Findings Of Fact The Petition named Dr. Decker as the physician providing obstetric services at Jeovani’s birth on January 18, 2008. Attached to the Motion for Summary Final Order is an affidavit of NICA's custodian of records, Tim Daughtry, attesting to the following, which has not been refuted: One of my official duties as Custodian of Records is to maintain NICA’s official records relative to the status of physicians as participating physicians in the Florida Birth-Related Neurological Compensation Plan who have timely paid the Five Thousand Dollar ($5,000.00) assessment prescribed in Section 766.314(4)(c), Florida Statutes, and the status of physicians who may be exempt from payment of the Five Thousand Dollar ($5,000.00) assessment pursuant to Section 766.314(4)(c), Florida Statutes. Further, I maintain NICA's official records with respect to the payment of the Two Hundred Fifty Dollar ($250.00) assessment required by Section 766.314(4)(b)1., Florida Statutes, by all non-participating, non-exempt physicians. * * * As payments of the requisite assessments are received, NICA compiles data in the “NICA CARES” database for each physician. The “NICA CARES physician payment history/report” attached hereto for Dr. Lawrence Decker, indicates that in the year 2008, the year in which Dr. Decker participated in the delivery of Jeovani Morataya, as indicated in the Petitioner’s Petition for Benefits, Dr. Decker did not pay the Five Thousand Dollar ($5,000) assessment required for participation in the Florida Birth-Related Neurological Injury Compensation Plan. Further, it is NICA’s policy that if a physician falls within the exemption from payment of the Five Thousand Dollar ($5,000) assessment due to their status as a resident physician, assistant resident physician or intern as provided in Section 766.314(4)(c), Florida Statutes, annual documentation as to such exempt status is required to be provided to NICA. NICA has no records with respect to Dr. Decker in relation to an exempt status for the year 2008. To the contrary, the attached "NICA CARES physician payment history/report shows that in 2008, Dr. Decker paid the Two Hundred and Fifty Dollar ($250) assessment required by Section 766.314(4)(b)1., Florida Statutes, for non- participating, non-exempt licensed physicians. The physician payment history/report for Dr. Decker supports Mr. Daughtry’s affidavit. Petitioners have not offered any exhibits, affidavits or any other evidence refuting the affidavit of Mr. Daughtry, which shows that Dr. Decker had not paid his $5,000 assessment for 2008. At the time of the birth of Jeovani, Dr. Decker was not a participating physician in the Plan. The Petition was filed on August 11, 2015, which is more than five years after Jeovani’s birth.
Findings Of Fact Provider received the correspondence giving notice of Provider’s right to an administrative hearing regarding the improper Medicaid reimbursement. Provider filed a petition requesting an administrative hearing, and then caused that petition to be withdrawn and the administrative hearing case to be closed. Provider chose not to dispute the facts set forth in the letter dated August 1, 2011. The facts alleged in the letter are hereby deemed admitted, including the total improper reimbursement amount of twelve thousand, one hundred sixty-four dollars ($12,164.00). The Agency hereby adopts the facts as set forth in the letter, including the improper reimbursement amount of twelve thousand, one hundred sixty-four dollars ($12,164.00). CONCLUSIONS OF LAW. The Agency incorporates and adopts each and every relevant statement and conclusion of law set forth in the August 1, 2011, letter. The admitted facts support the legal conclusion that the improper reimbursement in the amount of twelve thousand, one hundred sixty-four dollars ($12,164.00) was appropriate. As partial payment has previously been made, five thousand, eight hundred sixty-four dollars ($5,864.00) is now due and owing from Provider to the Agency. Based on the foregoing it is ORDERD AND ADJUDGED that Provider remit, forthwith, the amount of five thousand, eight hundred sixty-four dollars ($5,864). Provider’s request for an administrative hearing is hereby dismissed. DONE and ORDERED on this the We day of fojtimla__. 2012, in Tallahassee, Florida. and Mf SECRETARY Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Rachic’ Wilson, Esquire Agency for Health Care Administration (Interoffice Mail) Roberto E. Moran, Esq. Rasco, Klock, Reininger, et al 283 Catalonia Avenue Second Floor Coral Gables, Florida 33134 (U.S. Mail) June C. McKinney Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Mike Blackburn, Chief, Medicaid Program Integrity Finance and Accounting HOA Agency for Persons with Disabilities (Facility) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addressees by U.S. Mail on this the Ainot Sek W12. = —az, Richard Shoop, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 412-3630
Conclusions THIS CAUSE came before me for issuance of a Final Order on an August 1, 2011, letter from the Agency for Health Care Administration (“Agency”) to Bay Point Schools, Inc. (“Provider”) notifying Provider that it had been improperly reimbursed twelve thousand, one hundred sixty-four dollars ($12,264.00) by Medicaid. The August 1, 2011, letter indicated that partial payment had already been remitted by Provider and that five thousand, eight hundred sixty-four dollars ($5,864.00) remained due and owing from Provider to the Agency. The August 1, 2011, letter provided full disclosure and notice to Provider of procedures for requesting an administrative hearing to contest the allegations made in the letter. Provider filed a petition with the Agency requesting a formal administrative hearing on September 6, 2011. The Agency forwarded Provider’s hearing request to the Division of Administrative Hearings (“DOAH”) for a formal administrative hearing. On March 9, 2012, Provider filed a Motion to Withdraw Petition for Formal Hearing. DOAH issued an Order Filed September 6, 2012 1:46 PM Division of Administrative Hearings Closing File and Relinquishing Jurisdiction on March 12, 2012, closing the above-styled cause and relinquishing jurisdiction back to the Agency.
The Issue Whether the Petitioner is entitled to reimbursement for medical treatments received by his wife for 4 manipulation treatments received in 1983?
Findings Of Fact At all times pertinent hereto, the Petitioner was an insured employee under the State of Florida Employees' Group Health Insurance Plan, as provided in Section 110.123, Florida Statutes. Nora Gomez, the Petitioner's wife, is entitled to participate in the Plan as an eligible dependent. Mrs. Gomez first visited David L. Hartz, a chiropractic physician on August 2, 1983. Dr. Hartz's office is located at 1610 West Plaza Drive, Tallahassee, Florida. Dr. Hartz treated Mrs. Gomez primarily for upper back and neck pain. Between August 2, 1983, and December 14, 1983, Dr. Hartz treated Mrs. Gomez 33 times. Initially, Mrs. Gomez received chiropractic manipulations 3 times per week. Visits were subsequently reduced to 2 times a week and from November 1, 1983, until December 14, 1983, when treatments stopped, her treatments were reduced to once a week. Twenty-nine of the 33 visits received by Mrs. Gomez have been paid by the Respondent. The Respondent is not seeking to be reimbursed for payments made to the Petitioner in excess of 26. The Respondent has refused to pay for 4 of the visits. The Petitioner was charged $18.00 per visit for Mrs. Gomez's treatments. The Respondent has refused to pay the Petitioner a total of $72.00 (4 visits x $18.00). Mrs. Gomez received her 26th treatment on November 1, 1983. Mrs. Gomez's condition at that time was, according to Dr. Hartz, as follows: I show that she had improved considerably over her initial findings but she still had some persistent pain in her neck and upper back and some inflammation, some nerve roots in her neck and some persistent muscle weakness. Deposition testimony of Dr. Hartz, page 15, lines 18-21. Dr. Hartz also indicated that he believed that Mrs. Gomez "could still improve some past that point." Deposition testimony of Dr. Hartz, page 11, lines 12-13. Based upon Dr. Hartz's testimony, Mrs. Gomez's problem was of a type which could be eventually treated on a "periodic supportive type treatment, on a periodic nature." Dr. Hartz was trying to treat Mrs. Gomez's problem, however, during 1983 to a point where she could receive such treatment. She did not, however, continue the treatments long enough to reach that point because of the Respondent's position that only 26 treatments would be reimbursed by the Petitioner's insurance. The Respondent reimburses for rehabilitative therapy but not for maintenance therapy under the State Plan. The Respondent determined that Mrs. Gomez's treatments after November 1, 1983 (her 26th visit) were for maintenance and not rehabilitative therapy because the Respondent determined that her condition stabilized. Therefore, the Respondent refused to make further payments. Dr. Hartz did indicate that Mrs. Gomez reached a point where she had persistent pain that would feel better for a while and then would return, and therefore, he "either had a choice to extend her treatment and let her hurt or treat her and keep her feeling as good as possible." This statement and the rest of Dr. Hartz's testimony is not sufficient to conclude, however, that Mrs. Gomez stabilized as of November 1, 1983, and therefore was receiving maintenance treatment only after that date. Dr. Hartz did not, however, based upon all his testimony, believe that Mrs. Gomez had reached a point during her treatment in 1983 where her treatment was in the nature of maintenance only. Dr. Hartz was still treating Mrs. Gomez through her last visit in 1983 in an effort to correct her condition sufficiently for her to receive only maintenance treatments. The 4 visits in 1983 for which reimbursement has not been made, were part of Dr. Hartz's effort to get Mrs. Gomez to a point where she would only need maintenance type treatment. The visits were in the nature of rehabilitative therapy, for which the Petitioner is entitled to reimbursement.
