08-000103
Munroe Regional Medical Center vs.
Agency For Health Care Administration
Status: Closed
Recommended Order on Thursday, April 10, 2008.
Recommended Order on Thursday, April 10, 2008.
1STATE OF FLORIDA
4DIVISION OF ADMINISTRATIVE HEARINGS
8MUNROE REGIONAL MEDICAL CENTER, )
13)
14Petitioner, )
16)
17vs. ) Case No. 08-0103
22)
23AGENCY FOR HEALTH CARE )
28ADMINISTRATION, )
30)
31Respondent. )
33)
34RECOMMENDED ORDER
36This case is before Administrative Law Judge T. Kent
45Wetherell, II, for resolution based upon the stipulated record
54filed by the parties on March 20, 2008. No hearing is
65necessary.
66APPEARANCES
67For Petitioner: Nicole K. Oeinck
72Munroe Regional Medical Center
76Post Office Box 60182
80Fort Myers, Florida 33906-6182
84For Respondent: Mari H. McCully, Esquire
90Department of Financial Services
94Division of Workers' Compensation
98200 East Gaines Street
102Tallahassee, Florida 32399-4229
105STATEMENT OF THE ISSUE
109The issue is whether the Petition for Resolution of Reimbursement Dispute was timely filed.
123PRELIMINARY STATEMENT
125On September 10, 2007, Petitioner filed a Petition for
134Resolution of Reimbursement Dispute with the Agency for Health
143Care Administration (Agency). On November 27, 2007, the Agency
152dismissed the petition as untimely.
157On or about December 24, 2007, the Agency received a letter
168from Petitioner contesting the dismissal of the petition. The
177Agency treated the letter as a request for a formal hearing, and
189on January 4, 2008, the Agency referred the matter to the
200Division of Administrative Hearings (DOAH) to "conduct all
208necessary proceedings required under the law, and to submit a
218Recommended Order to [the] Agency."
223The Agency's referral letter indicates that copies of the
232letter were sent to FairPay Solutions, Inc. (FairPay), and Lion
242Insurance Company. Neither of those companies sought to
250intervene in this proceeding.
254This case was initially assigned to Administrative Law
262Judge Bram D.E. Canter and set for final hearing on April 15,
2742008. The case was transferred to the undersigned on
283February 6, 2008.
286On March 20, 2008, the parties filed a Joint Pre-hearing
296Statement [and] Joint Motion for Determination Without Hearing
304or Via Telephone (Joint Motion). The Joint Motion "request[s]
313determination of the issues raised by the Petitioner based on
323the pleadings, these stipulations and the exhibits submitted
331herewith."
332The final hearing was cancelled on March 21, 2008, based
342upon the Joint Motion. The Order Canceling Hearing stated that
"352[t]his case will be decided based upon a stipulated record
362consisting of the exhibits attached to the Joint Motion and the
373stipulations included in that filing." The exhibits attached to
382the Joint Motion were marked as Joint Exhibits A through G.
393The Order Canceling Hearing directed the parties to file
"402copies of the governing statutes and rules, as well as a copy
414of the repealed reconsideration rule referenced in the Joint
423Motion." On March 28, 2008, the parties filed copies of
433Sections 440.015 and 440.13, Florida Statutes 1/ ; Florida
441Administrative Code Rule 69L-7.602; the current and prior
449versions of Florida Administrative Code Rule Chapter 59A-31; and
458the current and prior version of Florida Administrative Code
467Rule 69L-7.501, along with the current and prior version of the
478hospital reimbursement manual incorporated by reference in that
486rule. Official recognition is taken of these statutes, rules,
495and manuals.
497The Order Canceling Hearing gave the parties until April 4,
5072008, to file proposed recommended orders (PROs). Neither party
516filed a PRO. On March 28, 2008, the parties filed a Joint
528Response to Order Canceling Hearing, which included argument in
537support of their respective positions. Due consideration has
545been given to that filing.
