15-003276MTR Randy R. Willoughby vs. Agency For Health Care Administration, Unitedhealthcare Of Florida, Inc., A Florida Corporation And Amerigroup Florida, Inc., A Florida Corporation Status: Closed DOAH Final Order on Monday, December 4, 2017.

Summary: Evidence fails to establish formula calculation should not be upheld.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

RANDY R. WILLOUGHBY,

Petitioner,

vs. Case No. 15 - 3276MTR

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Respondent.

_______________________________/

FINAL ORDER

On August 11, 2015, an a dministrative hearing in this case

was held by video teleconference in Tampa and Tallahassee,

Florida, before William F. Quattlebaum, Administrative Law Judge,

Division of Administrative Hearings .

APPEARANCES

For Petitioner: Brent Steinberg, Esquire

Brandon G. Cathey, Esquire

Swope , Rodante , P.A.

1234 E ast 5th Avenue

Tampa, Florida 33605

For Respondent: David N. Perry, Esquire

Xerox Recovery Services Group

Suite 300

2073 Summit Lake Drive

Tallahassee, Florida 32317

STATEMENT OF THE ISSUE

The issue in this proceeding is the amount payable to the

Agency for Health Care Administration (AHCA) to satisfy a

Medicaid lien under section 409.910, Florida Statutes (2015) . 1/

PRELIMINARY STATEMENT

On June 4, 2015, Randy R. Willoughby (Petitioner) filed with

the Division of Administrative Hearings (DOAH) a Petition to

Determine Amount Payable to Agency for Health Care Administrat ion

and Medicaid Health Maintenance Organizations in Satisfaction of

Medicaid Lien (the Petition).

On June 25, 2015, the Petitioner filed a Notice of Voluntary

Dismissal of the claims against the Health Maintenance

Organizations. The remaining claim cha llenges AHCAÓs lien for

recovery of medical expenses paid on behalf of the Petitioner in

the amount of $147,019.61.

By Notice of Hearing dated June 17, 2015, the hearing was

scheduled for August 11, 2015.

On July 30, 2015, the parties filed a Pre - heari ng

Stipulation containing an extensive statement of admitted facts.

The statement of admitted facts has been incorporated within the

Findings of Fact set forth below.

At the hearing, the PetitionerÓs E xhibits 1 through 39 were

admitted into evidence. A HCA presented no witnesses and offered

no exhibits.

The T ranscript of the hearing was filed on August 31, 2015.

Both parties filed proposed final orders that were reviewed in

the preparation of this Final Order.

FINDING S OF FACT

1. On November 2, 2012, the Petitioner, then 20 years old,

was a restrained passenger in his girlfriend's Ford Mustang when

it was t - boned on the passenger side by a Chevy pickup truck

operated by Eddie Ellison.

2. On November 2, 2012, immediately prior to the collision,

Eddi e Ellison, who was driving eastbound on Harney Road in

Hillsborough County, Florida, failed to stop at the stop sign at

Williams Road.

3. Eddie Ellison was negligent in the operation of his

Chevy Truck on November 2, 2012, and caused it to strike the Fo rd

Mustang occupied by the Petitioner.

4. Eddie Ellison's wife, Alberta Ellison, was the co - owner

of the Chevy truck.

5. The Petitioner was wearing his seatbelt at the time of

the collision, and there was no negligence on the part of the

Petitioner t hat was a proximate cause of any injury suffered by

him as a result of the motor vehicle collision.

6. There was no negligence on the part of any person other

than Eddie Ellison that was a proximate cause of the motor

vehicle collision on November 2, 20 12.

7. When the Hillsborough County Fire and Rescue team

arrived at the accident scene at approximately 8:20 p.m., the

Petitioner was unresponsive and exhibiting decorticate posturing.

He was extricated from the vehicle, intubated at the scene and

immed iately transported via ambulance to Tampa General Hospital

(TGH).

8. The Petitioner arrived at TGH by approximately

8:39 p.m., presenting in critical condition. He was admitted to

the Intensive Care Unit ( ICU ) , where he remained for 11 days.