Recommendation Based on the foregoing Findings of Fact and Conclusion of Law, it is RECOMMENDED that the Respondent reimburse the Petitioner $72.00 for the 1983 treatments received by the Petitioner's wife for which reimbursement has been refused. DONE AND RECOMMENDED this 3rd day of December, 1986, in Tallahassee, Florida. LARRY J. SARTIN Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9673 Filed with the Clerk of the Division of Administrative Hearings this 3rd day of December, 1986. APPENDIX TO RECOMMENDED ORDER, CASE NO. 86-2595 The Respondent has submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they were accepted. Those proposed findings of fact which have been rejected and the reasons for their rejection have also been noted. Paragraph numbers in the Recommended Order are referred to as "RO ." Paragraph Number of Petitioner's Proposed Findings of Fact: Accepted in RO 1-2. Accepted in RO 3-4. Accepted in RO 5. Accepted in RO 6. Accepted in RO 6-7. Accepted in RO 7. Accepted in RO 9-10. Accepted in RO 11 and 15. The quotation of Dr. Hartz's testimony contained in the last sentence of this proposed findings of fact is taken slightly out of context. See RO 15. Accepted in RO 14. This proposed finding of fact is rejected as contrary to the weight of the evidence. See RO 15-16. COPIES FURNISHED: Michael J. Gomez 2404 Harbor Drive Tallahassee, Florida 32303 Augustus D. Aikens, Jr., Esquire General Counsel Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550 Gilda Lambert, Secretary 435 Carlton Building Tallahassee, Florida 32301
The Issue The issue is whether FFVA Mutual Insurance Company (FFVA) should be required to pay an additional $4,169.00 (for a total of $13,155.60) to a health care provider for a pre-authorized scheduled outpatient surgery.
Findings Of Fact FFVA, an insurance company, is a "carrier" as defined in section 440.13(1)(c), Florida Statutes (2012).4/ Summerlin is a health care provider as defined in section 440.13(1)(h) and is located in Fort Myers, Florida. On March 1, 2012, the Patient, an insured of FFVA, underwent a pre-authorized arthroscopic knee surgery, which was performed at Summerlin. The surgery was performed by Fletcher A. Reynolds, III, M.D. Dr. Reynolds dictated an Operative Report wherein he described the "Procedures Performed" as: Right knee arthroscopy, subtotal medial meniscectomy of bucket-handle medical meniscus tear, major synovectomy, medial compartment chondroplasty, and abrasion chondroplasty of the inferior medial aspect of the trochlea down to bleeding bone.[5/] The Operative Report also contained a section, "Procedure in Detail," which explained the extent of the surgery performed on the Patient's knee. The Current Procedural Terminology (CPT) codes for use to bill for the Patient's procedures include: 29879 abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture; 29881 with meniscetomy (medial OR lateral, including any meniscal shaving); and 29875 synovectomy, limited (eg, plica or shelf resection) (separate procedure). A modifier is a number added to a particular CPT code that explains the procedure and what, if anything, is unusual about it. The two modifiers at issue are "51" and "59." Modifier 51 is defined as: Multiple Procedures: When multiple procedures . . . are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated "add- on" codes (see Appendix D). CPT 2010,® American Medical Association, Appendix A- Modifiers, page 529. Modifier 59 is defined as: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M [evaluation and management] services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25. CPT 2010,® American Medical Association, Appendix A- Modifiers, page 530. Summerlin submitted a bill to FFVA identifying the following CPT codes and charges for each procedure done on the Patient's knee: 29879RT ($8,338.00); 29881RT ($8,338.00); and 2987551RT ($8,338.00). Summerlin's total bill was $25,014.00. FFVA paid Summerlin $8,986.60, $5,836.60 for the primary procedure (CPT code 29879RT) and $3,150.00 for the second procedure (CPT code 29881RT), but disallowed any payment for CPT code 2987551RT. FFVA issued an Explanation of Bill Review (EOBR) explaining that the total recommended allowance for reimbursement was $8,986.60. FFVA's "EOBR CODE DESCRIPTION" listed number "69" to justify its decision. As explained on the EOBR: 69 PAYMENT DISALLOWED: BILLING ERROR: CORRECT CODING INITIATIVE GUIDELINES INDICATE THIS CODE IS A COMPREHENSIVE COMPONENT OF CODE XXXXX BILLED FOR SERVICE(S) PROVIDED ON THE SAME DAY (29875 IS A COMPREHENSIVE COMPONENT OF 29879).[6/] Summerlin timely filed a "Petition for Resolution of Reimbursement Dispute," and FFVA timely filed a "Carrier Response to Petition for Resolution of Reimbursement Dispute," each pursuant to section 440.13(7). The Department issued its "Workers' Compensation Medical Services Reimbursement Dispute Determination" wherein it found that FFVA improperly adjusted the reimbursement, but only as to the charges billed for CPT code 2987551RT. The uncontroverted facts are that the Patient underwent a pre-authorized arthroscopic surgical procedure to the knee. Summerlin's invoice for billing provided to FFVA accurately reflected the multiple procedures performed by the surgeon, as did the Operative Report. Julie Dunn, FFVA's "medical compliance person," has worked for several insurance companies over her 25-year career. Her description of the process of reviewing medical bills and coding, a "complicated process because there's [sic] multiple resources that are adopted . . . ," is credible. However, in this instance, Ms. Dunn, who is not a professional coder (but is a member of a professional coder organization), did not review the EOBR until after Summerlin filed a reimbursement dispute. Although helpful, her testimony is not without doubt. Ms. Dunn never reviewed the Operative Report for the Patient. Further, FFVA only brought up the "59" modifier concern after the EOBR was issued, and the request for additional payment was made. Arlene Cotton, the Department's registered nurse consultant, is tasked with reviewing cases where a provider is disputing the reimbursement received. Ms. Cotton holds a bachelor's degree and a master's degree in nursing. Additionally, she is a certified professional coder who has reviewed hundreds of cases involving ambulatory surgical centers. Ms. Cotton reviewed Summerlin's petition for reimbursement by reviewing the CPT codes and the Operative Report for the Patient. Summerlin properly coded the Patient's three procedures. Ms. Cotton credibly explained the three procedures via the codes as follows: CPT code 29879, the primary procedure was an arthroplasty which was done in both the medial and the patellofemoral compartments of the knee; CPT code 29881 was a meniscectomy which was done in the medial compartment; and CPT code 29875 was a synovectomy which was done in the medial aspect, the intercondylar, the anterior lateral, and the patellofemoral. Further, Ms. Cotton described two additional synovectomies (for a total of four synovectomies) performed that were detailed in the Patient's Operative Report. However, Summerlin only billed for one synovectomy. FFVA's claim that Summerlin should have used modifier "59" instead of modifier "51" to "identify that procedure code 29875 was a . . . unique identifiable or a separately identifiable service" is misplaced. The Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2011 Edition (CRM ABS), requires that a surgical center use modifier 51. There was no credible evidence that Summerlin incorrectly billed for the three procedures. FFVA failed to appreciate the significance of modifier "51" and failed to appropriately reimburse Summerlin.
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, Office of Medical Services, enter a final order affirming the Reimbursement Dispute Determination issued April 24, 2012, wherein the Department directed FFVA Mutual Insurance Company to pay a total of $13,155.60 for the reimbursement claim filed by Summerlin. DONE AND ENTERED this 16th day of November, 2012, in Tallahassee, Leon County, Florida. S LYNNE A. QUIMBY-PENNOCK 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 16th day of November, 2012.
The Issue The issue for determination in this proceeding is whether NME Hospitals, Inc., d/b/a Hollywood Medical Center (HMC), is entitled to a certificate of need to convert 30 existing medical-surgical beds to 30 short term psychiatric beds at its hospital located in Hollywood, Florida.
