STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
REDI-CARE HOME SERVICES, INC., )
)
Petitioner, )
)
vs. ) CASE NO. 89-6923
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES and )
CONSULTEC, INC., )
)
Respondents. )
)
RECOMMENDED ORDER
Pursuant to notice, the Division of Administrative Hearings, by its duly designated Hearing Officer, Veronica E. Donnelly, held a formal hearing in the above-styled case on the following dates at the designated locations:
January 15, 1991 in Fort Myers, Florida February 8, 1991 in Tallahassee, Florida
March 4, 1991 in Tallahassee, Florida APPEARANCES
For Petitioner: Barry Roth, Esquire
COHEN & ROTH, P.A.
Post Office Drawer 2650 Fort Myers, Florida 33902
For Respondent Karel Baarslag, Esquire HRS: Department of Health and
Rehabilitative Services Medicaid Office
1317 Winewood Boulevard Building Six, Room 233
Tallahassee, Florida 32399-0700
For Respondent Ken R. Syler, Qualified Representative Consultec, 2002 A1 Old St. Augustine Road
Inc.: Tallahassee, Florida 32314 STATEMENT OF THE ISSUES
Whether Redi-Care Home Services, Inc. should be paid by the Medicaid Program administered through the Department of Health and Rehabilitative Services by Consultec, Inc., for Medicaid Home Health Agency Medical services provided to two Medicaid eligible recipients prior to the completion of a certification survey by the Office of Licensure and Certification.
PRELIMINARY STATEMENT
On September 19, 1989, the Medicaid Program Office of the Department of Health and Rehabilitative Services (the Department) denied the request for payment submitted by Redi-Care Home Services, Inc. (Redi-Care) for Medical Home Health Agency Services provided to Medicaid eligible recipients between February 8, 1989 and April 30, 1989. The reason given for denial was that Redi-Care did not meet the requirements for participation in the payment program because the facility had not received a certification survey from the Department's Office of Licensure and Certification at the time the services were provided.
Redi-Care contested the determination that it is ineligible to receive payment. Essentially, it is Redi-Care's position that the services rendered to the two Medicaid eligible recipients were provided with the expectation that payment would be received from the Medicaid Program. The Department was aware of this expectation when the Medicaid eligible recipients were accepted by the facility and continued to receive ongoing services for over two months. Redi- Care further asserts that home health agency services were provided to the two individuals because the facility had detrimentally relied upon the actions of Consultec, the Department's agent when Redi-Care was issued a "Medicaid Provider" number by Consultec, and was told by a Consultec employee that the issuance of the number negated the requirement of further certification procedures. Based upon the material dispute of facts, Redi-Care timely requested a formal administrative hearing. The case was referred to the Division of Administrative Hearings on December 22, 1989.
During the hearing, Redi-Care presented four witnesses and filed twenty- three exhibits. The Department called five witnesses and submitted six exhibits. Consultec recalled one witness and had four exhibits marked. All of Redi-Care's exhibits were accepted into evidence. The Department's Exhibit number 6 was denied admission into evidence, as were Consultec's four exhibits. The Hearing Officer requested further documentation of Ms. Ingeborg G. Mausch's right to go forward in this proceeding since the assets of Redi-Care, Inc. were sold and transferred prior to final hearing. The requested documentation has been marked and admitted as Hearing Officer Exhibit number 1.
Proposed findings of fact were submitted by all parties. The Department had questions post hearing regarding the time period for filing its proposed recommended order. As the Department had already received Redi-Care's proposed findings, an objection was made to a later filing period. The Department was granted the extension of time to file its proposed recommended order, and Consultec's proposed recommended order was also accepted by the Hearing Officer. Redi-Care was granted leave to file a supplemental recommended order to alleviate the potential advantage gained by the Department and Consultec from reviewing Redi-Care's proposed findings prior to their own submissions. Redi- Care declined the opportunity to submit further proposed findings after the other proposed recommended orders were received. Rulings on the proposed findings are in the Appendix to this Recommended Order.