9. The Petitioner suffered serious injuries as a result of

the collision, including: injuries to the brain; multiple

fractures to the skull, face, jaw, and other head injuries;

multiple pelvic fractures; pulmonary contusions; acute

respiratory failure; dysphagi a; and splenic lacerations.

10. On November 3, 2012, Stephen Reintjes, M.D., performed

a ventriculostomy, wherein he drilled through the right parietal

region of the Petitioner's skull and placed an external

ventricular drain (EVD) into the right latera l ventricle to

relieve the Petitioner's elevated intracranial pressure. The EVD

was removed on November 12, 2012.

11. On November 6, 2012, David Ciesla, M.D., and a TGH

resident, performed a percutaneous tracheostomy, wherein he

created an opening thro ugh the Petitioner's neck and placed a

windpipe because of the Petitioner's prolonged respiratory

failure. That same day, John Cha, M.D. , performed a percutaneous

endoscopic gastrostomy (PEG) , wherein a feeding tube was placed

into the Petitioner's stomac h due to the Petitioner's dysphagia.

The Petitioner's PEG tube was removed on January 3, 2013.

12. On November 9, 2012, Michael Harrington, M.D. ,

performed an open reduction and internal fixation (ORIF) of the

Petitioner's right zygomaticomaxillary fract ure, and a closed

reduction with maxillomandibular fixation (MMF) of the

Petitioner's right zygomatic arch fracture. Essentially, screws

and plates were implanted into the Petitioner's right cheekbone

and then his jaw was wired shut to facilitate healing. The

Petitioner's jaw remained wired shut until December 3, 2012, and

the MMF hardware was surgically removed on December 20, 2012.

13. On November 13, 2012, the Petitioner was transferred

from the ICU to a surgical trauma unit.

14. Once the Petitio ner became medically stable on

December 6, 2012, he was transferred to the Tampa General

Rehabilitation Center (TGRC). There, the Petitioner received

intensive physical and occupational therapy, speech and swallow

therapy, psychological services , and 24/ 7 rehabilitation nursing

care.

15. The Petitioner remained at TGRC until January 16, 2013 ,

75 days after the crash , when he was discharged to his home.

16. Medicaid paid a total of $147,019.61 for the

Petitioner's past medical expenses.

17. For ne arly two years following his discharge, the

Petitioner was unable to perform the tasks of daily living and

was completely dependent on his parents and girlfriend for his

care and supervision. The Petitioner was toileted, bathed , and

dressed by his parents and his girlfriend. The Petitioner could

not walk without assistance. All of the Petitioner's meals were

prepared for him. The Petitioner would become obsessive over

minor things, easily agitated , and frequently combative. The

Petitioner had violent o utbursts which required all three of his

caretakers to physically restrain him. If left unattended at

meals, the Petitioner would overeat until he would vomit. The

Petitioner gained a life - threatening 100 pounds over this period.

Beyond the most basic l evel, the Petitioner could not use a

computer, play video games, or engage in an active social life,

much less skateboard or participate in any of the other physical

activities he once enjoyed. The Petitioner spent the majority of

his time at home with hi s parents and girlfriend watching

television, with occasional supervised trips outside the home.

18. On June 12, 2013, the Petitioner filed suit against

Eddie Ellison and Alberta Ellison in the Circuit Court of the

Thirteenth Judicial Circuit, in and fo r Hillsborough County,

Florida, Case No: 13 - CA - 008277 ("the underlying lawsuit"),

seeking to recover damages in excess of $15,000.

19. In the underlying lawsuit, the Petitioner seeks to

recover damages for the following: medical expenses incurred in

th e past; medical expenses to be incurred in the future; lost

earnings incurred in the past; loss of earning capacity in the

future; property damage incurred in the past; pain, suffering,

disability, physical impairment, disfigurement, mental anguish,

inconv enience, aggravation of a disease or physical defect, and

loss of capacity for the enjoyment of life sustained in the past;

and pain, suffering, disability, physical impairment,

disfigurement, mental anguish, inconvenience, aggravation of a

disease or phys ical defect, and loss of capacity for the

enjoyment of life to be sustained in the future. The Petitioner

also seeks to recover costs incurred by the Petitioner in the

underlying lawsuit, pre - judgment interest at the statutory rate

for actual, out - of - pock et pecuniary losses from the date of the

loss, and attorney's fees to the extent allowed by law.

