The Issue The issue is whether petitioners' request to terminate, without penalty, their participation in the state group health insurance plan should be granted.
Findings Of Fact Based upon all of the evidence, the following findings of fact are determined: Petitioners, Terri K. Cassano (Cassano) and Edward M. McDonald (McDonald), are employees of the Office of State Attorney, Tenth Judicial Circuit, in Bartow, Florida. As such, they are eligible to participate in the State Group Health Insurance Program (program) administered by respondent, Department of Administration, Division of State Employees' Insurance (Division). At issue in this case is approximately $1,500 paid by petitioners and their employer for health insurance coverage under the program during the period October through December 1989. Effective July 1, 1989 the State of Florida implemented the first phase of a two-phase Flexible Benefits Plan (plan) which allowed, among other things, for employees who participate in the program to make their required monthly insurance premium contribution through a salary reduction agreement which has the effect of reducing the employee's taxable income by the amount of such contribution. Although not made clear in the record, it may be inferred that the plan is embodied in Chapters 22FB-1, 2 and 3, Florida Administrative Code (1987), which rules became effective on August 3, 1989. In federal bureaucratic parlance, the plan is known as a ``cafeteria'' plan /1 and was implemented after approval was obtained from the Internal Revenue Service (IRS). All state employees were automatically enrolled in the plan unless they signed a waiver form. Cassano and McDonald chose to participate in the plan, and they acknowledge that they received a Division brochure describing the plan prior to their enrollment. Under the rules of the plan, a participant was required to remain in the plan for the entire plan year, which in this case ended on November 30, 1989, unless a so-called "qualifying status change" occurred. Rule 22BF-1.008(13) cites a number of events as constituting a "qualifying status change". However, the event defined in subparagraph (13)(b) as a "change in a participant's health insurance coverage resulting in cessation of coverage" is the event upon which petitioners rely. The manner in which that rule should be interpreted is the source of controversy in this proceeding. In July 1989 petitioners were utilizing as their health insurer Health Alliance Plan (HAP), a health maintenance organization (HMO) serving Polk County. HAP was designated as a qualifying HMO under the program. In late July petitioners learned that HAP would cease doing business in Polk County effective September 30, 1989. Because of this, it was necessary that they consider other insurance alternatives to replace their existing coverage. After considering enrollment in Blue Cross Blue Shield (BCBS), which was the only other health alternative offered by the Division,/2 Cassano decided to enroll as a dependent in her husband's health insurance program because of the lower monthly premiums and she would not have to meet a new deductible as she would with BCBS. As for McDonald, who is also a military retiree, he considered BCBS but opted instead for Medicare because he was being treated for an existing ailment and his physicians were not listed as primary providers with BCBS. Consequently, it would cost him approximately $200 per visit with those doctors if he elected to use BCBS. Under these circumstances, petitioners' health coverage under the program ended since their HMO was no longer in business and their only other option, BCBS, would result in petitioners paying significantly higher costs. Cassano was able to immediately obtain coverage with her husband's health plan effective on July 28, 1989 while McDonald's coverage with Medicare became effective on October 1, 1989, the day after his HAP coverage ended. When the Division learned that HAP was ceasing doing business in Polk County, it mailed to petitioners a "health care provider selection form" which offered them a special enrollment period from August 15 through 31, 1989. The form offered the choice of enrolling in HOPC, BCBS or to cancel their health insurance coverage. However, respondent contends that even though the form offered petitioners the option of cancelling their insurance, it did not apply and that petitioners' only choice was to transfer coverage to one of the two remaining state insurers. The form also noted that if petitioners had any questions they should contact their personnel office or the Division by telephone. Although their personnel office later informed them that respondent might not agree they could do so, Cassano and McDonald executed the form on August 23 and 28, 1989, respectively, and elected to