Findings Of Fact Background Information Hollywood Medical Center (HMC) is owned and managed by its parent company, NME Hospitals, Inc. NME Hospitals, Inc., is a wholly owned subsidiary of National Medical Enterprises, Inc. (NME), a Nevada corporation headquartered in California. HMC is a 334-bed acute care hospital located in Hollywood, Florida. HMC is a full service hospital with an emergency room, a nine-suite operating unit, an intensive care unit, a coronary care unit, a 40-bed telemetry unit, a progressive care unit, and a dedicated oncology unit. HMC has a medical staff of more than 400 physicians with virtually every medical specialty represented, including psychiatrists. In addition, it is accredited by the Joint Commission on Accreditation of Healthcare Organizations. Hollywood is in the southern portion of Broward County, which is the only county in HRS Service District 10. The primary service area of HMC is the southern portion of Broward County, generally described as between State load 84 on the north and the Broward/Dade County line on the south. HMC is located in a peaceful and serene residential area. A high percentage of elderly people reside in condominiums which surround the hospital. One of the largest condominium developments in South Broward County is located within walking distance of HMC. Almost all of the programs at HMC are geared toward elderly patients; HMC does not even offer pediatric or obstetrical services. In September 1988, HMC filed a CON application to convert 30 of its existing medical-surgical beds to short term psychiatric beds. The proposal calls for the conversion of existing space on the sixth floor of the hospital. The total project cost is $864,545.00. HMC's application was comparatively reviewed by HRS with an application by the South Broward Hospital District d/b/a Memorial Hospital ("Memorial") to add 30 additional short term psychiatric beds to its facility which is also located in Hollywood, Florida. In its State Agency Action Report ("SAAR"), HRS preliminarily denied both applications. Both HMC and Memorial filed Petitions for Formal Administrative Hearings challenging their respective denials. These Petitions were referred to the Division of Administrative Hearings and consolidated by Order dated March 28, 1989. On August 17, 1989, Memorial voluntarily dismissed its petition for Formal Administrative Hearing. HMC's Proposal The elderly have unique psychiatric as well as medical needs. For example, the elderly have a much higher incidence of medically related nervous system disorders. In addition, the elderly experience certain psychiatric syndromes such as bipolar and manic depressive disorders and organic brain syndrome much more commonly than the rest of the population. Many of the elderly with psychiatric disorders have concomitant physical or medical problems such as cerebral vascular problems, arteriosclerosis, pulmonary problems, arthritic problems, physical disabilities, and mental impairments caused by senile dementia. The availability of medical treatment is a significant consideration in the selection of the appropriate treatment setting of elderly psychiatric patients who also suffer from one or more physical or medical problems. HMC believes there is a need for additional short term psychiatric services in its service area. In keeping with its goal of being a full service hospital capable of providing a full continuum of care to the patients in its service area, HMC seeks to fill this perceived need by offering such services at its own facility. The need perceived by HMC was based in large part on in-house physicians informing HMC's hospital administration that the physicians felt there was a need for such services. In its application, HMC proposes a separate geri- psychiatric unit with programs focused on the specific needs of geriatric psychiatric patients with multi-medical problems. The principal difference between such a specialized unit and an ordinary psychiatric unit is in the nature of the staffing and the training given to staff. Staff in a geri-psychiatric unit need to be prepared to address more multi-medical problems than are customarily encountered in a general psychiatric unit. Rather than proposing to add new beds to the facility, HMC decided it would be much more economical and cost efficient to convert some of its existing and unused medical- surgical beds to short term psychiatric beds. In this regard, a high percentage of HMC's licensed medical-surgical beds are empty, with the facility experiencing an average daily census of only 110 patients in its 334 licensed beds. Findings Regarding Section 381.705(1)(a), F.S. Section 381.705(1)(a), Florida Statutes, requires HRS to review applications for CONs in relation to the applicable district plan and state health plan. The State Health Plan in effect at the time HMC's application was filed (and as of the date of final hearing) was published in 1985 and established goals for 1987. Because the planning horizon applicable to HMC's application is 1993, the goals of the applicable State Health Plan are not particularly relevant to HMC's application. HMC's application is consistent with several of the goals contained in the Local Health Plan. Specifically, the Local Health Plan identifies the elderly as an under-served group and encourages the conversion of under-utilized medical-surgical beds to other needed services. HMC's application is consistent with these goals because it proposes the conversion of under- utilized medical- surgical beds to a geri-psychiatric unit. In this regard, according to HRS' acute care bed need methodology, in 1993 District 10 will have over 1,200 excess medical-surgical beds. HMC's application is not consistent with that portion of the Local Health Plan which states that planning should be on a district-wide basis. Findings Regarding Sections 381.705(1)(b) and (2)(d), F.S. Existing Providers Section 381.705(1)(b), Florida Statutes, requires HMC's application to be reviewed against the availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of like and existing health care services in the service district of the applicant. In this regard, there are eight existing providers of short term psychiatric services in Broward County. Four of these providers are free-standing psychiatric hospitals. They are: Coral Ridge Psychiatric Hospital ("Coral Ridge"), CPC Fort Lauderdale Hospital, The Retreat, and Hollywood Pavilion Psychiatric Hospital ("Hollywood Pavilion"). Coral Ridge and CPC Fort Lauderdale Hospital are located north of State Road 84 in northern Broward County. The Retreat is located in western Broward County, south of State Road 84 Hollywood Pavilion is located in southern Broward County, across the street from the applicant, HMC. The existing acute care hospitals in Broward County that have psychiatric units are: Broward General Medical Center ("Broward General") , Florida Medical Center, Imperial Point Hospital, and Memorial Hospital. Broward General, Florida Medical Center, and Imperial Point Hospital are all located north of State Road 84. Memorial Hospital is located in southern Broward County, about a half mile from HMC. The existing providers of short term psychiatric services in Broward County have a total of 507 existing short term psychiatric beds, distributed as follows: South Broward Memorial Hospital 74 Hollywood Pavilion 46 The Retreat 80 (of which 24 are geriatric) North Broward Coral Ridge 74 Fla. Medical Center 74 (of which 10 are geriatric) CPC Ft. Lauderdale 64 Broward General 48 Imperial Point 47 (of which 8 are geriatric) The utilization or occupancy rates (expressed in percentages) for the seven Broward County providers of short term psychiatric services which were in operation during 1987 and 1988 were as follows: Facility Cal. Yr. 7/87 thru Cal. Yr. 1987 6/88 1988 Private Facilities Fla. Medical Center 57.3 63.0 67.3 CPC Ft. Lauderdale 42.2 43.5 52.0 Coral Ridge 19.9 20.8 [unk.] Hollywood Pavilion 34.0 61.7 59.2 Average pvt. utilization 38.4 47.3 [unk.] Public Facilities Broward General 94.0 88.9 86.3 Imperial Point 91.0 92.7 92.4 Memorial 91.8 91.7 94.8 Average pub. utilization 92.3 91.1 91.2 Average of all 7 21. On May 9, 1986, the 62.3 Florida 66.0 Psychiatric [unk.] Center, d/b/a The Retreat, was issued a certificate of need to construct a 100-bed facility in Broward County consisting of 80 short term psychiatric beds and 20 short term substance abuse beds. The 80 psychiatric beds were divided into 40 geriatric beds, 15 adolescent beds, and 25 adult beds. The Retreat began operation in late September of 1988. By mid-March of 1989, the Retreat was requesting that HRS grant it a modification of its certificate of need to reduce the number of geriatric beds from 40 to 24 and to redesignate the remaining 16 beds for short term psychiatric services for children under the age of 12. The Retreat's request to reduce the number of geriatric beds appears to have been motivated in large part by the fact that the occupancy rate for those beds from October 1988 through March 1989 never exceeded one percent, even though the Retreat's pro forma had projected 70 percent occupancy after six months of operation. During the same six-month period in which the Retreat achieved only one percent occupancy in its geriatric psychiatric unit, it achieved occupancy rates of 77 percent in its adolescent unit and 86 percent in its adult unit. The Retreat is a private facility. For some elderly psychiatric patients it is advantageous to provide in-patient psychiatric care in an acute care facility rather than in a free- standing facility. This is because many geriatric patients have a variety of, or multiple levels of, health care needs. An acute care facility that offers psychiatric services can take higher acute types of psychiatric patients because it has the resources, support, and back-up should a patient become medically unstable. In this regard, geriatric psychiatric patients often do not have a pure psychiatric illness. Rather, their psychiatric condition is often accompanied by a medical condition requiring medical coverage. These considerations are addressed in HRS' need determination rule. North/South Division HRS recognizes that there tends to be a north/south division in Broward County with respect to the delivery of acute care health services. In this regard, HRS acknowledges that individuals in South Broward County who are in need of acute care services will generally not travel to acute care hospitals located in north Broward County and vice versa. Broward County has been divided into two political taxing subdivisions, the North Broward Hospital District and the South Broward Hospital District, for purposes of providing tax revenues for the provision of health care services to the indigent. Memorial is the only district hospital located in the South Broward Hospital District. Memorial has a rule requiring physicians on staff at Memorial to both reside within the boundaries of the South Broward Hospital District and to have their offices located within said district. As a general rule, psychiatric patients residing south of State Road 84 tend to stay in southern Broward County for purposes of obtaining psychiatric services and psychiatric patients residing north of that line tend to stay in northern Broward County for