20. In the underlying lawsuit, the Petitioner sued his

uninsured motorist carrier, 21st Century Centennial Insurance

Company (21st Century), seeking to reco ver $10,000 in uninsured

motorist benefits owed to the Petitioner under an automobile

insurance policy paid for by the Petitioner's parents, Richard

and Linda Willoughby. The i nsurer denied coverage and refused to

pay the uninsured motorist benefits.

21 . In the underlying lawsuit, the Petitioner also sued

21st Century for violation of section 624.155, Florida Statutes,

seeking to recover the total amount of the Petitioner's damages

from 21st Century as provided in section 627.727(10), Florida

Statutes. The Petitioner also sought to recover from 21st

Century applicable pre - judgment interest, attorneys' fees

pursuant to sections 62 4.155, 627.727(10), and 627.428 and

taxable costs.

22. On February 13, 2015, the Petitioner agreed to settle

his claims aga inst 21st Century for $4,000,000.

23. The Petitioner received the settlement proceeds from

21st Century on March 16, 2015.

24. On March 20, 2015, the Petitioner and 21st Century

filed a joint stipulation to dismiss the PetitionerÓs claims

against 21s t Century with prejudice.

25. As of March 20, 2015, the Petitioner had incurred a

total of $50,375.32 in taxable costs, which the Petitioner repaid

to the Petitioner's counsel out of the 21st Century settlement

proceeds.

26. On May 14, 2015, a total of $147,844.16 was transferred

into an interest - bearing trust account for the benefit of AHCA

pending an administrative determination of the agency's right to

benefits under section 409.910.

27. The parties to this proceeding stipulated that, of the

$4 million paid by 21st Century, $3.99 million was Ðbad faith

damages , Ñ paid to settle the Petitioner's claim for damages under

s ection 627.727(10), on account of 21st Century's wrongful

failure to pay the Petitioner's uninsured motorist claim and

other viola tions of s ection 624.155.

28. The settlement agreement between the Petitioner and

21st Century does not specifically attribute any of the

$4 million settlement amount to Ðbad faithÑ and states that Ðall

sums set forth herein constitute damages on accou nt of personal

injuries or sickness.Ñ The settlement agreement further states

as follows:

The parties agree and acknowledge that this

agreement is a settlement of claims which are

contested and disputed. Any payments are not

to be construed as an admis sion of liability

on the part of 21st Century, which expressly

denies any liability for this action.

29 . The Petitioner also received a total of $20,000 from

Esurance Property and Casualty Insurance Co mpany , reflecting the

$10,000 limit of bodily injur y liability insurance and $10,000

limit of uninsured motorist coverage under the automobile

insurance policy that insured the driver of the Ford Mustang,

Kayliegh Lewis, at the time of the crash.

30 . The Petitioner's claims against Eddie Ellison and

Alb erta S. Ellison remain pending in the underlying lawsuit.

31 . As of the July 30, 2015, filing of the Pre - hearing

Stipulation, the Ellisons' insurer has only offered the $100,000

limit of bodily injury liability insurance to settle all of the

Petitioner' s claims against the Ellisons.

32 . The $4,020,000 paid to the Petitioner does not fully

compensate him for the full monetary value of all of his damages.

33 . The full monetary value of all of the Petitioner's

damages is at least $10 million.

34 . A t the time of the settlement with 21st Century, the

full monetary value of all of the Petitioner's damages was at

least $10 million.

35 . At the time of the settlement with 21st Century, the

Petitioner had suffered not less than $23,800 in lost wages.

36 . At the time of the settlement with 21st Century, the

Petitioner's work life expectancy through age 67 was 45 years.

37 . At the time of the settlement with 21st Century, the

Petitioner's loss of future earning capacity was within the range

of $794,1 35.92 and $2,093,950.12.

38 . At the time of the settlement with 21st Century, the

Petitioner's future medical expenses were projected to exceed

$5 million.