FINDINGS OF FACT
Background
At all times material to this proceeding, Redi-Care was a corporation doing business as a home health care agency in Florida and was duly licensed in that capacity by the Department. Prior to May 4, 1989, Redi-Care was not certified to receive payment for services provided to Medicaid recipients under the Florida Medicaid Program. At times, however, Redi-Care did provide services to Medicaid recipients under a waiver program involving "Home and Community Based Services." This program receives funding from a separate appropriation than the one administered by the Department for the Florida Medicaid Program.
Since the sale of some of the corporate assets on July 31, 1990, Ms. Ingeborg G. Mausch, Ph.D., has been authorized by the corporation to proceed with the collection of the accounts receivable that remained with the corporation. This proceeding involves Redi-Care's request for payment from the Department for medical services provided to two Medicaid eligible recipients, Richard Mow and Claire Jester.
The Florida Medicaid Program is jointly funded by the federal and state governments. The Department is the state agency responsible for the administration of Medicaid funds from both funding sources. To the extent monies are appropriated, the Department is authorized to provide payment for medical services given to Medicaid eligible recipients through certified home health care agencies.
Consultec was awarded the contract to replace EDS as the provider of fiscal agent services and the Medicaid agent for the Florida Medicaid Program in 1988. Pursuant to the agreement, Consultec was to become responsible for the enrollment of new providers and the processing of claims on December 15, 1988.
Prior to the assumption of the fiscal agent duties, Consultec was responsible for the re-enrollment of all existing Florida Medicaid Providers into the Florida Medicaid Management System as it had been redesigned by Consultec. Current enrollees were given new provider numbers to be used on all submissions made on or after the December 15, 1988 date. Any claims submitted prior to December 15, 1988 would be processed by Electronic Data Systems Corporation (EDS) under the provider numbers previously issued by that entity. As part of the re-enrollment program, Consultec also created vendor numbers for those home health care agencies involved in the waiver program. These vendor numbers are used within the Department's Developmental Services and Aging Adult Services operations. In the past, home health care providers have not had access to these numbers.
Consultec sent Vendor Information Sheets to all providers within the HRS Developmental Services and Aging Adult Services Waiver Program for "Home and Community Based Services" on October 7, 1988.
Redi-Care was listed as a provider with the waiver program at the time the vendor re-enrollment occurred. Upon receipt of the Vendor Information Sheet, Redi-Care certified that the information on the sheet prepared by Consultec was correct. The document was returned to Consultec, as requested on the form, on October 19, 1988. Unbeknownst to those providers who completed the form, Consultec was planning on issuing them vendor numbers. Although each of
the providers had such vendor numbers in the past, these numbers were never specifically issued to them because the Department undertook the responsibility to complete that portion of the waiver program's documentation.
Application Process
Originally, Redi-Care applied for enrollment as a "Medicaid Provider" in 1987. This original application was abandoned by Redi-Care when it learned that a provider had to be Medicare eligible as well. Instead, Redi-Care became a provider of "Medicaid Home and Community Based Services" in the waiver program.
In July of 1988, "Medicaid Providers" were no longer required to be Medicare eligible. Based upon this policy change, Redi-Care reapplied to the Department for enrollment as a "Medicaid Provider" who provides medical services to recipients of the Florida Medicaid Program. The enrollment application, known as a "Request for Certification," was completed by Redi-Care on September 7, 1988. Assurance of Compliance with Title VI of the Civil Rights Act of 1964 was attached to the application. The Ownership and Control of Interest Statement was completed by Redi-Care, but the evidence presented reveals that it may not have been included in the application documents sent to the Department's Office of Licensure and Certification on September 7, 1988, or shortly thereafter.
Pursuant to the agreement still in effect between the Department and EDS on the date of the submission of the application, EDS was the Medicaid Agent responsible for the review and processing of Redi-Care's application to become a Florida "Medicaid Provider" once it was received by EDS from the Department's Office of Licensure and Certification.
