STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

ROBERT H. WELLER, )

)

Petitioner, )

)

vs. ) CASE NO. 82-3075

) DEPARTMENT OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, the Division of Administrative Hearings, by its duly designated Hearing Officer, R. L. Caleen, Jr., conducted a formal hearing in this case on February 15, 1983, in Tallahassee, Florida.

APPEARANCES

For Petitioner: Robert H. Weller, pro se

224 Timberlane Road Tallahassee, Florida 32312

For Respondent: Daniel C. Brown, Esquire

Department of Administration

435 Carlton Building Tallahassee, Florida 32301

ISSUE

Whether petitioner is entitled to benefits in excess of those paid under the Florida Employees Group Health Self-Insurance Program for medical services provided to his newborn-son at Shands Hospital during April, 1982.

BACKGROUND

Blue Cross/Blue Shield of Florida, Inc. ("Blue Cross/Blue Shield"), which processes claims under the Florida Employees Group Health Self-Insurance Program ("Insurance Program"), denied petitioner payment for a portion of claimed medical charges relating to the birth of his son in Shands Hospital, Gainesville, Florida. As grounds, Blue Cross/Blue Shield explained that the disallowed charges exceeded those payable under the Approved Fee Schedule utilized by the Insurance Program.

Petitioner timely appealed this denial to the respondent Department of Administration ("Department") which, on November 8, 1982, forwarded this case to the Division of Administrative Hearings for assignment of a hearing officer.

Hearing was thereafter set for February 15, 1983. At hearing, petitioner testified in his own behalf and Presented the testimony of Riond C. Bucclarelli,

1. The Department presented the testimony of William Seaton. Petitioner's

   Exhibit Nos. 1-3 and respondent's Exhibit Nos. 1-3 were received into evidence. 1/

   
   

   Post-hearing findings of fact and conclusions of law were filed by the parties by February 25, 1983. No transcript of the hearing has been filed.

   
   

   Based on the evidence presented, the following facts are determined: FINDINGS OF FACT

   I.

   
   

   The Florida Employees Group Health Self-Insurance Program

   
   

   1. The Florida Employees Group Health Self-Insurance Program ("Insurance Program") is a self-insurance program established for state employees. The Department, which is responsible for administering and supervising the Program, contracts with Blue Cross/Blue Shield for the day-to-day processing of claims.

      
      

   2. The insurance benefits provided to covered state employees, of which petitioner is one, are described in a 35-page Benefit Document (R-3), summarized and furnished to employees through an Insurance [benefit] Booklet. (R-2)

      
      

   3. Generally, the Benefit Document and Booklet provide for payment of 100 percent of covered inpatient medical and surgical care, subject to the maximum allowances contained in the Approved Fee Schedule. This Schedule, containing 800 pages, lists maximum payments allowed for every medical, surgical, and obstetrical procedure covered by the Insurance Program--and is incorporated, by reference, into the Benefit Document and Booklet.

      
      

      II.

      
      

      Processing of Petitioner's Insurance Claims

      
      

   4. In April, 1982, petitioner's wife was admitted to Shands Teaching Hospital in Gainesville, Florida, because of complications arising from premature labor and birth. (Shands is one of nine licensed neonatal intensive care units in Florida providing specialized care to newborn infants and their mothers.) On April 9, 1982, petitioner's son was born seven weeks prematurely; extensive and specialized medical care was provided. The physicians attending his wife and newborn son submitted their charges, identified by medical procedure code number, directly to Blue Cross/Blue Shield for payment, (P-1, R- 1). Blue Cross/Blue Shield denied a portion of these charges, claiming, among other things, that they exceeded the amounts allowable under the Approved Fee Schedule.

      
      

   5. Petitioner appealed the denial to the Blue Cross/Blue Shield administrator in June, 1982. In July, 1982, additional information was requested and provided. In October, Blue Cross/Blue Shield agreed to pay a small portion of the charges which it had earlier denied. Petitioner then appealed to the Department, resulting in this proceeding.

      III.

      
      

      Two Disputed Items

      
      

   6. Among other things, petitioner contests two specific disallowances. Blue Cross/Blue Shield rejected a $200.00 charge by Dr. Haberkern for a medical procedure (code No. 990220) described as "CCMP INIT CARE," a medical service provided the newborn infant on April 9, 1982. The reason then (and now) given for denial was, "Payment for the visit(s) is included in the surgical allowance." (See, P-1, Benefit Payment Schedule 984854). Blue Cross/Blue Shield also rejected a $125.00 charge by the same doctor for a medical procedure described as, "Stand-by anesthesia" (procedure No. 99038), a medical service also provided the infant on the same day. The basis given then (and now) for rejection was, "Payment for anesthesia is included in the surgical allowance." Id.