purposes of obtaining psychiatric services. This appears to be due in large part to the fact that psychiatrists tend to obtain staff privileges and practice only at hospitals in southern Broward County or northern Broward County, but not both. If a physician is not on the staff of a facility, he or she cannot admit a patient to that facility. Therefore, the numerous psychiatrists who reside in southern Broward County and who are only on the staff of facilities located in southern Broward County generally cannot admit their patients to facilities located in northern Broward County. Unavailability of beds at Memorial and Hollywood Pavilion South of State Road 84 there are three available alternatives for inpatient psychiatric care for the elderly residents of southern Broward County; The Retreat, Hollywood Pavilion, and the 74-bed short term psychiatric unit at Memorial Hospital. Hollywood Pavilion and Memorial Hospital accept geriatric psychiatric patients, but neither has a designated geri-psychiatric unit. The Retreat started operations with a 40- bed geri-psychiatric unit, which has since been reduced to a 24- bed unit. The 74 psychiatric beds at Memorial are, for all practical purposes, operating at full capacity. Memorial has maintained waiting lists for its psychiatric unit for the last seven or eight years and the number of people on the waiting lists has been increasing. The 46 psychiatric beds at Hollywood Pavilion, which is located across the street from Memorial, have recently been operating at about sixty percent of capacity. It is often clinically desirable to treat geriatric psychiatric patients on a different unit from younger psychiatric patients. This consideration is reflected in the fact that The Retreat was originally approved for three distinct units, adolescent, adult, and geriatric, and has more recently been permitted to redesignate a unit of beds for short term psychiatric services for children under the age of 12. The 24- bed geriatric psychiatric unit at The Retreat has recently been operating at about two percent of capacity. Findings Regarding Section 381.705(1)(d), F.S. Section 381.705(1)(d), Florida Statutes, requires consideration of the availability and adequacy of other health care services such as outpatient care and ambulatory or home care services which may serve as alternatives for the services proposed by the applicant. On this issue, there was no real dispute that outpatient care and ambulatory or home care services were not viable alternatives for persons in need of short term inpatient psychiatric services. Findings regarding Section 381.705(1)(i), F.S. As noted above, HRS stipulated that if HMC's project was approved and met the occupancy projections contained in its application it would be financially feasible. The financial break-even point for the 30 psychiatric beds proposed by HMC is an average daily census of only 9 patients, which would constitute 30 percent occupancy. The psychiatric unit at HMC would be managed by a professional psychiatric management company, Psychiatric Management Services. Psychiatric Management Services is a company that specializes in the management of psychiatric units in acute care hospitals. It has already developed psychiatric programs for geriatric patients that would be utilized at HMC. In addition, Psychiatric Management Services has a large variety of programs, services and specialists available to assist HMC in establishing the proposed unit. Through Psychiatric Management Services, the proposed unit will have access to a wide variety of services, including but not limited to, marketing, community liaison development, sophisticated policies and procedures manuals, accreditation services, licensure, staffing and community education seminars. Approval of HMC's application would also give HMC an opportunity to attempt to broaden its base of business and thereby possibly increase the overall profitability of the hospital. This would, if successful, help relieve the cost pressures from the acute care side of the hospital and potentially lower future increases in acute care patient charges. Moreover, by expanding the services offered at HMC, approval of HMC's applications would allow HMC to compete more effectively for health maintenance organizations (HMOs) and preferred provider organizations (PPOs) agreements. Currently, HMC is precluded from competing for some HMOs and PPOs such as SIGNA and Health Options because HMC does not offer a full array of services. Approval of HMC's application would also have the effect of adding 30 more beds to the existing pool of under- utilized short term psychiatric beds in Broward County. Findings regarding Section 381.705(1)(n), F.S. In its application, HMC projects a higher Medicaid utilization rate in its psychiatric unit than for its hospital overall because Medicaid services can only be provided to psychiatric patients in an acute care hospital setting and the psychiatric beds at Memorial, the only acute care facility in South Broward County presently authorized to provide psychiatric services, are full. In this regard, HMC has a Medicaid contract with the State of Florida. It is reasonable to anticipate that HMC would encourage Medicaid business at its facility and achieve the Medicaid projection contained in its application because HMC receives more from the State of Florida under its Medicaid contract than it would from an HMO or PPO. It is HMC's policy to treat all patients, regardless of their ability to pay. If HMC's application is approved, this policy would apply to psychiatric patients admitted to the hospital. During the first six months of 1988, 2.2 percent of HMC's patient days were provided to indigents. HMC currently averages 60 to 70 percent Medicare utilization. For its proposed geri-psychiatric unit, HMC projects 70 percent Medicare utilization. Given that the proposed unit would be geared toward the elderly, it is reasonable to project that 70 percent of HMC's geri-psychiatric utilization would be Medicare patients, regardless of what the total utilization rate might be. Findings regarding Section 381.705(2)(a), F.S. The design of HMC's proposed geri-psychiatric unit conforms to the requirements contained in Chapter 10D-28, Florida Administrative Code. As noted above, HRS stipulated that the costs and proposed methods of construction are reasonable. The psychiatric unit at HMC would occupy existing space on the sixth floor of the hospital. The renovations can be made quickly and at substantially less expense than the cost of new construction. Nevertheless, a less costly, more efficient, and more appropriate alternative would be to make greater use of existing under- utilized short term psychiatric beds in Broward County, particularly the beds in the privately owned facilities, which are Florida Medical Center, CPC Ft. Lauderdale, Coral Ridge, Hollywood Pavilion, and the Retreat. Findings regarding Section 381.705(2)(b), F.S. To the extent the three publicly owned providers of short term psychiatric services are being operated at or near their optimal capacity, they are being used in an appropriate and efficient manner. To the extent some of such facilities, like Memorial Hospital, appear to be operating above their optimal capacity, some inefficiencies necessarily result. Similarly, inefficiencies necessarily result from the substantial under- utilization of beds in privately owned short term psychiatric units. Approval of a new psychiatric unit at an existing acute care hospital in southern Broward County might help alleviate the waiting list and over crowding at Memorial, but it would do so at the expense of adding to the inefficiencies that result from current under-utilization of other existing facilities. Further, in light of recent utilization trends in Broward County, if short term psychiatric beds were to be added in Broward County, it would appear to be more appropriate to add them at publicly owned facilities. Findings regarding Rule 1O-5.O11(1)(o)3 and 4, F.A.C. Rule 10-5.011(1)(o), Florida Administrative Code, provides that a CON application for short term psychiatric beds will "not normally" be approved unless need is indicated in accordance with the mathematical need formula contained in the short term psychiatric rule. That rule allocates .35 beds per 1,000 population based on a five-year planning horizon. Since the application was submitted in 1988, the five-year planning horizon requires that HMC's application be reviewed against the need projected for 1993. The parties agreed that the numerical bed need methodology projects a gross bed need for 458 short term psychiatric beds in Broward County in 1993. However, the parties disagreed on the inventory of beds that should be subtracted from this figure. The inventory of 507 existing and approved short term psychiatric beds relied upon by HRS includes the 74 beds at Coral Ridge Hospital. The beds at Coral Ridge are licensed as short term psychiatric beds. The average length of stay of psychiatric patients at Coral Ridge has usually been in excess of 30 days, but substantially less than 90 days. The average length of stay at Coral Ridge does not appear to result from treatment of adolescent patients. Subpart 4a of Rule 10-5.011(1)(o) provides that a minimum of .15 beds per 1,000 population shall be in hospitals holding a general license and Subpart 4b provides that .20 beds per thousand may be in specialty hospitals. The .15 standard is currently met in Broward County. The short term psychiatric rule requires applicants to be able to project occupancy rates of 70 percent for adults in the second year of operation and 80 percent for adults by the third year of operation. In light of the utilization rates of existing privately owned providers of short term psychiatric services, and especially in light of the most recent utilization rates in the geriatric psychiatric unit at The Retreat, it is unlikely that HMC would achieve these occupancy rates. The short term psychiatric bed need rule also considers the occupancy of existing psychiatric beds. In this regard, HRS agreed that a 70 percent occupancy figure was the appropriate figure to be applied in this case. As noted in paragraph 20 of these findings of fact, during the twelve-month period prior to submission of HMC's application, the average occupancy of short term psychiatric beds in Broward County was only 66 percent. Subpart 4g of Rule 10-5.011(1)(o) provides that short term inpatient psychiatric hospital based services should have at least 15 designated beds. By proposing to convert 30 beds, HMC's application meets this criterion of the Rule. Findings regarding Rule 1O-5.O11(1)(o), F.A.C. Regarding Subpart 5e of Rule 10-5.011(1)(o), Florida Administrative Code, an important component of the proposed psychiatric unit would be the community education and outreach services described in HMC's application. These services, which would be provided at no cost to local residents, are representative of HMC's commitment to developing a cooperative relationship with existing providers. As an existing hospital, HMC has already established linkages with numerous health care providers. If its application were to be approved, HMC would expand its existing network to include community mental health centers and other local providers of mental health services.