39 . At the time of the settlement with 21st Century, the

Petitioner's past non - economic damag es exceeded $1 million.

40 . At the time of the settlement with 21st Century, the

Petitioner's life expectancy was 59.7 years.

41 . At the time of the settlement with 21st Century, the

Petitioner's future non - economic damages were within the range of

$ 5 million to $10 million.

42 . Although the parties to this proceeding stipulated that

the Petitioner has recovered less than $147,019.61 as payment for

past medical expenses, the settlement agreement between the

Petitioner and 21st Century states that Ð all sums set forth

herein constitute damages on account of personal injuries or

sickness.Ñ

43 . The Petitioner is no longer eligible for Medicaid.

44 . Medicaid has not paid or committed to pay any funds for

the Petitioner's future medical care.

CONCLU SIONS OF LAW

45 . DOAH has jurisdiction over the parties to and subject

matter of this proceeding. See §§ 120.569, 120.57(1), and

409.910(17), Fla . Stat.

46 . Medicaid is a federal program, established in 1965 by

Title XIX of the Social Security Act, wh ich provides medical care

to needy individuals. The federal government provides funds to

state Medicaid programs, which then use the funds to pay the

costs of medical care provided to qualified individuals.

47 . AHCA is the state agency responsible for administering

the Florida Medicaid program. § 409.902, Fla. Stat.

48 . States that participate in the federal Medicaid program

are required to comply with applicable federal requirements,

including a requirement that a state must seek reimbursement for

me dical expenses incurred on behalf of qualified individuals if

such individuals subsequently recover funds from liable third

parties. It is often said that Congress wanted Medicaid to be a

"payer of last resort, that is, other available resources must be

u sed before Medicaid pays for the care of an individual enrolled

in the Medicaid program." S. Rep. No. 99 - 146, at 312 (1985),

reprinted in 1986 U.S.C.C.A.N. 42, 279. See also Ahlborn v.

Arkansas DepÓt of Human Servs. , 397 F.3d 620, 623 (8th Cir.

2005), af fÓd , Arkansas DepÓt of Health and Human Servs. v.

Ahlborn , 547 U.S. 268 (2006).

49 . In compliance with the federal requirements, the

Florida Legislature adopted s ection 409.910, the ÐMedicaid Third -

Party Liability Act.Ñ Section 409.910(1) provides as f ollows:

It is the intent of the Legislature that

Medicaid be the payor of last resort for

medically necessary goods and services

furnished to Medicaid recipients. All other

sources of payment for medical care are

primary to medical assistance provided by

Medicaid. If benefits of a liable third

party are discovered or become available

after medical assistance has been provided by

Medicaid, it is the intent of the Legislature

that Medicaid be repaid in full and prior to

any other person, program, or entity.

Medicaid is to be repaid in full from, and to

the extent of, any third - party benefits,

regardless of whether a recipient is made

whole or other creditors paid. Principles of

common law and equity as to assignment, lien,

and subrogation are abrogated to the extent

necessary to ensure full recovery by Medicaid

from third - party resources. It is intended

that if the resources of a liable third party

become available at any time, the public

treasury should not bear the burden of

medical assistance to the ext ent of such

resources.

50 . Section 409.910(11), which establishes the procedure by

which AHCA seeks reimbursement for Medicaid medical assistance

provided to a qualified individual, states as follows:

The agency may, as a matter of right, in

order to enf orce its rights under this

section, institute, intervene in, or join any

legal or administrative proceeding in its own

name in one or more of the following

capacities: individually, as subrogee of the

recipient, as assignee of the recipient, or

as lienhol der of the collateral.

(a) If either the recipient, or his or her

legal representative, or the agency brings an

action against a third party, the recipient,

or the recipientÓs legal representative, or

the agency, or their attorneys, shall, within

30 da ys after filing the action, provide to

the other written notice, by personal

delivery or registered mail, of the action,

the name of the court in which the case is

brought, the case number of such action, and

a copy of the pleadings. If an action is

broug ht by either the agency, or the

recipient or the recipientÓs legal

representative, the other may, at any time

before trial on the merits, become a party

to, or shall consolidate his or her action

with the other if brought independently.

