12-001065 Ffva Mutual Insurance Company vs. Department Of Financial Services, Division Of Workers' Compensation Status: Closed Recommended Order on Wednesday, July 25, 2012.

Summary: Hospital is entitled to reimbursement for charges related to services provided at their outpatient clinic.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

FFVA MUTUAL INSURANCE COMPANY , )

)

Petitioner , )

)

vs. ) Case No. 12 - 1065

)

DEPARTMENT OF FINANCIAL )

SERVICES, DIVISION OF WORKERS ' )

COMPENSATION , )

)

Respondent, )

)

and )

)

OKEECHOBEE HOSPITAL, INC., )

d/b/a RAULERSON HOSPITAL, )

)

I ntervenor . )

)

RECOMMENDED ORDER

On May 15, 2012, an administrative hearing in this case was

held by video teleconference in Orlando and Tallahassee, Florida,

be fore William F. Quattlebaum, Administrative Law Judge, Division

of Administrative Hearings.

APPEARANCES

For Petitioner: Julie Lewis Hauf, Esquire

Law Office of Julie Lewis Hauf, P.L.

15880 Summerlin Road , Suite 300

PMB 315

Fort Myers, Florida 33908

For Respondent: Mari H. McCully, Esquire

Department of Financial Services

Division of Workers ' Compensation

200 East Gaines Street

Tallahassee, Florida 32399 - 4229

For Intervenor: Richard M. Ellis, Esquire

Rutledge, Ecenia and Purnell, P.A.

119 South Monroe Street, Suite 202

Post Office Box 551

Tallahassee, Florida 32301

STATEMENT OF THE ISSUE

The issue in this case is whether the Petitioner should be

required to pay $300 as workers ' compensation reimbursement for

medical services provided to a pa tient.

PRELIMINARY STATEMENT

On January 20, 2012, the Department of Financial Services,

Division of Workers ' Compensation (Department) , issued a

Reimbursement Dispute Determination directing FFVA Mutual

Insurance Company (Petitioner) to pay a $300 reimburs ement claim

submitted by Okeechobee Hospital, Inc., d/b/a Raulerson Hospital

(Raulerson) , for services provided to Patient C.D. (Patient).

The Petitioner, having previously declined to pay the claim,

filed a Petition for Administrative Hearing (Petition) to

challenge the Department ' s determination. On March 21, 2012, the

Department forwarded the Petition to the Division of

Administrative Hearings, which scheduled and conducted the

proceeding.

R aulerson filed a Petition to Intervene on April 13, 2012,

th at was granted on April 19, 2012.

At the hearing, a Motion for Taking Official Recognition

filed by Raulerson on May 10, 2012 , was granted. Joint Exhibits

1 through 8 were admitted into evidence. The Petitioner

presented the testimony of one witness. The Department presented

no witnesses. Raulerson presented the testimony of three

witnesses and had Exhibit 11 admitted into evidence.

A T ranscript of the hearing was filed on June 25, 2012.

P roposed recommended orders were due on Ju ly 5, 2012. The

De partment and Raulerson filed a Joint Proposed Recommended Order

on that date. The Petitioner submitted a Proposed Recommended

Order after normal business hours on July 5, 2012, and it was

docketed as filed at 8:00 a.m. on July 6, 2012, pursuant to

Florida Administrative Code Rule 28 - 106.104(3).

On July 9, 2012, Raulerson filed a Motion to Strike the

Petitioner ' s Proposed Recommended Order on grounds that it was

not timely filed. In response, the Petitioner filed a Motion for

Acceptance of Filing on July 10, 2012. Upon review of the

m otions, the Motion to Strike is hereby denied. Both proposed

recommended orders have been considered in the preparation of

this Recommended Order.

Prior to the hearing, the parties filed a Joint Pre - hearing

Stipulation cont aining a statement of admitted facts that have

been adopted and are incorporated herein as necessary.

FINDING S OF FACT

1. Raulerson is an acute care hospital in Okeechobee,

Florida, owned by Okeechobee Hospital, Inc.

2. Raulerson ' s licensed premises incl udes the acute care

hospital building and an additional building that contains a

physical therapy department and an outpatient clinic identified

as " Company Care. "

3. Company Care provides occupational health and workers '

compensation services to employ ees working for participating

employers. The clinic operates as a department of the hospital

and is staffed by salaried employees of the hospital. The

ambulatory care services provided at the clinic are hospital

services pursuant to Florida Administrativ e Code Rules 59A -

3.065(4) and 59A - 3.2085(7).

4. The Patient suffered a compensable injury on August 4,

2011, and was treated on that date at the Raulerson emergency

room.

