STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
TYWAUN JONES,
Petitioner,
vs.
AGENCY FOR HEALTH CARE ADMINISTRATION,
Respondent.
/
Case No. 20-0861MTR
FINAL ORDER
This case came before Administrative Law Judge ("ALJ") John G. Van Laningham, Division of Administrative Hearings ("DOAH"), for final hearing in Tallahassee on May 7, 2020.
APPEARANCES
For Petitioner: Floyd B. Faglie, Esquire
Staunton & Faglie, PL 189 East Walnut Street Monticello, Florida 32344
For Respondent: Alexander R. Boler, Esquire
2073 Summit Lake Drive, Suite 300
Tallahassee, Florida 32317
STATEMENT OF THE ISSUES
The issues for determination are, first, whether a lesser portion of Petitioner's total recovery from a third-party tortfeasor should be designated as recovered medical expenses than the share presumed by statute; if so,
then the amount of Petitioner's recovery to which Respondent's Medicaid lien may attach must be determined.
PRELIMINARY STATEMENT
Petitioner Tywaun Jones ("Jones") settled a personal injury action for
$1,000,000. Respondent Agency for Health Care Administration (the "Agency" or "AHCA") asserted its intent to enforce a Medicaid lien in the amount of $188,757.39 against Jones's recovery. The Agency relies, as is its right, on the formula set forth in section 409.910(11)(f), Florida Statutes, to determine that portion of the settlement which should be allocated as past medical expense damages.
Jones objected to this presumptive allocation of the recovery, and, on February 17, 2020, he timely filed a petition with DOAH to contest the default amount designated by statute as recovered medical expense damages payable to the Agency.
On April 27, 2020, the parties filed a Joint Pre-hearing Stipulation, which contains a statement of facts that "are admitted and will require no proof at hearing." As a result, most, if not all, of the material historical facts of this case are undisputed.
At the final hearing, which took place as scheduled on May 7, 2020, with both parties present, Jones called trial attorneys Douglas J. McCarron and
R. Vinson Barrett as witnesses. Petitioner's Exhibits 1 through 11 were received in evidence without objection. The Agency rested without offering any evidence.
The final hearing transcript was filed on June 19, 2020. The parties timely filed proposed final orders, which have been considered.
Unless otherwise indicated, citations to the official statute law of the state of Florida refer to Florida Statutes 2019.
FINDINGS OF FACT
At all times material, Jones lived at a small apartment complex, which had a history of criminal activity involving drug trafficking. On September 1, 2016, Jones, who was then 37 years old, confronted a drug dealer on the premises concerning a disturbance during a previous night. The drug dealer shot Mr. Jones numerous times in the abdomen, chest, and left wrist. Jones underwent extensive medical intervention, but his wrist was inoperable.
As a result of his gunshot wound, Jones suffered catastrophic and permanent injury to his spinal cord, rendering him a paraplegic. Jones is now permanently wheelchair-bound and unable to use his left hand to assist in mobility and transfers. He is unable to care for himself and lives with his mother, who provides for his care. Further, he suffers from neuropathy, depression, and post-traumatic stress disorder. Jones's injury has had a profoundly negative impact on his life.
Jones's injury-related medical care was paid for by Medicaid. AHCA provided $188,757.39 in benefits, and a Medicaid Managed Care Organization known as Simply Health provided an additional $191,527.53 in medical assistance expenditures related to the incident. The combined amount of these benefits, $380,284.92, constituted Jones's entire claim for past medical expenses.
Jones brought a personal injury lawsuit against the owner of the apartment complex (the "Defendant"), alleging that the Defendant should have known about the risk of crime-related injuries on the premises and, accordingly, provided reasonable security for the tenants, which it negligently failed to do. For Jones, the main barrier to a full recovery of his damages was not liability, but the fact that the Defendant's only means of satisfying a judgment was an insurance policy with $1,000,000 limits. Based on the
limited insurance available, the case settled for an unallocated lump sum of
$1,000,000.
AHCA was notified of Jones's personal injury action. AHCA did not "institute, intervene in, or join in" the personal injury action to enforce its rights as provided in section 409.910(11), Florida Statutes, or participate in any aspect of the personal injury action against the Defendant.
Instead, AHCA asserted a $188,757.39 Medicaid lien against Jones's cause of action and settlement of that action. By letter, AHCA was notified of Jones's settlement. AHCA has not filed a motion to set-aside, have declared void, or otherwise disputed Jones's settlement.
