19-001517 Luis Aponte, M.D. vs. Department Of Financial Services, Division Of Workers' Compensation
 Status: Closed
Recommended Order on Friday, October 4, 2019.


View Dockets  
Summary: Petitioner failed to prove that petitions for resolution of reimbursement disputes in two separate cases met the requirements to be considered on the merits. Petitions in both cases were untimely; recommend dismissal.

1STATE OF FLORIDA

4DIVISION OF ADMINISTRATIVE HEARINGS

8LUIS APONTE, M.D.,

11Petitioner,

12vs. Case Nos. 19 - 1517

1819 - 2 653

22DEPARTMENT OF FINANCIAL

25SERVICES, DIVISION OF WORKERS '

30COMPENSATION,

31Respondent.

32_______________________________/

33RECOMMENDED ORDER

35On August 8, 2019, a disputed - fact evidentiary hearing was

46held in these consolidated cases by video teleconference at sites

56in Tampa and Tallahassee, Florida, before Elizabeth W. McArthur,

65Administrative Law Judge of the Divisio n of Administrative

74Hearings (DOAH) .

77APPEARANCES

78For Petitioner: Luis Aponte, M.D., pro se

85Post Office Box 4542

89Tampa, Florida 33677

92For Respondent: Thomas Nemecek, Esquire

97Keith C. Humphrey, Esquire

101Department of Financial Services

105Division of Workers ' Compensation

110200 East Gaines Street

114Tallahassee, Florida 32399 - 4229

119STATEMENT OF THE ISSUE

123The issue in these consolidated cases is whether two

132Petitions for Resolution of Reimbursement Dispute are entitled to

141be considered on the merits, or whether, instead, they should be

152dismissed.

153PRELIMINARY STATEMENT

155On February 8, 2019, Luis Aponte, M.D. (Dr. Aponte or

165Petitioner) , served a Peti tion for Resolution of Reimbursement

174Dispute on the Department of Financial Services, Division of

183Workers ' Compensation, Medical Services Section (Department or

191Respondent). On February 21, 2019, the Department issued a

200Reimbursement Dispute Dismissal, di smiss ing the pe tition as

210untimely. Dr. Aponte was informed of his right to request an

221administrative hearing to contest the dismissal, and he timely

230exercised that right. The matter was transmitted to DOAH, and

240assigned Case No. 19 - 1517.

246Dr. Aponte serve d another Petition for Resolution of

255Reimbursement Dispute on the Department on January 31, 2019,

264seeking resolution of different reimbursement disputes. The

271Department issued a Notice of Deficiency, and gave Dr. Aponte ten

282days to cure the deficiencies. Dr. Aponte timely responded to

292the Notice of Deficiency, but the Department took the position

302that he did not cure the deficiencies. On March 29, 2019, the

314Department issued a Reimbursement Dispute Dismissal, dismissing

321the p etition for failure to cure a ll deficiencies. Dr. Aponte

333was informed of his right to request an administrative hearing,

343and he timely exercised that right. The matter was transmitted

353to DOAH and assigned Case No. 19 - 2653.

362At the request of the parties, the two cases were

372consolidat ed and set f or hearing on August 8, 2019.

383At the hearing, Petitioner testified on his own behalf.

392Respondent presented the testimony of Marcia Paulk, R.N., and

401Stephanie Law, R.N. Respondent ' s Exhibits 1 through 6 1/ were

413admitted into evidence without o bjection.

419The one - volume Transcript of the final hearing was filed on

431August 22, 2019. Respondent timely filed its p roposed

440r ecommended o rder, which has been considered in the preparation

451of this Recommended Order. As of the date hereof, Petitioner has

462n ot filed a p roposed r ecommended o rder.

472FINDING S OF FACT

4761. The Department is the state agency with exclusive

485jurisdiction to resolve reimbursement disputes between health

492care providers and carriers under section 440.13(7), Florida

500Statutes (2019), 2/ part of the Workers ' Compensation Law.

5102. Dr. Aponte is a physician. As such, he is a health care

523provider, as defined in section 440.13(1)(g). Dr. Aponte

531operates a business called Body Contouring, Inc., at which he

541provides medical services to patients, i ncluding injured workers.

5503 . Sedgwick Claims Management Services, Indemnity Insurance

558Company of North America, The Hartford Medical Bill Processing

567Center, and Twin City Fire Insurance Company are carriers, as

577defined in section 440.13(1)(c).

5814. At is sue in both cases are bills submitted by Dr. Aponte

594to one of the referenced carriers for services provided to

604injured worker s , which were paid, in part, and adjusted by the

616carrier.

6175. In each case, Dr. Aponte was notified of the adjustments

628to each bi ll by means of an Explanation of Bill Review (EOBR)

641from the carrier explaining why his bill was not fully paid.

6526. If a health care provider such as Dr. Aponte is

663dissatisfied with a carrier ' s adjustment or disallowance of

673charges on a bill for services to an injured worker, the

684provider ' s recourse is to serve a Petition for Resolution of

696Reimbursement Dispute on the Department within 45 days after the

706provider receives the EOBR.