Recommendation For all of the foregoing reasons, it is RECOMMENDED: That the application by NME Hospitals, Inc., d/b/a Hollywood Medical Center, to convert 30 medical-surgical beds to 30 short term psychiatric beds be DENIED. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd day of November 1989. MICHAEL M. PARRISH Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Divisions of Administrative Hearings this 22nd day of November 1989. APPENDIX TO RECOMMENDED ORDER IN CASE NO. 89-1369 The following are my specific rulings on all findings of fact proposed by both parties. Findings proposed by Petitioner: Paragraphs 1 and 2: Accepted. Paragraph 3: Rejected as not supported by persuasive competent substantial evidence and as, in any event, unnecessary. Paragraphs 4, 5, 6, 7, 8, 9 and 10: Accepted. Paragraphs 11 and 12: Accepted in substance. Paragraphs 13, 14, and 15: Accepted. Paragraph 16: Rejected as unnecessary and as not fully consistent with the greater weight of the evidence. Paragraphs 17 and 18: Accepted. Paragraph 19: First sentence accepted. Last sentence rejected as constituting argument rather than findings of fact. Paragraph 20: Rejected as constituting a proposed conclusion of law rather than a proposed finding of fact. Paragraphs 21, 22, and 23: Accepted in substance. Paragraph 24: Rejected as not supported by persuasive competent substantial evidence. Although there is expert witness testimony in the record to the effect proposed in paragraph 24, I do not find that testimony to be persuasive. Specifically, I am not persuaded that the relationship between a patient and the patient's regular medical doctor is more severely impacted in a freestanding psychiatric facility than in a psychiatric facility located in an acute care facility. There are advantages and disadvantages to both types of psychiatric facilities. Paragraph 25: Rejected as repetitious. Paragraph 26: Rejected as subordinate and unnecessary details. Also, see comments above regarding paragraph 24. Paragraph 27: Rejected as constituting argument or proposed conclusions of law, rather than proposed findings of fact. Paragraph 28: Accepted. Paragraph 29: Rejected as constituting subordinate and unnecessary details. Paragraph 30: Accepted. Paragraph 31: First sentence rejected as constituting a broader statement than is supported by the competent substantial evidence. The remainder of this paragraph is accepted in substance. Paragraphs 32 and 33: Rejected as constituting subordinate and unnecessary details. Paragraph 34: Accepted. Paragraph 35: Rejected as irrelevant and as based on unpersuasive evidence. Although there is testimony to the effect that the considerations recited are significant considerations, it appears from the totality of the evidence that considerations of treating physician convenience (or efficiency) and where the treating physician has admitting privileges, are the primary determinants of patient placement. Paragraph 36: Rejected because this is a conclusion that does not necessarily follow from the evidence. [See Transcript, page 263, lines 5 to 10.] Paragraph 37: Rejected as not supported by persuasive competent substantial evidence. Although the record does contain opinion testimony to the general effect proposed here, the scope of that opinion testimony is more narrow than the fact proposed in paragraph 37. The testimony would support a finding that the Retreat is inconveniently located for some South Broward psychiatrists. Paragraph 38: First sentence rejected as not supported by persuasive competent substantial evidence. Second sentence rejected as contrary to the greater weight of the evidence. Paragraph 39: Accepted in substance. Paragraph 40: All but last sentence accepted in substance. Last sentence rejected as subordinate and unnecessary details. Paragraph 41: Rejected as quotation of testimony rather than proposed finding of fact. Also rejected as subordinate and unnecessary details. Paragraphs 42, 43 and 44: Rejected as subordinate and unnecessary details. Paragraph 45: First two sentences accepted. The remainder of this paragraph is rejected as not supported by competent substantial evidence. Although statements in the transcript, in depositions, and in affidavits contain opinions that Hollywood Pavilion offers quality of care that is "unacceptable" or "substandard," none of those opinions includes any factual basis for the opinion. (Ironically, the record contains more information about shortcomings in the psychiatric unit at Memorial Hospital; the unit with the highest occupancy rate and, therefore, presumably the most popular.) Paragraph 46: Rejected as not supported by persuasive competent substantial evidence. See comments above regarding paragraph 45. Paragraphs 47, 48, 49, 50, 51 and 52: Rejected as subordinate and unnecessary details. Paragraphs 53 and 54: Accepted. Paragraph 55: Rejected as irrelevant and unnecessary details, not all of which are fully supported by the evidence. For example, while the last sentence of paragraph 55 is sometimes true, it is not always true because if it were always true there would be precious little need for free standing psychiatric facilities. Paragraphs 56 and 57: Accepted. Paragraph 58: Accepted in substance with many subordinate and unnecessary details omitted. Paragraph 59: All but last sentence accepted. Last sentence rejected as contrary to the greater weight of the evidence. Paragraph 60: First sentence rejected as subordinate and unnecessary. Remainder of paragraph rejected as contrary to the greater weight of the evidence. Paragraph 61: Rejected as irrelevant and as not supported by persuasive competent substantial evidence. The testimony on this subject was too vague and generalized to form a basis for meaningful fact finding relevant to any issue in this case. Paragraphs 62 and 63: Accepted in substance. Paragraph 64: Rejected as contrary to the greater weight of the evidence. Paragraphs 65, 66, 67 and 68: Accepted. Paragraph 69: Accepted in substance. Paragraph 70: First two sentences accepted in substance. Last two sentences rejected as irrelevant as well as subordinate and unnecessary details. Paragraph 71: Rejected as contrary to the greater weight of the evidence. Paragraph 72: First sentence rejected as over broad and, therefore, not supported by competent substantial evidence. Also rejected as containing a conclusion not warranted by the evidence. Paragraph 73: Accepted. Paragraph 74: All but last sentence accepted. Last sentence rejected as constituting incomplete summary of rule definition. Paragraph 75: Accepted in substance. Paragraph 76: Rejected as constituting argument or conclusions of law rather than proposed findings of fact. Paragraph 77: Rejected as contrary to the greater weight of the evidence. Paragraph 78: Rejected as irrelevant in view of conclusion that the beds at Coral Ridge should be included in the inventory. Paragraph 79: Rejected as contrary to the greater weight of the evidence. Second sentence also rejected as constituting argument, rather than proposed findings of fact. Paragraph 80: Rejected as irrelevant, except for proposed findings regarding occupancy at The Retreat. Paragraph 81: Accepted. Paragraph 82: First sentence accepted. Last sentence rejected as contrary to the greater weight of the evidence. Paragraph 83: First two sentences accepted. Last sentence rejected as irrelevant because there is no demonstrated reason to exclude Coral Ridge. Paragraph 84: Accepted in substance. Paragraph 85: Rejected as not supported by competent substantial evidence. Paragraph 86: Rejected as contrary to the greater weight of the evidence. Paragraph 87: Accepted. Paragraph 88: Rejected as repetitious. Further, last sentence is not fully consistent with the greater weight of the evidence. Paragraphs 89 and 90: Accepted. Paragraph 91: Rejected as constituting a conclusion of law rather than a proposed finding of fact. Paragraphs 92 and 93: Rejected as constituting argument about the sufficiency of the evidence, rather than proposed findings of fact. Findings proposed by Respondent: Paragraphs 1, 2 and 3: Rejected as constituting subordinate procedural details which have been addressed in the Preliminary Statement. Paragraph 4: First two sentences accepted. The remainder is rejected as subordinate and unnecessary details. Paragraph 5: Rejected as constituting subordinate and unnecessary details or constituting argument and proposed conclusions of law. Paragraph 6: Rejected as constituting primarily argument and proposed ultimate conclusions rather than proposed findings of fact. Paragraph 7: First two lines of first sentence accepted. Remainder of first sentence rejected as argument. Second sentence rejected as irrelevant in view of HRS agreement that 70 percent occupancy was the appropriate standard. Third sentence accepted. Fourth sentence rejected as irrelevant. Fifth and sixth sentences rejected as argument. Paragraph 8: First and last sentences rejected as argument. Remainder rejected as subordinate and unnecessary details. Paragraph 9: First two sentences rejected as argument. Third and fourth sentences rejected as subordinate and unnecessary. Fifth and sixth sentences rejected as argument and comment on the testimony. Seventh, eight, and ninth sentences rejected as subordinate and unnecessary. Tenth sentence accepted in substance. Eleventh and twelfth sentences rejected as commentary on the evidence. Last sentence rejected as argument or ultimate conclusion. Paragraphs 10 and 11: Rejected as constituting primarily argument rather than proposed findings of fact. Paragraph 12: Rejected as constituting conclusion of law rather than proposed findings of fact. Paragraph 13 and the unnumbered paragraph following paragraph 13: Rejected as constituting discussion of the issues rather than proposed findings of fact. Paragraph 14: First two sentences rejected as discussion of issues, rather than proposed findings of fact. The remainder of this paragraph is accepted in substance, but with many unnecessary details omitted. Paragraph 15 and the unnumbered paragraph following paragraph 15: Rejected as constituting discussion of the issues, rather than proposed findings of fact. Paragraph 16 and 17: Accepted in substance with many unnecessary details omitted. Paragraph 18: First two sentences accepted in substance. The remainder of this paragraph is rejected as constituting discussion of issues or conclusions of law. Paragraph 19: Accepted in substance with many unnecessary details omitted. Paragraph 20: Rejected as constituting an amalgamation of conclusions of law, discussions of the issues, and argument. COPIES FURNISHED: C. Gary Williams, Esquire Stephen C. Emmanuel, Esquire Ausley, McMullen, McGehee, Carothers & Proctor 227 South Calhoun Street Post Office Box 391 Tallahassee, Florida 32302 Deanna Eftoda Department of Health and Rehabilitative Services 2727 Mahan Drive Suite 103 Fort Knox Executive Center Tallahassee, Florida 32308 Sam Power, Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Gregory L. Coler, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 John Miller General Counsel Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700
The Issue The issue for determination in this case is whether Respondent’s application of a fair rental value system of property cost reimbursement to Petitioner under the Florida Title XIX Long-Term Care Medicaid Reimbursement Plan is appropriate.