Because Redi-Care was already licensed as a home health agency, the Department's Office of Licensure and Certification was not required to grant a license prior to the transfer of this enrollment application to EDS. All that was required was a certification survey from this branch of the Department and a copy of Redi-Care's active license.
When the Office of Licensure and Certification went to complete the survey, the representative of the Department confused this Redi-Care entity with an entity next door known as Redi-Care, Inc. Consequently, the Redi-Care corporation seeking certification as a "Medicaid Provider" was not surveyed as it had requested via all of the proper channels.
As the Office of Licensure and Certification was unaware of its mistake regarding the Redi-Care entities, this Redi-Care application package was sent on to EDS for review and processing of the application without the documentation required from the Department.
After a few weeks, because Redi-Care was generally familiar with the application process from its prior experience, the Department was contacted and the follow-up package was requested. Redi-Care was sent a copy of the Medicaid Provider Agreement, which was signed and returned to the Office of Licensure and Certification on or about November 18, 1988.
Within a day or two after Redi-Care mailed the Medicaid Provider Agreement, a letter was received from Consultec which referred to Redi-Care as a "Medicaid Provider." Redi-Care was thanked for re-enrolling in the program and was issued a Florida Medicaid Provider number for Home and Community Based Services.
In actuality, the letter from Consultec was providing Redi-Care with the vendor number described previously in these Findings of Fact for use in the waiver program. Redi-Care was unaware that such a number was to be issued because it had not received such a number in the past, nor was it advised that one was forthcoming. When Ms. Mausch read the letter on behalf of Redi-Care, she assumed it related to the recent reapplication for Medicaid certification submitted in September 1988. The first sentence of the letter thanking Redi- Care for "re-enrollment" was interpreted as an acknowledgement of the first application for enrollment which had been abandoned, and an appreciation of the facility's current decision to assist in the provision of home health care to Medicaid recipients. Because the body of the letter appeared to be tailor made to Redi-Care's recent decision to participate as a "Medicaid Provider", Redi- Care believed its pending application for enrollment had been approved.
When the letter was read and interpreted by Ms. Mausch, she failed to notice that the letter was issued four days prior to Redi-Care's submission of the Medicaid Provider Agreement, and specifically referred to "Home and Community Based Services." This mistake does not dissuade the Hearing Officer from finding Redi-Care's interpretation of the document was reasonable in light of all of the surrounding circumstances under which it was read.
The references to Redi-Care as a "Medicaid Provider" in this letter issued by Consultec was ambiguous. The technical term "Medicaid Provider" was misused in a generic sense. Although the more casual use of the term might not have been misleading to most providers in the waiver program, it was very misleading to Redi-Care, who was awaiting the issuance of a "Medicaid Provider" number from the Medicaid Program.
At the time the Consultec letter of November 14, 1988 was issued, EDS was the Department's Medicaid agent responsible for the review and processing of Florida's "Medicaid Provider" applications.
On December 5, 1988, EDS acknowledged its receipt of Redi-Care's application to become a Florida "Medicaid Provider." The application packet was returned to Redi-Care, who was advised that additional items needed to be available with the application for processing to occur. Redi-Care was required to submit a copy of the Ownership and Control of Interest Statement. The Office of Licensure and Certification was required to complete its certification survey and submit this, along with a copy of Redi-Care's active license.
The requests made by EDS were questioned by Redi-Care for the following reasons: Consultec's letter of November 11, 1988, appeared to have already approved the Medicaid enrollment, and the Office of Licensure and Certification had already been notified by Redi-Care two months earlier, and should have sent a copy of the license and survey to EDS.
Instead of calling EDS, Ms. Mausch contacted Consultec, who had recently issued the "Medicaid Provider" number.