The Medicaid program, through AHCA, spent $188,757.39 on behalf of Jones, all of which represents expenditures paid towards Jones's past medical care and treatment. Jones's taxable costs incurred in securing the $1,000,000 settlement totaled $59,652.67. Application of the section 409.910(11)(f) formula to Jones's $1,000,000 recovery produces a statutory default allocation of $188,757.39 in settlement funds to past medical expenses, which would satisfy AHCA's Medicaid lien in full—a 100% recovery.
Jones has deposited the Medicaid lien amount in an interest-bearing account for the benefit of AHCA pending an administrative determination of AHCA's rights. This constitutes "final agency action" for purposes of
chapter 120, Florida Statutes, pursuant to section 409.910(17).
As mentioned, Jones's recovery was an undifferentiated lump sum. It is reasonable to infer that the Defendant (and its carrier) had little or no interest in negotiating an allocation, between elements of Jones's damages, of the $1,000,000 settlement. There is no evidence, in any event, of such bargaining between Jones and the Defendant.
There is no dispute that, under the anti-lien provisions in the federal Medicaid statute, the Agency's lien attaches only to the portion of Jones's recovery attributable to past medical expenses.
The ultimate question presented is whether the Agency's default distribution, in the stipulated amount of $188,757.39, reflects "the portion of the total recovery which should be allocated"1 to Jones's recovery of past medical damages, or whether a lesser sum, from the total settlement, "should be allocated" to the recovery of past medical damages. It is Jones's burden to prove that the statutory allocation is greater than the amount which "should be" distributed to the Agency, and that the Agency's default lien amount "should be" adjusted to better reflect the portion of his total recovery attributable to past medical expenses.
To meet his burden, Jones presented evidence at hearing, as is now typically done in cases such as this, with the goal of establishing the "true value" of his damages. Usually, and again as here, this evidence comes in the form of opinion testimony, from a trial attorney or attorneys who specialize in personal injury law and represent plaintiffs in negligence actions.
Jones called two experienced plaintiff's personal injury lawyers, one of whom represented him in the underlying personal injury lawsuit, to give opinions on the valuation of his damages. The undersigned finds their opinions in this regard to be credible and persuasive. Moreover, the Agency did not offer any evidence to challenge Jones's valuation; no expert testimony was given, for example, by an attorney specializing in personal injury defense, which might have provided a different perspective on the value of Jones's case. Having no evidential basis for discounting or disregarding the opinions of Jones's expert witnesses, the undersigned bases the findings on valuation that follow upon their unchallenged testimony.
Jones is requesting—and his expert witnesses opined that—the Medicaid lien should be adjusted according to a method that will be referred to herein as a "proportional reduction." A proportional reduction adjusts the lien so that the Agency's recovery is discounted in the same measure as the
1 See § 409.910(17)(b), Fla. Stat.
plaintiff's recovery. In other words, if the plaintiff recovered 25% of the "true value" of his damages, then, under a proportional reduction, the Medicaid lien is adjusted so that the Agency recovers 25% of the plaintiff's recovered past medical damages.
The mathematical operation behind a proportional reduction is simple and requires no expertise. Using "r" to signify the plaintiff's recovery; "v" to represent the "value" of his damages; "m" for past medical expenses; and "x" as the variable for the adjusted lien amount, the equation is: (r ÷ v) × m = x. In these cases, the only unknown number (usually) is v, i.e., the "value" of the plaintiff's total damages.
"True value," sometimes also called "full value" or "total value," is an elusive concept, given that the true value of damages which have not been liquidated by a judgment is not, and cannot be, known in a case that settles before the entry of a judgment.
For purposes of this discussion, the undersigned will use the term "plaintiff's best-case value" ("PBV"), instead of "true value," to refer to the amount that the plaintiff would have asked the jury to award him at trial.
Where there is a PBV, there is also a "defendant's best-case value" ("DBV"). In a jury trial, DBV might well be $0, if the defendant is contesting liability, and it will nearly always be, in any event, less than PBV. As mentioned above, the Agency chose not to present expert witness testimony as to DBV, or any value.
There are other constructs that might be considered in regard to value, such as, for example, "settlement value" as described in Mojica v. State, Agency for Health Care Administration, 285 So. 3d 393, 395 (Fla. 1st DCA 2019). "Settlement value," in the Mojica sense, takes into account, among other factors, the "defendant's ability to pay." Id.
Jones's recovery was arbitrarily capped at $1,000,000, the coverage limit of the Defendant's only available insurance policy. For purposes of this discussion, the undersigned will refer to a settlement such as Jones's as an
"arbitrary discount settlement." An arbitrary discount settlement is "arbitrary" in the sense that the amount of the settlement bears no relationship to PBV or even DBV; the plaintiff is simply forced to accept what is, for him, a random haircut owing to a hard limit on the defendant's ability to pay, which has nothing to do with the plaintiff's damages or the defendant's liability therefor.2
The uncontested and unimpeached expert testimony in this case establishes, by any standard of proof, that Jones's PBV is no less than
$20,000,000, which is the conservative figure presented by Jones's witnesses, Douglas J. McCarron, Esquire, and R. Vinson Barrett, Esquire.