Findings Of Fact Petitioner, CONSULTING MANAGEMENT AND EDUCATION, INC., d/b/a GULF COAST NURSING AND REHABILITATION CENTER (CME), is the licensed operator of a 103-bed nursing home in Clearwater, Florida, which is presently known as GULF COAST NURSING AND REHABILITATION CENTER (GULF COAST). CME participates in the Florida Medicaid Program as an enrolled provider. Respondent, AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA), is the agency of the State of Florida authorized to implement and administer the Florida Medicaid Program, and is the successor agency to the former Department of Health and Rehabilitative Services, pursuant to Chapter 93-129, Laws of Florida. Stipulated Facts Prior to 1993, the GULF COAST nursing home facility was known as COUNTRY PLACE OF CLEARWATER (COUNTRY PLACE), and was owned and operated by the Clearwater Limited Partnership, a limited partnership which is not related to CME. In 1993 CME agreed to purchase, and did in fact purchase, COUNTRY PLACE from the Clearwater Limited Partnership. Simultaneous with the purchase of COUNTRY PLACE, CME entered into a Sale/Leaseback Agreement with LTC Properties, Inc., a Maryland real estate investment trust which engages in the financing of nursing homes. The Purchase and Sale Agreement between Clearwater Limited Partnership and CME was contingent upon the Sale/Leaseback Agreement and the proposed Lease between CME and LTC Properties, Inc. On September 1, 1993, CME simultaneously as a part of the same transaction purchased COUNTRY PLACE, conveyed the facility to LTC Properties, Inc., and leased the facility back from LTC Properties, Inc. As required, CME had notified AHCA of the proposed transaction. AHCA determined that the transaction included a change of ownership and, by lease, a change of provider. CME complied with AHCA's requirements and became the licensed operator and Medicaid provider for COUNTRY PLACE. Thereafter, CME changed the name of the facility to GULF COAST. After CME acquired the facility and became the licensed operator and Medicaid provider, AHCA continued to reimburse CME the same per diem reimbursement which had been paid to the previous provider (plus certain inflation factors) until CME filed its initial cost report, as required for new rate setting. In the normal course of business, CME in 1995 filed its initial Medicaid cost report after an initial period of actual operation by CME. Upon review of the cost report, AHCA contended that the cost report was inaccurate and engaged in certain "cost settlement" adjustments. During this review, AHCA took the position that CME's property reimbursement should be based on FRVS methodologies rather than "cost" due to the lease. In November of 1995, CME received from AHCA various documents which recalculated all components of Petitioner's Medicaid reimbursement rates for all periods subsequent to CME's acquisition of the facility. In effect, AHCA placed CME on FRVS property reimbursement. The practical effect of AHCA's action was to reduce CME's property reimbursement both retroactively and prospectively. The retroactive application would result in a liability of CME to AHCA, due to a claimed overpayment by AHCA. The prospective application would (and has) resulted in a reduction of revenues. CME is substantially affected by AHCA's proposed action and by Sections I.B., III.G.2.d.(1), V.E.1.h., and V.E.4. of the Florida Medicaid Plan. Additional Findings of Fact The Florida Medicaid Plan establishes methodologies for reimbursement of a nursing home's operating costs and patient care costs, as well as property costs. The dispute in this matter relates only to reimbursement of property costs. CME as the operator of the GULF COAST nursing home facility is entitled to reimbursement of property costs in accordance with the Florida Medicaid Plan. CME as the operator of the GULF COAST facility entered into a Florida Medicaid Program Provider Agreement, agreeing to abide by the provisions of the Florida Medicaid Plan. The Sale/Leaseback Agreement entered into by CME and LTC Properties Inc. (LTC) specifically provides for a distinct sale of the nursing home facility to LTC. LTC holds record fee title to GULF COAST. LTC, a Maryland corporation, is not related to CME, a Colorado corporation. The Florida Medicaid Plan is intended to provide reimbursement for reasonable costs incurred by economically and efficiently operated facilities. The Florida Medicaid Plan pays a single per diem rate for all levels of nursing care. After a nursing home facility's first year of operation, a cost settling process is conducted with AHCA which results in a final cost report. The final cost report serves as a baseline for reimbursement over the following years. Subsequent to the first year of operation, a facility files its cost report annually. AHCA normally adjusts a facility's reimbursement rate twice a year based upon the factors provided for in the Florida Medicaid Plan. The rate-setting process takes a provider through Section II of the Plan relating to cost finding and audits resulting in cost adjustments. CME submitted the appropriate cost reports after its first year of operation of the GULF COAST facility. Section III of the Florida Medicaid Plan specifies the areas of allowable costs. Under the Allowable Costs Section III.G.2.d.(1) in the Florida Title XIX Plan, a facility with a lease executed on or after October 1, 1985, shall be reimbursed for lease costs and other property costs under the Fair Rental Value System (FRVS). AHCA has treated all leases the same under FRVS since that time. AHCA does not distinguish between types of leases under the FRVS method. The method for the FRVS calculation is provided in Section V.E.1.a-g of the Florida Medicaid Plan. A “hold harmless” exception to application of the FRVS method is provided for at Section V.E.1.h of the Florida Medicaid Plan, and Section V.E.4 of the Plan provides that new owners shall receive the prior owner’s cost-based method when the prior owner was not on FRVS under the hold harmless provision. As a lessee and not the holder of record fee title to the facility, neither of those provisions apply to CME. At the time CME acquired the facility, there was an indication that the Sale/Leaseback transaction with LTC was between related parties, so that until the 1995 cost settlement, CME was receiving the prior owner’s cost-based property method of reimbursement. When AHCA determined that the Sale/Leaseback transaction between CME and LTC was not between related parties, AHCA set CME’s property reimbursement component under FRVS as a lessee. Property reimbursement based on the FRVS methodology does not depend on actual period property costs. Under the FRVS methodology, all leases after October 1985 are treated the same. For purposes of reimbursement, AHCA does not recognize any distinction between various types of leases. For accounting reporting purposes, the Sale/Leaseback transaction between CME and LTD is treated as a capital lease, or “virtual purchase” of the facility. This accounting treatment, however, is limited to a reporting function, with the underlying theory being merely that of providing a financing mechanism. Record fee ownership remains with LTC. CME, as the lease holder, may not encumber title. The Florida Medicaid Plan does not distinguish between a sale/leaseback transaction and other types of lease arrangements. Sections IV.D., V.E.1.h., and V.E.4., the “hold harmless” and “change of ownership” provisions which allow a new owner to receive the prior owner’s method of reimbursement if FRVS would produce a loss for the new owner, are limited within the Plan’s organizational context, and within the context of the Plan, to owner/operators of facilities, and grandfathered lessee/operators. These provisions do not apply to leases executed after October 1, 1985. Capital leases are an accounting construct for reporting purposes, which is inapplicable when the Florida Medicaid Plan specifically addresses this issue. The Florida Medicaid Plan specifically addresses the treatment of leases entered into after October 1985 and provides that reimbursement will be made pursuant to the FRVS method.
The Issue Whether Petitioner's Medicaid provider number should be cancelled for the reason stated in Respondent's October 1, 1995, letter to Petitioner?