      
      

   7. But no surgical procedures were ever performed on the infant. Since no surgery was performed, and no surgical allowance given, the claims cannot reasonably be denied on the basis that they were included in a surgical allowance. No other basis has been provided to justify the disallowance of these two charges.

      
      

   8. The Department does not question the appropriateness of the procedure code number used or the medical service provided. Neither does it contend that either of the two disputed charges exceeds the amounts allowed by the Approved Fee Schedule.

      
      

      IV.

      
      

      Challenge of Approved Fee Schedule

      
      

   9. Numerous charges submitted by physicians at Shands Teaching Hospital's neonatal unit were rejected by Blue Cross/Blue Shield because they exceeded the amounts allowed under the Approved Fee Schedule. Petitioner challenges these disallowances, contending that the Approved Fee Schedule is incomplete and deficient because it does not contain medical charges sufficient to cover normal charges for medical services provided by physicians in a neonatal intensive care unit setting. In April, 1982, the maximum fees allowed by the Approved Fee Schedule were set at the 90th percentile of fees charged by Dade County physicians for each specific medical procedure. In setting fees, the Schedule gave no special consideration to whether the medical procedure was performed at an intensive care neonatal unit or elsewhere.

      
      

   10. Petitioner concedes that the disallowed charges exceed the maximums allowed by the Approved Fee Schedule. Nevertheless, he maintains that he is entitled to payment of those charges because of perceived inadequacy of the Approved Fee Schedule.

       
       

   11. The Insurance Program, and its benefits are based on the premiums received. The payment of those premiums is shared by covered state employees and the state, their employer. There is a direct relationship between premiums and benefits. If benefits increase, premiums must also. Here, petitioner enrolled in an insurance program which provided specific insurance benefits at specified premiums. Having paid premiums at one level, he cannot now reasonably argue that he should receive benefits at another.

       
       

       CONCLUSIONS OF LAW

   12. The Division of Administrative Hearings has jurisdiction over the parties and subject matter of this proceeding. 120.57(1), Fla. Stat. (1981).

       
       

   13. The Florida Employees Group Health Self-Insurance Program, established by Section 110.123(5)(c), is administered and supervised by the Department. The Department is also required to determine the benefits provided to employees participating in the program. 110.123(5)(a), Fla. Stat. (1981).

       
       

   14. The petitioner has presented a prima facie case in support of two disallowed charges, one for $200.00 the other for $125.00. The evidence provided to justify disallowing these charges is insufficient to overcome the effect of petitioner's presentation. Accordingly, these two claims should be paid by Blue Cross/Blue Shield, the entity which administers the Program on behalf of the Department.

       
       

   15. Petitioner however cannot successfully attack the sufficiency of the Insurance Program, including its Approved Fee Schedule. He is entitled to what he bargained and paid for--the benefits contained in the Benefit Document and the Approved Fee Schedule--no more and no less. His claim for payments in excess of those allowed by the Approved Fee Schedule must, therefore, be denied.

       
       

   16. The parties submitted proposed findings of fact and conclusions of law. To the extent their proposed findings are incorporated herein, they are adopted; otherwise they are rejected as unsupported by the evidence or unnecessary to resolution of the issues presented.

RECOMMENDATION

Based on the foregoing, it is RECOMMENDED:

That petitioner's claim for payment of the $200.00 and $125.00 medical charges be granted; and that his remaining claims, which seek payment in excess of amounts allowed by the Approved Fee Schedule, be denied.

DONE and RECOMMENDED this 29th day of April, 1983, in Tallahassee, Florida.

R. L. CALEEN, JR. Hearing Officer

Division of Administrative Hearings The Oakland Building

2009 Apalachee Parkway

Tallahassee, Florida 32301

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 29th day of April, 1983.

ENDNOTE

1/ Petitioner's and respondent's exhibits will be referred to as "R- " and "P- ," respectively.

COPIES FURNISHED:

Robert H. Weller

224 Timberlane Road Tallahassee, Florida 32312

Daniel C. Brown, Esquire Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Nevin G. Smith, Secretary Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Docket for Case No: 82-003075

Orders for Case No: 82-003075