5. On August 8 and 15, 2011, the Patient went to the

Raulerson outpatient clini c for evaluation and to have a

non - surgical wound dressing changed or removed.

6. Using a standard hospital billing form known as a UB - 04,

Raulerson submitted a single $400 bill to the Petitioner. The

bill contained a separate $200 charge for each of t he two

outpatient service dates.

7. The Florida workers ' compensation program refers to the

UB - 04 form as a DFS - F5 - DWC - 90 form.

8. Although the Petitioner attempted to assert at the

hearing that the outpatient services had not been fully

authorized, the stipulation filed by the parties prior to the

hearing clearly stated that the services were authorized by the

Petitioner and that there are no issues of medical necessity

presented in this case.

9. The Petitioner declined to pay the bill for the

out patient visits and issued an Explanation of Benefits Review

(EOBR) form that provided the following coded explanation for its

decision:

64 - PAYMENT DISALLOWED: BILLING ERROR: SERVI CE

" NOT COVERED " UNDER APPLICABLE WOR KERS '

COMPENSATION REIMBUR SEMENT MANUAL.

* * *

5218 - FACILITY CHARGE FOR TREATMENT ROOM OR

CLINIC VISIT HAS BEE N IMPROPERLY BILLED

PURSUANT TO NATIONAL UNIFORM BILLING MANU AL

GUIDELINES. PROFESS IONAL SERVICES RENDE RED

FOR FACILITY BASED P HYSICIAN ARE TO BE B ILLED

ON APPROPRIATE FORM. NO A DDITIONAL

REIMBURSEMENT GRANTE D FOR FACILITY FEE.

10. The standard billing form used by health care

professionals to file for reimbursement of medical claims is a

CMS - 1500 form (identified as the DFS - F5 - DWC - 9 form by the Florida

workers ' compensation pr ogram).

11. Essentially, the Petitioner has asserted that Raulerson

should have submitted bills for the outpatient services on a

professional services billing form rather than on a hospital

billing form.

12. The apparent effect of submitting the charge s on the

hospital billing form rather than the professional services

billing form was to increase the reimbursement rate paid for the

services.

13. There was no credible evidence that Raulerson ' s use of

the hospital billing form violated any applicable r equirements of

the Florida workers ' compensation program.

14. The Petitioner has previously paid similar claims that

were submitted on the UB - 04 hospital billing form.

15. Florida Administrative Code Rule 69L - 7.501 incorporates

by reference, the Florida Workers ' Compensation Manual for

Hospitals (2006 Edition), which, states, in relevant part, as

follows:

Section X: Outpatient Reimbursement

A. Reimbursement Amount

Except as otherwise provided in this Section,

hospital charges for services and supplies

provided on an outpatient basis shall be

reimbursed at seventy - five percent (75%) of

usual and customary charges for medically

necessary services and supplies, and shall be

subject to verification and adjustment in

accordance with Sections XI and XII of t his

manual.

* * *

Section XI: Disallowed, Denied and Disputed

Charges

* * *

B. Physician Services

The insurer shall not reimburse a hospital

for physician services when billed by the

hospital on the hospital billing form.

Proper billing an d reimbursement of physician

services rendered in any location, including

inside a hospital, shall be in accordance

with the requirements of rules 69L - 7.602 and

69L - 7.020.

16. Rule 69L - 7.602 is the Florida Workers ' Compensation

Medical Services Billing, F iling and Reporting Rule.

17. Rule 69L - 7.602(4)(c) requires that hospitals submit

bills using Form DFS - F5 - DWC - 90 (the hospital billing form).

18. Rule 69L - 7.602(4)(b)4.b. states as follows:

Outpatient billing - - Hospitals shall in

addition to filing a Form DFS - F5 - DWC - 90 :

I. Enter the CPT ® , HCPCS or workers '

compensation unique code and the applicable

CPT ® or HCPCS modifier code in Form Locator

44 on the Form DFS - F5 - DWC - 90, when required

pursuant to the UB - 04 Manual; and

II. Make written entry " scheduled " or

" non - scheduled " in Form Locator 80 of Form

revision 2006 -- ' Remarks ' on the DFS - F5 - DWC -

90, when billing outpatient surgery or

outpatient surgical services; and

III. Attach an itemized statement with

charges based on the facility ' s Charge

Master; and

IV. Submit all applicable documentation

required pursuant to Rule 69L - 7.501, F.A.C.;

V. Bill professional services provided by a

physician or recognized practitioner on the

Form DFS - F5 - DWC - 9, regardless of employment

arrangement . ( e mphasis supplied) .

