The Issue Whether Florida Hospital Medical Center is entitled to reimbursement in the amount preliminarily determined by the Department of Financial Services, Division of Workers’ Compensation, in a reimbursement dispute regarding bills submitted by Florida Hospital Medical Center to Macy’s Claims Services and Amerisure Mutual Insurance Company for medical services provided to two individuals involved in work-related accidents; and Whether Macy’s Claims Services and Amerisure Mutual Insurance Company properly adjusted those bills of Florida Hospital Medical Center in accordance with the requirements of Florida’s Workers’ Compensation law and applicable rules.
Findings Of Fact Florida Hospital is a full-service, not-for-profit hospital system located in Orlando, Florida, that operates a smaller satellite hospital in Winter Park, Florida. Florida Hospital is a “health care provider” within the meaning of Section 440.13(1)(h), Florida Statutes. Macy’s and Amerisure are “carriers” within the meaning of Sections 440.02(4) and 440.02(38), Florida Statutes. The Department has exclusive jurisdiction to resolve disputes between carriers and health care providers regarding payments for services rendered to injured workers, pursuant to Sections 440.13(7) and 440.13(11)(c), Florida Statutes. Qmedtrix is a medical bill review company.3/ Case No. 09-6871 R. P., an employee of Macy’s, slipped and fell at work on May 20, 2009, and presented to Florida Hospital Winter Park for evaluation and treatment where medical personnel documented vomiting, brain attack, and brain trauma. After evaluation and treatment, patient R. P. was diagnosed with a bruise to the head and released the same day. On September 16, 2009, Florida Hospital submitted its bill for services provided to R. P. totaling $5,547.20 to Macy’s for payment, utilizing Form DFS-F5-DWC-90, also known as UB-04 CMS-1450, identifying the charges billed for each line item by revenue code and HCPS or CPT codes. Macy’s forwarded the bill to its workers’ compensation medical bill review agent, Qmedtrix. Qmedtrix reviewed the bill by comparing the procedure codes and diagnosis codes reported by Florida Hospital with examples in the CPT book for billing of emergency department services. Florida Hospital reported ICD diagnosis code 920, which reads “contusion of face, scalp, or neck.” Use of this code means R. P. presented with a bruise or hematoma, but not a concussion. Florida Hospital also reported ICD diagnosis code 959.01 (“head injury, unspecified”) which also means that R. P. did not present with a concussion, loss of consciousness, or intracranial injuries. Florida Hospital’s bill included a charge of $2,417 with CPT code 99285 for emergency department services. The bill also included separate charges for a head CT, and various lab tests, drugs, and IV solutions. According to Mr. von Sydow, the bill was sent through Qmedtrix’s computer program for review, and was flagged for review by a physician. Mr. von Sydow further testified that one of Qmedtrix’s medical director’s suggested that the CPT code of 99285 be reduced. The medical director, who Mr. von Sydow said reviewed the bill, however, did not testify and no documentation of his recommendation was submitted at the final hearing. Qmedtrix determined that Florida Hospital should have used CPT code 99284 when billing for the emergency services rendered instead of CPT code 99285. Qmedtrix found that, while the hospital billed $2,417 with CPT code 99285, its usual charge for an emergency department visit billed with CPT code 99284 is $1,354. Macy’s paid Florida Hospital a total of $2,683.55, which amount included $1,010.24 for the emergency department visit based on [approximately] 75 percent of Florida Hospital’s usual charge for CPT code 99284. The payment was accompanied by an EOBR. The EOBR Macy’s (or its designated entity)4/ issued to Florida Hospital for services rendered to R. P. identifies the amount billed by Florida Hospital as to each line item in a column designated “Billed,” and has columns designated as “BR Red,” “PPO Red,” “Other Red,” and “Allowance,” each containing an amount for each line item in the “Billed” column. There is also a column entitled “Reason Code” which sets forth codes, as required by Florida Administrative Code Rule 69L-7.602(5)(o)3., that are supposed to explain the reason for adjustment of any line item.5/ The “reason code” set forth adjacent to the $2,417.00 billed by Florida Hospital for emergency department services is “82,” which means “Payment adjusted: payment modified pursuant to carrier charge analysis.” There is also another code, “P506” listed in the “Reason Code” column adjacent to the same line item, which, according to the key provided on the EOBR, means “[a]ny questions regarding this Qmedtrix review, please call (800)-833-1993.” “P506,” however, is not a “reason code” listed in Florida Administrative Code Rule 68L- 7.602(5)(o)3. The EOBR does not advise that the bill was adjusted because of a determination that Florida Hospital should have used CPT code 99284 when billing for the emergency services rendered instead of CPT code 99285 as originally billed. Upon receipt of the payment and the EOBR, Florida Hospital timely filed a Petition for Resolution of Reimbursement Dispute with the Department pursuant to Section 440.13(7)(a), Florida Statutes, and Florida Administrative Rule 69L-31, contending that payment should be at 75 percent of its total charges, and citing the Florida Workers’ Compensation Reimbursement Manual for Hospitals, 2006 Edition (Hospital Manual). Qmedtrix timely filed a response to Florida Hospital’s petition on behalf of Macy’s pursuant to Section 440.13(7)(b), Florida Statutes, and Florida Administrative Code Rule 69L-31, asserting that correct payment should be determined based on, first, whether the hospital in fact billed its usual charge for the services and, second, whether the hospital’s charges are in line with the charges of other hospitals in the same community, citing One Beacon Insurance v. Agency for Health Care Administration, 958 So. 2d 1127 (Fla. 1st DCA 2007) for the proposition that “SB-50 amended section 440.13 . . . [revealing] legislative intent to eliminate calculation of a “usual and customary charge” based on the fees of any one provider in favor of a calculation based on average fees of all providers in a given geographic area.” Qmedtrix’s response on behalf of Macy’s also contended that “upcoding” and “unbundling” were additional grounds for adjustment or disallowance that were not identified on the EOBR. The response explained that “upcoding” refers to billing with a procedure code that exaggerates the complexity of the service actually provided; that CPT codes 99281 through 99285 describe emergency department services; that the CPT book includes examples of proper billing with these codes; that the hospital billed $2,417 with CPT code 99285; and that the CPT book describes an “emergency department visit for a healthy, young adult patient who sustained a blunt head injury with local swelling and bruising without subsequent confusion, loss of consciousness or memory deficit” as an example of proper billing with CPT code 99283. The response requested a determination by the Department that Macy’s payment equaled or exceeded the amount usual and customary for CPT code 99283. On November 13, 2009, the Department, through its Office of Medical Services (OMS) issued a determination (Determination in 09-6871) which found, in pertinent part: The petitioner asserts that services provided by Florida Hospital Medical Center to the above-referenced injured employee on May 20, 2009, were incorrectly reimbursed. Florida Hospital Medical Center billed $5,547.20 and the carrier reimbursed $2,683.55. The petition does not address a contract and does not reflect a contract discount in the calculation of requested reimbursement. The Carrier Response to Petition for Resolution of Reimbursement Dispute disputes the reasonableness of the hospital’s “usual and customary charges”, maintains the petitioners’ charges should be based on the average fee of other hospitals in the same geographic area, references a manual not incorporated by rule, and provides CPT codes that the respondent alleges are correct. There are no rules or regulations within Florida’s Workers’ Compensation program prohibiting a provider from separately billing for individual revenue codes. The carrier did not dispute that the charges listed on the Form DFS-F5-DWC-90 (UB-92) or the charges listed on the itemized statement did not conform to the hospital’s Charge Master. Nor did the carrier submit the hospital’s Charge Master in the response or assert that the carrier performed an audit of the Charge Master to verify the accuracy of the billed charges. Therefore, since no evidence was presented to dispute the accuracy of the Form DFS-F5-DWC-90 or the itemized statement as not being representative of the Charge Master, the OMS finds that the charges billed by the hospital are the hospital’s usual and customary charges. Rule 69L-7.602, F.A.C., stipulates the appropriate EOBR codes that must be utilized when explaining to the provider the carrier’s reasons for disallowance or adjustment. The EOBR submitted with the petition conforms to the EOBR code requirements of Rule 69L-7.602(5)(q), F.A.C. Only through an EOBR is the carrier to communicate to the health care provider the carrier’s reasons for disallowance or adjustment of the provider’s bill. Pursuant to s. 440.13(12), F.S., a three member panel was established to determine statewide reimbursement allowances for treatment and care of injured workers. Rule 69L-7.501, F.A.C., incorporates, by reference, the applicable reimbursement schedule created by the panel. Section 440.13(7)(c), F.S., requires the OMS to utilize this schedule in rendering its determination for this reimbursement dispute. No established authority exists to permit alternative schedules or other methodologies to be utilized for hospital reimbursement other than those adopted by Rule 69L-7.501, F.A.C., unless the provider and the carrier have entered into a mutually agreeable contract. Rule 69L-7.501, F.A.C., incorporates, by reference, the Florida Workers’ Compensation Reimbursement Manual for Hospitals, 2006 Edition (Hospital Manual). Since the carrier failed to indicate any of the services are not medically necessary, the OMS determined proper reimbursement applying the above referenced reimbursement guidelines. Therefore, the OMS has determined that the carrier improperly adjusted reimbursement to Florida Medical Center for services rendered to the above- referenced injured employee on May 20, 2009. Based on the above analysis, the OMS has determined that correct reimbursement equals $4,160.40 ($5,547.20 x 75% [Hospital Manual]=$4,160.40). The carrier shall reimburse Florida Hospital Medical Center $4,160.40 for services rendered to the above-referenced employee; and submit proof of reimbursement of the amount determined by the OMS within thirty days of the date the Determination is received. . . . The difference between what Petitioner Macy’s paid Florida Hospital for services rendered to R. P., and the amount the Department determined that Petitioner Macy’s is required to pay for such services, equals $1,476.85. The Determination in 09-6871 did not directly address Macy’s allegation of the alleged billing error of “upcoding.” The Determination in 09-6871 provided a 21-day notice for request of an administrative hearing and, as noted in the Preliminary Statement above, Macy’s timely requested a hearing. Case No. 09-6872 J. L., an employee of Major League Aluminum, was injured in a work-related accident on the evening of May 3, 2009, and visited the emergency department of Florida Hospital Orlando. After evaluation and treatment, J. L. was diagnosed with a bruise to the knee and released the next morning. On September 23, 2009, Florida Hospital submitted its bill for services provided to J. L. totaling $2,851 to Amerisure, Major League Aluminum’s workers’ compensation insurer, for payment, utilizing Form DFS-F5-DWC-90, also known as UB-04 CMS-1450, identifying the charges billed for each line item by revenue code and HCPS or CPT codes. Amerisure forwarded the hospital bill to its medical bill review agent, Qmedtrix for review. Qmedtrix’s medical bill review in this case, as in the companion case, entailed comparing the procedure codes and diagnosis codes reported by the hospital with examples in the CPT book. The hospital reported ICD diagnosis code 924.11, which reads “contusion of . . . knee.” The hospital also reported ICD diagnosis codes 724.2 (“lumbago”), E888.1 (“fall on or from ladders or scaffolding”) and 959.7 (“injury, other and unspecified . . . knee, leg, ankle, and foot.”). Florida Hospital billed $1,354 with CPT code 9924 for emergency department services and also billed for X-rays and various drugs and IV solutions. Comparing procedure codes and diagnosis codes reported by the hospital with examples in the CPT book, Qmedtrix concluded that billing with CPT code 99284 was not appropriate, but that billing with CPT code 99282 was. Qmedtrix also found that, while the hospital billed $1,354 with CPT code 99284, the average charge in the community for a visit to the emergency department billed with CPT code 99282 is $721. Qmedtrix determined the “usual and customary charge” in the community from its own database compiled by entering all of particular hospital bills into Qmedtrix’s database, along with data from the American Hospital Directory. Qmedtrix derives the average charge in the community