During the conversation with "Deborah" of Consultec, who represented she was able to speak to Ms. Mausch's concerns, Redi-Care was advised that it need not complete the directions issued by EDS because a "Medicaid Provider" number had already been assigned by Consultec.
It is unknown what exactly was said by Ms. Mausch to "Deborah" which resulted in this reply. However, the advice from "Deborah" was accepted and relied upon by Redi-Care because it was very compatible with what Redi-Care was willing to do under the known circumstances and what it reasonably believed the facts to be.
Neither Redi-Care nor EDS were advised of the Department's failure to conduct the certification survey. It is also unknown whether the Department was aware of its confusion of the two Redi-Care entities at this point in time.
Shortly after the re-application was returned to Redi-Care by EDS, this Department agent was relieved of its responsibility to review and process Florida "Medicaid Provider" applications. This responsibility was transferred to Consultec, the new Medicaid agent. At the time of the transfer, Consultec interpreted the return of Redi-Care's application for further attachments as a rejection of the application by EDS. Therefore, no further action was taken by Consultec on the application because it was considered to be a resolved matter. It should be noted however, that Redi-Care had not been advised that its application had been rejected, nor was any completion deadline given before rejection would occur.
Redi-Care heard nothing more about the application after the discussion with "Deborah", so it continued to rely upon the representation that the new Florida "Medicaid Provider" number had been properly issued by the new Medicaid agent, and that nothing more was currently required of Redi-Care prior to its acceptance of Medicaid eligible recipients.
The Acceptance and Care of Medicaid Eligible Recipients
Once Redi-Care began to hold itself out as a home health agency who could accept Medicaid eligible recipients under the Medicaid Program, Richard Mow and Claire Jester were referred by their physicians and accepted as clients.
There is no dispute in these proceedings about the Medicaid eligibility of either Richard Mow or Claire Jester. Further, there is no dispute regarding the quality of medical care, the dates of services, the necessity for the services and the reasonableness of the amount of the bills submitted for claims review and processing under the Medicaid Program.
Richard Mow and Claire Jester were accepted as clients and services were performed based upon Redi-Care's reliance upon the representation that Redi-Care had a valid "Medicaid Provider" number that would allow it to receive payment from Medicaid appropriations for the medical care of these two clients.
The Department was aware of the acceptance of these two Medicaid eligible recipients as clients by Redi-Care. The Department was also aware that they were being provided medical services for which Redi-Care expected to be reimbursed by the Medicaid Program. The two clients also relied upon this method of payment for the medical services provided by Redi-Care as third-party beneficiaries to the purported agreement between Redi-Care and the Medicaid Program.
The amount of the claim submitted for services provided to Richard Mow from February 8, 1989 through April 16, 1989 was $7,411.45.
The amount of the claim submitted for services provided to Claire Jester from February 12, 1989 through April 30, 1989 was $753.83.
The Submission of Claims and Claims Denial
Redi-Care first submitted billings and notes for the claims involving Richard Mow and Claire Jester to Consultec on March 29, 1989.
On April 11, 1989, Redi-Care contacted Elizabeth Campbell, a Human Services Program Specialist with the HRS Medicaid Program Office in Fort Myers, Florida. At the time Ms. Campbell was contacted, her job duties included claims resolution for providers in the home health and nursing home areas. The purpose of the phone call from Redi-Care was to ask Ms. Campbell to find out why it had not received word on its claim submission to Consultec for Richard Mow and Claire Jester.
After Ms. Campbell researched the issue, she discovered that Redi-Care was not listed as a "Medicaid Provider" on the rolls maintained by Consultec. Redi-Care was ineligible for payment through Medicaid. Payment could be received only as a provider of "Home and Community Based Services" under the waiver program.
When Redi-Care was advised that it did not have a "Medicaid Provider" number on April 11, 1989, the Department was told about the information given to Ms. Mausch by Consultec's letter and her follow-up conversation with "Deborah". Ms. Campbell, as a representative of the Department, assured Redi-Care that the matter would be pursued further. In the meantime, through its employees, the Department allowed Redi-Care to continue to rely on the representation that it would be paid at the Medicaid rates for the continuing care provided to Richard Mow and Claire Jester.