Mr. McCarron represented Jones in his personal injury claim. Mr. McCarron has been an attorney for 24 years and practices with the
Haggard Law Firm in Coral Gables, Florida. For the past 20 years he has practiced personal injury and wrongful death law representing clients who have been catastrophically injured or killed. He is a trial attorney and routinely handles jury trials. He routinely reviews medical records, life care plans, and economist reports, and interviews or deposes expert witnesses.
As a routine part of his practice, Mr. McCarron stays abreast of jury verdicts, which is important in making assessments concerning the value of damages suffered by injured clients. Mr. McCarron is familiar with, and routinely participates in, allocation of settlements in the context of health insurance liens, workers' compensation liens, and Medicare set-asides, as well as allocations of judgements made by trial judges post-verdict.
A regular practice of Mr. McCarron's is to "roundtable" cases with the other attorneys in his firm to discuss valuation of damages, as well as the strengths and weaknesses of cases. Jones's case was "roundtabled" at
2 The amount of an arbitrary discount settlement should ordinarily be less than the settlement value of the plaintiff's case, because the defendant's limited ability to pay is the only relevant factor in determining the amount of an arbitrary discount settlement, whereas settlement value takes other factors into account, including but not limited to the defendant's ability to pay.
Mr. McCarron's firm, and it was the consensus of the attorneys involved that Jones's damages had a value more than $20,000,000.
In preparing Jones's case for trial, Mr. McCarron obtained a life care plan and an economist's report, to ascertain the present value of Jones's future medical and life care needs. The economist placed the present value of Jones's future medical expenses and claim for lost services at $12,598,946.3 Together with the $380,284.92 claim for past medical expenses, therefore, Jones's economic damages alone would have had a value of approximately
$13,000,000.
Jones's claim for noneconomic damages, such as past and future pain and suffering, would have a high monetary value of at least $7,000,000.
Mr. McCarron testified that, based on his experience, valuing Jones's total damages at $20,000,000 is very conservative.
Jones's other expert witness, Mr. Barrett, has been a trial attorney for more than 40 years and is a partner with the law firm of Barrett, Nonni and Homola, PA , in Tallahassee, Florida. His practice is dedicated to plaintiff's personal injury and wrongful death cases. He has handled cases involving catastrophic injuries and routinely handles jury trials. Mr. Barrett is familiar with medical records, life care plans, and economist reports. Mr. Barrett stays abreast of jury verdicts by reviewing jury verdict reports and discussing cases with other trial attorneys. As a routine part of his practice, Mr. Barrett makes assessments concerning the value of damages suffered by injured parties. He is familiar with the process of allocating settlements in the context of Medicaid liens. Mr. Barrett has been accepted as a credible expert in the valuation of damages by judges in numerous cases such as this.
Mr. Barrett testified that, based on his professional training and experience, he believed Jones's damages had a conservative value of
3 Jones's life care plan and economist report are in evidence as Petitioner's Exhibits 3 and 4, respectively.
$20,000,000. Mr. Barrett noted that the economist's report placed the present value of Jones's future medical needs and lost services at $12,598,946, an amount which, when added to the $380,284.92 claim for past medical expenses, brings the value of Jones's economic damages, alone, to nearly
$13,000,000. Mr. Barrett testified that Jones's noneconomic damages would be, "quite, quite conservatively," $10,000,000.
Mr. Barrett testified that Jones's recovery of $1,000,000 did not fully compensate Jones for all the damages he had suffered. Mr. Barrett testified that the $1,000,000 settlement represents a recovery of 5% of the total value of Jones's damages, conservatively appraised at $20,000,000. Mr. Barrett testified that because Jones recovered only 5% of his total damages, conservatively appraised, it stands to reason that he recovered only 5% of the
$380,284.92 in past medical damages caused by the shooting, or $19,014.25. Mr. Barrett testified that it would be very reasonable to allocate $19,014.25 of the settlement to past medical expenses. Mr. Barrett testified, and the undersigned finds, that the allocation of $19,014.25 of the settlement to past medical expenses, and the methodology for making that allocation, are consistent with Mr. Barrett's expert testimony in other Medicaid lien adjustment cases, which has been accepted by ALJs and reviewing courts.