based upon zip codes of the hospitals. Amerisure paid Florida Hospital a total of $1,257.15, which amount included $524.70 for the emergency department visit codes based on 75 percent of what Qmedtrix determined to be the average charge in the community for CPT code 99282. The payment was accompanied by an EOBR. The EOBR Petitioner Amerisure (or its designated entity)6/ issued to Florida Hospital for services rendered to J. L. identifies the amount billed by Florida Hospital as to each line item in a column designated “Billed Charges,” and has columns designated as “FS/UCR Reductions,” “Audit Reductions,” “Network Reductions,” and “Allowance,” each containing an amount for each line item in the “Billed Charges” column. There is also a column entitled “Qualify Code” which sets forth reason codes that are supposed to explain the reason for adjustment of any line item.7/ The code set forth adjacent to the $1,354.00 billed by Florida Hospital for emergency department services is “82,” which means “Payment adjusted: payment modified pursuant to carrier charge analysis.” The EOBR does not advise that the bill was adjusted because of a determination that Florida Hospital should have used CPT code 99282 when billing for the emergency services rendered instead of CPT code 99284 as originally billed. Upon receipt of the payment and the EOBR, Florida Hospital timely filed a Petition for Resolution of Reimbursement Dispute with the Department pursuant to Section 440.13(7)(a), Florida Statutes, and Florida Administrative Code Rule 69L-31, contending that payment should be at 75 percent of its total charges, and citing the Hospital Manual. Qmedtrix timely filed a response to Florida Hospital’s petition on behalf of Amerisure pursuant to Section 440.13(7)(b), Florida Statutes, and Florida Administrative Code Rule 69L-31, asserting that correct payment should be determined based on, first, whether the hospital, in fact, billed its usual charge for the services and, second, whether the hospital’s charges are in line with the charges of other hospitals in the same community, citing One Beacon, supra. Qmedtrix’s response on behalf of Amerisure contended “upcoding” as an additional ground for adjustment or disallowance that was not identified on the EOBR. As in the companion case, the response explained “upcoding,” that CPT codes 99281 through 99285 describe emergency department services, and that the CPT book includes examples of proper billing with these codes. The response further stated that the hospital billed $1,354 with CPT code 99284, and that the CPT book describes an “emergency department visit for a patient with a minor traumatic injury of an extremity with localized pain, swelling, and bruising” as an example of proper billing with CPT code 99282. The response requested a determination by the Department that Amerisure’s payment equaled or exceeded the usual and customary charge for CPT code 99282. On October 20, 2009, the Department’s OMS issued a determination (Determination in 09-6872) which found, in pertinent part: The petitioner asserts that services provided by Florida Hospital Medical Center to the above-referenced injured employee on May 3, 2009, and May 4, 2009, were incorrectly reimbursed. Florida Hospital Medical Center billed $2,851.00 and the carrier reimbursed $1,257.15. The petition does not address a contract and does not reflect a contract discount in the calculation of requested reimbursement. The Carrier Response to Petition for Resolution of Reimbursement Dispute disputes the reasonableness of the hospital’s “usual and customary charges”, maintains the petitioners’ charges should be based on the average fee of other hospitals in the same geographic area, and references a manual not incorporated by rule. There are no rules or regulations within Florida’s Workers’ Compensation program prohibiting a provider from separately billing for individual revenue codes. Therefore, the charges, as billed by the hospital, did not constitute billing errors. The carrier did not dispute that the charges listed on the Form DFS-F5- DWC-90 (UB-92) or the charges listed on the itemized statement did not conform to the hospital’s Charge Master. Nor did the carrier submit the hospital’s Charge Master in the response or assert that the carrier performed an audit of the Charge Master to verify the accuracy of the billed charges. Therefore, since no evidence was presented to dispute the accuracy of the Form DFS-F5- DWC-90 or the itemized statement as not being representative of the Charge Master, the OMS finds that the charges billed by the hospital are the hospital’s usual and customary charges. Rule 69L-7.602, F.A.C., stipulates the appropriate EOBR codes that must be utilized when explaining to the provider the carrier’s reasons for disallowance or adjustment. The EOBR submitted with the petition conforms to the EOBR code requirements of Rule 69L-7.602(5)(q), F.A.C. Only through an EOBR is the carrier to communicate to the health care provider the carrier’s reasons for disallowance or adjustment of the provider’s bill. Pursuant to s. 440.13(12), F.S., a three member panel was established to determine statewide reimbursement allowances for treatment and care of injured workers. Rule 69L-7.501, F.A.C., incorporates, by reference, the applicable reimbursement schedule created by the panel. Section 440.13(7)(c), F.S., requires the OMS to utilize this schedule in rendering its determination for this reimbursement dispute. No established authority exists to permit alternative schedules or other methodologies to be utilized for hospital reimbursement other than those adopted by Rule 69L-7.501, F.A.C., unless the provider and the carrier have entered into a mutually agreeable contract. Rule 69L-7.501, F.A.C., incorporates, by reference, the Florida Workers’ Compensation Reimbursement Manual for Hospitals, 2006 Edition (Hospital Manual). Since the carrier failed to indicate any of the services are not medically necessary, the OMS determined proper reimbursement applying the above referenced reimbursement guidelines. Therefore, the OMS has determined that the carrier improperly adjusted reimbursement to Florida Medical Center for services rendered to the above- referenced injured employee on May 3, 2009, and May 4, 2009. Based on the above analysis, the OMS has determined that correct reimbursement equals $2,138.25 ($2,851.00 x 75% [Hospital Manual]=$2,138.25). The carrier shall reimburse Florida Hospital Medical Center $2,138.25 for services rendered to the above-referenced employee; and submit proof of reimbursement of the amount determined by the OMS within thirty days of the date the Determination is received. . . . The difference between what Petitioner Amerisure paid Florida Hospital for services rendered to J. L. and the amount the Department determined that Petitioner Amerisure is required to pay for such services equals $881.10. The Determination in 09-6872 did not directly address Amerisure’s allegation of the alleged billing error of “upcoding.” The Determination in 09-6872 provided a 21-day notice for request of an administrative hearing and, as noted in the Preliminary Statement above, Amerisure timely requested a hearing. Alleged “Upcoding” for Emergency Department Services The Petitioners’ responses in both cases allege that Florida Hospital “upcoded” its bill for emergency department evaluation and management services. Neither EOBR submitted to Florida Hospital, however, reported alleged “upcoding” as an explanation for the Petitioners’ adjustment or disallowance of reimbursement. While the Dispute Determinations by the Department do not directly address the carrier’s allegation of the alleged billing error of “upcoding” raised in the Petitioners’ responses, they found that “Rule 69L-7.602, F.A.C., stipulates the appropriate EOBR codes that must be utilized when explaining to the provider the carrier’s reasons for disallowance or adjustment[, and that] [o]nly through an EOBR is the carrier to communicate to the health care provider the carrier’s reasons for disallowance or adjustment of the provider’s bill.” According to Mr. von Sydow, who was offered by Petitioners as an expert in billing, coding, reimbursement, and payment issues,8/ the “reason codes” that workers’ compensation carriers are to use pursuant to Florida Administrative Code Rule 69L-7.602, do not mention “upcoding,” and therefore an EOBR could not be generated with a reason code explaining reduction or disallowance based on “upcoding.” The following reason codes, however, are included in Florida Administrative Code Rule 69L-7.602: 23 – Payment disallowed: medical necessity: diagnosis does not support the services rendered. – Payment disallowed: insufficient documentation: documentation does not substantiate the service billed was rendered. – Payment disallowed: insufficient documentation: level of evaluation and management service not supported by documentation. Neither EOBR submitted to Florida Hospital includes reason code 23, 40, or 41. And neither EOBR explains or otherwise suggests that that Florida Hospital’s level of billing was not supported by medical necessity, services rendered, or sufficient documentation. In fact, Petitioners did not disallow reimbursement and do not contend that reimbursement should be denied for any services rendered by Florida Hospital to R. P. and J. L. on the grounds that the billed services were not medically necessary for the injured employees’ compensable injuries. In addition, Petitioners did not adjust or disallow payment for any of the billed procedures on the grounds that the procedures were not provided. In sum, the EOBR’s did not give Florida Hospital notice that alleged “upcoding” was an issue. Even if Petitioner’s EOBR’s gave Florida Hospital notice that it was asserting “upcoding” as a reason to reduce or adjust the hospital’s bill, the evidence does not support a finding that Florida Hospital utilized the wrong code in its billing for emergency department evaluation and management services. The CPT® 2009 Current Procedural Terminology Professional Edition, (Copyright 2008), (CPT book), is adopted by reference in Florida Administrative Code Rule 69L-7.602(3)(d) and Florida Administrative Code Rule 60L-7.020(2). The CPT book sets forth the procedure codes for billing and reporting by hospitals and physicians. The CPT book sets forth CPT codes ranging from 99281 through 99285 used to report evaluation and management services provided in a hospital’s emergency department, described as follows: 99281: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies and provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. 99282: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies and provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. 99283: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies and provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. 99284: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies and provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. 99285: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies and provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Mr. von Sydow testified that a Qmedtrix “medical director,” reviewed Florida Hospital’s bill for services rendered to R. P., but not the medical records, and recommended that the hospital’s charge for emergency department services under CPT 99285 be “re-priced” to Qmedtrix’s determination of the “usual and customary charge” for CPT 99284. Mr. von Sydow acknowledged the need for physician review for some cases (as opposed to review by non-physician coders) by testifying, “The more complicated the medicine, the more likely it is that he [a medical director at Qmedtrix] wants to see it.” Despite Qmedtrix’s original determination to “reprice” the bill from CPT code 99285 to CPT code 99284 (reflected in the reduced payment but not explained in the EOBR), Mr. von Sydow opined that the correct CPT code for emergency department services provided to patient R. P. was 99283, as opposed to 99285 billed by the hospital. Mr. von Sydow testified that his opinion was based upon his own review of the medical records, without the assistance of a medical director or medical expert, and review of examples for the CPT codes for emergency department services from the CPT book, and various provisions of ICD-9 and CPT book coding resources. Aside from the fact that Mr. von Sydow’s opinion differed from the purported recommendation of a Qmedtrix “medical director,” Mr. von Sydow is not a physician. Moreover, Qmedtrix failed to provide the testimony of the medical director, or anyone else with medical expertise to evaluate the medical records and services provided or to validate either the opinion of Mr. von Sydow or the original recommendation to “re- price” Florida Hospital’s use of CPT Code 99285 in its bill for emergency department services rendered to patient R. P. Mr. von Sydow offered similar testimony and examples to explain Qmedtrix’s “re-pricing” of Florida Hospital’s bill from CPT code 99284 to CPT code 99282 for emergency services rendered to patient J. L. on behalf of Amerisure. According to Mr. von Sydow, an internal Qmedtrix coder (not a medical director) reviewed the bill for emergency services rendered to J. L. and determined it should be re-priced to the usual and customary charge, as determined by Qmedtrix, using that CPT code 99282. While knowledgeable of the various codes and their uses, given the manner in which preliminary diagnostics under emergency circumstances drives Florida Hospital’s determination of the appropriate CPT code for billing emergency