On April 12, 1989, Ms. Campbell recorded in her field notes that she did not make any assurances to Redi-Care that it would be paid for providing services for the two clients. However, there is no evidence to show that she affirmatively advised Redi-Care that they might not get paid for past or continuing services. Redi-Care was allowed to continue to care for the clients under the the assumption that Medicaid would provide payment.
On April 18, 1989, it was clear to Department employees involved in this factual scenario that the Office of Licensure and Certification had confused this Redi-Care entity with Redi-Care, Inc. when the survey and certification was scheduled to occur in November 1988. This mistake had never been corrected.
On April 26, 1989, Consultec completed its review of the claims submitted by Redi-Care and denied the claims because Redi-Care did not have a "Medicaid Provider" number.
Attempts to Cure Certification Issue
The Office of Licensure and Certification completed its survey on May 4, 1989. Redi-Care's enrollment application was complete, and contained all of the required information on this date. Although no deficiencies were noted during the survey, the Department did not send a copy of the letter stating Redi-Care met its requirements until June 27, 1989. On that date, the letter was sent to Redi-Care, who was required to forward it to Consultec, along with the application Redi-Care had previously submitted with the attachments requested in December 1988 by EDS. Once Redi-Care received the letter in early July 1989, the information was immediately forwarded to Consultec.
Consultec reviewed the application and issued Redi-Care a "Medicaid Provider" number on August 6, 1989.
When Redi-Care received its "Medicaid Provider" number, it was advised by Consultec that it could use this number to submit billings to the Medicaid Program for eligible services provided since September 1988. Apparently, Consultect relied on the date EDS acknowledged receipt of the application and related the eligibility date to the 90 day period prior to the application receipt.
On September 19, 1989, the Department issued a letter through the Program Administrator, Medicaid Program Office, advising Redi-Care that the Medicaid billings for Richard Mow and Claire Jester would not be paid by the Medicaid Program, even though these services were provided after the effective date of eligibility given to Redi-Care by Consultec in its letter of August 6, 1989.
The Department's letter advising Redi-Care of the Medicaid Program's decision to deny payment for the services provided to the two Medicaid eligible recipients also told Redi-Care that its "Medicaid Provider" number could be used only for services rendered on or after May 4, 1989.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of this proceeding, pursuant to Section 120.57(1), Florida Statutes.
The gravamen of this case is whether the Department is obligated to pay the costs of the medical services provided by Redi-Care to two Medicaid eligible persons who were cared for by Redi-Care in reliance on its reasonable belief that the costs of their care would be paid by the Medicaid Program administered by the Department and its agents.
Evidence adduced at hearing shows that Redi-Care was not properly certified as a "Medicaid Provider" at the time the services were rendered. This lack of certification, however, did not occur through any intentional action or inaction by this home health care agency. In November 1988, Redi-Care initiated the certification process. Its belief that Medicaid eligibility had been secured was justified, based upon all of the surrounding events set forth in the Findings of Fact.
This lack of certification, which caused the Department to deny payment to Redi-Care, was not caused by a single act of an individual party to this proceeding. Instead, the lack of certification was caused by a combination of events that occurred in an unfortunate and uncanny time sequence that operated to prevent the proper application processing which usually occurs in these situations. Each party was responsible for one mishap or another within the process that would have been negligible but for the surrounding happenstances of this case. Therefore, no particular party can be looked to as the primary cause of the confusion because all parties contributed to the application remaining in limbo until May 4, 1989.
The reason the certification problem was not cured sooner was because none of the parties had all of the necessary information to correct the series of unrelated mistakes and misinterpretations until April 18, 1989. This is when Ms. Campbell, a Department employee, was able to retrace what occurred during Redi-Care's application for certification. It is at this point in time that concerns developed as to how Redi-Care's application was handled within the Department.