cancel their coverage. They also executed a "qualifying status change form" so that they could cease participation in the plan even though the plan year did not end until November 30, 1989. In so doing, they noted on the form that the qualifying status change event was "cessation of coverage by Health Alliance Plan" and relied in part upon a Division document sent to them which outlined the plan and listed a qualifying status change event as being a "change in participant's health coverage: resulting in cessation of coverage". That same document noted that in order to prove that such an event had occurred, the employee had to furnish a "letter from carrier stating that coverage has ceased due to change in insurance plan". In addition, explanatory literature concerning the plan previously disseminated: by the Division reflected that "a cafeteria plan may also allow for revocation of health plan elections of all affected participants in the event coverage is significantly curtailed or completely terminated in connection with a health plan, if the coverage is provided by an independent third party." Thus, petitioners reasonably assumed that a qualifying status change had occurred by virtue of the cessation of coverage by HAP. After informal efforts to resolve the matter were unsuccessful, on September 28, 1989 Cassano and McDonald formally requested by letter the right to discontinue their participation, without penalty, in the state program. Their requests were essentially denied by letters dated October 5, 1989 from the Division director. In the proposed agency action, the Division stated that it would be happy to comply with their requests but "since the premiums you pay for such coverage have been pretaxed for the five month period ending December 1, 1989, we will continue to deduct these premiums through October 1989 payroll pursuant to rule 22FB-2.005 F.A.C." /3 As a consequence, petitioners were involuntarily required to pay for coverage in BCBS during the months of October through December 1989 even though they were enrolled in other health insurance plans, and their employer (the office of state attorney) was forced to make its required contribution. Through testimony of the state benefits administrator, William R. Seaton, it was established that the Division interprets the term "cessation of (insurance) coverage" as the cessation of all health insurance coverage by the state, including BCBS, an event unlikely to ever occur. Indeed, the administrator acknowledged that such an event would not occur unless the state no longer functioned as a viable entity. Because the state offered petitioners the option of enrolling in BCBS, Seaton contended there was no cessation of insurance coverage, even if petitioners' former HMO in Polk County went out of business. Seaton also opined that petitioners' request was prohibited by IRS regulations and, if approved, would subject the Division to a possible fine if audited by IRS. However, he could not identify a regulation that prohibited approval of their request. Further, there is no evidence that the Division has received specific advice from the IRS on the subject or made inquiry as to whether or not petitioners' request is permissible under federal regulations. Petitioners construe the termination of coverage by their HMO to be a qualifying status change since they no longer could be covered by that HMO. Relying on the plain language in the rule and Division explanatory literature, they did not telephone the Division to ascertain whether they could discontinue state coverage since they had no reason to do so. Through a proffer of agency counsel at hearing, it was pointed out that the federal regulation that allegedly prohibits petitioners from obtaining relief is found on page 14,847-6 of the Standard Federal Tax Reports published by Commerce Clearing House and received in evidence as a part of respondent's composite exhibit 1. 4/ It reads as follows: (2) Coverage changes. If the coverage under a health plan provided by an independent, third-party provider is significantly curtailed or ceases during a period of coverage, a cafeteria plan may permit all affected participants to revoke their election of the health plan and, in lieu thereof, to receive on a prospective basis coverage under another health plan with similar coverage.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the requests of Terri K. Cassano and Edward M. McDonald to discontinue participation in the state health program be granted and that appropriate refunds be given to petitioners and their employer. DONE and ORDERED this 9 day of February, 1990 in Tallahassee, Leon County, Florida. DONALD R. ALEXANDER Hearing Officer Division of Administrative Hearings The Desoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 9 day of February, 1990.