department services, without the testimony of a medical expert familiar with the medical records generated in these cases in light of the facts and circumstances surrounding the emergency care rendered to patients R. P. and J. L., Mr. von Sydow’s testimony was unpersuasive. Ross Edmundson, M.D., an employee, vice-president, and medical manager for Florida Hospital, explained that, unlike other settings, hospitals generally do not have the medical histories of patients presenting for emergency hospital services. When a patient comes to Florida Hospital for emergency services, they are triaged by a nurse to determine the level of urgency, then a doctor sees the patient, conducts a differential diagnosis to rule out possible causes, obtains the patient’s history, and then performs a physical examination. While emergency room physicians at Florida Hospital do not decide which CPT code is utilized for the evaluation and management services provided by its emergency department, the various tests and procedures they undertake to evaluate and treat emergency department patients do. James English, the director of revenue management for Florida Hospital explained the process through his deposition testimony. Florida Hospital, like over 400 other hospitals, uses the “Lynx System” – a proprietary system for creating and maintaining medical records electronically. The program captures each medical service, supply, and physician order that is inputted into the electronic medical record. The hospital’s emergency evaluation and management CPT code is generated from the electronic record. A “point collection system” in the Lynx System translates physician-ordered services, supplies it to a point system, and then assigns the CPT code that is billed based upon the total number of “points” that are in the system at the time the patient is discharged from the emergency department. The level of the evaluation and management CPT code (99281 to 99285) that is reported on Florida Hospital’s bill is a direct reflection of the number and types of medical services that a patient receives from his or her arrival through discharge. In light of evidence showing the manner in which emergency services are provided and the importance of medical records in generating the appropriate billing code for emergency evaluation and management services, it is found that Petitioners failed to provide an adequate analysis of the medical records of either R. P. or J. L. to show that the appropriate CPT codes were not utilized by Florida Hospital in billing for those services. On the other hand, both Petitions for Resolution of Reimbursement Dispute filed by Florida Hospital with the Department attached appropriately itemized bills utilizing Form DFS-F5-DWC-90, also known as UB-04 CMS-1450, identifying the charges billed for each line item by revenue code and HCPS or CPT codes. In addition, medical records for the evaluation and treatment provided by Florida Hospital for both patients R. B. and J. L. supporting the itemized bills were submitted to the Department. These documents were also received into evidence at the final hearing. Florida Hospital’s bills at issue correctly identified the hospital’s usual charges for each individual and separately chargeable item, service or supply, with the corresponding code assigned to such billable items as maintained in Florida Hospital’s “charge master.” In addition, Petitioners concede the compensability of both patients’ work-related injuries and do not dispute whether any service or supply rendered and billed by Florida Hospital for these two cases were “medically necessary.”9/ Unbundling As noted above, in Case No. 09-6871, Qmedtrix’s response to Florida Hospital’s petition for resolution of reimbursement dispute contended “unbundling” as a ground for adjustment or disallowance of reimbursement. At the final hearing, Arlene Cotton, the nurse who issued the Dispute Determinations, explained that reason code 63 regarding “unbundling” is inapplicable to hospital billing, as there is no rule that requires hospitals to bundle bill for its services. Mr. von Sydow agreed that reason code 63 was inapplicable. In addition, footnote 2 of Petitioners’ Proposed Recommended Order states, “they did not pursue the allegations of unbundling.” Therefore, it is found that Petitioners did not prove and otherwise abandoned their claim of “unbundling” as a ground to adjust or disallow reimbursement to Florida Hospital. Usual and Customary Charges The Dispute Determinations issued by the Department found that correct payment in both cases equaled 75% of billed charges, citing “Rule 69L-7.501, F.A.C., [which] incorporates, by reference, the Florida Workers’ Compensation Reimbursement Manual for Hospitals, 2006 Edition (Hospital Manual). Both Section 440.13(12)(a), Florida Statutes, and the Hospital Manual provide that hospital services provided to patients under the workers’ compensation law “shall be reimbursed at 75 percent of usual and customary charges.” The Department interprets the term “usual and customary charges” as set forth in the Hospital Manual and Section 440.13(12)(a), Florida Statutes, quoted above, to mean a hospital’s usual charges of the hospital, whereas Petitioners contend that “usual and customary charges” means the average fee of all providers in a given geographical area. While apparently not contending that Petitioners failed to raise the issue of “usual and customary” charges in their EOBR’s,10/ at the final hearing, the Department argued that “nowhere in [either Macy’s or Amerisure’s] response is the issue of customary charges raised.” A review of the responses filed by Qmedtrix to Florida Hospital’s reimbursement dispute petitions filed with the Department reveal that both raise the issue of “usual and customary charges.” Paragraphs 3 and 4 of Mr. von Sydow’s letter attached to both responses state: As you may know, the proposed adoption of Medicare’s Outpatient Prospective Payment System as a methodology for reimbursing hospitals 60% and 75% of “usual and customary charges” follows from the decision of the First District Court of Appeals in One Beacon Insurance v. Agency for Health Care Administration, No. 1D05-5459 (Fla. 1st DCA 2007) (SB-50 amended section 440.13 to remove all reference to the charges of any individual service provider; this amendment reveals the legislative intent to eliminate calculation of a “usual and customary charge” based on the fees of any one provider in favor of a calculation based on average fees of all providers in a given geographical area). This court decision requires DFS to define payment rates for out patient service that are uniformly applicable to all hospitals in a given geographic area. In addition, at the final hearing, the Department argued that the petitions for administrative hearing did “not raise as a disputed issue of fact or law whether or not usual and customary charges should apply in this case.” Indeed, a review of the request for relief set forth in the petitions for administrative hearings filed by Petitioners do not mention the issue of “usual and customary charges.” Rather, the relief requested by both petitions for administrative review of the Dispute Determinations, as summarized in the Joint Prehearing Stipulation, is: Petitioner[s] seeks reversal of OMS’ Determination(s) and the matters remanded for the Department to: direct payment based upon the actual treatment required/provided and pursuant to the correct CPT code; find that the hospital upcoded and that Petitioner properly reimbursed (or exceeded amount due); and determine that the hospital has the burden of proof to substantiate its billing and the use of the chosen CPT code. Contrary to the Department’s argument, however, both petitions for administrative hearing raise the issue of “usual and customary charges.” Page 9 of Macy’s petition, in pertinent part states: Petitioner submits that in issuing the above findings OMS failed to consider the holding in One Beacon Insurance v. Agency for Health Care Administration (wherein the Court determined that reimbursement should not be based solely upon a mathematical equation [as found within the Reimbursement Manual] and applying it to the fee charged by a particular provider; and that by eliminating the reference to any one facility’s charges, the legislature intended that the charges be based on average fees of all providers in a geographical area as opposed to the fees of the particular provider in question). Likewise, review of Amerisure’s petition for administrative hearing reveals that the issue of “usual and customary charges” was raised. Pages 7 and 8 of Amerisure’s petition state, in pertinent part: Further, if the Hospital is permitted to utilize incorrect revenue codes it would be impossible to determine whether the charges are consistent with the Hospital’s own [usual and customary] charges for the service, procedure or supplies in question and, further, whether such charges are consistent with charges by other like facilities (in the same geographical area) for the same services, procedures, or supplies. See One Beacon Insurance, supra. In addition, Amerisure’s petition on page 12 states with regard to the Department’s determination: Such finding was issued without consideration of . . . the amounts charged for the same services in the Orlando area where this hospital is located. Petitioners further preserved the issue of “usual and customary charges” in the first paragraph of their statement of position on page 3 of the Joint Prehearing Statement, as follows: Petitioners, Macy’s and Amerisure, take the position that the Determinations must be reversed as the Department has the duty to scrutinize the bills in question in order to determine, first, whether the hospital, in fact, charged its usual charge for the services provided, and second, whether the billed charges are in line with the customary charges of other facilities in the same community (for the same or similar services) and that the Department failed to do so. As such, Petitioners contend that payment for services provided by Florida Hospital should have been based upon 75% of usual and customary charges, not 75% of billed charges. Therefore, it is found that Petitioners have preserved the issue of “usual and customary charges” for consideration in this administrative proceeding. Although preserved, Petitioners failed to demonstrate that their interpretation of “usual and customary charges” should prevail. The Department has consistently interpreted the term “usual and customary charges” as used in the Hospital Manual, Section 440.13(12)(a), Florida Statutes, and rules related to hospital reimbursement under the workers’ compensation law as the “usual and customary charges” of the hospital reflected on the hospital’s “charge master.” The Hospital Manual requires each hospital to maintain a charge master and to produce it “when requested for the purpose of verifying its usual charges. . . .” (Emphasis added). Petitioners did not conduct or request to conduct an audit to verify whether the charges billed by Florida Hospital corresponded with the Florida Hospital’s charge master. In fact, Mr. von Sydow conceded at the final hearing that Florida Hospital’s bills at issue were charged in accordance with Florida Hospital’s charge master. Nor did Petitioners institute rule challenge proceedings against the Department regarding the Hospital Manual, incorporated by reference into Florida Administrative Code Rule 38F-7.501. Instead, Petitioners assert that they should be able to reduce Florida Hospital bills based upon a different interpretation of the phrase “usual and customary charges” to mean the average charge in the community as determined by Qmedtrix. Qmedtrix is not registered with the Florida Department of State, Division of Corporations, and does not employ any Florida-licensed insurance adjuster, physician, or registered nurse. Qmedtrix earns 12 to 15 percent of “savings” realized by carriers utilizing their bill review services. For example, if a bill is reduced by $100, Qmedtrix is paid $12.11/ Qmedtrix uses a proprietary bill review system called “BillChek.” According to Qmedtrix’s website: BillChek reviews out-of-network medical charges for all bill types in all lines of coverage, including group health, auto, medical, and workers’ compensation. BillChek is a unique specialty cost- containment service that determines an accurate and reasonable reimbursement amount for non-network facility and ancillary medical charges. BillChek incorporates historical data to help determine reasonable payment recommendations across all sectors of the health care industry. All BillCheck recommendations are backed by extensive medical and legal expertise, and supported by Qmedtrix’s experienced Provider Relations and Dispute Resolution teams. According to the testimony of Mr. von Sydow, Qmedtrix collects and maintains data from various sources, including Florida’s Agency for Health Care Administration (AHCA), the American Hospital Directory (AHD.com), and HCFA 2552’s (data reported to the Centers of Medicare and Medicaid Services on HCFA 2522) in order to construct a database of health care providers’ usual charges. Mr. von Sydow advised that AHD.com data was a principle source for constructing the database. He also advised that AHCA data was included in the database even though Qmedtrix found the AHCA data defective. Examples of data downloaded from AHD.com for Florida Hospital showing a profile of the facility was received into evidence as P-5. The data did not, however, show usual charges for the CPT codes for emergency department