
- Date: 06/10/1999
- Proceedings: Order of Pre-hearing Instructions sent out.
- Date: 06/10/1999
- Proceedings: Notice of Hearing sent out. (hearing set for June 29 and 30, 1999; 9:00 a.m.; Tallahassee, FL)
- Date: 06/09/1999
- Proceedings: Order of Assignment sent out.
- Date: 06/07/1999
- Proceedings: Letter to Liz Cloud & Carroll Webb from M. Lockard w/cc: Agency General Counsel sent out.
- Date: 06/01/1999
- Proceedings: Petition to Determine the Invalidity of Rule 59G-4.010, F.A.C. filed.
Case Information
- Judge:
- LAWRENCE P. STEVENSON
- Date Filed:
- 06/01/1999
- Date Assignment:
- 06/09/1999
- Last Docket Entry:
- 11/27/2001
- Location:
- Tampa, Florida
- District:
- Middle
- Agency:
- Agency for Health Care Administration
- Suffix:
- RX