Once Jones made a prima facie showing of PBV by adducing competent substantial evidence thereof, the Agency, if it wanted to prove that the PBV in question, $20,000,000, is an inflated figure, needed to introduce some evidence that would have given the fact-finder an evidentiary basis for discounting or rejecting this value.4 Here, the Agency elected not to present
4 To be clear, the undersigned is not shifting the burden of proof to the Agency. A petitioner, however, does not have the initial burden of putting on the personal injury defense case, in order to prove DBV, nor does the petitioner have the initial burden of establishing matters, such as comparative negligence, which the defense might have relied upon in an arms-length negotiation to settle the case. Defense arguments are matters that the Agency may address in its case, if it wants to show that PBV is inflated. But the Agency is not required to put on any such evidence. The Agency is free to present no evidence, rely solely on cross- examination of the petitioner's witnesses to undermine the testimony elicited by the
evidence of value, but instead it chose to argue that Jones has failed to prove that the particular medical-expense allocation he advocates should be made, and that, as a result, the default, statutory allocation should be made. As far as the evidence goes, therefore, the undersigned has no reasonable basis for rejecting the value of $20,000,000 that Jones's witnesses testified, credibly, was a conservative appraisal of Jones's total damages.
The opinion testimony elicited at hearing, in addition to being unchallenged and unimpeached, is otherwise persuasive to the fact-finder and convincingly establishes that the probable "value" of Jones's case, i.e., v in the proportional reduction formula, is $20,000,000. The unchallenged expert testimony convincingly shows, as well, that a proportional reduction methodology appropriately identifies the "portion of the total recovery which should be allocated" in this case as past medical expense damages.
Accordingly, the undersigned determines as a matter of ultimate fact that the portion of Jones's $1,000,000 recovery that "should be allocated" to past medical expenditures is $19,014.25, or 5% of Jones's total past medical expenses. This distribution places AHCA in a better position, percentagewise, than Jones, since $19,014.25 amounts to a recovery of approximately 10% of AHCA's total expenditures, whereas Jones recovered only 5% of his total damages.5
petitioner on direct, and then argue that the petitioner has failed to meet his burden of proof—as the Agency has done in this case. If the Agency takes this approach, however, it loses the opportunity affirmatively to prove that PBV is too high, and it risks a finding that the unrebutted evidence of PBV is a fair reflection of value. If, however, the Agency presents evidence of DBV, settlement value, or some alternative value, then the petitioner must rebut the evidence and try to overcome it, for the petitioner bears the ultimate burden of persuasion with regard to establishing the value of the petitioner's damages.
5 This is because Jones's past medical damages ($380,284.92), which include expenditures on his behalf by Simply Health, exceed AHCA's total outlay (188,757.39) by just over 100%.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has personal and subject matter jurisdiction in this proceeding, as well as final order authority, pursuant to section 409.910(17)(b).
Section 409.910(1) provides as follows:
It is the intent of the Legislature that Medicaid be the payor of last resort for medically necessary goods and services furnished to Medicaid recipients. All other sources of payment for medical care are primary to medical assistance provided by Medicaid. If benefits of a liable third party are discovered or become available after medical assistance has been provided by Medicaid, it is the intent of the Legislature that Medicaid be repaid in full and prior to any other person, program, or entity. Medicaid is to be repaid in full from, and to the extent of, any third-party benefits, regardless of whether a recipient is made whole or other creditors paid. Principles of common law and equity as to assignment, lien, and subrogation are abrogated to the extent necessary to ensure full recovery by Medicaid from third-party resources. It is intended that if the resources of a liable third party become available at any time, the public treasury should not bear the burden of medical assistance to the extent of such resources.
Section 409.910(6)(c) provides, in relevant part, as follows:
The agency is entitled to, and has, an automatic lien for the full amount of medical assistance provided by Medicaid to or on behalf of the recipient for medical care furnished as a result of any covered injury or illness for which a third party is or may be liable, upon the collateral, as defined in s. 409.901[, which includes "[a]ny and all causes of action, suits, claims, counterclaims, and demands that accrue to the recipient or to the recipient's legal representative, related to any covered injury, illness, or necessary medical care, goods, or services that necessitated that Medicaid provide medical assistance."]
Section 409.910(11)(f) provides, in pertinent part, as follows:
Notwithstanding any provision in this section to the contrary, in the event of an action in tort against a third party in which the recipient or his or her legal representative is a party which results in a judgment, award, or settlement from a third party, the amount recovered shall be distributed as follows:
After attorney's fees and taxable costs as defined by the Florida Rules of Civil Procedure, one-half of the remaining recovery shall be paid to the agency up to the total amount of medical assistance provided by Medicaid.
The remaining amount of the recovery shall be paid to the recipient.