In the letter from the Department to Redi-Care dated September 19, 1989, Redi-Care was advised that its Medicaid eligibility for filing claims relates back to May 4, 1989. That date is the day upon which the Office of Licensure and Certification completed its certification survey. Although this determination of eligibility would be proper in most cases and under Rule 10C- 7.044(3)(a), Florida Administrative Code, it does not appear to be appropriate here because of the Department's mistake when it confused two different Redi- Care entities with each other, and failed to complete the requested survey. This mistake severely affected Redi-Care, who had substantially completed the documentation required of a home health care agency prior to the Department's error in November 1988. All that was missing was the Ownership and Control of Interest Statement, along with the Department's documentation.
It is obvious from the file documentation kept within the Department that the Office of Licensure and Certification has been aware of its error in failing to provide the survey since at least April 18, 1989. Yet, this office made no attempt to quickly rectify its error and assure a speedy processing of Redi-Care's application. If the Department had acted promptly, Redi-Care would have been eligible for coverage relating back to the time period before Redi- Care first accepted Medicaid eligible clients. Medicaid coverage would have been provided, and the Department's obligation to the Medicaid eligible recipients and the provider of services would have been satisfied. This remedy was contemplated in the policy manual entitled "Medicaid Provider Handbook Home Health Services," which reads as follows, in pertinent part:
You will become eligible 90 days prior to the day Consultec receives your application as long as your license is active.
Consultec's letter of August 6, 1989, to Redi-Care which gave an eligibility date of September 1, 1988, assumes EDS received a completed application for Redi-Care. As the letter from EDS to Redi-Care of December 5, 1988 requires an Ownership and Control of Interest Statement from Redi-Care, the evidence shows the application was not fully completed by Redi-Care on that date. Therefore, this proposed Medicaid eligibility date is also incorrect.
A fair alternative would be to allow Redi-Care to be "Medicaid eligible" 90 days prior to the completion of the application on May 4, 1989. This would allow the eligibility period to begin on February 4, 1989, which is four days prior to the provision of any services to Medicaid eligible recipients by Redi-Care. This interpretation aligns itself with all of the policies in effect at the time the application was actually completed, and it does not allow any party to this proceeding to profit from its own mistakes or to suffer from the mistakes of others. Home health care services were provided to Medicaid eligible recipients and the Department is liable under Medicaid for the balance owed to the extent this program provides reimbursement to the provider. See Shands Teaching Hospital and Clinics, Inc. v. Department of Health and Rehabilitative Services, 11 FALR 5301 (FO 1989).
Based upon the foregoing Findings of Fact and Conclusions of Law, it is recommended:
Redi-Care's application for enrollment as a "Medicaid Provider" be deemed complete on May 4, 1989.
Redi-Care's eligibility period to submit claims as a "Medicaid Provider" should be listed as February 4, 1989, based upon the eligibility period set forth in the "Medicaid Provider Handbook, Home Health Care Services" in effect on the date the application was completed.
The Department waive time limits for claims received beyond the usual
12 month period, as allowed in Rule 10C-7.030(6), Florida Administrative Code, based upon the unusual circumstances of this case because the circumstances pose an undue hardship on the provider or recipients.
That the claims for services provided to Richard Mow and Claire Jester be re-submitted to Consultec for claims processing once the 12-month deadline is waived by the Department.
That the amount of the reimbursement allowed to Redi-Care should be provided at the rates in effect at the time the services were rendered.
RECOMMENDED this 11th day of June, 1991, in Tallahassee, Leon County, Florida.
VERONICA E. DONNELLY
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904)488-9675
Filed with the Clerk of the
Division of Administrative Hearings this 11th day of June, 1991.
APPENDIX TO RECOMMENDED ORDER, CASE NO. 89-6923
Redi-Care's proposed findings of fact are addressed as follows:
Accepted. See HO number 4.