Unless waived by t he other, the recipient, or

his or her legal representative, or the

agency shall provide notice to the other of

the intent to dismiss at least 21 days prior

to voluntary dismissal of an action against a

third party. Notice to the agency shall be

sent to a n address set forth by rule. Notice

to the recipient or his or her legal

representative, if represented by an

attorney, shall be sent to the attorney, and,

if not represented, then to the last known

address of the recipient or his or her legal

representat ive.

(b) An action by the agency to recover

damages in tort under this subsection, which

action is derivative of the rights of the

recipient or his or her legal representative,

shall not constitute a waiver of sovereign

immunity pursuant to s. 768.14.

(c) In the event of judgment, award, or

settlement in a claim or action against a

third party, the court shall order the

segregation of an amount sufficient to repay

the agencyÓs expenditures for medical

assistance, plus any other amounts permitted

und er this section, and shall order such

amounts paid directly to the agency.

(d) No judgment, award, or settlement in any

action by a recipient or his or her legal

representative to recover damages for

injuries or other third - party benefits, when

the age ncy has an interest, shall be

satisfied without first giving the agency

notice and a reasonable opportunity to file

and satisfy its lien, and satisfy its

assignment and subrogation rights or proceed

with any action as permitted in this section.

(e) Exc ept as otherwise provided in this

section, notwithstanding any other provision

of law, the entire amount of any settlement

of the recipientÓs action or claim involving

third - party benefits, with or without suit,

is subject to the agencyÓs claims for

reimbu rsement of the amount of medical

assistance provided and any lien pursuant

thereto.

(f) Notwithstanding any provision in this

section to the contrary, in the event of an

action in tort against a third party in which

the recipient or his or her legal

re presentative is a party which results in a

judgment, award, or settlement from a third

party, the amount recovered shall be

distributed as follows:

1. After attorneyÓs fees and taxable costs

as defined by the Florida Rules of Civil

Procedure, one - half of the remaining recovery

shall be paid to the agency up to the total

amount of medical assistance provided by

Medicaid.

2. The remaining amount of the recovery

shall be paid to the recipient.

3. For purposes of calculating the agencyÓs

recovery of medical assistance benefits paid,

the fee for services of an attorney retained

by the recipient or his or her legal

representative shall be calculated at 25

percent of the judgment, award, or

settlement.

4. Notwithstanding any provision of this

sectio n to the contrary, the agency shall be

entitled to all medical coverage benefits up

to the total amount of medical assistance

provided by Medicaid. For purposes of this

paragraph, Ðmedical coverageÑ means any

benefits under health insurance, a health

main tenance organization, a preferred

provider arrangement, or a prepaid health

clinic, and the portion of benefits

designated for medical payments under

coverage for workersÓ compensation, personal

injury protection, and casualty.

(g) In the event that th e recipient, his or

her legal representative, or the recipientÓs

estate brings an action against a third

party, notice of institution of legal

proceedings, notice of settlement, and all

other notices required by this section or by

rule shall be given to th e agency, in

Tallahassee, in a manner set forth by rule.

All such notices shall be given by the

attorney retained to assert the recipientÓs

or legal representativeÓs claim, or, if no

attorney is retained, by the recipient, the

recipientÓs legal representa tive, or his or

her estate.

(h) Except as otherwise provided in this

section, actions to enforce the rights of the

agency under this section shall be commenced

within 5 years after the date a cause of

action accrues, with the period running from

the la ter of the date of discovery by the

agency of a case filed by a recipient or his

or her legal representative, or of discovery

of any judgment, award, or settlement

contemplated in this section, or of discovery

of facts giving rise to a cause of action

unde r this section. Nothing in this

paragraph affects or prevents a proceeding to

enforce a lien during the existence of the

lien as set forth in subparagraph (6)(c)9.

51 . The formula set forth at s ection 409.910(11)(f)

essentially provides that the amoun t to be recovered by AHCA is

half of the total settlement recovery, after deducting taxable

costs and attorney fees (25 percent of the total settlement or

judgment) not to exceed the amount actually paid by Medicaid on

the beneficiary's behalf. In this ca se, the calculation under

the formula results in an amount in excess of what Medicaid

actually paid on behalf of the Petitioner, and accordingly, the

recovery amount being sought is $147,019.61.