For purposes of calculating the agency's recovery of medical assistance benefits paid, the fee for services of an attorney retained by the recipient or his or her legal representative shall be calculated at 25 percent of the judgment, award, or settlement.
Section 409.910(17)(b) provides as follows:
If federal law limits the agency to reimbursement from the recovered medical expense damages, a recipient, or his or her legal representative, may contest the amount designated as recovered medical expense damages payable to the agency pursuant to the formula specified in paragraph (11)(f) by filing a petition under chapter 120 within 21 days after the date of payment of funds to the agency or after the date of placing the full amount of the third-party benefits in the trust account for the benefit of the agency pursuant to paragraph (a). The petition shall be filed with the Division of Administrative Hearings. For purposes of chapter 120, the payment of funds to the agency or the placement of the full amount of the third-party benefits in the trust account for the benefit of the agency constitutes final agency action and notice
thereof. Final order authority for the proceedings specified in this subsection rests with the Division of Administrative Hearings. This procedure is the exclusive method for challenging the amount of third-party benefits payable to the agency. In order to successfully challenge the amount designated as recovered medical expenses, the recipient must prove, by clear and convincing evidence, that the portion of the total recovery which should be allocated as past and future medical expenses is less than the amount calculated by the agency pursuant to the formula set forth in paragraph (11)(f). Alternatively, the recipient must prove by clear and convincing evidence that Medicaid provided a lesser amount of medical assistance than that asserted by the agency.
Section 409.910 provides no guidance, instructions, or criteria that the ALJ is required to consider in determining the portion of a recipient's total recovery which "should be allocated" as medical expenses, nor does it prohibit the ALJ from considering any specific criteria or from using any particular methodology. This lack of specific statutory standards limiting the decision- maker's discretion extends to the recipient, as well, who must prove that some amount less than the default allocation "should be allocated" to medical expense damages, without any clear statutory direction as to what must be proved to make the required showing.
The U.S. Supreme Court has interpreted the anti-lien provision in federal Medicaid law as imposing a bar which, pursuant to the Supremacy Clause, precludes "a state from asserting a lien on the portions of a settlement not allocated to medical expenses." See, e.g., Mobley v. State, 181 So. 3d 1233, 1235 (Fla. 1st DCA 2015).
In 2017, the United States District Court for the Northern District of Florida enjoined the Agency from enforcing section 409.910(17)(b) to seek "reimbursement of past Medicaid expenses from portions of a recipient's recovery that represents future medical expenses of past Medicaid expenses,"
and from advocating that "a Medicaid recipient [must] affirmatively disprove
§ 409.910(17)(b)'s formula-based allocation with clear and convincing evidence." Gallardo v. Senior, WL 3081816, at *9 (N.D. Fla. July 18, 2017).
The Agency appealed the Gallardo decision, which remained under review in the U.S. Eleventh Circuit Court of Appeal ("Eleventh Circuit") through the date of the final hearing in this case. As a result of Gallardo, the parties stipulated that the standard of proof in this case shall be the greater weight, or preponderance of the evidence, standard.
Recently, however, the Eleventh Circuit issued its opinion reversing the district court's judgment. See Gallardo v. Dudek, 2020 WL 3478027 (11th Cir. June 26, 2020). The court of appeals held that Florida's statutory formula is not preempted by federal law. Thus, under Dudek, the Medicaid lien may attach to all medical expenses recovered, including damages for future care and treatment, and the standard of proof by which the recipient must rebut the formulaic allocation is clear and convincing evidence. Id. at
*8-9.
Meantime, independent of Gallardo, the Florida Supreme Court ruled, in Giraldo v. Agency for Health Care Administration, 248 So. 3d 53, 54 (Fla. 2018), that, under preemptive federal law, the state's Medicaid lien may attach only to that portion of a recipient's settlement recovery attributable to past medical expense damages. Thus, the Florida Supreme Court held that section 409.910(17)(b) is invalid and unenforceable to the extent it would allow the Agency to recover from future medical expense damages. As an authoritative decision of the state's highest court, Giraldo is binding precedent on all lower courts, which a state ALJ, applying state law, must follow. See Dudek, 2020 WL 3478027, at *19 ("Florida Medicaid recipients will now head to state administrative court to benefit from the Florida Supreme Court's holding in Giraldo.")(Wilson, J., concurring in part and dissenting in part).
As a result of Dudek, however, the statutory standard of proof is back, because Florida state courts have not held this aspect of Florida law to be preempted or otherwise unenforceable. The undersigned concludes, however, that it is unnecessary to decide here whether the parties' stipulation regarding the standard of proof—which was a function of the since-reversed injunction—should be set aside. Neither party has requested such relief, nor, in any event, would imposing the stricter evidentiary standard change the outcome of this case. Jones has proved his case by clear and convincing evidence, as required by statute, even if, by stipulation, he did not need to.
