STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

HIALEAH HOSPITAL, )

)

Petitioner, )

)

vs. ) CASE NO. 92-1065

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to written notice, a formal administrative hearing was held in this proceeding before Daniel Manry, a duly designated Hearing Officer of the Division of Administrative Hearings, on June 25, 1992, in Miami, Florida.

APPEARANCES

For Petitioner: Deborah A. Rogers, R.N.

Administrative Director Utilization Management Hialeah Hospital

651 East 25 Street

Hialeah, Florida 33013

For Respondent: Gordon B. Scott, Esquire

HRS Medicaid Office 1317 Winewood Boulevard Building 6, Room 234A

Tallahassee, Florida 32399-0700 STATEMENT OF THE ISSUE

The issue for determination in this proceeding is whether Petitioner has been overpaid for inpatient hospital services.

PRELIMINARY STATEMENT

At the formal hearing, Petitioner submitted the testimony of Dr. Walter Furr and Grace Grau-Biagotti, R.N., director of Petitioner's addiction unit. Dr. Furr was accepted without objection as an expert in medicine and in quality assurance and utilization. Petitioner also submitted copies of the Florida Medicaid Criteria for Generic, Alcohol/Substance Abuse, and Female Reproductive

Disorders as a composite exhibit. The composite exhibit was identified as Joint Exhibit 1 and admitted in evidence pursuant to the agreement of the parties.

Respondent submitted the testimony of Medra Mansager, a Registered Nurse Consultant with the Florida Department of Health and Rehabilitative Services, Medicaid Program Office, Medicaid Program Integrity, and Mr. Henry Luckower,

Administrator, Peer Review Section of the Office Program Integrity, Department of Health and Rehabilitative Services. Ms. Mansager was accepted without objection as an expert in utilization review as it applies to Medicaid reimbursement policies. Respondent submitted 13 exhibits for admission in evidence. Respondent's Exhibits 1-13 are identified in the transcript of the formal hearing and were admitted in evidence without objection.

A transcript of the formal hearing was filed with the undersigned on July 17, 1992. Proposed findings of fact and conclusions of law were timely filed by Respondent on July 27, 1992. Petitioner was granted additional time to file its proposed findings of fact and conclusions of law pursuant to the Order Granting Enlargement of Time entered on August 21, 1992. Petitioner timely filed its proposed findings of fact and conclusions of law on September 25, 1992. The parties' proposed findings of fact are addressed in the Appendix to this Recommended Order.

FINDINGS OF FACT

1. Petitioner is a Florida Medicaid provider; provider number 100412. Respondent is the state agency responsible for administering the Florida Medicaid program pursuant to Section 409.901-409.920, Florida Statutes.

   
   

2. Respondent reimburses hospitals for inpatient services supplied to Medicaid eligible recipients if the services are medically necessary. Services are medically necessary if:

   
   

   ". . . provided in a hospital on an inpatient basis [and cannot], consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type."

   
   

   Florida Administrative Code Rule 10C-7.039.

   
   

3. Respondent utilizes the 1986 Interqual ISD criteria to determine the medical necessity of services rendered by Medicaid providers. ISD is an acronym for severity of illness, intensity of service, and discharge screens. Severity of illness indicates the severity of the patient's condition on admission. Intensity of service relates to the diagnostic and therapeutic services the patient receives while hospitalized. Discharge screens indicate the patient's readiness for discharge. Petitioner had actual notice of the applicable ISD criteria to be used in determining Medicaid coverage for inpatient services.

   
   

4. The amount of Medicaid benefits at issue in this proceeding, the patients, and the dates of hospitalization to which the benefits apply are as follows:

   
   

   (a) Laura Lakatos, 10/17/89 to 11/9/89,

   $13,351.27;

   1. Jeannette Moore, 3/19/90 to 3/24/90,

      $2,324.26;

   2. Catherine Rosa, 3/16/90 to 3/20/90,

      $580.49;

   3. Cheyenne Williams, 1/20/90 to 2/1/90,

      $3,482.94;

   4. Kimberly Williams, 2/20/90 to 3/6/90,

      $8,126.86; and

      (f) Gail Woodley, 8/28/89 to 9/28/89,

      $17,995.19

      
      

5. Ms. Laura Lakatos was admitted clinically intoxicated. Her drug screens showed cocaine metabolites. The ISD criteria in effect at the time of her admission required the patient to be comatose or in an impending comatose condition prior to any clinical findings and the presence of one of the following clinical findings:

   
   

   1. delirium and/or mania;

   2. impending delirium tremens; or

   3. seizures (withdrawal or toxic).

   
   

6. Ms. Lakatos' condition upon admission satisfied none of the applicable ISD criteria. She was confused, delusional, and had slurred speech but was neither comatose nor suffering from an impending comatose condition. She did not suffer from impending delirium tremens or seizures. No evidence was introduced that she suffered from delirium and/or mania or was otherwise not in actual contact with reality. Ms. Lakatos could have been treated in more economical setting.

   
   

7. Ms. Jeannette Moore's chief complaint on admission was pain in both thighs. The ISD criteria applicable to Ms. Moore at the time of admission required one of the following findings to be present in order to continue inpatient hospitalization for Medicaid reimbursement purposes:

   
   

   1. monitoring (at least every 2 hours);

   2. intravenous medications; or

   3. treatments of radioactive materials or plasma, surgery.

