Judges: D. R. ALEXANDER
Agency: Department of Management Services
Latest Update: May 05, 1991
Summary: Employee required to repay health benefits erroneously paid to her.
83-2939STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
PATRICIA A. WOTRING, )
)
Petitioner, )
)
vs. ) CASE NO. 83-2939
) STATE OF FLORIDA, DEPARTMENT ) ADMINISTRATION, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, a formal hearing was in the above case held before the Division of Administrative Hearings by its duly designated Hearing Officer, DONALD R. ALEXANDER, on November 9, 1983 in Tallahassee, Florida.
APPEARANCES
For Petitioner: Patricia A. Wotring, pro se
1833 Mayfair Road
Tallahassee, Florida 32303
For Respondent: Daniel C. Brown, Esquire
435 Carlton Building Tallahassee, Florida 32301
BACKGROUND
By petition filed with respondent, Department of Administration, On August 30, 1983 petitioner, Patricia A. Wotring, requested an administrative hearing to contest the claim for reimbursement made by Blue Cross - Blue Shield for $513 previously paid to Wotring for claims she submitted under the State of Florida Employees Group Health Self Insurance Plan. The matter was referred to the Division of Administrative Hearings by respondent on September 14, 1983 with a request that a Hearing Officer be assigned to conduct a hearing.
By notice of hearing dated October 27, 1983, the final hearing was scheduled for November 9, 1983 in Tallahassee, Florida. At the final hearing petitioner testified on her own behalf and offered petitioner's exhibits 1-5; all were received in evidence. Respondent presented the testimony of William R. Seaton, a Department insurance benefits analyst, and Cathy H. Rowe, a personnel technician with the Department's bureau of insurance, and offered respondent's exhibit 1 which was received in evidence.
There is no transcript of hearing in this proceeding. The parties have waived their right to file proposed findings of fact and conclusions of law.
The issue herein as clarified at the outset of the hearing is whether petitioner should be required to repay $633 in benefits previously received from Blue Cross - Blue Shield.
Based upon all of the evidence, the following findings of fact are determined:
FINDINGS OF FACT
Petitioner, Patricia A. Wotring, is an employee of the Department of Health and Rehabilitative Services. At all times relevant hereto she was enrolled as a member of the State of Florida Employees Group Health Self Insurance Plan (Plan).
The State of Florida is a self-insurer. It has contracted with Blue Cross - Blue Shield to act as its administrator in processing and paying all claims by employees under the Plan. Claims are suppose to be paid-in accordance with coverage requirements, limitations and exclusions that have been adopted by the State. These requirements are set forth in the Employees Group Health Self Insurance Booklet (Booklet) which has been received in evidence as respondent's exhibit 1.
Between November, 1982 and January, 1983 petitioner submitted five claims for benefits with Blue Cross - Blue Shield. The claims totaled $633, of which $620 were for mental health services provided by a Tallahassee clinical psychologist and $13 for laboratory services performed by a Tallahassee physician. Although Blue Cross - Blue Shield had been "instructed" to not pay this type of claim, the claims were nonetheless honored in early 1983 and Wotring received checks at that time for $633.
Upon advice from respondent, Department of Administration, Blue Cross - Blue Shield requested reimbursement from petitioner in June, 1983 for $633. That request prompted the instant proceeding.
As a basis for claiming reimbursement, Blue Cross - Blue Shield relied upon Section H of the Exclusions portion of the Booklet. That section reads as follows:
No payment shall be made under the Plan for the following:
H. Services, care, treatment, and supplies furnished by a person who ordinarily resides in the Insured's home or by any person or institution not otherwise defined in the Definitions section of this booklet. (Emphasis Added)
It then referred to page 39 of the Booklet which defines a "physician" as follows:
"Physician" shall mean the following:
a doctor of medicine (M.D.), doctor of osteopathy (D.O.), doctor of surgical chiropody (D.S.C.) or doctor of podiatric medicine (D.P.M.), who is legally qualified
and licensed to practice medicine and perform surgery at the time and place the service is rendered;
a licensed chiropractor acting within the scope of his/her license, provided the insured receiving his/her services is covered under the chiropractic coverage option of the Plan and the proper premium has been paid;
a licensed dentist who performs specific surgical procedures covered by the Plan, or who renders services due to injuries resulting
from Accidents, provided such procedures or services are within the scope of the dentist's professional license;
a licensed optometrist who performs procedures covered by the Plan provided such procedures are within the scope of the optometrist's professional license.
A clinical psychologist is not defined within the Definitions section of the Plan.
Because a clinical psychologist does not fall within the definition of a physician, and is not otherwise defined within that section, the services received by Wotring were properly excluded from coverage by the Plan.
Effective October 1, 1983, the Legislature amended the law to require that services rendered by a clinical psychologist be covered by the Plan.
In the event payments are made in error, the Department's policy is to instruct its Administrator (Blue Cross - Blue Shield) to request reimbursement from the insured.
Petitioner acknowledged that the five claims were paid in error. However, she contended that the claims were submitted in good faith over a period of time and were honored. Accordingly, she argues it is wrong to now require her to repay those amounts.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter and the parties thereto pursuant to Subsection 120.57(1), Florida Statutes.
Subsection 110.123(5), Florida Statutes, provides in pertinent part as follows:
(5) The Secretary of Administration shall be responsible for the administration of the state group insurance program.
The Department of Administration shall initiate and supervise the program as established by this section. To implement
this program, the department shall, subject to legislative approval:
(a) Determine the benefits to be provided... for the state group insurance program.
Pursuant to this statutory authorization, respondent had determined the benefits to be provided under the Plan. These are set forth in the Employees Group Health Self Insurance Booklet.
The evidence discloses that prior to October 1, 1983 all outpatient therapy services provided by a clinical psychologist were excluded from coverage under the Plan. Accordingly, all payments to petitioner, except those for laboratory services provided by a physician ($20), were in error.
Petitioner does not dispute that the above payments were in error, but contends that it is unfair and wrong to now require her to repay moneys received in good faith. There has been no rule or statute cited by the Department which authorizes it to recover payments made in error. Nonetheless, in order to give the proper effect to the administration of the Plan, such a power is necessarily implied, and the Department, through its administrator, is deemed to have the power to seek reimbursement from Wotring.
It is concluded as a matter of law that all payments received for mental health services ($613) were improper, and that such amount Should be repaid to the State. The remaining payment ($20) appears to be proper and, assuming all deductibles have been met, should not be subject to repayment.
RECOMMENDATION
Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that petitioner repay respondent $613 for payments previously
received in error that are not covered by the Plan. It is further
RECOMMENDED that in view of the size of the amount owed, petitioner be allowed to repay that amount on an installment basis over a six-month period, if she so chooses. It is further
RECOMMENDED that she not be required to repay $20 to respondent if all deductibles for the appropriate calendar year have been met.
DONE and ENTERED this 18th day of November, 1983, in Tallahassee, Florida.
DONALD R. ALEXANDER
Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32301
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 18th day of November, 1983.
COPIES FURNISHED:
Patricia A. Wotring 1833 Mayfair Road
Tallahassee, Florida 32303
Daniel C. Brown, Esquire
435 Carlton Building Tallahassee, Florida 32301
Nevin G. Smith, Secretary Department of Administration Room 435, Carlton Building Tallahassee, Florida 32301
Docket for Case No: 83-002939
Orders for Case No: 83-002939