Conclusions THIS CAUSE comes before the AGENCY FOR HEALTH CARE ADMINISTRATION (the "Agency"”) concerning co-batched Certificate of Need ("CON") Application Nos. 10069 - 10072 seeking to establish a new hospice program in Orange County, District 7/B. ODYSSEY HEALTHCARE OF COLLIER COUNTY, INC. d/b/a ODYSSEY HEALTHCARE OF CENTRAL FLORIDA (hereinafter “Odyssey Healthcare”) filed CON Application No. 10071 in the Second Batching Cycle of 2009. The application was denied. Thereafter, Odyssey Healthcare timely filed a Petition for Formal Administrative Hearing with respect to its denial. The Petition was Filed August 27, 2010 3:01 PM Division of Administrative Hearings. forwarded by the Agency Clerk to the Division of Administrative Hearing (“DOAH"). On June 8, 2010, Odyssey Healthcare filed its voluntary dismissal of the DOAH Case No. 10-1681CON (Ex. 1). On June 9, 2010, an Order Severing DOAH Case No. 10-1681CON (Ex. 2) and an Order Closing file (Ex. 3) were issued by DOAH as a result of Odyssey Healthcare’s voluntary dismissal. It is therefore ORDERED and ADJUDGED: 1. The voluntary dismissal by Odyssey Healthcare is hereby acknowledged and accepted. 2. CON Application No. 10071 is hereby denied. 3. The above-styled case is hereby closed. DONE and ORDERED this 2) day of August, 2010, in Tallahassee, _y W. ARNOLD, Secretary AGENCY FOR HEALTH CARE ADMINISTRATION Florida. ae eeeneeeeeaeneneneenmmnenneneeennnaaneneieemnenenamemenenneE mat a
Findings Of Fact Based on the evidence and stipulations received at hearing, the Hearing Officer makes the following findings of fact: Marlene Harsh is now, and has been at all times material herein, an employee of the State of Florida enrolled in the State Group Health Insurance Plan with family coverage. The benefits of the Plan and its limitations and exclusions are set forth in a Benefit Document, a copy of which is furnished to the personnel office of every state agency. Subsection VII. L. of the Benefit Document excludes the following services and supplies from the Plan's coverage: Services and supplies provided by a specialty institution or residential facility except as provided in accordance with Subsection II. G. Subsection II. G. provides as follows: Covered Specialty Institution or Residential Facility Services: Eighty percent (80%) of the reasonable charge by a licensed specialty institution or residential facility for covered inpatient rehabilitative services related to alcoholism or drug addiction shall be paid by the Plan, subject to the following: coverage shall only include an insured employee and requires that employee's treatment in such institution be requested by the employing agency and approved by the Department of Administration; payment shall not be made for more than thirty-one (31) inpatient days of treatment during any calendar year; payment for room and board shall be as provided under Paragraph II. A. 1 Enrclled employees are not given their own individual copies of the Benefit Document. Instead, they receive a brochure which summarizes in an easily understood fashion the provisions of the Plan, including the exclusion contained in Subsection VII. L. of the Benefit Document relating to speciality institutions. Harsh received a copy of this brochure prior to incurring the medical expenses at issue in the instant case, but failed to read it and therefore was unaware of its contents. The State of Florida has contracted with Blue Cross/ Blue Shield to administer the Plan. Among Blue Cross/Blue Shield's contractual responsibilities is the issuance of Pre-admission and Hospital Stay Certifications at the request of insured employees seeking elective hospital admission for themselves or their covered dependents. In performing this task, Blue Cross/Blue Shield simply determines the appropriateness of the setting for treatment and, if appropriate, a reasonable length of stay, without making any determination as to whether the costs associated with the stay will be covered by the Plan or will be subject to its limitations and exclusions. Blue Cross/ Blue Shield representatives, acting on instructions given by William Seaton, a State of Florida employee who holds the position of State Benefits Administrator, routinely so advise those requesting Pre-admission and Hospital Stay Certification when they issue the requested Certification. Mary Merkel is Harsh's daughter. In the spring of 1987, Harsh was told by Jennifer Burke, a counselor at the Starting Place, a facility run by the Florida Department of Health and Rehabilitative Services, that Merkel was suffering from depression and was in need of treatment. Following Burke's advice, Harsh sought to have her daughter, who was 15 or 16 years of age at the time, admitted to CPC Fort Lauderdale Hospital, which is a specialty institution. Before doing so, however, Harsh asked Burke, who was a former employee of the Hospital, to find out for her whether the cost of her daughter's hospitalization would be covered by her insurance. Burke agreed to make such an inquiry on Harsh's behalf. She told Harsh that she would speak with someone from the Hospital and have that person contact Harsh. Tim Paquette is the Hospital's admitting coordinator. It is his responsibility to verify that patients seeking admission to the Hospital are covered by insurance. When providing information to Paquette or representatives of other health care providers, insurors typically give a disclaimer that they are not guaranteeing payment by disclosing such information, a practice which was followed in the instant case. See Section 90.406, Florida Statutes. ("Evidence of the routine practice of an organization, whether corroborated or not and regardless of the presence of eyewitnesses, is admissible