   
   

8. Ms. Moore satisfied the ISD criteria for one day of inpatient services. On the second day, she did not meet the ISD criteria for intensity of service and should have been released.

   
   

9. Ms. Catherine Rosa was admitted on March 16, 1990, to deliver her baby. She had a normal vaginal delivery for which Medicaid covers two days of hospitalization. Ms. Rosa did not satisfy the ISD criteria for continued hospitalization after March 17, 1990, and should have been released on March 18, 1990.

   
   

10. Ms. Cheyenne Williams was admitted on January 20, 1990, and placed on a detoxification program with seizure precautions. She was given both oral and intramuscular medication for seizure prevention. While Ms. Williams satisfied applicable ISD criteria upon admission, none of the requisite clinical findings were present after January 24, 1990, and Ms. Williams should have been released from the hospital on January 25, 1990.

    
    

11. Ms. Kimberly Williams was admitted on February 20, 1990, for drug addiction. She was agitated, depressed, had delusions of grandeur, a tremor, and an irregular gait. Her toxicology screen showed nicotine and cocaine metabolites.

    
    

12. Mr. Williams did not meet the ISD criteria for admission. She was neither comatose nor suffering from an impending comatose condition. She did

    not meet ISD criteria of delirium and/or mania, impending delirium tremens, or seizures to warrant hospital admission. She could have been treated in a more economical setting.

    
    

13. Ms. Gail Woodley was admitted on August 28, 1989, for drug addiction. She had slurred speech and tremors. Her toxicology screen showed cocaine metabolites. The uncontroverted evidence established that Ms. Woodley failed to meet the ISD criteria for inpatient services.

    
    

    CONCLUSIONS OF LAW

    
    

14. The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of this proceeding. Section 120.57(1), Florida Statutes. The parties were duly noticed for the formal hearing.

    
    

15. The burden of proof in this proceeding is on Petitioner. Petitioner must establish by a preponderance of evidence that the medicaid recipients in question met the admission criteria and/or continued inpatient stay criteria to warrant reimbursement from the Florida Medicaid program. Department of Transportation v. J.W.C. Company, Inc., 396 So.2d 778 (Fla. 1st DCA 1981); Balino v. Department of Health and Rehabilitative Services, 348 So.2d 349 (Fla. 1st DCA 1977). The Petitioner failed to sustain its burden of proof.

    
    

16. Florida Administrative Code Rule 10C-7.039 provides in relevant part that Medicaid must pay for covered services which are medically necessary and which:

    
    

    . . . could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis, or in a inpatient facility of a different type."

    
    

    Florida Administrative Code Rule 10C-7.039(1)(j).

    
    

17. Respondent is required by federal regulation to implement a utilization review program to oversee services rendered by Medicaid providers.

    42 C.F.R. 456. Utilization review systematically evaluates inpatient services provided to medicaid recipients for the purpose of determining the need for admission and continued stay.

    
    

18. Each Florida Medicaid provider must have a utilization review committee which systematically reviews inpatients in accordance with specified criteria to determine whether a patient should be there. The Florida Medicaid program employs a Peer Review Organization ("PRO") to review a sample of those cases previously reviewed by the Medicaid provider's utilization review committee. The PRO applies the same criteria applied by the hospital utilization review committee.

    
    

19. Respondent reasonably relied upon and properly applied ISD criteria for Medicaid reimbursement purposes. Each patient must meet the applicable ISD criteria for severity of illness prior to hospital admittance before the Florida Medicaid Program can reimburse the hospital for its inpatient services. The patient must continue to meet the ISD intensity of service criteria for continued hospitalization to be entitled to reimbursement.

RECOMMENDATION

RECOMMENDED this 12th day of January 1993, at Tallahassee, Florida.

DANIEL MANRY

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 12th day of January, 1993.

APPENDIX TO RECOMMENDED ORDER, CASE NO. 92-1065

Petitioner's Proposed Findings of Fact

1. Rejected as irrelevant.

2. Accepted in finding 9.

3. Accepted in finding 4.

4. Accepted in finding 11.

5. Accepted in finding 12.

6. Accepted in finding 4. 18.-19. Accepted in finding 13.

Respondent's Proposed Findings of Fact

21. Accepted in findings 5, 12-13. 22.-25. Acceepted in finding 5.

26.-28. Accepted in finding 7.

29. Accepted in finding 8. 30.-31. Accepted in finding 9. 32.-35. Accepted in finding 10. 36.-37. Accepted in finding 11. 38.-39. Accepted in finding 12. 40.-42. Accepted in finding 13.

COPIES FURNISHED:

Deborah A. Rogers, R.N. Administrative Director Utilization Management Hialeah Hospital

651 East 25 Street

Hialeah, Florida 33013

Gordon B. Scott, Esquire Department of Health and

Rehabilitative Services HRS Medicaid Office

1317 Winewood Boulevard Building 6, Room 234A Tallahassee, Florida 32399-0700

Robert L. Powell, Agency Clerk Department of Health and

Rehabilitative Services 1323 Winewood Boulevard Building One, Suite 407

Tallahassee, Florida 32399-0700

John Slye, General Counsel Department of Health and

Rehabilitative Services 1323 Winewood Boulevard Building One, Suite 407

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.

Docket for Case No: 92-001065

Orders for Case No: 92-001065