550FINDINGS OF FACT
5531. Petitioner, a hospital, provided medical services to an
562injured employee/claimant in March 2006.
5672. In January 2007, Petitioner provided an itemized bill
576totaling $3,401.12 to the workers' compensation insurance
584carrier responsible for providing benefits to the injured
592employee/claimant. The bill was submitted through the carrier's
600claims handling entity, Packard Claims Administration (Packard).
6073. On or about February 13, 2007, Packard issued payment
617to Petitioner in the amount of $1,889.14. The payment was
628accompanied by a document showing how much of each charge was
639being paid. The parties refer to this document as the first
650Explanation of Bill Review (EOBR).
6554. The first EOBR uses Agency-approved "reason
662codes"-- e.g. , 08 ("Reimbursement is based on the applicable
673reimbursement fee schedule"); 13 ("Reimbursement is included in
683the allowance of another service"); and 20 ("Other: Unique EOBR
695code description")--in conjunction with other codes-- e.g. ,
703S01 ("This charge has been reviewed to a standard of
714reasonableness based on current industry benchmarks of charges
722and typical reimbursement for comparable services in your
730geographical area"--to explain the disallowances and reductions
738in the hospital's charges.
7425. Petitioner retained the services of The M.A.R.C. of the
752Professionals, Inc. (M.A.R.C.), for the purposes of securing
760additional payment from the carrier.
7656. On March 16, 2007, M.A.R.C. sent a "Pre-Suit Demand
775Letter" to FairPay, whose address and phone number was listed on
786the first EOBR. 2/ The letter contested the disallowances and
796reductions in the hospital's charges "due to Usual and Customary
806allowances," and demanded payment "on the total hospital
814charges."
8157. On May 22, 2007, M.A.R.C. sent a "formal appeal" letter
826to Packard, which stated in pertinent part:
833The hospital received a payment but the
840charges were reduced as usual and customary.
847Per the Florida Statute all compensable
853services for outpatient care shall be
859reimbursed at 75 percent of the hospital
866charges for medically necessary care.
871We are asking that you review this claim and
880reprocess for the correct amount of payment.
8878. On or about June 4, 2007, a second EOBR was sent to
900Petitioner. No additional payment accompanied the second EOBR.
9089. The second EOBR refers to the $1,889.14 that was "paid
920on prior bill," and denies additional payment based upon Agency-
930approved "reason code" 18 ("Duplicate Billing: Service
938previously paid, adjusted and paid, disallowed, or denied on
947prior claim form or multiple billing of service(s) billed on
957same date of service.").
96210. Thereafter, M.A.R.C. sent two additional "formal
969appeal" letters to Packard. The first letter, dated July 13,
9792007, took issue with the payment being based upon "usual and
990customary charges" rather than 75 percent of the hospital's
999charges, as well as the disallowance of certain charges. The
1009second letter, dated August 3, 2007, stated that "a formal
1019complaint may be filed" if the correct payment is not received
1030within ten days.
103311. On or about August 10, 2007, a third EOBR was sent to
1046Petitioner. No additional payment accompanied the third EOBR.
105412. The third EOBR, like the second EOBR, refers to the
1065$1,889.14 that was "paid on prior bill," and cites "reason code"
107718 as the basis for denying additional payment. The third EOBR
1088also cites code 901 ("Reviewer has previously reconsidered these
1098items timely and properly. Additional inquiries are untimely to
1107sustain any dispute over the payment recommendation.").
111513. The third EOBR was received by Petitioner on
1124August 17, 2007.
112714. On September 6, 2007, Petitioner mailed a Petition for
1137Resolution of Reimbursement Dispute to the Agency. The petition
1146contends that "the bill was not paid at 75%," that "some charges
1158were disallowed as included in other services," and that
"1167$668.45 [is] still due" on the bill.
117415. The petition was received by the Agency on
1183September 10, 2007, which is more than 30 days after Petitioner
1194received the first and second EOBRs, but within 30 days after
1205Petitioner received the third EOBR.