services at issue in this case. Petitioners also introduced into evidence Exhibits P-6 and P-7, which contained AHD.com data showing average charges for Florida Regional Medical Center and Florida Hospital, respectively, for Level 1 through Level 5 emergency room visits (corresponding to CPT codes 99281 through 99285). Mr. von Sydow explained that the data was part of the information Qmedtrix used to construct the average charge in the community. Petitioners failed to provide similar AHD.com data for other hospitals in the area Qmedtrix determined to be the “community.” In addition, Petitioners introduced AHCA’s Florida Health Finder Web-site, as Exhibit P-8, which ostensibly included average charges for all hospitals in Florida for the subject emergency department CPT codes (99281 through 99285). Mr. von Sydow explained, however, “[w]e find that [the AHCA data] is not refreshed very often, unfortunately, and some other defects in the scrubbing of the data by the agency, which they know, I will say. But this is incorporated in our database to a large extent.” The exhibit was received into evidence for the purpose of helping to explain how Qmedtrix constructed its database, with the recognition that it was largely composed of hearsay. In sum, while Petitioners showed their methodology of constructing the database, other than the AHD.com data for Orlando Regional Medical Center and Florida Hospital, Petitioners failed to introduce reliable evidence sufficient to show the “usual and customary charge” of all providers in a given geographical area as determined by Qmedtrix. In addition, the AHCA data, though characterized by Mr. von Sydow as unreliable, indicates that there is a wide range of differences in emergency room charges between hospitals in Florida. Petitioners’ interpretation of “usual and customary charge” to mean the average fee of all providers in a given geographical area does not take into account an individual hospital’s indigent care, cost of labor, overhead, number of beds, size, age, or various other differences between facilities that could affect amounts each hospital charges for emergency department and other services; the Department’s interpretation does.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Financial Services, Division of Workers’ Compensation, enter a Final Order consistent with this Recommended Order that: Directs Macy’s Claims Services to reimburse Florida Hospital Medical Center $4,160.40 for services rendered to patient R. P., and to submit proof of reimbursement of that amount within 30 days from the date the Final Order is received; Directs Amerisure Mutual Insurance Company to reimburse Florida Hospital Medical Center $2,138.25 for services rendered to patient J. L., and submit proof of reimbursement of that amount to the Department within 30 days from the date the Final Order is received. DONE AND ENTERED this 17th day of June, 2010, in Tallahassee, Leon County, Florida. S JAMES H. PETERSON, III 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 June, 2010.
The Issue Whether Respondent committed the violations alleged in the Administrative Complaint, and, if so, what sanctions, if any, should be imposed.
Findings Of Fact Based on the evidence adduced at the final hearing and the record as a whole, including the factual stipulations contained in parties' Joint Prehearing Stipulation,2 the following findings of fact are made: Respondent operates a Skilled Nursing Facility (Facility) located at 5725 N.W. 186th Street in Hialeah, Florida. The Facility is licensed by the Agency under Chapter 400, Part II, Florida Statutes. Aida Rodriguez has been a Florida-Certified Nursing Assistant (CNA) for the past three or four years. Ms. Rodriguez was employed as a CNA at the Facility on a part-time basis from November 6, 2002, until March 31, 2003, when she resigned for "family reasons." She worked only Fridays, Saturdays, and Sundays. Among the residents living in the Facility during the period of Ms. Rodriguez's employment were Residents 16 and 30.3 In accordance with his care plan, when Resident 30 was in the dining room for a meal, "staff [were] supposed to keep an eye on him" and "encourage him and attempt to assist him [if] he stop[ped] feeding himself" and needed help. Resident 30's daughter was often with her father at mealtime and provided him with whatever assistance he required, thus obviating the need, on these occasions, for staff intervention. On Saturday, March 15, 2003, Ms. Rodriguez was in the dining room when she observed Resident 30, without his daughter, seated at a table with a plate of uneaten food, that had been served a half an hour earlier, in front of him. Ms. Rodriguez approached Resident 30 and "offered him help." Ms. Rodriguez, who is bilingual in Spanish and English,4 spoke to Resident 30 in Spanish. Resident 16, who was nearby, interjected. She rebuked Ms. Rodriguez by telling her, "Don't touch him because the daughter is coming to assist him with feeding." Ms Rodriguez replied, in English, to Resident 16, who is not Spanish-speaking, "Let me ask Resident 30." Ms. Rodriguez then asked Resident 30, "Do you want water? Do you want me to help you?" Resident 30 responded, "Give me water." Ms. Rodriguez did as she was asked. After Resident 30 finished the glass of water Ms. Rodriguez had given him, Ms. Rodriguez asked Resident 30 if he "want[ed] to eat." When Resident 30 responded in the negative, Ms. Rodriguez left and tended to other business. At no time did Ms. Rodriguez tell Resident 16 to "shut up" or that Resident 16 should "mind [her] own business." At no time did Ms. Rodriguez force Resident 30, against his will, to eat or drink.5 Jeannette Barrett is now, and was at all times material to the instant case, a Florida-Licensed Practical Nurse (LPN) employed at the Facility. Ms. Barrett was in the dining room on March 15, 2003, when Ms. Rodriguez came over to the area where Residents 16 and 30 were seated. From her vantage point, Ms. Barrett was able to visually observe the encounter. Ms. Barrett did not "see Resident 30 get upset or aggravated during that meal." Ms. Barrett was unable to "hear any conversation between [Ms.] Rodriguez and Resident 16." As Resident 16 was leaving the dining room in her wheelchair, she "calm[ly]" told Ms. Barrett that she did not want Ms. Rodriguez "put[ting] [her] back to bed." When Ms. Barrett asked her why, Resident 16 responded, untruthfully, that Ms. Rodriguez had told her to "mind [her] own business" when she had suggested to Ms. Rodriguez that perhaps Resident 30 did not want to eat because he was waiting for his daughter to come and feed him.6 Ms. Barrett immediately informed the LPN who supervised the CNAs on Resident 16's "side" of the Facility of Resident 16's request and, in accordance with Facility policy, another CNA was assigned to care for Resident 16. Delia Rudio was the Director of Nursing at the Facility from February 11, 2002, until July 31, 2003.7 Ms. Rudio was not at the Facility on March 15, 2003. She was off from work that weekend. Upon Ms. Rudio's return to the Facility the following Monday, March 17, 2003, Ms. Barrett reported to Ms. Rudio about the conversation she had had with Resident 16 the previous Saturday and asked Ms Rudio to speak with Resident 16 and Ms. Rodriquez to sort out what had really happened in the dining room. Ms. Barrett brought the matter to Ms. Rudio's attention because it would have been "rude," in Ms. Barrett's opinion, for Ms. Rodriguez to have told a resident to "mind [her] own business." Tony Farinella is now, and was at all times material to the instant case, the Administrator of the Facility. On March 17, 2003, Mr. Farinella conducted a department supervisors meeting, at which (as his notes of the meeting, which were offered and received into evidence as Respondent's Exhibit 9, reflect) he was advised, by Ms. Rudio, of the "concerns" that Resident 16 had expressed, over the weekend, to Ms. Barrett regarding Ms. Rodriguez. That same day, after having received Ms. Barrett's report on the matter, Ms. Rudio spoke with Resident 16, Ms. Rodriguez, and other CNAs who were on duty at the Facility the previous Saturday with Ms. Rodriguez. Ms. Rudio asked them if there had been any problems at the Facility over the weekend. They all responded in the negative, indicating that the weekend had been uneventful with no unusual occurrences. Having talked to these individuals, Ms. Rudio reasonably believed that "nothing had occurred . . . over the weekend" that required her to take any remedial action. Ms. Rodriguez was not formally suspended pending Ms. Rudio's inquiry; however, Ms. Rudio concluded her inquiry before Ms. Rodriguez was next scheduled to report to work. Prior to the relicensure survey that led to the filing of the instant Administrative Complaint, Ms. Rudio did not document that she had done anything in response to the report she had received from Ms. Barrett concerning Resident 16's allegations against Ms. Rodriguez. Ms. Rudio, though, did verbally relate, at a department supervisors meeting conducted by Mr. Farinella on March 18, 2003, that she had looked into the matter and found that, in fact, there had been "no problem[s]" involving Resident 16 the previous weekend (as Mr. Farinella's notes of the meeting, which were offered and received into evidence as Respondent's Exhibit 10, reflect). The Agency conducted its relicensure survey of the Facility from March 31, 2003, through April 3, 2003. Elizabeth Rojas-Mariaca, a Health Facility Evaluator II with the Agency, was involved in conducting the survey. Resident 16 was interviewed during the survey. She alleged that, some time previous, Ms. Rodriguez had "told her to shut up and mind her own business" and that she (Resident 16) had "brought those allegations to the [attention of] the LPN [Ms. Barrett]." Resident 16 indicated that she "fe[lt] bad[ly] because Ms. Rodriguez was nasty and mean to [her]," but "still work[ed] there" at the Facility. Ms. Rojas-Mariaca spoke to staff at the Facility, including Ms. Barrett and Ms. Rudio, about Resident 16's allegations. She did not communicate, however, with either Ms. Rodriguez or Resident 30. When Ms. Rojas-Mariaca initially requested "some type of documentation" showing that, in accordance with the Facility's policy, an "investigation [into Resident 16's allegations] had been done" and documented, the Facility was unable to produce any such documentation. Shortly thereafter, however, the Facility prepared such documentation. Copies thereof were provided to Ms. Rojas- Mariaca and placed in the file the Facility maintained on Resident 16. The documentation accurately indicated that the Facility's investigation had revealed that Resident's 16's allegations were unfounded. Cindy Goldman, a Public Health Nutrition Consultant with the Agency, also participated in the survey. While at the Facility on April 1, 2003, Ms. Goldman went into a room in the sub-acute wing of the Facility shared by Resident 31 and another resident. Resident 31 was a recent admittee to the Facility. While she was "able to move her upper extremities" freely, as an amputee with only one leg, she needed assistance moving the lower half of her body. She was unable to, among other things, get on or off a bedpan by herself. When Ms. Goldman entered Resident 31's room, she observed Resident 31 lying in her bed with a bedpan under her buttocks. Resident 31 complained to Ms. Goldman that she was "in pain" as a result of having "been on the bedpan since yesterday"8 and she asked if Ms. Goldman could help her. There was a "call bell" tied to the upper bed rail to the right of Resident 31, which Ms. Goldman asked Resident 31 to "try to reach." Resident 31 moved her arm but not far enough to make contact with the "call bell." Ms. Goldman then activated the "call bell" to get assistance for Resident 31. Linda Mohammad, an LPN at the Facility, was in the sub-acute wing of the Facility when she noticed the "call light" outside of Resident 31's room was on. Ms. Mohammad was not "the person who [had] placed [Resident 31] on the bedpan."9 Ms. Mohammad nonetheless went to Resident 31's room and, after knocking on the door and entering the room, asked if she could be of any assistance. Ms. Goldman, who was standing in between the two beds in the room, responded that, according to what she had been told, Resident 31 had "been on the bedpan since yesterday." Ms. Mohammad then went to Resident 31's bedside. Resident 31 was "[i]n a normal position [on the bed] with her head up toward the head of the bed [which was elevated at approximately a 45 degree angle] on the pillow." As was apparent to Ms. Mohammad, based upon her past experiences with Resident 31, the "call bell" on the upper bed rail was within Resident 31's reach. On previous occasions, Ms. Mohammad had come to Resident 31's assistance in response to the activation of Resident 31's "call bell" and had found Resident 31 in the same position in relation to the "call bell" as she was in on this particular occasion.10 After putting on gloves, turning off the "call bell," and closing the privacy curtain around Resident 31's bed, Ms. Mohammad cleaned Resident 31 and removed and emptied the bed pan that she had been on. At no time did Resident 31 complain to Ms. Mohammad that she was in pain. When Ms. Mohammad "asked [Resident 31] if she was okay," Resident 31 "stated that she was fine." Ms. Mohammad re-opened the privacy curtain and left the room (which Ms. Goldman had already vacated), but not before making "sure [that Resident 31] was comfortable" and that "the call bell was still within [Resident 31's] reach."