to prove that the conduct of the organization on a particular occasion was in conformity with the routine practice"). According to the credible testimony of Peg Mitchell, the Hospital's Assistant Business Manager and its records custodian, the Hospital's records reflect that Paquette telephoned Blue Cross/ Blue Shield and was advised that Harsh was insured under the State Group Health Insurance Plan which afforded her 80%/31-day coverage with respect to charges by specialty institutions. The records themselves, however, were not offered into evidence and neither Paqette, the Blue Cross/Blue Shield employee to whom he spoke, nor anyone who overheard their conversation testified at hearing. Harsh subsequently received a telephone call from Paquette's colleague, Steve Barlow. Barlow told Harsh that she was "covered" and that her daughter could be admitted "right away." A "lady" from Blue Cross/Blue Shield also contacted Harsh concerning this matter and, to use the words employed by Harsh, "said it was all right." Harsh's vague account of this conversation was the only evidence adduced at hearing regarding what was said, other than the evidence concerning Blue Cross/ Blue Shield's routine business practices. The latter evidence establishes that Harsh was told, in conformity with this practice, that no determination had been made as to whether her daughter's hospitalization was within the scope of her insurance coverage. See Section 90.406, Florida Statutes. Based on her conversations with Barlow and the "lady" from Blue Cross/Blue Shield, Harsh erroneously believed that her insurance would pay for her daughter's hospitalization at CPC Fort Lauderdale Hospital. She therefore had her daughter admitted to the hospital at 6:30 a.m. on April 2, 1987. The admitting diagnosis was depression. Had Harsh known that her daughter's stay at the hospital would not be covered by her insurance she would not have had her admitted. On April 3, 1987, Blue Cross/ Blue Shield sent Harsh a Pre-admission and Hospital Stay Certification letter which read as follows: Thank you for cooperating with the Preadmission and Hospital Stay Certification component of your health insurance coverage. As you know, this is one mechanism which enables us to work together to monitor health care costs and make available high quality care. It should be noted that Preadmission Certification is only a determination of the appropriateness of the location of service and does not necessarily indicate that coverage is available under your benefit contract, or that payment will be made by Blue Cross and Blue Shield of Florida for the services provided. All services rendered are still subject to the limitations and exclusions stated in your benefit contract. Your physician indicated your admission to the hospital was of an urgent or emergency nature. While Preadmission Certification does not apply to an admission of this type, the HOSPITAL STAY CERTIFICATION component of your benefit package does apply. Based on the medical information obtained on your admission, your stay in the hospital is CERTIFIED FOR 06 DAYS. If your stay should warrant additional days in the hospital, beyond the certified days, your hospital and/or physician will contact Blue Cross and Blue Shield of Florida, and we will review your condition based on medical criteria established by physicians in your community area, for an extension of the approved days. Your physician and hospital have been notified of this certification. However, the certification in this letter is valid only if you are eligible for benefits under your benefit contract on the dates that the services are rendered and maintain such eligibility until such services have been completed. We appreciate your efforts in containing the cost of quality health care. On April 27, 1987, Blue Cross's/ Blue Shield sent Harsh a second Pre- admission and Hospital Stay Certification letter. It read as follows: Thank you for cooperating with the Preadmission and Hospital Stay Certification component of your health insurance benefit coverage. The hospital admission has been CERTIFIED FOR 021 DAYS. While the initial days assigned to your hospital stay may have been less than those noted here your condition warranted additional inpatient days in the hospital. This letter is being sent to you for your records should you have any questions on the Hospital Stay Certification component of your health insurance benefit package. Your physician and hospital have been notified of the total number of days certified for your admission. However, this certification is valid only if you are eligible for benefits under your benefit contract on the days that services are rendered and maintain such eligibility until the services are completed. ALL SERVICES RENDERED ARE STILL SUBJECT TO THE LIMITATIONS AND EXCLUSIONS STATED IN YOUR BENEFIT CONTRACT. We appreciate your efforts in containing the cost of quality health care. Harsh received both of these letters, but did not review them carefully. Had she done so she would have realized, as the letters clearly stated, that Blue Cross/ Blue Shield, was not representing to her that "coverage [was] available under [her] benefit contract or that payment [would) be made by Blue Cross/Blue Shield of Florida for the services provided" her daughter at the Hospital. Harsh made no effort following her receipt of these letters to verify that she had such coverage and that Blue Cross/Blue Shield would therefore pay for the services provided her daughter. Merkel was discharged from CPC Fort Lauderdale Hospital on April 30, 1989. Harsh was billed by the Hospital $9,003.83 for her daughter's stay. She has unsuccessfully sought to have Blue Cross/Blue Shield pay the bill.