121016. The Agency dismissed the petition as untimely in a
1220letter dated November 27, 2007. The letter was addressed to
1230Petitioner, M.A.R.C., the workers' compensation insurance
1236carrier responsible for paying the claim, and FairPay.
1244CONCLUSIONS OF LAW
124717. DOAH has jurisdiction over the parties to and subject
1257matter of this proceeding pursuant to Sections 120.569 and
1266120.57(1), Florida Statutes.
126918. Workers' compensation insurance carriers are required
1276to disallow or adjust payment to health care providers if the
1287carrier, or its designee, "finds that overutilization of medical
1296services or a billing error has occurred, or there is a
1307violation of the practice parameters and protocols of treatment
1316established in accordance with this chapter." See § 440.13(6),
1325Fla. Stat.
132719. The carrier is required to provide notice of its
1337disallowance or adjustment of payment to the provider through an
1347EOBR. See Fla. Admin. Code R. 69L-7.602(1)(v), (5)(q).
135520. The EOBR is required to explain the disallowance or
1365adjustment of payment by using the "reason codes" listed in
1375Florida Administrative Code Rule 69L-7.602(5)(o). Id.
138121. The EOBR must provide additional explanation when
1389reason code 20 is used. See Fla. Admin. Code R.
139969L-7.602(5)(o)2.t. ("Use of EOBR code '20' is restricted to
1409circumstances when an above-listed EOBR code does not explain
1418the reason for payment, adjustment and payment, disallowance or
1427denial of payment. When using EOBR code '20,' an insurer must
1439reflect code '20' and include the specific explanation of the
1449code on the EOBR sent to the health care provider. . . .").
146322. The health care provider has 30 days from the receipt
1474of the EOBR to petition the Agency to resolve any dispute
1485concerning the disallowance or adjustment of payment by the
1494carrier. See § 440.13(7)(a), Fla. Stat. ("Any health care
1504provider, carrier, or employer who elects to contest the
1513disallowance or adjustment of payment by a carrier under
1522subsection (6) must, within 30 days after receipt of notice of
1533disallowance or adjustment of payment, petition the agency to
1542resolve the dispute."); Fla. Admin. Code R. 59A-31.008(1)
1551("[T]he thirty (30) day time period within which a petition must
1563be served upon the Agency begins upon receipt of the [EOBR] by
1575the health care provider . . . .").
158423. If the petition is not timely filed with the Agency,
1595it must be dismissed. See , e.g. , Specialty Risk Services v.
1605Agency for Health Care Admin. , Case No. 01-4148, at ¶ 98(DOAH
1616Jan. 9, 2003; AHCA Apr. 29, 2003) (dismissing untimely petition
1626for reimbursement dispute).
162924. The primary dispute in this case is when the 30-day
1640period commenced. If the period commenced upon Petitioner's
1648receipt of the first EOBR (or the second EOBR), then the
1659petition is untimely. If, however, the period commenced upon
1668Petitioner's receipt of the third EOBR, then the petition is
1678timely.
167925. Section 440.13(7)(a), Florida Statutes, is clear and
1687unambiguous, and must be strictly construed in accordance with
1696its plain meaning. See Fairpay Solutions v. Agency for Health
1706Care Admin. , 969 So. 2d 455, 458 (Fla. 1st DCA 2007) (strictly
1718construing Section 440.13(7)(b), Florida Statutes.)
172326. There is nothing in Section 440.13(7), Florida
1731Statutes, that allows for the 30-day period for filing a
1741petition with the Agency to be tolled for any reason.
175127. The Agency previously had a rule requiring the
1760provider to give the carrier an opportunity to "reconsider" its
1770disallowance or adjustment before the provider could file a
1779petition with the Agency, but that rule was repealed prior to
1790the events giving rise to this case. See Fla. Admin. Code R.