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Petitioner is a provider of community mental health services. It provides these services to residents of Palm Beach County and the surrounding areas. Some of the services it provides are unique to the area it serves. Petitioner provides services to Medicaid recipients pursuant to a Medicaid provider agreement dated September 6, 1994, paragraphs 8 and 9 of which provide as follows: The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. The agreement may be terminated upon thirty days written notice by either party. The Depart- ment may terminate this agreement in accordance with Chapter 120, Florida Statutes. Petitioner has attempted to enter into a contract with the Department of Health and Rehabilitative Services' Alcohol, Drug Abuse and Mental Health office (hereinafter referred to as "ADM"), but to date has been unable to do so because ADM has not had the money to fund such a contract.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered terminating Petitioner's provider agreement and cancelling its provider number on the grounds that it "does not have a contract with the [Department of Health and Rehabilitative Services] ADM [Alcohol, Drug Abuse and Mental Health] office." DONE and ENTERED this 26th day of February, 1996, at Tallahassee, Leon County, Florida. STUART M. LERNER, Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 SC 278-9675 Filed with the Clerk of the Division of Administrative Hearings this 26th day of February, 1996. COPIES FURNISHED: Darlene Silvernail, Esquire Forest Hill Counseling Center 2624 Forest Hill Boulevard West Palm Beach, Florida 33406 Gordon B. Scott, Esquire Agency for Health Care Administration 2727 Mahan Drive, Fort Knox Number 3 Tallahassee, Florida 32308-5403 Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Fort Knox Number 3 Tallahassee, Florida 32308-5403 Sam Power, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Fort Knox Number 3 Tallahassee, Florida 32308-5403
The Issue Whether Respondent, Department of Financial Services, Division of Workers’ Compensation, Medical Services (the Department), correctly determined the amount of reimbursement Petitioner, Zenith Insurance Company (Zenith), owes to Lawnwood Regional Medical Center (Lawnwood) for medical services, pursuant to section 440.13(7), Florida Statutes (2018).1/ More specifically, the issues raised in this case are: whether Zenith properly adjusted or disallowed payment by paying what it believed were “reasonable” charges for the Workers’ Compensation medical services provided; whether the Department’s consideration of a “Stop-Loss” percentage-based methodology, as opposed to a per diem rate, may serve as a basis for reimbursement; and what, if any, is the additional amount Zenith owes to Lawnwood for reimbursement in this case.
Findings Of Fact Parties and Participants The Department is the state agency responsible for administration of the Florida’s Workers’ Compensation process set forth in chapter 440. As such, it has exclusive jurisdiction to decide any matters concerning reimbursement for medical services under this process. See § 440.13, Fla. Stat. Zenith is a carrier as defined by section 440.13(1)(c). Lawnwood, a non-party, is a health care facility as defined by section 440.13(1)(g). Lawnwood is part of a network known as East Florida Division, Inc. (East Florida), a division of HCA Inc. Parallon, a non-party, manages the billing, revenue cycle management, and reimbursement dispute process for certain hospitals, including Lawnwood. (Jt. Stip. Facts, ¶¶ 33 and 34). Parallon filed the Petition for Resolution of Reimbursement Dispute in this case on behalf of Lawnwood. Coventry Health Care Workers Compensation, Inc., and/or Coventry Life and Health Insurance Company on behalf of First Health Group Corp. (Coventry), serves as a “middleman” between insurance carriers and health care providers. As explained by Carol Brodie, Coventry offers carriers, such as Zenith, access to special rates it has negotiated with health care facilities and providers. Essentially, Zenith is a third-party beneficiary of the rates negotiated between East Florida and Coventry. Medical Services at Issue Lawnwood provided health services to a workers’ compensation patient (patient) from January 21 through 25, 2016. The patient was to be treated for a routine outpatient surgical procedure to release an extensor tendon of his index finger. According to the unrefuted testimony of Linda Joy (a Zenith employee), the surgeon inadvertently cut the patient’s digital nerve, artery, and vein. This resulted in more extensive treatment than originally contemplated. The patient was ultimately admitted to the hospital for inpatient care, and released four days later. Payment Dispute Lawnwood issued a bill to Zenith for $163,697.30 (Lawnwood bill) for the services and treatment it provided to patient. Zenith regularly audits bills it receives from health care providers and makes adjustments if necessary. These adjustments are provided to the health care provider along with the payment in the form of an Explanation of Bill Review (EOBR). The EOBR goes through each itemized line in a bill and explains to the provider what was reduced and why. In this case, Zenith sent the Lawnwood bill to Ms. Joy for review. She reviewed the patient’s relevant medical records, as well as billing documentation, and a coding summary sheet (containing codes for procedures, medications, and other services utilized by the health care and insurance industry) from Lawnwood. Ms. Joy opined the Lawnwood bill was very high for the services provided. Both of the Department’s witnesses also felt the amount billed by Lawnwood was unexpected. Andrew Sabolic (an assistant director at the Department) was surprised at Lawnwood’s bill, stating: “it was an amount that I didn’t anticipate a hospital would charge for those types of services.” Similarly, Lynne Metz (a Department employee) testified: “The charges were high compared to what I would expect.” The Department has not made any determination or review of whether the bills or charges submitted by the hospital are reasonable for the services provided. (Jt. Stip. Fact, ¶ 28). Ms. Joy and other Zenith staff compared the charges and the information on the coding summary sheet with payments of other similar providers through a medical revenue and billing database program, known as “OPTUM 360 Revenue Cycle Program” (OPTUM360). In making the comparison, Zenith also utilized databases and benchmarks that are accepted in the industry, including Medicare, the MediSpan Drug Database, Health Care Blue Book, Health Engine, other state’s workers’ compensation reimbursement formulas, usual and customary charges, and other hospitals’ charges in the same zip code as Lawnwood. Based on the OPTUM360 results and its own analysis, Zenith calculated the total reimbursement amount acceptable to other health care providers under Medicare for the same treatment and services would be $11,173.81. As a result, Zenith issued an EOBR that adjusted the Lawnwood bill and indicated, “THIS BILL HAS BEEN PRICED IN ACCORDANCE WITH THE TERMS OF YOUR CONTRACT WITH COVENTRY NATIONAL.” Along with the EOBR, Zenith provided benchmark data to Lawnwood to support its repricing, editing or adjustment of the bills at issue. (Jt. Stip. Facts, ¶¶ 36 and 37). In the EOBR, Zenith used four explanation codes: “47,” “81,” “92,” and “93,” as authorized by Florida Administrative Code Rule 69L-7.740(13)(a) and (b), to explain why payment was disallowed or adjusted. Code “47” (Payment disallowed: insufficient documentation: invoice or certification not submitted for implant) was used for the disallowance on a line item for an implant. Id. The parties agree that was appropriate. Code “81” (Payment adjusted: billing errors: payment modified pursuant to charge audit) was used for the line items other than the disallowed implant charge, based on Zenith’s review of the entire bill, line by line, and resulting adjustment. Id. Code “92” (Paid: no modification to information provided on the medical bill: payment made pursuant to workers’ compensation reimbursement manual for hospitals) was used because it is generally on all hospital bills. Id. Code “93” (Paid: no modification to information provided on the medical bill: payment made pursuant to written contractual arrangement) was used because Zenith had a contract with Coventry, and Coventry had an agreement with East Florida and Lawnwood. The Department has not adopted a rule establishing an EOBR code (or similar descriptive explanation) to be used by a carrier when the carrier identifies a bill or charge from a hospital that the carrier deems to be so excessively high so as to be an unreasonable basis for reimbursement under the Florida Worker’s Compensation Law. (Jt. Stip. Fact, ¶ 8). In other words, there is no code in rule 69L-7.740 for disputing a line item as being “unreasonable” or “too high.” Based on the repriced and adjusted bill, Zenith reimbursed Lawnwood $31,844.70 for the medical services provided. (Jt. Stip. Fact, ¶ 40). This amount was approximately three times the OPTUM360 amount of $11,173.81. When asked how Zenith made the decision to give three times the OPTUM360 amount, Ms. Brodie explained: We didn’t take the [OPTUM360] Medicare payment or even 120 or 140 percent of Medicare, which we thought was more than fair. . . . So because Florida -- I don't want to say they're problematic, but Florida bills, we're seeing such an increase in the amount of billed charges and we're seeing a lot of disputes when we don't pay to the penny of what the expected amount is, that we were trying to go above and beyond and try to make our payment more palatable, I guess, to the provider. So we wanted to be more than generous, so we came up with three times Medicare. Catherine Trotter (a Parallon employee) Parallon filed a request for reconsideration of the EOBR with Zenith after Lawnwood had reviewed it and determined $31,844.70 was insufficient. On April 18, 2016, Parallon, on behalf of Lawnwood, filed a Petition for Resolution of Reimbursement dispute with the Department challenging the EOBR and demanding additional payment. Based on Ms. Joy’s testimony, Zenith did not contest the medical necessity of the services provided by Lawnwood, nor was there evidence Zenith claimed overutilization (the appropriateness of the level and quality of health care provided to the patient). Rather, Zenith claimed, and still claims in these proceedings, it did not pay the billed amount because the individual charges were unreasonable. Contract Provisions Zenith and Parallon, on behalf of Lawnwood, agree that a reimbursement contract applies to this dispute. (Jt. Stip. Fact, ¶ 35). The Department also based the