7107. In both consolidated cases, Dr. Aponte seeks to contest

720certain carrier adjustments to bills submitted for services he

729rendered to injured workers. The specific adjustments he seeks

738to contest are reductions to his charges that were explained in

749EOBRs as being made pursuant to a contractual arrangement. Each

759EOBR making this adjustment identified a preferred provider

767organization (PPO) network -- Coventry Pend and Transmit, or

776Coventry P&T -- and each EOBR explained that the PPO reduction was

788made pursuant to the terms of Dr. Aponte ' s/Body Contouring,

799Inc. ' s contract with Aetna.

8058. Dr. Aponte seeks to contest these PPO reductions because

815he claims that the contract with Aetna was terminated. The

825merits of the reimbursement disputes a re not at issue, however.

836The sole issue presented is whether the Department should accept

846Dr. A ponte ' s p etitions and proceed to resolve the reimbursement

859disputes presented.

861Case No. 19 - 1517

8669. On May 2, 2018, an injured worker had a 15 - minute

879outpatient office visit with Dr. Aponte at Body Contouring, Inc.

88910. Dr. Aponte submitted a bill for the 15 - minute

900outpatient office visit to the employer ' s carrier. The billed

911amount was $125.00.

91411. The bill was adjusted by the carrier for two reasons

925explained in an EOBR issued on May 11, 2018. The carrier reduced

937the charge because it exceeded the fee schedule allowance in the

948Florida Workers Compensation Health Care Provider Reimbursement

955Manual (Provider Manual). The carrier also reduced the charge by

965an additional $25.37, based on a written contractual arrangement.

974The EOBR identified the " PPO Net work " as Coventry Pend and

985Transmit, or Coventry P&T, and the explanatory notes indicated

994that the Coventry P&T PPO reduction was " in accordance with your

1005Aetna contract. " After the two adjustments, Dr. Aponte was paid

1015$54.63.

101612. The May 11, 2018, EOBR included the notice required by

1027the Department for carrier EOBR forms. The notice specified that

1037the health care provider may elect to contest the disallowance or

1048adjustment of payment under section 440.13(7), and that such an

1058election must be made by the provider within 45 days of receipt

1070of the EOBR.

107313. Dr. Aponte did not timely serve a Petition for

1083Resolution of Reimbursement Dispute on the Department to contest

1092the adjustments in the May 11, 2018, EOBR. Instead, he

1102communicated directly with the car rier. Ultimately, on

1110February 6, 2019, Dr. Aponte resubmitted the same bill to the

1121carrier for the 15 - minute outpatient office visit on May 2, 2018,

1134with the same $125.00 charge, and asked the carrier to

1144reconsider.

114514. That same day -- February 6, 2019 -- t he carrier issued a

1159second EOBR. The EOBR indicated that payment of the resubmitted

1169$125.00 bill was disallowed in its entirety, and gave the

1179following explanation: " billing error: duplicate bill. "

118515. Dr. Aponte prepared a Petition for Resolution of

1194R eimbursement Dispute on the form required by the Department

1204(incorporated by reference in a rule), and served it on the

1215Department on February 8, 2019.

122016. Dr. Aponte ' s petition asserted that the EOBR he was

1232contesting was received on February 6, 2019, wh ich was the date

1244on which the second EOBR was issued.

125117. Dr. Aponte identified a single issue in dispute:

1260whether the carrier improperly adjusted the charge by applying a

1270PPO network reduction of $25.37. Dr. Aponte contended that

" 1279there is no contract between Luis Aponte, MD/Body Contouring [,]

1290Inc. [,] and Coventry. "

129518. However, the PPO network adjustment was not made in the

1306February 6, 2019, EOBR. The adjustment Dr. Aponte wanted to

1316contest was made in the May 11, 2018, EOBR.

132519. Dr. Aponte attache d both the May 11, 2018, EOBR and the

1338February 6, 2019, EOBR to his petition. He added the following

1349explanation for attaching the two EOBRs: " A petition for

1358resolution of reimbursement dispute was previously submitted to

1366the FL Dept. Financial Services on 07/30/18 initiating this

1375reimbursement dispute. "

137720. The Department reviewed the petition and attachments to

1386determine if the petition was timely served. Since the 45 - day

1398window to serve a petition begins to run upon receipt of the

1410EOBR, the Departme nt has a " computation of time " rule providing

1421alternative ways for a provider to prove the date of EOBR

1432receipt. See Fla. Admin. Code R. 69L - 31.008. One way is by

1445showing a date stamp affixed by the provider to the EOBR on the

1458date of receipt. Another w ay is through a verifiable login

1469process. The third way is to show the postmark date on the

1481envelope in which the EOBR was received, in which case five

1492calendar days is added to the postmark date to allow for mail

1504time. If the provider does not utilize o ne of these three

1516methods to prove the date of receipt, the Department will use the

" 1528default " method in its rule, whereby the EOBR receipt date is

1539deemed to be five calendar days after the date on which the EOBR

1552was issued.

