STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

UTOPIA HOME CARE, INC.,

Petitioner,

vs.

AGENCY FOR HEALTH CARE ADMINISTRATION,

Respondent.

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) Case No. 03-2386MPI

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RECOMMENDED ORDER

Pursuant to notice, a formal hearing was held in this case on September 25, 2003, in Tallahassee, Florida, before

Carolyn S. Holifield, a duly-designated Administrative Law Judge of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Robert C. Fritz, pro se

Utopia Home Care, Inc.

215 Second Avenue, North

St. Petersburg, Florida 33701

For Respondent: Jeffries H. Duvall, Esquire

Agency for Health Care Administration Fort Knox Building III, Mail Station 3 2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308-5403 STATEMENT OF THE ISSUE

The issue is whether Petitioner, Utopia Home Care, Inc. (Utopia or Petitioner), is entitled to payment of $38,432.71 for

the services it provided to Medicaid recipients during the period of January 1, 2000, through December 31, 2000.

PRELIMINARY STATEMENT

By letter dated June 17, 2002, Respondent, the Agency for Health Care Administration (Agency), advised Utopia that certain claims for services submitted to the Agency were never billed to Medicaid and, therefore, were not reimbursable under Medicaid guidelines as enunciated in the Medicaid Provider Reimbursement Handbook, Non-Institutional 081, which is incorporated by reference in Florida Administrative Code Rule 59G-8.200(6).

Utopia challenged the decision and requested an informal hearing.

The informal hearing was conducted on November 18, 2002, before George D. Shirejian, who served as the Agency's designated Hearing Officer. Following the informal hearing, on June 16, 2003, the Hearing Officer issued an Order Dismissing the Case and Recommending Referral to the Division of Administrative Hearing (Order Dismissing the Case). In the Order Dismissing the Case, the Hearing Officer determined "that a disputed issue of material fact exists and thus, this hearing officer is without subject matter jurisdiction to reach a conclusion in this case."

On June 26, 2003, the Agency forwarded the matter to the Division of Administrative Hearings for assignment of an

Administrative Law Judge to conduct the formal hearing and prepare a recommended order. By Notice issued July 7, 2003, the final hearing was set for September 3, 2003. Upon request of the parties, the hearing was continued and rescheduled for September 25, 2003.

On August 12, 2003, the parties filed a Joint Pre-hearing Stipulation in which they stipulated to facts which required no proof at hearing. When the hearing convened and prior to the evidentiary part of the final hearing, the parties also stipulated to the following facts: (1) Utopia rendered authorized services to eligible Medicaid recipients between January 1, 2000, through December 31, 2000, for which it did not receive Medicaid payments; and (2) the cost of those services was $38,432.71.

At hearing, Utopia called two witnesses, Robert C. Fritz, vice president of Utopia, and Jenne Williams, an employee of Utopia. Utopia offered and had four exhibits received into evidence. The Agency presented the testimony of one witness, Ellen L. Emenheiser, a contract manager with the Agency. The Agency offered and had two exhibits received into evidence. At the conclusion of the hearing, by agreement of the parties, the time for filing proposed recommended orders was set for 30 days from the date the transcript was filed.

The Transcript was filed on October 7, 2003. Thereafter, on October 21, 2003, the Agency filed a Motion to Supplement the Record Presented at Final Hearing (Motion). The Motion requested that the "valid Medicaid provider agreement," referred to in the Joint Pre-Hearing Stipulation, which was not submitted by either party at the final hearing, be included in the record of this case. By Order issued November 6, 2003, the unopposed Motion was granted.

Both parties filed Proposed Recommended Orders which have been considered in preparation of this Recommended Order.

FINDINGS OF FACT

1. At all times relevant to this proceeding, Utopia was an authorized Medicaid provider in the State of Florida. Pursuant to a valid Medicaid provider agreement, Utopia was authorized to provide home and community-based services to Medicaid recipients.

2. The Agency is charged with the administration and oversight of the Medicaid Program and funds throughout the State of Florida. One of the Agency's responsibilities is to monitor the provision of Medicaid services and make payments to providers for services which have been appropriately provided and for which claims have been correctly processed.

3. During the period of January 1, 2000, through December 31, 2000 (the audit period), Utopia rendered services

   to Medicaid recipients who receive home care services through the Medicaid Program. The cost of these services, for which Utopia has not received payment, is $38,432.71. There is no dispute that these services were authorized and provided by Utopia.