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency issue a final order dismissing the instant Administrative Complaint in its entirety. DONE AND ENTERED this 22nd day of December, 2003, in Tallahassee, Leon County, Florida. S STUART M. LERNER 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 22nd day of December, 2003.
The Issue Whether petitioners have standing to challenge the validity of respondent's proposed rules, 38F-5.30 through 38F-5.70, Florida Administrative Code I.
The Issue Whether the Florida Medical Association, Inc. and Florida Association of Physicians Assistants have standing to initiate this challenge to an existing rule. (See Section 120.56(3), Florida Statutes.) Whether Rule 64B1-3.001(6), Florida Administrative Code, constitutes an invalid exercise of delegated legislative authority because it exceeds the Board of Acupuncture's rulemaking authority contained in Section 457.104, Florida Statutes. (See Section 120.52(8)(b), Florida Statutes). Whether Rule 64B1-3.001(6), Florida Administrative Code, constitutes an invalid exercise of delegated legislative authority because it enlarges, modifies, or contravenes the provisions of Section 457.102, Florida Statutes. (See Section 120.52(8)(c), Florida Statutes).
Findings Of Fact It was stipulated that Petitioner FMA is organized and maintained for the benefit of approximately 16,000 licensed allopathic and osteopathic Florida physicians. FMA's standing in this proceeding has always been at issue. The foregoing stipulation encompasses all of the factual allegations about the Petitioner contained in the Petition. It was stipulated that there is only one Respondent, the Board of Acupuncture, created by the Florida Legislature and placed within the Florida Department of Health. It is axiomatic that the Respondent has standing herein. There were no stipulations as to the standing of either Intervenor, and both the Board and FSOMA have asserted in their respective Proposed Final Orders that FAPA, as well as FMA, is without standing to bring this rule challenge. However, no party has contested the veracity of the factual statements concerning standing in either Petition to Intervene, and no party opposed intervention. The Petitions to Intervene of FAPA and FSOMA were granted, subject to proving-up standing at hearing. Even stipulations as to standing do not preclude consideration of standing as a matter of law. Florida Medical Ass'n., Inc., et al. v. Dept. of Health, Florida Bd. of Nursing, et al., DOAH Case No. 99-5337RP (Final Order March 13, 2000), per curiam affirmed Bd. of Nursing, et al. v. Florida Medical Ass'n. Inc., So. 2d (Fla. 1st DCA 2001). Therefore, under these circumstances, and applying that case, the Intervenors' factual allegations for purposes of standing may be taken as true for findings of fact, but each Intervenor's status still depends upon that of the respective party upon whose behalf each Intervenor entered this case. Therefore, with regard to the status of FAPA, it is found that: FAPA is organized and maintained for the benefit of the licensed Florida physicians assistants who compromise [sic] its membership and has as one of its primary functions to represent the interests of its members before various governmental entities of the State of Florida, including the Department of Health and its boards. (FAPA Petition to Intervene) Therefore, with regard to the status of FSOMA, it is found that: FSOMA is a Florida nonprofit corporation comprised of over one-third of the doctors of oriental medicine and licensed acupuncturists under the regulatory aegis of the Board of Acupuncture, State of Florida Department of Health, Chapter 457, F.S., with a mission to represent the acupuncture and oriental medicine practitioner interests of its members in judicial administrative, legislative and other proceedings. (FSOMA Petition to Intervene) Existing Rule 64B1-3.001(6), Florida Administrative Code, was promulgated by the Board of Acupuncture. The challenged rule provides: (6) Acupuncture physician means any person certified as provided in this Chapter to practice acupuncture as a primary health care provider. The rule was adopted on August 13, 1984. It was most recently amended on February 27, 1992. The "authority" cited by the Board for the challenged rule is Section 457.104, Florida Statutes. The Board cites the "law implemented" for the challenged rule as Section 457.102, Florida Statutes. Section 457.104, Florida Statutes, currently provides: The board has authority to adopt rules pursuant to ss. 120.536(1) and 120.54 to implement provisions of this chapter conferring duties upon it. Section 457.102, Florida Statutes, currently provides: "Acupuncture" means a form of primary health care, based on traditional Chinese medical concepts and modern oriental medical techniques, that employs acupuncture diagnosis and treatment, as well as adjunctive therapies and diagnostic techniques, for the promotion, maintenance, and restoration of health and the prevention of disease. Acupuncture shall include, but not be limited to, the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body and the use of electroacupuncture, Qi Gong, oriental massage, herbal therapy, dietary guidelines, and other adjunctive therapies, as defined by board rule. "Acupuncturist" means any person licensed as provided in this chapter to practice acupuncture as a primary health care provider. "Board" means the Board of Acupuncture. "License" means the document of authorization issued by the department for a person to engage in the practice of acupuncture. "Department" means the Department of Health. "Oriental medicine" means the use of acupuncture, electroacupuncture, Qi Gong, oriental massage, herbal therapy, dietary guidelines, and other adjunctive therapies. "Prescriptive rights" means the prescription, administration, and use of needles and devices, restricted devices, and prescription devices that are used in the practice of acupuncture and oriental medicine. (Emphasis supplied) Section 457.116(1)(b), Florida Statutes, provides: A person may not: (b) Use, in connection with his or her name or place of business, any title or description of services which incorporates the words "acupuncture," "acupuncturist," "certified acupuncturist," "licensed acupuncturist," "oriental medical practitioner"; the letters "L.Ac.," "R.Ac.," "A.P.," or "D.O.M."; or any other words, letters, abbreviations, or insignia indicating or implying that he or she practices acupuncture unless he or she is a holder of a valid license issued pursuant to ss. 457.101-457.118; (Emphasis supplied) It was stipulated that witnesses for the Respondent Board of Acupuncture would testify that "A.P." as employed in Section 457.116 (1) (b), Florida Statutes, means "acupuncture physician."1
The Issue The issue is whether Petitioner's request for an exemption from disqualification from employment in a position of special trust should be granted.