52 . Section 409.910(17) establishes the procedure by which

a recipient can contest the medical expense damages payable to

the agency and provides as follows:

(17)(a) A recipient or his or her legal

representative or any person representing, or

acting as agent for, a recipient or the

recipientÓs legal represent ative, who has

notice, excluding notice charged solely by

reason of the recording of the lien pursuant

to paragraph (6)(c), or who has actual

knowledge of the agencyÓs rights to third -

party benefits under this section, who

receives any third - party benefit or proceeds

for a covered illness or injury, must, within

60 days after receipt of settlement proceeds,

pay the agency the full amount of the third -

party benefits, but not more than the total

medical assistance provided by Medicaid, or

place the full amoun t of the third - party

benefits in an interest - bearing trust account

for the benefit of the agency pending an

administrative determination of the agencyÓs

right to the benefits under this subsection.

Proof that such person had notice or

knowledge that the r ecipient had received

medical assistance from Medicaid, and that

third - party benefits or proceeds were in any

way related to a covered illness or injury

for which Medicaid had provided medical

assistance, and that such person knowingly

obtained possession or control of, or used,

third - party benefits or proceeds and failed

to pay the agency the full amount required by

this section or to hold the full amount of

third - party benefits or proceeds in an

interest - bearing trust account pending an

administrative det ermination, unless

adequately explained, gives rise to an

inference that such person knowingly failed

to credit the state or its agent for payments

received from social security, insurance, or

other sources, pursuant to s. 414.39(4)(b),

and acted with the intent set forth in s.

812.014(1).

(b) A recipient may contest the amount

designated as recovered medical expense

damages payable to the agency pursuant to the

formula specified in paragraph (11)(f) by

filing a petition under chapter 120 within 21

days a fter the date of payment of funds to

the agency or after the date of placing the

full amount of the third - party benefits in

the trust account for the benefit of the

agency pursuant to paragraph (a). The

petition shall be filed with the Division of

Adminis trative Hearings. For purposes of

chapter 120, the payment of funds to the

agency or the placement of the full amount of

the third - party benefits in the trust account

for the benefit of the agency constitutes

final agency action and notice thereof.

Final order authority for the proceedings

specified in 1this subsection rests with the

Division of Administrative Hearings. This

procedure is the exclusive method for

challenging the amount of third - party

benefits payable to the agency. In order to

successful ly challenge the amount payable to

the agency, the recipient must prove, by

clear and convincing evidence, that a lesser

portion of the total recovery should be

allocated as reimbursement for past and

future medical expenses than the amount

calculated by t he agency pursuant to the

formula set forth in paragraph (11)(f) or

that Medicaid provided a lesser amount of

medical assistance than that asserted by the

agency . (Emphasis add ed.)

53 . The evidence in this case fails to establish that

Medicaid provided a lesser amount of medical assistance than that

claimed by AHCA. The parties stipulated that Medicaid paid a

total of $147,019.61 for the Petitioner's past medical expenses.

The parties also stipulated that AHCA has not paid or committed

to pay any expen ses related to future medical care.

54 . Accordingly, the remaining issue presented in this case

is whether the Petitioner has established, by clear and

convincing evidence, that a lesser portion of the total recovery

should be allocated as reimbursement than the amount calculated

by AHCA pursuant to the formula set forth at s ection

409.910(11)(f). The Petitioner has failed to meet the burden.

55 . The parties stipulated that Ðof the $4 million paid by

21st Century, $3.99 million was Ò bad faith Ó damage s, paid to

settle the Petitioner's claim for damages under s ection

627.727(10), Florida Statutes.Ñ The Petitioner asserts that Ðbad

faithÑ damages are unavailable as a source for reimbursement of

medical expenses incurred by ACHA on the PetitionerÓs behal f.