4. Robert Fritz is vice president of Utopia and works in Utopia's St. Petersburg, Florida, office. In or about February 2002, while Mr. Fritz was participating in an accounts receivable project, he discovered that Utopia had not been paid for some of the services it had provided to Medicaid recipients during the audit period.

5. Mr. Fritz contacted the Agency soon after he discovered that Utopia had not received payment for the services it rendered during the audit period. Over a period of several months, Utopia, through Mr. Fritz, provided the Agency with documentation that the services were authorized and had been invoiced at or near the time the services were provided. Additionally, at the request of the Agency, Utopia completed numerous 081 Forms, Request for Payment Forms for the Florida Medicaid Program, to establish a baseline as to what claims were unpaid. Utopia completed the 081 Forms for the services which were provided during the audit period and for which it had not received payment in or about February 2002.

6. In addition to the completed 081 Forms, dated February 2002, Utopia also provided to the Agency documentation generated from Utopia's computer system in Florida. The documents, created by the computer system on a weekly basis, included payroll checks for employees and invoices for services rendered.

7. As part of Utopia's contractual requirements with the lead agency, which oversees the Medicaid Program at the local level, a monthly Medicaid Expenditure Tracking Report (Expenditure Tracking Report) is created by Utopia's

   St. Petersburg, Florida, office. The Expenditure Tracking Report lists anticipated expenditures from the Medicaid system to Utopia for services rendered in a particular month. Many of these documents were provided to the Agency in seeking to establish that the services had been provided during the audit period and to obtain payment for the services.

8. The documents created by Utopia's computer system and discussed in paragraph 6 above were created at or near the time services were rendered.

9. Due to the documentation provided by Utopia, the Agency stipulated that Utopia provided authorized services to Medicaid recipients and that the cost of these services was $38,432.71. Nonetheless, the Agency has refused to pay Utopia for the services because the claims were not filed in accordance with Medicaid procedures, as established in the Medicaid Provider

   Reimbursement Handbook, Non-Institutional 081 (Reimbursement Handbook). Based on the Agency's review of its records, it determined that Utopia had not filed the claims within 12 months of the services being rendered.

10. The procedures for filing claims for Medicaid payments are outlined in the Reimbursement Handbook, which is referenced and incorporated by reference in Florida Administrative Code Rule 59G-8.200(6). Also, for purposes of this case, the Reimbursement Handbook sets forth the applicable Medicaid requirements for processing claims.

11. The Reimbursement Handbook, pages 6-2 and 6-3, provides in relevant part the following:

    Medicaid providers should submit claims timely so that any problems with a claim can be corrected and the claim resubmitted before the filing deadline.

    
    

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    A clean claim for services rendered must be received by the agency or its fiscal agent no later than 12 months from the date of service.

    
    

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    The date electronically coded on the provider's electronic transmission by the Medicaid fiscal agent is the recorded date of receipt for an electronic claim.

12. At all times relevant to this proceeding, Consultec was the company responsible for receiving claims from and paying those claims to Medicaid providers in the State of Florida.

13. The Reimbursement Handbook indicates that the processing time for claims "under normal circumstances" is within 10 to 30 days after the claim is filed. The Reimbursement Handbook also provides that a "remittance voucher" is mailed each week if Consultec processed any claims or put any claims in "Suspend" status. With regard to the remittance voucher, the Reimbursement Handbook, page 8-4, states in relevant part the following:

    The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment--whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted.

    
    

    The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received.

    
    

14. Utopia filed all its claims electronically.

    
    

    Therefore, to determine whether Utopia was entitled to payment for services rendered during the audit period, the Agency searched its data warehouse. The data warehouse allows the Agency to review claims that have been electronically filed and the status of those claims. Based on the Agency's review, which

    compared claims filed by Utopia in February 2002 for services rendered during the audit period, the Agency found that 36 claims had been submitted by Utopia and paid and 108 claims had not been paid. With regard to the 108 claims that were not paid, the Agency found no evidence that the claims had ever been filed.

15. Utopia's St. Petersburg, Florida, office provided the services in question. Staff members in that office generate and enter data into the computer system that creates the documents described in paragraph 6 above and provide billing information to the local lead agency. Utopia provides this information to the local lead agency, Neighborly Senior Services (Neighborly), pursuant to a contractual arrangement which authorizes Utopia to provide services to Medicaid recipients.