Accepted. See HO number 5.
Accepted.
Accepted.
Accepted.
Accepted. See HO number 15.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted. See HO number 40.
Accepted.
Accepted. See HO number 42.
Accepted. See HO number 14 - number 27.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted. See HO number 45.
Accepted. See HO number 29.
Accepted. See HO number 38.
Accepted. See HO number 35.
Rejected. Contrary to fact.
See HO number 5 - number 7 and number 16.
Rejected. Contrary to fact and Redi-Care Exh. number 9.
Rejected. See HO number 35 - number 38.
Accepted. See HO number 39.
Accepted.
Rejected. Contrary to fact.
Accepted.
Rejected. Improper conclusion of law.
Accepted. See HO number 32.
Accepted. See HO number 33.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted. See HO number 8.
Accepted.
Accepted. See HO number 8.
Accepted. See HO number 9.
Reject due to use of technical term "Medicaid Provider." See HO number 18. Otherwise, accepted. See HO number 15.
Accepted.
Accepted. See HO number 28.
Accepted. See HO number 30 - number 31.
Accepted. See HO number 34.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted. See HO number 5.
Accepted.
Accepted.
Accepted.
Accepted. See HO number 2.
Accepted. See HO number 2.
The Department's proposed findings of fact are addressed as follows:
Accepted. See HO number 2.
Accepted. See HO number 3.
Rejected. Contrary to fact. See HO number 5.
Accepted. See HO number 1.
Accepted. See HO number 1.
Accepted. See HO number 5, number 15 and number 16.
Accepted. See HO number 6 and number 7.
Accepted. See HO number 7.
Accepted.
Accepted. See HO number 15 and number 16.
Accepted. See HO number 45.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted.
Rejected. Irrelevant.
Rejected. Conclusion of Law, not fact.
Accepted.
Accepted.
Rejected. Contrary to fact.
Accepted. See HO number 5.
Accepted.
Accepted.
Accepted.
Accepted.
Accepted. See HO number 9.
Accepted. See HO number 40.
Accepted.
Accepted. See HO number 43 - number 45.
Rejected. Improper conclusion.
Accepted.
Accepted. See HO number 20.
Accepted. See HO number 22 - number 24.
Rejected. Contrary to fact. See HO number 27.
Rejected. Irrelevant to this proceeding.
Consultec's proposed findings of fact are addressed as follows:
Accepted. See HO number 1 - number 2.
Accepted. See HO number 3.
Accepted. See HO number 3.
Generally accepted, except for the dates of enrollment and claims processing. See HO number 4 and number 5.
Accepted. See HO number 5 - number 7.
Rejected. Conclusionary and contrary to fact. See HO number 15 - number 17.
Accepted. See HO number 15 - number 17.
Accepted.
Rejected. Contrary to fact. See HO number 20.
Accepted, except for the conclusion that this was a rejection letter. See HO number 20 and number 26.
Reject the classification as rejection letter. Improper conclusion. See HO number 20. The rest of the paragraph is factually correct. See HO number 22 - number 24.
Rejected. Irrelevant.
Rejected. Improper definition of hearsay.
Accepted.
Accepted. See HO number 45.
Accepted. See HO number 40.
Accepted. See HO number 40.
Rejected. Contrary to fact.
See HO number 16, number 17 and number 27.
COPIES FURNISHED:
Karel Baarslag, Esquire Senior Attorney Department of Health and
Rehabilitative Services 1317 Winewood Boulevard Building Six, Room 233
Tallahassee, Florida 32399-0700
Barry Roth, Esquire COHEN AND ROTH, P.A.
1375 Jackson Street, Number 201 Post Office Drawer 2650
Fort Myers, Florida 33902-2650
Ken Syler CONSULTEC, INC.