155421. Dr. Aponte did not utilize one of the three options in

1566the Department ' s rule, which are set forth in the form petition,

1579to prove the dates on which he received either EOBR. As noted

1591above, he completed the petition by giving only the date on which

1603he received the second EOBR.

160822. The Department applied the default method in its rule

1618to determine the receipt date of the first EOBR, which is the

1630EOBR that made the PPO reduction adjustment sought to be

1640challenged. The Department determined that Petitioner was deemed

1648to have received the first EOBR on May 16, 2018. Accordingly,

1659the deadline for serving a petition to contest the adjustments in

1670the May 11, 2018, EOBR was June 30, 2018, 45 calendar days after

1683May 16, 2018.

168623. The Petition for Resolution of Reimbursement Dispute at

1695iss ue in this case, served on the Department on February 8, 2019,

1708was more than seven months too late. 3/ Petitioner offered no

1719evidence or argument to excuse his untimely submittal.

1727Case No. 19 - 2653

173224. Dr. Aponte provided services to an injured worker at

1742Body Contouring, Inc., on October 10, 2018, and October 31, 2018,

1753for which Dr. Aponte submitted bills to the employer ' s carrier.

1765Bill for Services on October 10, 2018

17722 5. On October 10, 2018, Dr. Aponte saw the patient for an

1785outpatient office visit at B ody Contouring, Inc., at which

1795Dr. Aponte provided prolonged evaluation and management (E&M).

1803Dr. Aponte ' s charges submitted to the carrier were $450.00 for

1815the office visit and $220.00 for the prolonged E&M service.

182526. An EOBR was issued on November 16 , 2018, adjusting both

1836charges for two reasons explained in the EOBR.

184427. Both charges were reduced because they exceeded the fee

1854schedule in the Provider Manual. Both charges were further

1863reduced by a total of $79.91 pursuant to a written contractual

1874ar rangement. The EOBR explained these adjustments as Coventry

1883P&T PPO reductions " in accordance with your Aetna contract. "

189228. After the adjustments, Dr. Aponte was paid $260.09.

190129. The 45 - day deadline to serve a petition on the

1913Department to contest th e adjustments explained in the

1922November 16, 2018, EOBR was January 5, 2019 (using the default

1933methodology to determine the EOBR receipt date in the absence of

1944any other evidence). Dr. Aponte did not timely serve a Petition

1955for Resolution of a Reimburseme nt Dispute on the Department to

1966contest the adjustments in the November 16, 2018, EOBR. Instead,

1976he communicated directly with the carrier and requested a re -

1987evaluation of the bill.

199130. The carrier issued a second EOBR on December 31, 2018,

2002disallowing p ayment of both line item charges on the resubmitted

2013bill. The explanation in the EOBR for disallowing payment was

" 2023billing error: line item service previously billed and

2031reimbursement decision previously rendered. "

2035Bill for Services on October 31, 2018

20423 1. On October 31, 2018, Dr. Aponte saw the same injured

2054worker for another outpatient office visit at Body Contouring,

2063Inc., at which the patient received two injections. Dr. Aponte ' s

2075charges submitted to the carrier were : $300.00 for the office

2086visit ; $330.00 for one injection ; and $100.00 for the other

2096injection.

209732. An EOBR was issued on November 21, 2018, adjusting the

2108office visit charge and disallowing the two injection charges,

2117for reasons explained in the EOBR.

212333. The $300.00 office visit char ge was reduced because it

2134exceeded the fee schedule allowance in the Provider Manual. The

2144charge was further reduced by $48.16, pursuant to a written

2154contractual arrangement. The EOBR explained the latter reduction

2162as a Coventry P&T PPO reduction, " in ac cordance with your Aetna

2174contract. " The EOBR also explained that both injection charges

2183were disallowed because the documentation did not substantiate

2191that the services billed were rendered. After the adjustments

2200and the disallowances, Dr. Aponte was pai d $110.84.

220934. The 45 - day deadline to serve a petition on the

2221Department to contest the adjustments or disallowances in the

2230November 21, 2018, EOBR was January 10, 2019 (using the default

2241methodology to determine the EOBR receipt date in the absence of

2252an y other evidence). Dr. Aponte did not timely serve a petition

2264for resolution of a reimbursement dispute on the Department to

2274contest the adjustments in the November 21, 2018, EOBR. Instead,

2284he communicated directly with the carrier and requested a re -

2295eva luation of the bill.