16. Utopia's staff at the St. Petersburg, Florida, office prepares and compiles billing information regarding the services it has provided and electronically transmits the information to Utopia's corporate office in Kingsburg, New York. The practice of Utopia is that the corporate office in New York then finalizes the billing information and transmits the claims to the entity designated by the Agency to process and pay claims. At all times relevant to this proceeding, that entity was Consultec.

17. Once the St. Petersburg, Florida, office transmits the billing information to the corporate headquarters in New York, it has no further responsibility or control over the billing information sent to Medicaid. Utopia's St. Petersburg, Florida, office also has no responsibility to reconcile the services actually billed to Medicaid by the corporate office with the services provided in Florida.

18. At this proceeding, no evidence was presented to establish that Utopia's corporate office in New York ever filed claims for the services during the audit period for which no payment has been made. Likewise, Utopia never provided the Agency with documentation or evidence that claims for the services provided during the audit period were ever filed within

    12 months of the services being provided. Similarly, no such evidence was ever produced at this proceeding.

19. The Reimbursement Handbook provides for exceptions to the 12-month time limit if the claim meets one or more of the following conditions: (1) original payment voided, (2) court or hearing decision, (3) delay in recipient eligibility determination, (4) agency delay in updating eligibility file,

    (5) court ordered or statutory action, and (6) system error on a claim that was originally filed within 12 months from the date of service.

20. Upon consideration of the applicable provisions of the Reimbursement Handbook, the Agency properly determined that Utopia did not file the claims within 12 months from the date of the service and that none of the conditions were present which warranted granting an exception.

    CONCLUSIONS OF LAW

    
    

21. The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of this proceeding. §§ 120.569 and 120.57(1), Fla. Stat.

22. The Agency is the Medicaid agency for the State of Florida as provided under federal law. § 409.902, Fla. Stat. (2003). The Agency is authorized to make payments for designated services furnished by Medicaid providers to recipients who are determined eligible on the date the services were provided. See § 409.905, Fla. Stat. Among the authorized services for which the Agency may reimburse Medicaid providers are home health care services. See § 409.905(4), Fla. Stat. (2003).

23. Section 409.919, Florida Statutes, authorizes the Agency to "adopt any rules necessary to comply with or administer ss. 409.901-409.920 and all rules necessary to comply with federal law."

24. Pursuant to its rulemaking authority, the Agency adopted Florida Administrative Code Rule 59G-8.200 that

    enumerates the requirements for the Home and Community-Based Program.

25. Florida Administrative Code Rule 59G-8.200(6), provides in relevant part the following:

    Program Requirements--General. All HCB [Home and Community-Based] services waiver providers and their billing agents must comply with the provisions of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, which is incorporated by reference and available from the Medicaid fiscal agent.

    
    

26. The Reimbursement Handbook is incorporated by reference in Florida Administrative Rule 59G-8.200 and is applicable to this case. The relevant provision of the Reimbursement Handbook, quoted in paragraph 11 above requires that each Medicaid provider submit claims for services provided "no later than 12 months form the date of service."

27. Petitioner has the burden of proving by a preponderance of the evidence that it is entitled to the payments which it seeks. In order to prevail, Petitioner must establish that it complied with all applicable statutes, rules, and handbooks that were effective during the relevant audit period.

28. Petitioner has failed to meet its burden of proof in this case. Petitioner presented no evidence to establish that the required claims were filed within the 12-month time frame

    required in the Reimbursement Handbook. The documents subsequently furnished to the Agency do not establish that Petitioner timely filed the appropriate claims with Consultec, the company designated by the Agency to process and pay claims.

29. As noted in paragraph 19 above, the Reimbursement Handbook provides limited exceptions for payment of claims that are not timely filed. However, in this case, the exceptions enumerated in the Reimbursement Handbook are inapplicable in this case.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby

RECOMMENDED that the Agency enter a final order finding that the disputed claims were not filed within the required 12-month period and denying reimbursement of those services.

DONE AND ENTERED this 29th day of December, 2003, in Tallahassee, Leon County, Florida.

S

CAROLYN S. HOLIFIELD

Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 29th day of December, 2003.

COPIES FURNISHED:

Jeffries H. Duvall, Esquire

Agency for Health Care Administration Fort Knox Building III, Mail Station 3 2727 Mahan Drive, Suite 3431

Tallahassee, Florida 32308-5403

Robert C. Fritz Utopia Home Care, Inc.

215 Second Avenue, North

St. Petersburg, Florida 33701

Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308

Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive

Fort Knox Building, Suite 3431 Tallahassee, Florida 32308

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of 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: 03-002386MPI

Orders for Case No: 03-002386MPI