Findings Of Fact Based upon all of the evidence, the following findings of fact are determined: This case involves a request by Petitioner, Raymond A. Baker, for an exemption from disqualification from employment in a position of special trust. If the request is approved, Petitioner would be allowed to return to work as a supervisor in a unit for developmentally disabled adults at Florida State Hospital (FSH). Respondent, Department of Children and Family Services (DCFS), is the state agency charged with the responsibility of approving or denying such requests. In a preliminary decision entered on September 2, 1997, a DCFS committee denied the request. Petitioner is now barred from doing such work because of a disqualifying offense which occurred on September 19, 1993. On that date, Petitioner was arrested for the offense of committing a "battery upon his live-in girlfriend," a misdemeanor under Section 784.03(1)(a), Florida Statutes (1993). Since the victim in that case was a person with whom Petitioner was then residing, the offense constituted domestic violence as it subsequently became defined in 1994 by Section 741.28, Florida Statutes. Petitioner entered a plea of No Contest to the charge of "[b]attery-domestic" on October 12, 1993. Adjudication of guilt was withheld, he was fined $150.00, and he was placed on twelve months probation. In addition, he was required to complete "New Hope & Alcohol Counseling," and he was ordered to have no contact with the victim. Petitioner successfully completed all terms of his probation, including counseling courses in both spousal abuse and substance abuse. In October 1993, Petitioner began working at FSH in an Other Personnel Services position. Eventually, he attained the position of unit treatment rehabilitation senior supervisor I in Unit 4, a position involving supervision of developmentally disabled adults. Due to a change in the law, in 1996, he was required to undergo a background screening. That screening uncovered his 1993 offense, and on July 18, 1997, he was disqualified from working in a position of special trust with developmentally disabled adults. Petitioner then accepted a position of fiscal assistant in the financial services section of FSH, a position having no contact with residents. He has continued working in that position pending the outcome of this case. Because of his desire to return to his former position, he has applied for an exemption from disqualification. Petitioner is a graduate of Florida State University with a degree in government and criminology. He also holds a Doctor of Jurisprudence from Howard University School of Law. He eventually plans to take the Florida Bar examination, and if he passes the examination, the Florida Bar will accept him for membership, notwithstanding his 1993 misdemeanor conviction. This assertion was not contradicted. In interpreting the statutory criteria which govern the granting of exemptions, the DCFS considers the following factors, among others, to be important. First, the applicant should not minimize the seriousness of the offense; he must express some remorse; and he must have insight into the seriousness of the incident and the risks involved. A three-person committee preliminarily denied the request in early September 1997 because at that time it believed that Petitioner minimized the incident, that he expressed little or no remorse, and that he had no insight into the seriousness of his offense. More than four years have elapsed since the criminal incident, a sufficient time for rehabilitation. Since that time, there have been no other blemishes on Petitioner's record. Except for a "bleeding toe," which was caused when the victim either cut it on broken glass or accidentally jammed it against the door, there was no injury to the victim. Petitioner has worked continuously at FSH since the incident, and he was described by former colleagues in Unit 4 as having a good rapport with patients and staff. According to co-workers, he also handled crises in the unit "in the right way." During the years 1995, 1996, and 1997, he received satisfactory evaluations from his supervisor. There is no evidence that Petitioner would present a danger to the residents if the exemption is granted. Petitioner's description of the circumstances surrounding the incident was not altogether accurate. This finding is made after considering the testimony of the victim who reluctantly testified on behalf of DCFS. For example, Petitioner recalled that the altercation ensued after the two had an argument over finances. However, it was established that it was caused when the victim attempted to break off the relationship and to leave the premises. In an effort to keep her from leaving, Petitioner tried to disrobe her. Also, he was extremely argumentative when speaking with the investigating law enforcement officer, and he refused to leave the premises when requested. According to the victim, Petitioner's verbally abusive behavior and his refusal to leave, rather than the altercation itself, ultimately led to his arrest that evening. While Petitioner was somewhat evasive and had no recollection about some of the facts surrounding the incident, this is probably attributable, at least in part, to his being highly intoxicated when the incident occurred. Petitioner expressed regret for his actions on the evening of September 19, 1993. His assertion that he has had no problems with alcohol since that night was not contradicted. Given the lapse of time since the incident, a record of continuous employment with the FSH with good evaluations, the completion of two counseling courses, and an expression of regret, the request for an exemption should be granted.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Department of Children and Family Services enter a final order granting Petitioner's request for an exemption from disqualification for employment in a position of special trust. DONE AND ENTERED this 11th day of February, 1998, in Tallahassee, Leon County, Florida. DONALD R. ALEXANDER 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 Filed with the Clerk of the Division of Administrative Hearings this 11th day of February, 1998. COPIES FURNISHED: Gregory D. Venz, Agency Clerk Department of Children and Family Services Building 2, Room 204 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Pete Peterson, Esquire Department of Children and Family Services Building 2, Room 204 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Ben R. Patterson, Esquire Post Office Box 4289 Tallahassee, Florida 32315-4289 John R. Perry, Esquire Department of Children and Family Services 2639 North Monroe Street, Suite 252A Tallahassee, Florida 32399-2949
Findings Of Fact The Department of Professional Regulation, Board of Dentistry, filed an Administrative Complaint in DPR Case Number 00-52375 against the Petitioner's license to practice dentistry on May 13, 1986. The Petitioner did not dispute the facts alleged in the Administrative Complaint and the Board of Dentistry held an informal hearing, pursuant to Section 120.57(2), Florida Statutes, on September 13, 1986. On October 2, 1986, the Board of Dentistry issued a Final Order suspending the Petitioner from the remunerative practice of dentistry for a period of ten (10) years and advised the Petitioner of his right to appeal the Board's Final Order. The Petitioner did not appeal the October 2, 1986 Final Order of the Board of Dentistry. On or about May 1, 1987, and/or May 2, 1987, the Board of Dentistry met to consider correspondence from the Petitioner seeking a determination of compliance with the Board's October 2, 1986 Final Order for his proposal to do volunteer community service dental work at "St. Catherine Laboure Manor" in Jacksonville, Florida. The Board of Dentistry requested further clarification from the Petitioner and took no further action with respect to the Petitioner's request. On June 10, 1987, the Board of Dentistry met to consider the Petitioner's request to allow him to provide volunteer community service dental work under indirect supervision, and on June 26, 1987, the Board of Dentistry issued an Order Denying the Modification. The Petitioner did not appeal the June 26, 1987, Order of the Board of Dentistry. On or about March 9, 1988, the Petitioner submitted his second request to the Board of Dentistry for modification of its October 2, 1986 Final Order. The Petitioner identified the following reasons as why the Board of Dentistry should grant his request: My obligation to the people of the State of Florida was fully satisfied on September 28, 1987 (enc.). My civil rights were restored on February 25, 1988 (enc.). The fine imposed by the Board of Professional Regulation ($2000.00) has been paid in full. Since July 1987 I have been treating patients in St. Catherine Laboure' Manor under the direct supervision of Owen Boales D.D.S., as required by order of the Board (enc.). I am currently 64 years of age and need gainful employment. My wife and I are currently surviving primary on her earnings as an employee of the Florida Community College at Jacksonville. My mentally disabled son was admitted to The Northeast Florida State Hospital approximately one month after my arrest. His condition would be benefited by whatever personal attention and care my wife and I may be able to provide. The ten year suspension order now in effect is tantamount to lifetime punishment. This long suspension does not benefit the public but severely obstructs rehabilitative effort. It minimizes the opportunities for professional public service and prevents professional employment. It reduces the available options to demonstrate reliability and observable conformity to the profession's ethical standards. It will continue to impede all my effort to becoming a self sustaining productive and worthy member of society. On April 23, 1988, the Board of Dentistry met to consider the Petitioner's second request for modification of the Board's October 2, 1986 Final Order. After discussion and consideration of the evidence and arguments of the Petitioner, the Board of Dentistry on July 13, 1988, issued an Order Denying Modification of Final Order. The Petitioner did not appeal the Board's July 13, 1988 Order denying his second request. On or about June 5, 1990, the Petitioner through his attorney submitted his third request to the Board of Dentistry for a modification of the October 2, 1986 Final Order. The Petitioner's third Motion for Modification of Final Order submitted to the Board on or about June 5, 1990, did not contain information or circumstances that were substantially different from those known to the Board at the time the Final Order of October 2, 1986, was entered, at the time the first order was entered denying the modification request, or that were known to the Board when it had previously heard and denied Petitioner's second request in 1988. On July 28, 1990, the Board of Dentistry met to consider the Petitioner's third request for modification of the October 2, 1986 Final Order. After discussion of the parties and upon the advice of legal counsel, the Board of Dentistry on August 13, 1990, issued an Order Denying Modification of Final Order. The Petitioner timely sought an appeal of the Board's August 13, 1990 Order in the First District Court of Appeal, Case Number 90-2369. On September 4, 1991, the First District Court of Appeal issued its opinion where they found the August 13, 1990 Final Order to be ambiguous, vacated the August 13th Final Order, and remanded the case back to the Board of Dentistry for further proceedings. On October 8, 1991, the First District Court of Appeal issued its Mandate to the Board of Dentistry to hold further proceedings consistent with the Court's opinion. On or about October 15, 1991, the Petitioner submitted an Amended Motion for Modification alleging for the first time that "there had been material changes in circumstances since his suspension was entered and/or since the previous rulings as to his suspension." On November 8, 1991, the Board of Dentistry met to consider the Petitioner's third request for modification of the Board's October 2, 1986 Final Order, the Amended Motion for Modification of Final Order, and the Opinion and Mandate of the First District Court of Appeal. After discussion and consideration of the Petitioner's requests for modification, the Opinion and Mandate of the First District Court of Appeal, and the evidence presented, on December 12, 1991, the Board of Dentistry issued a Final Order on Remand granting the Petitioner's Amended Motion for Modification of the Board's October 2, 1986 Final Order. The Petitioner is a sole proprietor of a professional practice of dentistry. His principal office and domicile are located in Jacksonville, Florida. He has fewer than twenty-five (25) full-time employees, and his net worth, at the time of filing, was less than two million ($2,000,000) dollars. The Petitioner incurred appellate attorney's fees in the amount of $8,990.00 and costs in the amount of $323.92. The Respondent did not dispute the reasonableness of the fees and costs in this case.