56. Section 627.727(10) provides as follows:

The damages recoverable from an uninsured

motorist carrier in an action brought under

s. 624.155 shall include the total amount of

the claimantÓs damages, including the amount

in excess of the policy lim its, any interest

on unpaid benefits, reasonable attorneyÓs

fees and costs, and any damages caused by a

violation of a law of this state. The total

amount of the claimantÓs damages is

recoverable whether caused by an insurer or

by a third - party tortfeasor .

57 . Section 624.155(1)(b) establishes a civil cause of

action against an insurer for a variety of reasons including Ðnot

attempting in good faith to settle claims when, under all the

circumstances, it could and should have done so, had it acted

fairl y and honestly toward its insured and with due regard for

her or his interests.Ñ

58 . The actual settlement agreement executed between the

Petitioner and 21st Century fails to support a finding that the

$3.99 million was a Ðbad faithÑ penalty based on th e alleged

wrongful failure by 21st Century to pay the Petitioner's

uninsured motorist claim and other violations of s ection 624.155.

The agreement states that it was not to be construed as an

admission of liability by 21st Century and that the parties

ent ered into the agreement to settle the dispute. The agreement

further specifically states that Ðall sums set forth herein

constitute damages on account of personal injuries or sickness.Ñ

59 . Additionally, the agreement to settle the case was

executed so lely between the Petitioner and the insurer. AHCA was

not a party to the settlement. Even assuming the settlement

agreement contained an allocation of damages as asserted by the

Petitioner, AHCA would not be bound by the allocation. To find

otherwise wo uld allow the parties to a settlement to escape the

statutory Medicaid reimbursement formula merely by reducing the

allocation identified in the settlement as Ðmedical expenses.Ñ

See Agras v Ag. for Health Care Admin. , Case No. 14 - 2403MTR,

(Fla. DOAH Oct. 30, 2014); Mobley v. Ag. for Health Care Admin. ,

Case No. 13 - 4785MTR (Fla. DOAH May 21, 2014); Savasuk v. Ag. for

Health Care Admin. , Case No. 13 - 4130MTR (Fla. DOAH Jan. 29,

2014).

ORDER

Based on the foregoing Findings of Fact and Conclusions of

Law, it is hereby ORDERED that the Respondent, Agency for Health

Care Administration, is entitled to reimbursement from the

Petitioner , Randy R. Willo u ghby, in the amount of $147,019.61,

pursuant to section 409.910(11)(f), in satisfaction of its

Medicaid lien.

DON E AND ORDERED this 7th day of October , 2015 , in

Tallahassee, Leon County, Florida.

S

WILLIAM F. QUATTLEBAUM

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahass ee, 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 7th day of October , 2015 .

ENDNOTE

1/ All citations to the Florida Statutes are to the 2015 editio n

unless stated otherwise.

COPIES FURNISHED:

Alexander R. Boler, Esquire

Xerox Recovery Services Group

Suite 300

2073 Summit Lake Drive

Tallahassee, Florida 32317

(eServed)

Brandon G. Cathey , Esquire

Swope , Rodante, P.A.

1234 East 5th Avenue

Tampa, F lorida 33605

Brent Steinberg, Esquire

Swope, Rodante , P.A.

1234 E ast 5th Avenue

Tampa, Florida 33605

(eServed)

C.T. Corporation System

1200 South Pine Island Road

Plantation, Florida 33324

David N. Perry, Esquire

Xerox Recovery Services Group

Suite 3 00

2073 Summit Lake Drive

Tallahassee, Florida 32317

(eServed)

Richard Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Elizabeth Dudek, Secretary

Agency for Health Care Admin istration

2727 Mahan Drive, Mail Stop 1

Tallahassee, Florida 32308

(eServed)

Stuart Williams, General Counsel

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is entitled

to judicial review pursuant to section 120.68, Florida Statutes.

Review proceedings are governed by the Florida Rules of Appellate

Procedure. Such proceedings are commenced by filing the ori ginal

notice of administrative appeal with the agency clerk of the

Division of Administrative Hearings within 30 days of rendition

of the order to be reviewed, and a copy of the notice,

accompanied by any filing fees prescribed by law, with the clerk

of th e District Court of Appeal in the appellate district where

the agency maintains its headquarters or where a party resides or

as otherwise provided by law.