230035. The carrier issued another EOBR on December 27, 2018,

2310disallowing payment of the resubmitted bill for services rendered

2319on October 31, 2018. The reason given for disallowing payment as

2330to each of the three charges on the bill was " billing error:

2342line item service previously billed and reimbursement decision

2350previously rendered. " 4/

235336. Dr. Aponte prepared a Petition for Resolution of

2362Reimbursement Dispute on the required form, seeking to contest

2371the PPO adjustments made to the b ills for services rendered to

2383the same injured employee on October 10 and 31, 2018. He

2394attached only the final re - evaluation EOBRs, issued December 31,

24052018 (for the bill for services on October 10, 2018), and

2416December 27, 2018 (for the bill for services on October 31,

24272018).

242837. Dr. Aponte named the Petitioner as " Luis Aponte/Body

2437Contouring, Inc. " The instructions on the form specify that the

2447named Petitioner must be a health care provider as defined in

2458section 440.13(1)(b).

246038. Dr. Aponte gave a si ngle date -- January 7, 2019 -- as the

2475EOBR receipt date. However, he did not select the method used to

2487establish the EOBR receipt date, as provided in the form

2497petition. The form instructs that if the EOBR receipt date is

2508not established by one of the speci fied methods, then the EOBR

2520receipt date will be deemed to be five days from the issue date

2533on the EOBR.

253639. Dr. Aponte identified the issue in dispute as the PPO

2547adjustments applied to the bills. However, neither of the re -

2558evaluation EOBRs attached to t he petition made any PPO

2568adjustment.

256940. Dr. Aponte identified the disputed amount of the PPO

2579adjustments as $162.69. That is the sum of the PPO adjustments

2590made in the November 16, 2018, EOBR ($79.91), the November 21,

26012018, EOBR ($48.16), and the Decem ber 7, 2018, EOBR ($34.62) ( see

2614endnote 4).

261641. Dr. Aponte did not attach any of the EOBRs that made

2628the disputed PPO adjustments, but he did attach a letter that he

2640identified and explained as follows: " A copy of the contract

2650termination notice sent to Aetna has been provided. " 5/

265942. The Department reviewed the petition for completeness.

2667The Department evaluator noted that the attached EOBRs were

2676identified as " Re - evaluation " EOBRs that did not make the

2687disputed PPO adjustments. However, no timelines s determination

2695could be made because the EOBRs that explained the PPO

2705adjustments were not attached.

270943. In addition to failing to attach the relevant EOBRs,

2719the petition was found to also be deficient in several other

2730respects. The Department identif ied all perceived deficiencies

2738in a Notice of Deficiency sent to Dr. Aponte by certified mail.

2750He was instructed to correct all of the deficiencies with in ten

2762days after his receipt of the notice.

276944. Dr. Aponte timely responded, and cured all perceive d

2779deficiencies except one. The Department had found the petition

2788deficient because it named as the petitioner " Luis Aponte/Body

2797Contouring, Inc. " However, the instructions on the form petition

2806emphasize that the named petitioner had to be a " health care

2817provider " as defined in section 440. 13(1)(g) . The Notice of

2828Deficiency required a new form petition curing " Petitioner name

2837and mailing address. This is the provider name, not the business

2848name. " The directive is not very clear. It could be interpreted

2859as describing what is in the petition Dr. Aponte submitted ( " This

2871is " ), instead of describing what shoul d have been in the

2883petition.

288445. Dr. Aponte ' s transmittal letter, listing the documents

2894enclosed to cure the deficiencies, states that he provided a

2904completed petition with the P etitioner 's name and address. The

2915transmittal letter was signed, with the following typed on two

2925separate lines below the signature line: " Luis Aponte, MD " and

" 2935Body Contouring, Inc. " The enclosed petition, however, named

2943t he P etitioner in the same manner as in the original petition:

" 2956Luis Aponte/Body Contouring, Inc. "

296046. The undersigned appreciates the Department ' s concern

2969that a Petition for Resolution of Reimburseme nt Dispute must be

2980submitted by a " health care provide r " meeting the statutory

2990definition. But in this instance, the Department was well aware

3000that the health care provider was Luis Aponte, M.D., as were the

3012carriers involved in reviewing and adjusting his bills, and

3021issuing the EOBRs that Dr. Aponte is seek ing to contest. Indeed,

3033the Department ' s initial decision, set forth in a Reimbursement

3044Dispute Dismissal , names the P etitioner as " Luis Aponte, M.D. "

305447. The Department ' s Reimbursement Dispute Dismissal

3062recites that Dr. Aponte failed to provide the cura tive

3072documentation as required in the Notice of Deficiency. At

3081hearing, the Department, through its evaluator who signed the

3090Reimbursement Dispute Dismissal, testified that the sole

3097deficiency not cured by Dr. Aponte was to name a petitioner that

3109met the definition of a " health care provider. " According to the

3120Department, Dr. Aponte needed to add " M.D. " after his name on the

3132petition (as he did in the transmittal letter).

314048. The Department ' s evaluator also testified that since

3150she determined that the p etition had to be dismissed for failure

3162to cure this deficiency, she did not go on to address the

3174timeliness issue that could not be determined previously without

3183the relevant EOBRs.