Findings Of Fact Respondent, Patricia Major, M.D., graduated from Harvard undergraduate school with honors; graduated with honors from New York University School of Medicine; served her internship at Yale New Haven Hospital, as well as completing a residency program and fellowship program in pulmonary diseases at Yale in 1974. She was certified in 1974 by the American Board of Internal Medicine. She was a teaching fellow at Yale during her pulmonary fellowship and had a faculty appointment thereafter at that same school. She was Assistant Director and Educational Coordinator at the Family Practices Residency Program for the University of Connecticut and from 1974 through 1976 had teaching appointments there. In 1976, she left New England and returned to Florida to practice internal medicine in Key West where she had grown up. During the period from 1976 to 1980, when she practiced medicine in Key West, she also worked with Emory University and the University of Miami as a clinician teaching medical students who were placed in Key West on rotating clerkships. She served as an emergency room physician at Florida Keys Memorial Hospital and was an admitting physician on the staff. In 1978 she was selected as one of five physicians to become the first civilians to go through the Navy's Diving Medical Officers Training Program and served as a civilian diving medical officer for the Navy in Key West. In 1980, the Board of Medical Examiners of the State of Florida brought charges against Respondent that resulted in a stipulation being entered into between Respondent and the Board that she would voluntarily cease practicing in Florida and relinquish her Florida license. The stipulation was signed in December, 1981, and her license was relinquished by Order of the Board in February, 1982. The charges that resulted in the initial suspension of Respondent's license and in the stipulation between the Respondent and the Board dealt with charges based on impairment due to drugs and alcohol. Respondent moved to Massachusetts where she practiced medicine under a temporary license and voluntarily participated in the Impaired Professionals Program for two years. From 1982 to 1984 she had twice-weekly urine screens under her contract between the assigned Massachusetts monitoring physician and herself. In no instance was there evidence of impairment or a positive urine screen during her Massachusetts stay. In 1984, Respondent returned to Florida and applied to the Board of Medical Examiners for permission to return to practice. On March 14, 1984, the Board of Medical Examiners entered an order reinstating Respondent's medical license for the State of Florida, placing her on probation for a period of three years and setting up a monitoring agreement under which Dr. John Buckner of the Island Clinic would serve as supervising physician for Respondent. From March, 1984, until April, 1986, Respondent worked at the Island Clinic with Dr. Buckner, seeing 15 to 25 patients a day. During that period of time, she only missed one working day, in September, 1985, when she was moving from one house to another and during the period of time immediately before and during her October, 1985 stay at South Miami Hospital. Respondent, and all of the witnesses who had personal knowledge of her contact with patients, denied that she ever treated or dealt with patients while under the influence of drugs or alcohol from 1984 until the current time. Iris Carleen Cervantes, who served as secretary to Dr. Buckner and is currently on the staff of Dr. Davidson, Respondent's current monitoring physician, has had the opportunity over two and one-half years to observe Respondent on a regular basis in her dealings with patients. She has been with Respondent socially as well. She has never seen Respondent drink alcoholic beverages. She uses Respondent as her personal physician and for all other members of her family. She is aware of the Respondent's regular visits to her psychiatrist, Dr. Jerrold Weinstock, and takes those into account in doing the scheduling for Dr. Major. She is similarly aware of Respondent's regular attendance at Alcoholics Anonymous meetings, has never heard Respondent disparage A.A.; and in fact, has a brother whom Respondent helped get into A.A. At no time has Cervantes ever seen any indication, even when Respondent has returned to the office late at night, of any use of drugs or alcohol. Linda Susan Park, a counselor at the Delphus Drug and Alcohol Treatment Center at Florida Keys Memorial Hospital for the last three and one-half years, knows Respondent both personally and professionally. She has never seen Respondent under the influence of any mood-altering chemicals. Although they go out socially together, she has never seen Respondent order an alcoholic beverage. When they are together, they talk program, i.e., A.A. steps. Parks has regularly seen Respondent at A.A. meetings, and they attend a number of the same groups including a Wednesday night women's group called The New Beginnings Group. Parks is aware of the interest Respondent has shown in drug and alcohol-impaired nurses at Keys Memorial and of her attendance at the impaired nurses Caducues meetings. Respondent has worked with the Delphus Program at Florida Keys Memorial Hospital referring a number of patients to the program. Park has seen the Respondent under extremely stressful situations, particularly in the past year; and has seen her act only appropriately. With the Board's approval, Respondent has also worked with indigent patients at the Health Care Center at Florida Keys Memorial Hospital since August, 1986. The Director of that program, Thomas C. Puroff, testified regarding her employment there. Respondent was originally hired on a temporary basis to cover for the primary care physician for three weeks. The Director's assessment of her initial period of employment at the Health Care Center is as follows: The staff was very, very pleased with her performance, and I was very pleased with her performance. The staff felt that they were learning a lot from her, that she was an exemplary doctor who explained why she was doing things with patients and it became a learning process for our nurse practitioners and nurses. Her interaction with the receptionist, administrative assistant was very high level, very positive, and the patients loved her. And both--well, later on when we did hire her on a one day per week basis to fill in when the regular doctor could not be there, a lot of patients would call and specifically request an appointment when she was going to be there. (Transcript, P. 199) The Health Care Center ultimately hired the Respondent for one to two days a week when the other physician was not there. She works the longest day of the stretch, which is a ten-hour day. The Director describes the job as a high stress one in which he has seen no difficulty in handling stress on Respondent's part. He has never seen any indication of impairment of faculties or inability to handle her job in any fashion on Respondent's part. When he hired Respondent, Puroff had full knowledge that she had problems with the Board of Medical Examiners, had been assigned a monitoring physician, had been brought in restraints to the emergency room at Florida Keys Memorial Hospital and had been committed under the Baker Act in September of 1985, that she was an alcoholic who attended A.A., and that she regularly visited a psychiatrist. None of these matters were kept secret from him. Karl Michael Davidson, M.D., who became Respondent's monitoring physician after Dr. Buckner abruptly left town in April, 1986, has similarly seen no sign of any kind of impairment during the time he has worked with her. He has never seen her indulge in any drugs or alcohol. He knows that she regularly sees her psychiatrist. He has received no complaints from anyone in the medical community, the patient community, or the general community of Key West with regard to Respondent since he has served in a monitoring capacity for her. Even Sally Parr who testified on behalf of the Petitioner denied that Respondent ever used alcohol when she was in a situation in any way connected with patients. Regarding the change of monitoring physicians in April, 1986, the testimony of Respondent and her witnesses was consistent and uncontradicted, with Petitioner presenting no facts other than those stipulated. The individual having the most knowledge regarding the circumstances under which Dr. Buckner left Key West, was his secretary, Iris Cervantes. She, like the other witnesses, was aware that he had gone to look at a number of schools and other medical positions. He would say he was going to leave, but he always came back. On April 6, 1986, Buckner's wife told Respondent the Island Clinic was being closed and Buckner was leaving. On April 7, the locks on the doors to the Island Clinic were changed. Cervantes was one of two people to have a new key; Respondent and the other doctors practicing with Dr. Buckner were not given keys. This left Respondent in a position where she could not write some pharmaceutical prescriptions, all appointments had to be cancelled, and there was no way to treat ongoing patients who were ill at the time. When the locksmiths changed the locks, Respondent contacted Buckner to ask if he knew what he was doing and if he were going to be gone permanently. He indicated that he had started working in California, but he did not know whether it would be permanent. He said that he had spoken with Dr. Davidson and asked him to act as a temporary supervising physician in addition to himself. Respondent spoke with Dr. Davidson who said that she was welcome to see patients at his office and that he would monitor until Buckner decided what he was doing. They spoke about immediately notifying the Board of the change in her office location. It was her impression that Dr. Davidson had actually notified the Board with a handwritten memo the first day she was there and that was how the investigator from the Department knew how to find her when the investigator came to see Respondent at Davidson's office on April 18, 1986. On that date Davidson also discussed with the investigator Buckner's abrupt departure which might be permanent. Respondent ultimately wrote the Board herself. That correspondence dated April 22, 1986, was received by the Department of Professional Regulation on April 28, 1986, the same day on which the Department received from Davidson his notification letter dated April 17, 1986. Four to six weeks after that letter, Dr. Davidson and Respondent were advised that the Board had received the information and would consider Dr. Davidson as her supervisor. On August 2, 1986 Davidson and Respondent appeared before the Board of Medical Examiners and received formal approval. The remaining allegations involve two separate incidents occurring during the week of September 16, 1985. At that time, and since January of that year, Respondent was living in the home of Sally Parr, an Assistant State Attorney for Monroe County. It was Parr's testimony that several months after Respondent moved in, Respondent began to drink wine on a regular basis sometimes to the point of intoxication. Parr is the sole person to testify to having seen Respondent drink alcoholic beverages. Other witnesses testified to Parr's own problems with alcohol. The emotional relationship between Parr and Respondent from March, 1985, until September, 1985, was "stormy" and "tremendously emotional." The two of them attended therapy with Dr. Jerrold Weinstock. On September 16-17, 1985, all of this emotionalism culminated in Parr calling the emergency number 911. During the evening of Monday, September 16, Parr's sister arrived in town. There were highly controverted scenes which both Parr and Respondent described. The two participants were clearly emotionally charged, angry, and upset. It was Parr's testimony that Respondent walked into the back bedroom and with a syringe in her hand with a pale yellow fluid in it, lifted her shirt and injected that material into her chest under her left breast Saying she was going to kill herself. According to Parr, Respondent said the fluid was 100 percent xylccaine and she would die in one minute. Parr then called 911, Respondent told her she was a fool to believe that, and Respondent left the house and drove away. Parr also confusedly describes a later scene that night with Respondent and another syringe and more light yellow fluid. Officer Cynthia Tingley responded to that call from Parr. The report was treated as one for an "attempted suicide". At no time did Ms. Parr tell the officer that Respondent was not in danger or that Respondent had told Parr that she was "a fool" to believe that this was a way to kill oneself. In the opinion of the investigating officer, Parr had an odor of alcoholic beverage on her breath. The officer had no personal knowledge that Respondent had administered the legend drug to herself. She did note an empty bottle of xylocaine in the room but no syringe was found. Later the officer was called to where another officer had stopped Respondent and had given her a citation for careless driving. Respondent was cooperative and did not seem to be having health problems, although she did appear to be under a lot of stress and appeared anxious. Neither officer made any attempt to detain Respondent after the stopping. Under Parr's version of this event, it ended with Respondent refusing to go to sleep in the back bedroom and only agreeing to go to sleep if she could sleep in Parr's room. That occurred and ended the evening. Respondent continued to live at the house, and on Thursday Parr and her sister left for a short vacation. Parr testified that she called from out-of-town to tell Respondent that she was not coming back to the house unless Respondent had moved out. Respondent agrees that Parr called and told her that but adds that Parr had promised to go on vacation with Respondent and told Respondent to arrange that vacation while Parr and her sister were gone. Respondent specifically denies that she made a suicide attempt or attempted to give the impression she was trying to commit suicide on September 16-17, 1985, or any other time. She denies that the events described by Parr occurred but agrees that it was a very confusing, emotional night. She denies that there was any further incident when she returned that night and only recalls them both being pretty tired and having gone to bed. Dr. Jerrold Weinstock, Respondent's treating psychiatrist and the individual to whom Parr and Respondent had gone for counselling, testified that the only description of the xylocaine/suicide incident he received came from Parr, not from Respondent. No information that Weinstock gained from his psychotherapy of Respondent indicated that Respondent's version of the event (or non-event) was incorrect. It is specifically found based upon the credibility of the witnesses that Respondent did not inject herself or attempt to inject herself with anything and specifically not with xylocaine. The second incident of that week occurred on Friday evening, September 20-21, 1985. This was the evening when Parr called Respondent and told her to move out of the house. Respondent describes that scene as follows. She [Parr] called. We had arranged that she would call at that time. I had seen my last patient about 5:30 or 5:45 and I was waiting at home for her call . . . She started screaming at me to get out of her home, that she did not want me there when she got back. I was stunned because I was making arrangements for vacation. I said, "What about the vacation?" She said, "I lied to get out." And I said, "Well, what will you do." "Call the police," she said. "I know people on the police force and I won't hesitate to use them." And then she hung up on me. (Transcript, P. 248) Respondent had taken steps during the day to arrange a trip to New York and Connecticut because Parr had never been to New York. An acquaintance came by while Respondent was still sitting stunned and asked her if she wanted to go to the Black Angus and have a drink. Respondent went with this individual to the Black Angus and had three very strong drinks there. She realized that she was feeling intoxicated after the third drink. She asked the woman, who was driving, to drop her off at Sally's house, but the woman wanted to go downtown to a few more bars. Respondent pleaded to be dropped off, and her companion became belligerent. Ultimately, the acquaintance assaulted Respondent tearing her shirt off, punching her in the face, hitting her about the head, grabbing her purse and pulling it away from her. During the scuffle, Respondent even lost her sandals. Petitioner has not controverted this account. Cervantes and Buckner both confirmed the bruises and scratches from the fight. Cervantes also described an incident a few days later whereby the same woman came into the