In regard to the methodology for determining that portion of the total recovery which should be allocated to past medical expense damages, recent appellate decisions have moved towards acceptance of the proportional reduction as a valid, albeit nonexclusive, basis for making the required distribution. As the First District Court of Appeal explained:
[W]hile not established as the only method, the pro rata [or proportional reduction] approach has been accepted in other Florida cases where the Medicaid recipient presents competent, substantial evidence to support the allocation of a smaller portion of a settlement for past medical expenses than the portion claimed by AHCA. See Giraldo v. Agency for Health Care Admin., 248 So. 3d 53 (Fla. 2018); Mojica v. Agency for Health Care Admin., 285 So. 3d 393 (Fla. 1st DCA 2019); Eady v. State, 279 So. 3d 1249 (Fla. 1st DCA 2019). But see Willoughby v. Agency for Health Care Administration, 212 So. 3d 516 (Fla. 2d DCA 2017) (quoting Smith v. Agency for Health Care Administration, 24 So. 3d 590, 591 (Fla. 5th DCA 2009)) (explaining that the pro rata formula is not the "required or sanctioned method to determine the medical expense portion of an overall settlement amount").
Ag. for Health Care Admin. v. Rodriguez, 294 So. 3d 441, 444 (Fla. 1st DCA 2020).
To the cases cited by the court in Rodriguez may be added another recent decision, Bryan v. Agency for Health Care Administration, 291 So. 3d 1033 (Fla. 1st DCA 2020). In Bryan, the recipient settled a medical malpractice action arising out of a catastrophic brain injury for $3,000,000, and then initiated an administrative proceeding to adjust the Medicaid lien, which the Agency asserted should be payable in the full amount of approximately $380,000. Bryan, 291 So. 3d at 1034. At hearing, the recipient "offered the testimony of two trial attorneys who were both admitted as experts in the valuation of damages." Id. These witnesses relied upon a life care plan and an economist's report, which were filed as exhibits, as well as jury verdicts in similar cases, to support their opinion that "the value of [the recipient's] damages exceeded $30 million." Id.
The "experts both testified that, using the conservative figure
$30 million, the $3 million settlement only represented a 10% recovery," and that, "based on that figure, it would be reasonable to allocate 10% of [the recipient's approximately $380,000] claim for past medical expenses—[or, approximately $38,000]—from the settlement to settle [the Agency's] lien." Id. The recipient also "submitted an affidavit of a former judge," who affirmed that the proportional allocation was a reasonable, rational, and logical "method of calculating the proposed allocation." Id.
Regarding the Agency's case, the court wrote:
In turn, AHCA did not: (1) call any witnesses, (2) present any evidence as to the value of Ms. Bryan's damages, (3) propose a differing valuation of the damages, or (4) present evidence contesting the methodology used to calculate the $38,106.28 allocation to past medical expenses.
Id. at 1035.
The ALJ rejected the recipient's proposed proportional reduction methodology as a "'one size fits all' approach which place[s] each element of [the recipient's] damages at an equal value." Id. The ALJ determined that it
was the recipient's burden to "prove that it was more probable than not" that the parties in the personal injury action had intended to allocate only 10% of the settlement recovery as past medical expenses, and that the recipient had failed to do that. Id. Accordingly, the ALJ ordered the recipient to pay the Medicaid lien in full. Id.
The court reversed the ALJ's order, explaining:
[I]n this case, [the recipient] presented unrebutted competent substantial evidence to support that the value of her case was at least $30 million. She also presented unrebutted competent substantial evidence that her pro rata methodology did indeed support her conclusion that $38,106.28 was a proper allocation to her past medical expenses. Such methodology was similar to the methodology employed in Giraldo, Eady, and Mojica. [The Agency] did not present any evidence to challenge [the recipient's] valuation, nor did it present any alternative theories or methodologies that would support the calculation of a different allocation amount for past medical expenses. Without any evidence to contradict the pro rata methodology proposed by [the recipient], the ALJ's rejection of that methodology was not warranted.
Id.
There are a number of similarities between this case and Bryan. Here,
as in Bryan, two trial attorneys gave unrebutted testimony that, using a conservative (and uncontested) appraisal of the recipient's case ($20,000,000), the settlement ($1,000,000) represented only a small fraction (5%) of the recipient's PBV. They expressed the opinion, as in Bryan, that a proportional reduction was the proper method of determining the portion of the recipient's recovery which should be allocated as past medical expenses. As in Bryan, the Agency did not present testimony or other evidence as to: (i) the value of the recipient's case; (ii) an alternative appraisal of the recipient's damages; or
(iii) the weaknesses, if any, in the proportional reduction methodology as applied to the particular facts.