318649. Had the evaluator determined the deficiencies to be

3195cured, she would have proceeded to ass ess the relevant EOBRs,

3206which were provided by Dr. Aponte in response to the deficiency

3217notice. She would have determined that the petition was not

3227served on the Department within 45 days of receipt of the EOBRs

3239that explained the co ntested PPO adjustments, and she would have

3250dismissed the petition as untimely.

325550. Based on the Department ' s evidence and an independent

3266assessment of the facts by which timeliness is determined, the

3276undersigned finds that Dr. Aponte ' s petition, served o n

3287February 8, 2019, was not timely. The 45 - day deadlines to serve

3300petitions contesting the PPO adjustments explained in three

3308different EOBRs were: January 5, 2019 (for the November 16,

33182018, EOBR); January 10, 2019 (for the November 21, 2018, EOBR);

3329and January 19, 2019 (for the December 7, 2018, EOBR).

3339Dr. Aponte ' s petition was untimely, and not just by a day or two,

3354but by at least 20 days. He offered no evidence or argument to

3367excuse his untimely submittal.

3371CONCLUSIONS OF LAW

337451 . The Division of Ad ministrative Hearings has

3383jurisdiction over the parties and subject matter, pursuant to

3392sections 120.569 and 120.57(1), Florida Statutes.

339852. At issue in these consolidated cases is whether two

3408Petitions for Resolution of Reimbursement Dispute are entitle d to

3418be considered on the merits, or whether, instead, they should be

3429dismissed.

343053. The proposed agency action by the Department, following

3439its free - form review, was that both petitions should be dismissed

3451because Dr. Aponte did not meet the threshold re quirements that

3462must be met before such petitions are entitled to consideration

3472on the merits.

347554. Dr. Aponte timely requested administrative hearings to

3483contest the Department ' s initial decisions. His position is that

3494the petitions submitted to the Depa rtment are entitled to

3504consideration on the merits. Although not articulated in so many

3514words, he contends that his petitions met the statutory and rule

3525requirements.

352655. As the party asserting the affirmative of the issue,

3536Dr. Aponte has the burden of p roving by a preponderance of the

3549evidence that his petitions meet the statutory and rule

3558requirements that entitle them to consideration on the merits.

3567See generally Balino v. De p ' t of Health & Rehab. Servs. , 348

3581So. 2d 349, 350 (Fla. 1st DCA 1977); § 120 .57(1)(j), Fla. Stat.

359456. Section 440.13(7)(a) sets forth requirements to

3601petition the Department to resolve a reimbursement dispute,

3609providing as follows:

3612Any health care provider who elects to

3619contest the disallowance or adjustment of

3625payment by a carri er under subsection (6)

3633must, within 45 days after receipt of notice

3641of disallowance or adjustment of payment,

3647petition the department to resolve the

3653dispute. The petitioner must serve a copy of

3661the petition on the carrier and on all

3669affected parties by c ertified mail. The

3676petition must be accompanied by all documents

3683and records that support the allegations

3689contained in the petition. Failure of a

3696petitioner to submit such documentation to

3702the department results in dismissal of the

3709petition.

371057 . Florid a Administrative Code Rule 69L - 7.710(1)(y)

3720contains the following definition germane to section

3727440.13(7)(a): "' Explanation of Bill Review ' (EOBR) means the

3737document used to provide notice of payment or notice of

3747adjustment, disallowance or denial by a [c arrier]. "

375558. Rule 69L - 7.740 addresses the carrier ' s responsibilities

3766in reviewing provider bills for payment, adjustment,

3773disallowance, or denial. Paragraph (14) provides that a carrier

" 3782shall notify the health care provider of notice of payment or

3793not ice of adjustment, disallowance or denial only through an

3803EOBR. An EOBR shall specifically state that the EOBR constitutes

3813notice of disallowance or adjustment of payment within the

3822meaning of subsection 440.13(7), F.S. "

38275 9 . The EOBR, therefore, is the " notice of disallowance or

3839adjustment of payment " referred to in section 440.13(7)(a).

3847Receipt of the EOBR starts the 45 - day period within which a

3860health care provider electing to contest adjustments in the EOBR

" 3870must " petition the D epartment to resolve th e dispute.

388060 . Rule 69L - 31. 008 addresses computation of time .

3892Paragraph (1) sets forth the three alternative methods by which a

3903provider can prove the date of receipt of an EOBR ( received date

3916stamp on the EOBR, verifiable login process, or EOBR envelope

3926with postmarked date to which five days will be added for mail

3938time). Where, as in both cases here, the provider does not prove

3950EOBR receipt dates using one of the rule's options, the rule

3961provides that the EOBR is deemed received five calendar days

3971afte r the date on which the EOBR was issued.

398161 . Rule 69L - 31.008 (2) addresses the end point of the 45 -

3996day time period. It provides : "Petitioning the Department shall

4006be effectuated upon service of the petition upon the Department. "

4016Details for establishing the date of service are set forth for

4027different mode s of transmitting a petition to the Department.