Clinic, gave Cervantes some earrings she said she had taken out of Respondent's purse, and slashed the tires on Respondent's car on her way out. Respondent was left intoxicated, running, frightened, with no top on and three miles from Parr's house. She did not have her keys which had been in her purse and could not get into the clinic but felt she could get into Parr's house if she could get there. She felt intoxicated and becoming more so, uncertain whether it was the alcohol or being beaten that was affecting her. She was disoriented and embarrassed to be running down the street wearing only a pair of shorts. She crawled under a garage on the side of the road to sleep to clear her head to find a solution to her predicament. She was awakened by police officers but said nothing in response to questioning. Respondent was taken by the police to Florida Keys Memorial Hospital. When the police officers tried to transport Respondent, she became physically violent, kicking at the officers and attempting to kick out the windows of the patrol car. When she arrived at the hospital, she was physically restrained with arm and leg restraints. A drug analysis performed on Respondent at the hospital showed her blood alcohol level to be 0.235 percent. Respondent was next transported to Marc House in Marathon, Florida. She was involuntarily committed under the Baker Act for that one night. The next morning, Dr. Jesse Sewell, Director of Marc House, spoke with Respondent, determined there was absolutely no reason for Respondent to be there, and called Buckner to pick up Respondent and transport her back to Key West. Dr. Buckner did and took Respondent to Parr's house so she could move out her belongings. Respondent and Buckner discussed the episode at great length and she got in touch with Dr. Weinstock. Buckner and Respondent called her probation officer with the Department of Professional Regulation, a Diane Robie, who advised them to contact Dr. Roger Goetz, head of the Florida Impaired Physicians Program. Buckner called Goetz and described the incident that resulted in Respondent being committed overnight. He told Goetz that Respondent had moved out of the place where she had been living which seemed to have precipitated the disturbance; that she was in daily contact with her psychiatrist; that she had started attending A.A. meetings daily as recommended to someone who has had an episode of drinking; and that she would bring her support systems together. Goetz suggested going for evaluation at South Miami Hospital with Dr. Lynn Hankes. When Respondent was evaluated by Hankes, he recommended entry into South Miami's treatment program. Respondent went back to Key West and conferred with Buckner, Weinstock, and Goetz. Although Weinstock believed the inpatient program at South Miami would be therapeutically counterproductive, Respondent followed the recommendations of Goetz and Hankes and entered the treatment program on October 6, 1985. Buckner (whose deposition was taken prior to his departure from Key West in April, 1986) considers Respondent the best internal medicine doctor in Monroe County. Since he had noticed nothing wrong with Respondent through Friday afternoon, September 20, 1985, he was surprised by the telephone call from Dr. Sewell at Marc House on Saturday morning. When Buckner spoke with Weinstock that day, Weinstock explained that Respondent completely removes her emotional problems from her professional self. After the Friday/Saturday Marc House incident, Respondent finished her weekend move from Parr's house on Monday and came back to work on Tuesday. From Tuesday until she entered South Miami's treatment program, her performance as a practicing physician remained exemplary, analytical and calm. Respondent entered the program committed to making the program work and seeking insights into the nature of her disastrous interpersonal relationships as well as the episode that led to her admission to Marc House. Dr. Lynn Hankes testified that Respondent is a chronic alcoholic who will always be an impaired physician. He described in detail the South Miami Treatment Program beginning with the first phase of detox and assessment. He admitted that Respondent did not require detoxification and that she suffered no abstinence syndrome or withdrawal syndrome. She became immediately oriented to the program and began interacting with her counselor. However, Dr. Hankes believes that Respondent only intellectually admitted to the problem and that she was preoccupied with only interacting with the other medical professionals on the unit. He described at some length Respondent's "negative limit testing" and her preoccupation with the medical professionals on the unit. He regarded her as "sabotaging her own treatment". For example, Respondent did not initially tell program personnel that she sometimes had a glass of wine at dinner over the last several months or that she shared a marijuana cigarette on her way from Key West to admit herself into South Miami Hospital although she did disclose that information during her stay in the program. It is his opinion that there is a clear medical indication for extended treatment in a secondary facility for many reasons. Basically, in his opinion, it was a bottom line of an intellectual admission of the disease with only minimal acceptance. He administratively discharged Respondent from the program on October 31, 1985 just prior to her completing the program because she refused to accept his recommendation for extended care for an indefinite period of time. Dr. Hankes did not see Respondent after October 31, 1985 in any capacity. All of his testimony was based on information which he had prior to October 31, 1985. Dr. Hankes admitted that the only limit testing, rule breaking that Respondent had engaged in was that she spoke to other medical professionals, she spoke to male patients in their room while she stood at the door, and she walked a friend to the lobby of the hospital but did not leave the premises. He also observed isolation tendencies on her part. His dire predictions of doom have not proven accurate. In the subsequent year and a quarter Respondent has stayed sober and practiced medicine successfully with no further incident. It was Buckner's impression that the major reason Respondent was being required to go into the hospital for the inpatient treatment was because other impaired physicians in the Key West area had had to go through the program, and they were unhappy that she had somehow missed it. Buckner encouraged Respondent to enter the treatment program, even against the advice of her psychiatrist, so that the Board would be on her side after she "completed the drill." Buckner spoke with her counselor and therapist regularly during the time she was at South Miami Hospital and got indications that everything was progressing well and that she would be back to Key West to practice at the scheduled time. Buckner went to South Miami Hospital three weeks after Respondent's admission to meet with Dr. Hankes on a Saturday. Hankes did not show up for the appointment, but Buckner later reached him by phone. Hankes told Buckner that Respondent was progressing fine, although she still had some problems. Hankes said Respondent would be back in Key West practicing the next week and could have outpatient treatment with Dr. Weinstock. Buckner returned to Key West and told his staff to schedule Respondent for patients the next week when she would return. On Monday Respondent telephoned to tell him that Hankes had changed his mind, that they were not going to release her, and that she was going to have to sign herself out. No explanation has been offered as to why Hankes changed his mind between Saturday and Monday so radically from outpatient treatment with Respondent's treating psychiatrist to indefinite inpatient hospitalization. Buckner and Weinstock agreed the best treatment for Respondent was to get her back practicing medicine. Buckner contacted Cecilia Bradley, the attorney representing the Department and the Board, asking for direction. Bradley advised Buckner that he would have to personally decide whether Respondent was a threat to the community. He saw no such threat. Respondent returned to the Island Clinic and resumed her practice. Buckner saw her there on a daily basis, and her performance was, in his opinion, the same as before, "absolutely flawless." When Respondent did not accept Hankes' recommendation of indefinite long-term treatment in Mississippi, she became, in Dr. Goetz's opinion, in noncompliance with the Florida statute on impaired physicians. Dr. Goetz subsequently reported her to the Department of Professional Regulation for her failure to continue satisfactorily in the program. Goetz admitted that his role as Director of the program was one of an administrative officer, and he has offered no opinion as to whether Respondent is in fact impaired. Goetz has received no information that Respondent's impairment, if any, has in any way affected her practice or patient contact. All the information that Goetz relies on is information prior to Respondent's discharge from South Miami Hospital on October 31, 1985. It was Buckner's understanding, and that of Respondent, that she had not violated the Order of the Board in having an instance where she "slipped" with regard to drinking. Dr. Goetz agreed with that assessment a "slip" can be a part of a rehabilitation program. Linda Parks, Diane Robie, and Dr. Weinstock agree with that assessment. Respondent could not have financially afforded the Mississippi program. Despite the testimony of Hankes and Goetz that Respondent could have gone there for free, Goetz did not tell her that, Hankes did not know what the financial arrangement was, and the Director of that program whom Respondent personally contacted regarding the program did not mention such a possibility. Jerrold Weinstock has been Respondent's treating psychiatrist since 1984. His opinion is that there is no basis for the allegation that Respondent be considered an impaired physician incapable of rendering safe, quality, and competent services to her patients. In fact, Weinstock refers members of his own family to her. That opinion is shared by two independent psychiatrists, Stanley I. Holzberg, M.D., and Milton Burglass, M.D. Dr. Holzberg examined Respondent initially on behalf of the Florida Impaired Physicians Program in 1983; reexamined her at the request of the Department in February, 1984; and saw her for a third time at her own request in November, 1985, following Respondent's discharge from South Miami Hospital. On all of the occasions when he examined Respondent, Holzberg opined that she could practice medicine with skill and safety with the conditions that she have treatment and monitoring. Holzberg considers the treatment she is receiving from Weinstock, including the prescription of an antidepressant, as appropriate long-term treatment. He agrees with Weinstock and Buckner that long-term inpatient hospitalization would not be helpful to Respondent. Holzberg further agrees with Weinstock that Respondent's major illness is chronic depression, the affective disorder. Dr. Milton Burglass evaluated Respondent on March 25 and April 2, 1986, and reached the same conclusion. Burglass administered a full series of psychological tests to Respondent, including the Minnesota Multi-Phasic' Personality Inventory; the Beck Depression Inventory; the Cattell Use for Tension and Anxiety Survey Schedule; the Rotter Incomplete Sentences Blank; the Cattell Assertive Behavior Survey Schedule; the Cattell Thought Stopping Survey Schedule; and the Standardized Medical and Personal History Form. He spent, in addition, a total of five hours interviewing Respondent, and he went over all the records from other psychiatric and related medical evaluations that she had had from 1980 forward. Burglass found nothing to suggest that Respondent is incapable of practicing medicine with skill and safety. Burglass believes that people can, in fact, function normally and be able to perform professionally in their chosen profession after recovering from a chemical dependency, be it drug or alcohol. Burglass specifically opined that Respondent is not impaired.
Recommendation Based upon the foregoing Findings of Facts and Conclusions of Law, it is RECOMMENDED that a final order be entered: Dismissing with prejudice the complaint filed against Respondent in DOAH Case NO. 86-0469; Finding Respondent guilty of the allegation contained in the Administrative Complaint filed in Case No. 86-2065 but taking no disciplinary action against her, and Allowing Respondent to continue to practice medicine under reasonable monitoring conditions until the period of her probation has been completed on March 15, 1987. DONE AND ORDERED this 5th day of March, 1987, in Tallahassee, Florida. LINDA M. RIGOT Hearing Officer Division of Administrative Hearings The DeSoto Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 5th day of March, 1987. APPENDIX TO RECOMMENDED ORDER DOAH Case Nos. 86- 0469 and 86-2065 Rulings are made as to each of Petitioner's proposed findings of fact as follows: 1-2. Adopted. 3. Rejected as irrelevant. 4-5. Adopted. 6-7. Rejected as not supported by the weight of the credible evidence. Rejected as being contrary to the weight of the credible evidence. Adopted. Rejected as not supported by the weight of the credible evidence. Adopted. Rejected as being a statement taken totally out of context. Adopted. Rejected as being contrary to the weight of the credible evidence. 15-17. Adopted. Rejected as not supported by the weight of the credible evidence. Adopted. Rejected as not supported by the weight of the credible evidence. First two sentences adopted; third sentence rejected as being contrary to the weight of the credible evidence. 22-23. Adopted. Rejected as being secondary. Adopted. First sentence rejected as being contrary to the weight of the credible evidence. Second sentence adopted. Rejected as being contrary to the weight of the credible evidence. 28-29. Adopted. 30-32. Rejected as not supported by any evidence. Rejected as being secondary. Rejected as being contrary. Rejected as being irrelevant. Rejected as being secondary. Adopted. Rejected as not supported by any evidence. Rejected as being irrelevant. 40-45. Adopted. Rejected as being irrelevant. Adopted. Rulings are made as to each of Respondent's proposed findings of fact as follows: 1-27. Adopted. 28. Rejected as being redundant. 29-32. Adopted. 33. Rejected as being redundant. 34-39. Adopted. 40-41. Rejected as being unnecessary. 42-43. Adopted. COPIES FURNISHED: Leslie Brookmeyer, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Elizabeth Du Fresne, Esquire 2950 S.W. 27th Avenue, Suite 10 Coconut Grove, Florida 33133 Nathan Eden, Esquire 417 Eaton Street Key West, Florida 33040 Van Poole, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Dorothy Faircloth Executive Director Board of Medical Examiners 130 N. Monroe Street Tallahassee, Florida 32301