Third Determination on the contract provisions. The parties disagree, however, as to what contract provisions apply and how they should be applied. At the hearing, the parties also disputed whether the Department was provided with the applicable contractual provisions during the petition process. The undersigned need not determine who sent what to whom, because this is a de novo proceeding; and what matters is the evidence admitted at the hearing. See 120.57(1)(k), Fla. Stat.; Haines v. Dep’t of Child. & Fams., 983 So. 2d 602, 606 (Fla. 5th DCA 2008). No contract directly between Zenith and Lawnwood was presented at the hearing. The following documents, however, establish the agreement between Coventry and Lawnwood: (1) Amendment to Model Facility Agreement executed January 20, 2015 (MFA Amendment); Appendix A, “Payment Rate” (Appendix A); and Attachment 1, “Participating Facility List (Attachment 1); and (4) Amendment to Model Facility Agreement between Lawnwood and Coventry (also known as First Health), effective October 1, 2006 (Lawnwood Amendment). Parallon’s legal manager testified the MFA Amendment, Appendix A, Attachment 1, and the Lawnwood Amendment were the only contract provisions relevant to the reimbursement determination. These documents set the rates for Coventry (and its network clients such as Zenith), but do not provide definitions or terms that may have been included in the original “Model Facility Agreement.” Nonetheless, the Lawnwood Amendment defines the “Workers’ Compensation Contract Rate” as follows: “the amount payable under the terms of this Contract shall be the lesser of the Contract rate or a 5% discount from the amount payable under hospital guidelines established under any state law or regulations pertaining to health care services rendered to occupationally ill/injured employees.” Therefore, to make a determination of how much is owed, findings must be made as to what is the “Contact rate,” and what is the amount payable under “any state law or regulations” governing workplace injuries (State rate). Relevant to determining the “Contract rate,” Paragraph 3 of the MFA Amendment provides the following under “Rates”: The current rate reflected on Appendix A to the Agreement shall be increased by 3% for inpatient dates of admission and/or outpatient dates of service occurring on and after October 1, 2014. Appendix A contains a table depicting inpatient rates for Lawnwood as “35% Discount from Hospital’s Total Billed Charges.” (emphasis added). Because the services were provided after October 2014, the 35 percent discount reduced by the three percent discount results in Lawnwood’s expected contractual reimbursement rate to be 68 percent of the “Hospital’s Total Billed Charges,” from any of Coventry’s clients, including Zenith. Thus, the applicable Contract rate is 68 percent of the total bill submitted by Lawnwood. Zenith disputes the meaning of “Hospital’s Total Billed Charges” and argues for application of a “reasonableness” standard to this term. In support of this assertion, Zenith offers the following documents which relate to the agreement between Zenith and Coventry: (1) the Workers’ Compensation Network Services Agreement effective November 1, 2008, (Network Agreement); (2) Supplement A to the Network Agreement, titled “Network Access” (Supplement A); and (3) the Sixth Amendment to the Network Agreement executed November 24, 2015 (6th Amendment). The Network Agreement, Supplement A, and 6th Amendment are heavily redacted. Regardless, it is clear these documents classify Zenith as a “client,” who pays Coventry for access to a discounted rate for medical services with a “Contract Provider.” The Contract Provider and Coventry have a separate “provider agreement” setting this discounted rate. Although, the terms “contract rates,” “fee,” and “provider fee schedule,” are all defined in the Network Agreement Coventry has with Zenith, the definitions or explanation of these terms are redacted. Thus, there is no evidence these terms apply to the Lawnwood bill or the rate established between Coventry and Lawnwood. Similarly, Supplement A defines “Bill” but is also redacted. Regardless, based on the inclusion of these sections in the Network Agreement and attachments, Zenith and Coventry knew how to define special terms. If they intended to give a special meaning to the term “Hospital’s Total Billed Charges,” they could have done so. Section 2.2 of the 6th Amendment states, “[Zenith] agrees that the Contract Rate shall be applied to bills received from [Lawnwood] and further agrees that no other rates . . . shall be applied to such bills.” (emphasis added). Again, without any evidence to the contrary, “bills received” applies to the Lawnwood bill. Although Zenith argues the remaining language in section 2.2 allows it to “modify, edit or otherwise dispute any bill,” this modification must be done pursuant to the contract and workers’ compensation laws and regulations. As stated before, the EOBR regulations do not contemplate adjustments to be based on the reasonableness or fairness of prices or charges. More importantly, there is no basis in the contract provisions or state law and regulations allowing Zenith to reimburse Lawnwood in the amount of three times the OPTUM360 amount. As explained in the Conclusions of Law, the undersigned also cannot infer this as a basis for modification of the reimbursement amount. Zenith also cites to section 2.6 of Supplement A to justify its repricing based on the OPTUM360 results and other industry-used benchmark comparison data. That section, titled “Benchmarking Database,” states, “In the event [Zenith] . . . performs a bill review or repricing function on [Lawnwood’s] bills, Zenith shall . . . update at least twice annually and utilize a nationally accepted charge-benchmarking database to determine the proper percentile of charges in the applicable zip code as approved by Coventry and Client.” Granted this section contemplates that benchmark databases can be used by Zenith in repricing bills, but it speaks to the proper percentile of charges, not the reasonableness of the underlying prices or charges. There was no evidence Coventry approved a “proper percentile of charges” as required. The undersigned finds there is no language in the redacted versions of the Network Agreement, Supplement A, or 6th Amendment that changes Zenith’s requirement (as Coventry’s client) to pay the lesser of (1) 68 percent of the “Hospital’s Total Billed Charges” or (2) 5 percent less than the rate provided pursuant to applicable state laws and regulations. Finally, Zenith argues that the definition provided in a Coventry contract with an undisclosed health care provider, titled “Workers’ Compensation Product Addendum,” should be used to determine the meaning of the term “Hospital’s Total Billed Charges.” See Zenith’s PRO, p. 22-23 (“By implication, these are all in the same network and use the same contractual provisions.”). This document (Zenith’s Exhibit 39) provides definitions, if applicable, that could have been helpful in addressing Zenith’s arguments. For example, this document ties the amount owed by a Coventry client to an “allowable amount” and “eligible bill charges.” There is no evidence, however, that Zenith’s Exhibit 39 was executed by Lawnwood (or East Florida), or that the provisions in this document were part of any agreement between Coventry and Lawnwood, or Coventry and Zenith. As such, the undersigned finds it is not applicable to these proceedings. Applying the Contract rate--68 percent of the “Hospital’s Total Billed Charges” indicated in the Network Agreement and attachments--to the Lawnwood bill would require Zenith to provide a total amount of $110,859.24, or an additional amount of $79,014.54. The Workers’ Compensation System The analysis does not stop there. The next step is to determine how much would be owed at “a 5% discount from the amount payable under hospital guidelines established under any state law or regulation pertaining to health care services rendered to occupationally ill/injured employees.” The undersigned finds this provision refers to the laws and regulations under Florida’s workers’ compensation system set forth in chapter 440 and the Department’s rules. In making the determination decisions in this case, the Department used the Florida Workers’ Compensation Reimbursement Manual for Hospitals, 2014 Edition, and incorporated by reference in rule 69L-7.501 (HRM). The HRM generally provides for reimbursement based on either a per diem fee or the amount agreed upon by contract between the carrier and medical services provider. Under the section titled “Reported Charges,” the HRM provides: “charges for hospital inpatient services shall be reimbursed according to the Per Diem Fee Schedule provided in this chapter or according to a mutually agreed upon contract reimbursement agreement between the hospital and the insurer.” HRM at 15. “Per Diem” is defined as “a reimbursement allowance based on a fixed rate per calendar day which is inclusive of all services rather than on a charge by charge basis.” HRM at 35. In certain circumstances when provider bills are in excess of $59,891.34, a per diem rate is not used. Rather, the HRM provides that the reimbursement amount is calculated using a percentage methodology of 75 percent of the billed charges. This “Stop-Loss Reimbursement” is defined as “a reimbursement methodology based on billed charges once reaching a specified amount that is used in place of, and not in addition to, per diem reimbursement for an inpatient admission to an acute care hospital or a trauma center.” HRM at 17 and 35 (emphasis added). As explained below, the Stop-Loss methodology conflicts with section 440.13(12)(a), which specifically provides for establishment of a maximum reimbursement amount (MRA) based on a per diem rate for inpatient hospital care.5/ Applying the State rate--the per diem rate set forth in the HRM--Lawnwood would receive $3,850.33 per day, except for the day of discharge, which equals $11,550.99. HRM at 16. Applying the five percent discount, as set forth in the Lawnwood Amendment, to the $11,550.99 amount, the total amount payable by Zenith to Lawnwood equals $10,973.44. Because the State rate is less than the amount calculated using the Contract rate, the undersigned finds Zenith owed Lawnwood a total reimbursement amount of $10,973.44, which is less than the $31,844.70 already paid by Zenith.
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 dismissing the petition of Lawnwood Regional Medical Center for resolution of a reimbursement dispute. DONE AND ENTERED this 8th day of May, 2019, in Tallahassee, Leon County, Florida. S HETAL DESAI 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 8th day of May, 2019.