180259A-31.001(5) (repealed Apr. 2, 2006). And cf. Mednet Connect,
1811Inc. v. Agency for Health Care Admin. , Case No. 04-2978, 2006
1822Fla. Div. Adm. Hear. LEXIS 383, at ¶¶ 109-129 (DOAH Aug. 9,
18342006) (concluding that the "reconsideration process"
1840contemplated by the Agency's prior rules had been legally
1849ineffective since 1994 because the rule conflicted with the
1858timeframes in Section 440.13(7), Florida Statutes, including the
186630-day period for filing a petition), recommendation rejected on
1875other grounds , Order No. AHCA-07-0002-FOF-OLC (AHCA Jan. 1,
18832007), appeal pending , Case No. 1D07-0378.
188928. The Agency's current rules provide for a period of
1899negotiations between the provider and the carrier after the
1908petition and the carrier's response to the petition are filed
1918with the Agency. See Fla. Admin. Code R. 59A-31.012. Moreover,
1928the Agency's current rules make clear that:
1935Neither the request for, nor the conducting
1942of, an on-site audit, nor the referral of
1950the health care provider for peer review
1957consultation, nor independent medical
1961examination shall toll the time period for
1968petitioning the Agency for the resolution of
1975a reimbursement dispute as set forth in
1982section 440.13(7)(a), F.S. or the time
1988period for the carrier to submit requested
1995documentation under section 440.13(7)(b),
1999F.S.
2000Fla. Admin. Code R. 59A-31.008(4).
200529. It is not necessary to consider whether this rule
2015conflicts with Section 12 of the 2004 reimbursement manual,
2024which was incorporated by reference in the prior version of
2034Florida Administrative Code Rule 69L-7.501(1) and was in effect
2043at the time the medical services at issue in this case were
2055provided by Petitioner. Even if, as Petitioner argues, that
2064provision of the manual allows a petition to be filed with the
2076Agency after completion of an on-site audit, 3/ there is no
2087evidence that such an audit was conducted in this case.
209730. The period within which Petitioner was required to
2106file a petition contesting the disallowances and adjustments in
2115the first EOBR was not tolled by Petitioner's use of "other
2126means to secure additional payment from the carrier," nor was
2136the period "revived" by the second or third EOBRs, which simply
2147reaffirmed the disallowances and adjustments in the first EOBR.
2156Likewise, the second and third EOBRs did not give Petitioner new
2167opportunities to petition the Agency for resolution of the
2176reimbursement dispute that was clearly framed by the first EOBR.
218631. This is not a case where the EOBR was unclear or
2198otherwise insufficient to give the provider the required "notice
2207of disallowance or adjustment of payment" and commence the
221630-day period in Section 440.13(7)(a), Florida Statutes.
2223Compare Wyatt Bros. Construction v. Dept. of Labor & Employment
2233Security , Case 00-2572, 2000 Fla. Div. Adm. Hear. LEXIS 5421, at
2244the contrary, the first EOBR used the Agency-approved reason
2253codes to explain the disallowances and adjustments to payments
2262and provided additional, more specific explanations where
2269required; and, as reflected in M.A.R.C.'s March 2007 letter to
2279FairPay on Petitioner's behalf, there was no confusion regarding
2288the carrier's rationale for the disallowances and adjustments in
2297the first EOBR.
230032. In sum, the 30-day period in Section 440.13(7)(a),
2309Florida Statutes, commenced upon Petitioner's receipt of the
2317first EOBR, and the Agency properly dismissed the petition as
2327untimely because it was filed more than 30 days after Petitioner
2338received the first EOBR.
2342RECOMMENDATION
2343Based upon the foregoing Findings of Fact and Conclusions
2352of Law, it is
2356RECOMMENDED that the Agency issue a final order dismissing
2365the Petition for Resolution of Reimbursement Dispute as
2373untimely.
2374DONE AND ENTERED this 10th day of April, 2008, in
2384Tallahassee, Leon County, Florida.