40376 2 . Applying the foregoing statutory and rule provisions to

4048the facts found above, Dr. Aponte failed to prove that his

4059petitions at issue in these conso lidated cases were timely s erved

4071on the Department. Instead, the facts establish that Dr. Aponte

4081did not serve his petitions within 45 days of receiving any of

4093the EOBRs that made the PPO adjustments he is seeking to d ispute.

410663 . That Dr. Aponte chose to pursue resolution of his

4117disputes directly with the carriers by asking them to reconsider

4127or re - evaluate his bills does not explain or excuse the

4139untimeliness of his petitions. The 45 - day window to submit a

4151petition to the D epartment is mandatory if a pr ovider wants the

4164Department to resolve a reimbursement dispute regarding a

4172carrier's adjustments to the provider's bills . Nothing prevented

4181Dr. Aponte from timely submitting petitions to the D epartment

4191within 45 days after he received the EOBRs that notif ied him of

4204the disputed PPO adjustments. He could have filed petitions

4213while also seeking to resolve the disputes directly with the

4223carriers. Indeed, the D epartment’s ru le s contemplate this dual

4234path . Rule 69L - 31.012 provides that after a reimbursement

4245dispute resolution petition and carrier response have been filed,

4254t he provider and carrier can stipulate to holding the

4264reimbursement dispute in abeyance for a specified period of time

" 4274for the parties to seek resolution of their reimbursement

4283dispute with out the need for a determination by the Department. "

42946 4 . Dr. Aponte 's attempt to use subsequent EOBRs making no

4307changes on reconsideration as springboards for opening up new 45 -

4318day windows to petition the D epartment must be rejected, because

4329tha t would r e nder the 45 - day statutory limit meaningless. Any

4343time a provider failed to timely avail himself of the limited

4354recourse in 440.13(7), he could manufacture a new 45 - day window

4366by asking a carrier to reconsider and having the carrier deny the

4378request.

437965 . Instead, the Department’s position is the only

4388reasonable way to apply the statute as interpreted in Department

4398rules: I f a provider wants the D epartment to resolve a

4410reimbursement dispute pursuant to section 440.13(7) , the provider

4418must serve his petit ion on the D epartment within 45 days of the

4432provider recei pt of an EOBR that gives notice of the disputed

4444adjustment or disallowance . Dr. Aponte failed to do so in both

4456cases.

445766 . While the foregoing conclusion is dispositive as to

4467both cases , the Depart ment's alternative theory for dismissing

4476Dr. Aponte's petition at issue in Case No. 19 - 2653 , set forth in

4490its initial decision, is rejected . The petition form provides a

4501blank for "Petitioner Name" and emphasizes in bold print

4510underneath the blank: " ( MUS T BE 'Healthcare Provider' as defined

4521[in the statute]). " Luis Aponte's name was set forth, along with

4532his business's name, Body Contouring, Inc. Luis Aponte is, in

4542fact, a health care provider, as defined in the statute. He is,

4554in fact, a physician. T he Department knew this , and identified

4565him as such in its initial decision to dismiss the petition . Dr.

4578Aponte's petition complied with this particular statutory and

4586rule requirement by providing the name of a petitioner who is a

4598health care provider.

46016 7 . Notably, the petition form does not require that a

4613na m ed petitioner demonstrate that he, she, or it is a "health

4626care provider," such as by providing a license number. While

"4636M.D." after a name is an indicator that the person is a

4648physician, it is not part of the provider's actual name, which is

4660what the form requires. Moreover, other types of health care

4670providers would not self - announce as health care provider s simply

4682by providing their name s . For example, "health care provider"

4693includes a healt h care facility, which is defined as "any

4704hospital licensed under chapter 395 and any health care

4713institution licensed under chapter 400 or chapter 429."

4721§ 440.13(f), Fla. Stat. Nursing homes and other licensed health

4731care facilities may , and often do, have names that sound more

4742like vacation resorts , hotels, or apartment complexes than like

4751health care facilit ies .

47566 8 . The Department's demand for more than the name of a

4769petitioner (who is, in fact, a health care provider) might be a

4781reasonable deman d that could be added via rule amendment

4791procedures , but it is not currently called for under the

4801Department's form petition, adopted as a rule.

4808RECOMMENDATION

4809Based on the foregoing Findings of Fact and Conclusions of

4819Law, it is RECOMMENDED that a final o rder be entered in these

4832consolidated cases by the Department of Financial Services,

4840Division of Workers ' Compensation , dismissing as untimely the

4849Petitions for Resolution of Reimbursement Dispute submitted by

4857Petitioner, Luis Aponte, M.D.

4861DONE AND ENTERED this 4th day of October , 2019 , in

4871Tallahassee, Leon County, Florida.