The undersigned concludes that Bryan is applicable and controlling. Following that court's lead, the undersigned accepts the premise that the proportional reduction methodology, when established, as here, by unrebutted, competent substantial evidence, provides a valid formula for determining the portion of the recipient's recovery which should be allocated as past medical expense damages.
That said, the undersigned notes that there appears to be some tension between Bryan and Gray v. Agency for Health Care Administration, 288 So. 3d 95 (Fla. 1st DCA 2019), which is yet another relatively recent decision. In Gray, the recipient sustained a spinal cord injury in a car accident, sued the driver, and was "awarded a jury verdict of over
$2.8 million." Id. at 98.6 The verdict itemized each element of the recipient's damages, awarding a specific dollar amount for each item, including
$128,760.56 for past medical treatment. Medicaid had provided the recipient
$65,610.05 in medical assistance payments. Id. The default lien under section 409.910(11)(f) was $3,750, which the recipient sought to reduce by requesting a hearing under section 409.910(17)(b).
At hearing, the recipient moved the verdict form and final judgment into evidence, among other documentation. Id. at 99. He argued that the presumptive amount under the statute should be adjusted using a basic proportional reduction approach, whereby the lien would be limited to the same ratio (0.003498) that his recovery ($10,000) bore to the judgment ($2,859,120.56), "which would equate to $229.49." Id. at 98. The recipient conceded at hearing "that no case law or other statute authorized the ALJ to apply a pro rata formula instead of the formula provided in the statute." 7 Id.
6 The total award was $2,859,120.56.
7 It should be mentioned that the ALJ's final order was entered on December 29, 2016. See Gray v. Ag. for Health Care Admin., Case No. 16-5582MTR, 2016 WL 7496778 (Fla. DOAH Dec. 29, 2016). The recipient's concession would not likely be made today, because many cases decided since 2016, as discussed herein, have authorized the use of a pro rata formula.
The ALJ rejected the pro rata approach, ruling that the Agency was entitled to $3,750, because he "found no evidence in the record to show that 'the
$10,000 recovery does not include at least $3,750 that could be attributed to [the recipient's] medical costs.'" Id.
The court upheld the ALJ's decision. It wrote:
The record supports the ALJ's conclusion that Gray failed to show that the $10,000 recovery was anything other than a lump-sum payment, with no allocations for any category of Gray's damages. Because the $10,000 recovery was unallocated, Gray's argument that the lien was improperly imposed on future medical expenses must fail.
* * *
The evidence offered by Gray consisted of the verdict form, the final judgment, and letters providing the amount of the liens imposed by Florida's Medicaid Program, Georgia's Medicaid Program, and Florida's Brain and Spinal Cord Injury Program. None of these records showed that the $10,000 recovery was allocated in any way between different categories of damages, costs, or attorney's fees. Gray could not show—even by a preponderance of the evidence—that an amount other than the total recovery of $10,000 should be considered when applying the statutory formula to determine the amount of the Medicaid lien.
* * *
[I]n situations such as this case, when the plaintiff fails to produce evidence or present testimony showing that the lien amount should be reduced, the plain language of section 409.910(11)(f) requires the ALJ to apply the statutory formula.
Indeed, it is probably accurate to say that, under the present state of the law, an ALJ is practically required to accept the use of a proportional reduction, provided certain conditions are met, e.g., where unrebutted expert testimony is received both as to the value of the recipient's damages and as to the use of the pro rata methodology.
The ALJ did exactly that here and did not err in calculating the lien amount.
Id. at 99.
The Gray decision comes close to announcing, as a rule, that the default lien amount which attaches to the recovery of an undifferentiated, lump sum insurance payment is irreducible in a section 409.910(17)(b) proceeding, precisely because the payment was unallocated. This impression is reinforced by the Rodriguez case, in which the court distinguished Gray as follows:
Unlike Gray, … , the documentary evidence admitted in this case pertained to the settlement itself. In Gray, the recipient's lawsuit resulted in a jury verdict of over $2.8 million but he recovered only $10,000 from the defendant's insurer. Id. at
98. There was no evidence in Gray that the insurance payout was based on anything other than the total coverage limits. In Gray, we found no ground to set aside the ALJ's rejection of the recipient's (17)(b) petition to reduce [the Agency's] recovery. In contrast here, Rodriguez's pre-trial settlement was based on an offer of settlement enumerating the various types of damages, admitted into evidence by the ALJ, and the defense in the civil suit accepted the plaintiff's assertions of the various types of damages. No lump-sum insurance proceeds were at issue here.