2388S
2389T. KENT WETHERELL, II
2393Administrative Law Judge
2396Division of Administrative Hearings
2400The DeSoto Building
24031230 Apalachee Parkway
2406Tallahassee, Florida 32399-3060
2409(850) 488-9675 SUNCOM 278-9675
2413Fax Filing (850) 921-6847
2417www.doah.state.fl.us
2418Filed with the Clerk of the
2424Division of Administrative Hearings
2428this 10th day of April, 2008.
2434ENDNOTES
24351/ All statutory references in this Recommended Order are to the
24462007 version of the Florida Statutes.
24522/ According to the parties' stipulations, FairPay is a medical
2462bill review company often retained by workers' compensation
2470insurance carriers or their claims handling entities to review
2479medical bills.
24813/ The 2004 reimbursement manual defines "on-site audit" as "an
2491audit conducted at the hospital which compares the charges
2500listed on an itemized statement accompanying the DWC-90 (UB-92)
2509with the charges listed on the hospital's charge master. It
2519includes verifying that services were medically necessary,
2526related to the compensable admission, ordered and provided to
2535the patient based on the documentation in the patient's medical
2545record."
2546COPIES FURNISHED :
2549Nicole K. Oeinck
2552Munroe Regional Medical Center
2556Post Office Box 60182
2560Fort Myers, Florida 33906-6182
2564Mari H. McCully, Esquire
2568Department of Financial Services
2572Division of Workers' Compensation
2576200 East Gaines Street
2580Tallahassee, Florida 32399-4229
2583Richard J. Shoop, Agency Clerk
2588Agency for Health Care Administration
25932727 Mahan Drive, Mail Station 3
2599Tallahassee, Florida 32308
2602Holly Benson, Secretary
2605Agency for Health Care Administration
2610Fort Knox Building, Suite 3116
26152727 Mahan Drive
2618Tallahassee, Florida 32308
2621Craig H. Smith, General Counsel
2626Agency for Health Care Administration
2631Fort Knox Building, Suite 3431
26362727 Mahan Drive, Mail Station 3
2642Tallahassee, Florida 32308
2645NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
2651All parties have the right to submit written exceptions within
266115 days from the date of this Recommended Order. Any exceptions
2672to this Recommended Order should be filed with the agency that
2683will issue the Final Order in this case.
- Date
- Proceedings
- PDF:
- Date: 04/10/2008
- Proceedings: Recommended Order cover letter identifying the hearing record referred to the Agency.
- PDF:
- Date: 03/21/2008
- Proceedings: Order Canceling Hearing (parties to advise status by April 4, 2008).
- PDF:
- Date: 03/20/2008
- Proceedings: Joint Pre-hearing Statement Joint Motion for Determination Without Hearing or Via Telephone Hearing (exhibits not available for viewing) filed.
- PDF:
- Date: 01/22/2008
- Proceedings: Notice of Hearing by Video Teleconference (hearing set for April 15, 2008; 9:00 a.m.; Fort Myers and Tallahassee, FL).
- Date: 01/17/2008
- Proceedings: CASE STATUS: Pre-Hearing Conference Held.
- PDF:
- Date: 01/14/2008
- Proceedings: Notice of Authorization to Represent/Substitution of Counsel (filed by M. McCully).
Case Information
- Judge:
- T. KENT WETHERELL, II
- Date Filed:
- 01/04/2008
- Date Assignment:
- 02/04/2008
- Last Docket Entry:
- 10/24/2008
- Location:
- Fort Myers, Florida
- District:
- Middle
- Agency:
- ADOPTED IN TOTO
Counsels
-
Mari H. McCully, Esquire
Address of Record -
Nicole K. Oeinck
Address of Record -
Mari H McCully, Esquire
Address of Record
Related Florida Statute(s) (4):
Related Florida Rule(s) (5):
- 59A-31.001
- 59A-31.008
- 59A-31.012
- ......