4875ELIZABETH W. MCARTHUR

4878Administrative Law Judge

4881Division of Administrative Hearings

4885The DeSoto Building

48881230 Apalachee Parkway

4891Tallahassee, Florida 3 2399 - 3060

4897(850) 488 - 9675

4901Fax Filing (850) 921 - 6847

4907www.doah.state.fl.us

4908Filed with the Clerk of the

4914Division of Administrative Hearings

4918this 4th day of October , 2019 .

4925ENDNOTE S

49271/ Respondent ' s Exhibits 1 and 2 pertain to Case No. 19 - 1517.

4942Respondent ' s Exhibits 3 through 6 pertain to Case No. 19 - 2653.

49562/ References to Florida Statutes are to the 2019 codification

4966and references to Department rules are to the current versions,

4976unless otherwise noted. The relevant statute and rules in effect

4986when Dr . Aponte ' s petitions were submitted and addressed by the

4999Department remain unchanged.

50023/ At the hearing, Dr. Aponte explained the reference in his

5013petition to an earlier petition previously submitted to the

5022Department on July 30, 2018. Although the un derlying facts were

5033not established in the record, apparently Dr. Aponte sent a

5043letter or petition to the Department to dispute the May 11, 2018,

5055EOBR. Dr. Aponte admitted that he did not follow the

5065instructions in the EOBR ' s notice stating that he had to submit

5078his dispute within 45 days after receipt of the EOBR. Instead,

5089Dr. Aponte admitted that he did not attempt to dispute the

5100adjustment until after he received the check, which he claims was

5111not issued until June 14, 2018. Assuming he did not receiv e the

5124check until on or a bout June 19, 2018 , he still had over ten days

5139of the 45 - day period remaining to submit a petition contesting

5151the EOBR ' s adjustment. Instead, he apparently waited until

5161July 30, 2018, to submit his dispute to the Department.

5171D r. Aponte testified that he received a Reimbursement

5180Dispute Dismissal in August 2018, dismissing his July 30, 2018,

5190submittal as untimely. Dr. Aponte admitted that, unlike in these

5200two consolidated cases, he did not ask for an administrative

5210hearing to c ontest the dismissal. Therefore, even if the

5220underlying facts were established in this record, the dismissal

5229of his prior attempt to contest the May 11, 2018, EOBR is final

5242and not at issue in this case. Regardless, if Dr. Aponte were to

5255argue in this ca se that a petition for resolution of

5266reimbursement dispute could be considered timely if filed 75 days

5276after receipt of the EOBR that explains the adjustments the

5286provider wants to dispute, the undersigned would have to reject

5296that argument as contrary to the plain language of the statute

5307and implementing rules. The window to contest a carrier ' s

5318adjustment to a bill is within 45 days after receipt of the EOBR

5331explaining the adjustments, not within 45 days after receipt of

5341the check.

53434/ the December 27, 2018, EOBR was the third EOBR It appears that

5356issued with respect to the bill for services rendered October 31,

53672018. An interim re - evaluation was conducted based on additional

5378documentation submitted by Dr. Aponte to support the charges for

5388two injectio ns. An EOBR was issued on December 7, 2018. The

5400EOBR document in evidence is blurry ( see Pet. Ex. 5 at Bates

5413p. 047), but it appears that the carrier reconsidered and adjusted payment on the two injection charges, rather than

5432disallowing payment entirely . Although not all of the numbers

5442can be discerned, the PPO adjustment numbers are legible, and

5452those are the adjustments that Dr. Aponte is attempting to

5462dispute. The carrier reduced one injection charge by $34.22 and

5472the other injection charge by $0.40 as the PPO adjustments in

5483accordance with the Aetna contract. The 45 - day period to serve a

5496petition on the Department to dispute these adjustments would

5505have ended on January 19, 2019, applying the default methodology

5515to prove the EOBR receipt date in th e absence of any other

5528evidence.

55295/ As previously noted, the merits of Dr. Aponte ' s claim that no

5543PPO reductions should have been applied are not at issue in this

5555proceeding. However, the undersigned notes that the August 30,

55642018, letter in evidence, from Luis Aponte, MD, Body Contouring,

5574Inc., to Aetna, Inc., states: " Consider this communication the

5583notice of my immediate termination as a contract provider with

5593Aetna becoming effective today in view that Body Contouring [ , ]

5604Inc. ' s [,] practice has clos ed. Please respond by sending through

5618certified mail the confirmation of the termination of the

5627agreement between Body Contouring [,] Inc. [,] and Aetna. " Pet.

5639Ex. 5 at Bates p. 042. But Dr. Aponte continued to bill for

5652services provided through his pract ice, Body Contouring, Inc.;

5661all of the EOBRs at issue in these cases identify both Dr. Aponte

5674and Body Contouring, Inc.; and Dr. Aponte named as the p etitioner

5686in the two Petitions for Resolution of Reimbursement Dispute at

5696issue in these cases " Luis Apont e, MD/Body Contouring [,] Inc. "

5708(Case No. 19 - 1517) and " Luis Aponte/Body Contouring [,] Inc. "

5720(Case No. 19 - 2653). It is unknown if Dr. Aponte ever received

5733the requested confirmation from Aetna, and it is unknown if his

5744notice would have been effective to t erminate the contract, given

5755that the premise of the notice was contradicted by the subsequent

5766continued practice and billing in the name of Body Contouring,

5776Inc. These issues would have to be considered based on evidence

5787not offered here, such as the con tract itself, if the merits of

5800Dr. Aponte ' s reimbursement disputes were presented for

5809determination.