19. Rule 69L - 7.602(1)(nn) sets forth the following relevant

definition:

" Recognized Practitioner " means a non -

physician health care provider licensed by

the Department of Health who works under the

protocol of a physician or who, upon referral

from a phys ician, can render direct billable

services that are within the scope of their

license, independent of the supervision of a

physician.

20. The services in this case were provided by an advanced

registered nurse practitioner (ARNP), a recognized practitione r

as defined by the rule. The coding on the bill submitted to the

Petitioner by Raulerson indicated that the services were provided

in a clinical setting (Revenue Code 510) by a recognized

practitioner (CPT Code 99211).

21. Review of the bill by the Dep artment indicated that the

charge for services attributed to " Revenue Code 5 10 " was a

" facility fee " rather than a professional services fee.

22. Raulerson did not submit a bill for the professional

services provided to the patient on August 8 and 15, 20 11 , by the

ARNP. No specific charges for physician services were included

on the bill at issue in this proceeding.

23. Whether rendered on an inpatient or outpatient basis,

the provision of hospital - based services routinely entails the

services of medic al professionals.

24. The evidence failed to establish that Raulerson was

legally required to submit a bill for professional services or

that the bill at issue in this case should have been submitted on

a professional services billing form.

CONCLUSIONS O F LAW

25. The Division of Administrative Hearings has

jurisdiction over the parties to and subject matter of this

proceeding. §§ 120.569 and 120.57, Fla. Stat. (2011).

26. The Department is the state agency charged with the

responsibility for resolving di sputes related to utilization and

reimbursement in the Florida workers ' compensation program.

§ 440.13(7), Fla . Stat. In this case, the Department determined

that the Petitioner ' s refusal to reimburse Raulerson was

improper.

27. Section 440.13 does not address which party bears the

burden of proof in this proceeding. The general rule is that

" the burden of proof, apart from statute, is on the party

asserting the affirmative of an issue before an administrative

tribunal. " Balino v. Dep ' t of HRS , 348 So . 2d 349, 350 (Fla. 1st

DCA 1977). Accordingly, Raulerson, as the party asserting that

it is owed money, bears the burden of establishing entitlement to

the payment by a preponderance of the evidence. Dep ' t of Banking

& Fin., Div. of Sec. & Investor Prot . v. Osborne Stern & Co. , 670

So. 2d 932, 934 (Fla. 1996); Fla. Dep ' t of Transp. v. J.W.C. Co. ,

396 So. 2d 778, 788 (Fla. 1st DCA 1981); also see § 120.57(1)(j)

( " Findings of fact shall be based upon a preponderance of the

evidence, except in penal or lice nsure disciplinary proceedings

or except as otherwise provided by statute. . . . " ). A

preponderance of the evidence is defined as " the greater weight

of the evidence " or evidence that " more likely than not " tends to

prove a certain proposition. Fireman ' s Fund Indemnity Co. v.

Perry , 5 So. 2d 862 (Fla. 1942); Gross v. Lyons , 763 So. 2d 276,

280 n.1. (Fla. 2000). Raulerson has established , by a

preponderance of the evidence, that it is entitled to be

reimbursed for seventy - five percent (75%) of usual and c ustomary

charges for medically necessary services and supplies pursuant to

Section X, Subsection A , of the Florida Workers ' Compensation

Manual for Hospitals (2006 Edition), which, in this case, is

$300.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that the Department of Financial Services,

Division of Workers ' Compensation, enter a final order affirming

the Reimbursement Dispute Determination dated January 20, 2012,

wherein the Department directed FFVA Mutual Insurance Company to

pay a $300 reimbursement claim filed by Raulerson Hospital.

DONE AND ENTERED this 25th day of July , 2012 , in

Tallahassee, Leon County, Florida.

S

WILLIAM F. QUATTLEBAUM

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 25th day of July , 2012 .

COPIES FURNISHED:

Julie Jones, CP, FRP, Agency Clerk

Department of Financial Services

Division of Legal Services

200 East Gaines Street

Tallahassee, Florida 32399 - 0390

Julie Lewis Hauf, Esquire

Law Office of Julie Lewis Hauf, P.L.

15880 S ummerlin Road , Suite 300

PMB 315

Fort Myers, Florida 33908

Mari H. McCully, Esquire

Department of Financial Services

Division of Workers ' Compensation

200 East Gaines Street

Tallahassee, Florida 32399 - 4229

Richard M. Ellis, Esquire

Rutledge, Ecenia and Purnell, P.A.

119 South Monroe Street, Suite 202

Post Office Box 551

Tallahassee, Florida 32301

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any e xceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.