2002 A1 Old St. Augustine Road Post Office Box 5497 Tallahassee, Florida 32314-5497
R. S. Power, Agency Clerk Department of Health and
Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, Florida 32399-0700
Linda K. Harris, Esquire General Counsel Department of Health and
Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, Florida 32399-0700
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least 10 days in which to submit written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
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AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
REDI-CARE HOME SERVICES, INC.,
Petitioner,
vs. CASE NO: 89-6923
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES and CONSULTEC, INC.,
Respondents.
/
FINAL ORDER
This cause came on before me for the purpose of issuing a final agency order. The Hearing Officer assigned by the Division of Administrative Hearing (DOAH) in the above-styled case submitted a Recommended Order to the Department of Health and Rehabilitative Services (HRS). A copy of that Recommended Order is attached hereto.
RULING ON EXCEPTIONS
Counsel for the department excepts at great length to the Hearing Officer's findings of fact. It is not necessary to address the exceptions as the key to the proper disposition of the case is the Hearing Officer's recommendation on page 19, the second paragraph. Petitioner was licensed as a home health agency at the time it provided the services at issue. In addition the services were
provided within the 90 day window of eligibility as it was clearly established that petitioner's completed application for Medicaid certification was received by Consultec on May 4, 1989. The HRS-Consultec provider handbook for home health agencies allows a licensed agency to be eligible for reimbursement 90 days prior to the day Consultec receives the agency's application for enrollment in the Medicaid Program. This eligibility assumes, of course, that the agency's application for enrollment is approved and that the agency was in compliance with Medicaid requirements during the 90 day period. If the 90 day pre- enrollment period of eligibility is inconsistent with Federal or State Medicaid regulations and rules, the HRS-Consultec provider handbook should be corrected without delay.
FINDINGS OF FACT
The department hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order except for the estoppel type findings of mistake and reliance which are unnecessary to the disposition.
CONCLUSIONS OF LAW
The department hereby adopts and incorporates by reference the conclusions of law set forth in the Recommended
Order except where inconsistent with this Final Order and except for the restatement of unnecessary factual findings.
Based upon the foregoing, it is
ADJUDGED, that it is therefore determined that petitioner was eligible for Medicaid reimbursement from February 4, 1989. To the extent necessary, the 12 month deadline for submission of the claims for services to Mow and Claire Jester is waived. Payment shall be based on Medicaid rates in effect at the time the services were rendered.
DONE and ORDERED this 3rd day of October 1991, in Tallahassee, Florida.
Robert B. Williams Secretary
Department of Health and Rehabilitative Services
by Deputy Secretary for Human Services
NOTICE OF RIGHT TO JUDICIAL REVIEW
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 ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF THE DIVISION OF ADMINISTRATIVE HEARINGS AND A SECOND COPY, ACCOMPANIED BY FILING FEES PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL, FIRST DISTRICT, OR WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE PARTY RESIDES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.
Copies furnished to:
Barry Roth, Esquire COHEN & ROTH, P. A.
Post Office Drawer 2650 Fort Myers, FL 33902
Karel Baarslag, Esquire Department of Health and Rehabilitative Services 1317 Winewood Boulevard
Building 6, Room 233
Tallahassee, FL 32399-0700
Ken R. Slyer, Qualified Representative
2002 A1 Old St. Augustine Road Tallahassee, FL 32314
Veronica E. Donnelly Hearing Officer
Division of Administrative Hearings 1230 Apalachee Parkway
The DeSoto Building Tallahassee, FL 32399-1550
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of the foregoing was sent to the above named people by U. S. Mail this 8th day of October, 1991.
R. S. Power, Agency Clerk Assistant General Counsel Department of Health and
Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407 Tallahassee, FL 32399-0700 904/488-2381
| Issue Date | Proceedings |
|---|---|
| Jun. 11, 1991 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Oct. 03, 1991 | Agency Final Order | |
| Jun. 11, 1991 | Recommended Order | Lack of proper certification as Medicaid provider result of series of mishaps; reimbursement for services should occur. |