Rodriguez, 294 So. 3d at 444 n.4.
It is possible to derive from Gray, as illumined by Rodriguez, the proposition that the portion of a lump sum, coverage-limits insurance payout which must be allocated to past medical expense damages is the presumptive lien amount under section 409.910(11)(f). Under such a rule, a recipient who has accepted an arbitrary discount settlement (as described herein) and later seeks an administrative allocation of his or her unallocated recovery would be doomed to fail in the section 409.910(17)(b) proceeding.
The undersigned, however, hesitates to conclude that Gray goes that far. For one thing, as the court stated in Eady, "a Medicaid recipient is entitled to put on evidence to prove that he is entitled to a reduction of the Medicaid lien." Eady, 279 So. 3d at 1259. A strict reading of Gray would effectively deprive some Medicaid recipients of that entitlement. Notably, as well, the court in Eady distinguished Gray, not because "[n]o lump-sum insurance proceeds were at issue" in the case before it, but because the "evidentiary infirmities" which had caused the recipient's case to fail in Gray were not present, as the instant recipient had "presented expert testimony directed towards the appropriate share of the settlement funds to be allocated to past medical expenses[, and the Agency had] not present[ed] any evidence to refute the experts' opinions." Id.
It should be emphasized that in Gray, the recipient did not present the testimony of trial attorneys to support the pro rata allocation he advocated, relying instead on the verdict form and judgment as his evidentiary grounds. This would be a bold move in the wake of the Florida Supreme Court's decision in Giraldo. Remember, however, that the final hearing in Gray had taken place in 2016, nearly two years before Giraldo, at a time when the strategy would not have seemed so risky and, indeed, could reasonably have been regarded as sound. At any rate, the recipient in Gray had depended heavily on the argument that the basic proportional reduction should be applied to reduce the default lien, probably anticipating that the ALJ would adopt the approach as a legal conclusion.
In sum, although this case is like Gray in that there is "no evidence … that the insurance payout was based on anything other than total coverage limits," Rodriguez, 294 So. 3d at 444 n.4, the undersigned distinguishes Gray on the grounds that (i) Jones presented unrebutted expert testimony both as to the value of his damages and in support of the proportional reduction methodology, thereby avoiding the "evidentiary infirmities" which doomed the recipient's case in Gray; and (ii) the proportional reduction advocated
here does not, as in Gray, under-allocate the portion of the recipient's recovery which should be designated as past medical expenses.8
Accordingly, as found above, Jones carried his burden, as a matter of fact, by proving that the portion of his total recovery which should be designated as compensation for past medical expenses is $19,014.25.
DISPOSITION
Based on the foregoing Findings of Fact and Conclusions of Law, it is ORDERED that the amount payable to the Agency for Health Care Administration in satisfaction of its Medicaid lien for medical assistance provided to Jones is $19,014.25.
DONE AND ORDERED this 17th day of July, 2020, in Tallahassee, Leon County, Florida.
S
JOHN G. VAN LANINGHAM
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the
Division of Administrative Hearings this 17th day of July, 2020.
8 In Gray, as here, the recipient's past medical expenses were greater than the Medicaid expenditures by AHCA, but here, unlike Gray, the recipient has accounted for that fact, by using all of his past medical expenses as the value of m in the proportional reduction formula. See ¶15.
COPIES FURNISHED:
Floyd B. Faglie, Esquire Staunton & Faglie, PL 189 East Walnut Street Monticello, Florida 32344 (eServed)
Alexander R. Boler, Esquire
2073 Summit Lake Drive, Suite 300
Tallahassee, Florida 32317 (eServed)
Mary C. Mayhew, Secretary
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 1
Tallahassee, Florida 32308 (eServed)
Stefan Grow, General Counsel
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308 (eServed)
Richard J. Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308 (eServed)
Shena L. Grantham, Esquire
Agency for Health Care Administration Building 3, Room 3407B
2727 Mahan Drive
Tallahassee, Florida 32308 (eServed)
Thomas M. Hoeler, Esquire
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308 (eServed)
NOTICE OF RIGHT TO JUDICIAL REVIEW
A party who is adversely affected by this Final Order is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings are commenced by filing the original notice of appeal with the Clerk of the Division of Administrative Hearings and a copy, accompanied by filing fees prescribed by law, with the First District Court of Appeal in Leon County, 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.
| Issue Date | Document | Summary |
|---|---|---|
| Jul. 17, 2020 | DOAH Final Order | Petitioner established grounds for using a proportional reduction to determine the portion of his settlement to which the Medicaid lien may attach, limiting Respondent's recovery to 5% of its expenditures. |