5810COPIES FURNISHED:

5812Luis Aponte , M.D.

5815Post Office Box 4542 Tampa, Florida 33677 (eServed)

5823Thomas Nemecek, Esquire

5826Department of Financial Services

5830Div ision of Workers ' Compensation

5836200 East Gaines Street

5840Tallahassee, Florida 32399 - 4229

5845(eServed)

5846Keith C. Humphrey, Esquire

5850Department of Financial Services

5854200 East Gaines Street

5858Tallahassee, Florida 32399 - 4229

5863(eServed)

5864Julie Jones, CP, FRP, Agency C lerk

5871Division of Legal Services

5875Department of Financial Services

5879200 East Gaines Street

5883Tallahassee, Florida 32399 - 0390

5888(eServed)

5889NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

5895All parties have the right to submit written exceptions within

590515 days from the date of this Recommended Order. Any exceptions

5916to this Recommended Order should be filed with the agency that

5927will issue the Final Order in this case.

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Date
Proceedings
PDF:
Date: 02/12/2020
Proceedings: Agency Final Order filed.
PDF:
Date: 02/12/2020
Proceedings: Agency Final Order filed.
PDF:
Date: 02/10/2020
Proceedings: Agency Final Order
PDF:
Date: 02/10/2020
Proceedings: Agency Final Order
PDF:
Date: 10/04/2019
Proceedings: Recommended Order
PDF:
Date: 10/04/2019
Proceedings: Recommended Order (hearing held August 8, 2019). CASE CLOSED.
PDF:
Date: 10/04/2019
Proceedings: Recommended Order cover letter identifying the hearing record referred to the Agency.
PDF:
Date: 09/03/2019
Proceedings: Respondent's Proposed Recommended Order filed.
PDF:
Date: 08/22/2019
Proceedings: Notice of Filing Transcript.
Date: 08/22/2019
Proceedings: Transcript of Proceedings (not available for viewing) filed.
Date: 08/08/2019
Proceedings: CASE STATUS: Hearing Held.
PDF:
Date: 08/02/2019
Proceedings: Notice of Substitution of Counsel (Keith Humphrey; filed in Case No. 19-002653).
Date: 07/31/2019
Proceedings: Respondent's Proposed Exhibits filed (exhibits not available for viewing).
PDF:
Date: 07/31/2019
Proceedings: Department's Notice of Filing Proposed Exhibits filed.
PDF:
Date: 07/31/2019
Proceedings: Department's Proposed Exhibit List filed.
PDF:
Date: 07/31/2019
Proceedings: Department's Proposed Witness List filed.
PDF:
Date: 07/30/2019
Proceedings: Notice of Transfer.
PDF:
Date: 07/30/2019
Proceedings: Notice of Substitution of Counsel filed (Keith Humphrey).
PDF:
Date: 05/31/2019
Proceedings: Notice of Hearing by Video Teleconference (hearing set for August 8, 2019; 9:00 a.m.; Tampa and Tallahassee, FL).
PDF:
Date: 05/31/2019
Proceedings: Order Canceling Hearing (parties to advise status by September 2, 2019).
PDF:
Date: 05/31/2019
Proceedings: Order of Consolidation (DOAH Case Nos. 19-1517, 19-2653).
PDF:
Date: 05/29/2019
Proceedings: Department's Agreed Motion to Continue and Consolidate filed.
PDF:
Date: 03/28/2019
Proceedings: Order of Pre-hearing Instructions.
PDF:
Date: 03/28/2019
Proceedings: Notice of Hearing by Video Teleconference (hearing set for June 4, 2019; 9:00 a.m.; Tampa and Tallahassee, FL).
PDF:
Date: 03/27/2019
Proceedings: Respondent's Agreed Response to Initial Order filed.
PDF:
Date: 03/26/2019
Proceedings: Notice of Appearance (Samuel Gilot) filed.
PDF:
Date: 03/20/2019
Proceedings: Initial Order.
PDF:
Date: 03/19/2019
Proceedings: Reimbursement Dispute Dismissal filed.
PDF:
Date: 03/19/2019
Proceedings: Request for Administrative Hearing filed.
PDF:
Date: 03/19/2019
Proceedings: Agency referral filed.

Case Information

Judge:
LYNNE A. QUIMBY-PENNOCK
Date Filed:
03/19/2019
Date Assignment:
07/30/2019
Last Docket Entry:
02/12/2020
Location:
Tampa, Florida
District:
Middle
Agency:
ADOPTED IN TOTO
 

Counsels

Related Florida Statute(s) (4):