Recommendation In view of the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Administration enter a final order denying the instant petition filed by Marlene Harsh. DONE and ENTERED this 18th day of April, 1989 in Tallahassee, Florida. STUART M. LERNER 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 Division of Administrative Hearings this 18th day of April, 1989. COPIES FURNISHED: Robert Orovitz, Esquire 12th Floor One Datran Center 9100 South Dadeland Boulevard Miami, Florida 33156 Stan Danek, Esquire 435 Carlton Building Tallahassee, Florida 32399-1550 Adis Villa, Secretary Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1500 Augustus D. Aikens, Jr., Esquire General Counsel 435 Carlton Building Tallahassee, Florida 32399-1550
Conclusions THE PARTIES resolved all disputed issues and executed a settlement agreement, which is attached and incorporated by reference. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is hereby CLOSED. DONE AND ORDERED on this G05 day of Wark . 2014, in Tallahassee, Florida. : Aa Lhe 7 Agency for Health Care Administration Agency for Health Care Administration v. Gulfside Regional Hospice, Inc. C.1. No.: 13-0812-000; Case No.: 13-1571MPI Final Order Page 1 of 3 Filed March 27, 2014 4:51 PM Division of Administrative Hearings 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: Karl D. Acuff, Esquire 1615 Village Square Boulevard, Suite 2 Tallahassee, Florida 32309-2770 Telephone: (850) 671-2644 Fax: (850) 671-2732 Email: kd_acuff@floridacourts.com (Via Electronic Mail) Tracie L. Hardin, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Mail Station 3 Tallahassee, Florida 32308 (Via Electronic Mail) Agency for Health Care Administration Bureau of Financial Services 2727 Mahan Drive Building 2, Mail Station 14 Tallahassee, Florida 32308 (Via Electronic Mail) Bureau of Health Quality Assurance 2727 Mahan Drive, Mail Stop 9 Tallahassee, Florida 32308 (Via Electronic Mail) Richard Zenuch, Chief Medicaid Program Integrity 2727 Mahan Drive Building 2, Mail Station 6 Tallahassee, Florida 32308 (Via Electronic Mail) Eric W. Miller, Inspector General Medicaid Program Integrity 2727 Mahan Drive Building 3, Mail Station 4 Tallahassee, Florida 32308 (Via Electronic Mail) Division of Administrative Hearings The Desoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (Via Electronic Mail) Agency for Health Care Administration v. Gulfside Regional Hospice, Inc. C.1. No.: 13-0812-000; Case No.: 13-1571MPI CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to ——— the above named addressees by Electronic Mail, or the method designated, on this th day of J tore , 2014. Richard Shoop, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building 43 Tallahassee, Florida 32308-5403 (850) 412-3630 Agency for Health Care Administration v. Gulfside Regional Hospice, Inc. C.1, No.: 13-0812-000; Case No.: 13-1571MPI Final Order Page 3 of 3 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No.: 13-1571MP1 vs. CL. No.: 13-0812-000 Provider No.: 087570800 License No.: 5005096 NPI No.: 1144328881 GULFSIDE REGIONAL HOSPICE, INC., Respondent. / SETTLEMENT AGREEMENT Petitioner, the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, (“AHCA” or “Agency” or “Petitioner), and Respondent, GULFSIDE REGIONAL HOSPICE, INC., (“PROVIDER”), by and through the undersigned, hereby stipulate and agree as follows: 1. The parties enter into this agreement for the purpose of memorializing the resolution to this matter. 2. PROVIDER is a Medicaid provider in the State of Florida, provider number 087570800, and was a provider during the audit period. 3. In its Final Audit Report, dated March 18, 2013, the Agency notified PROVIDER that a review of Medicaid claims performed by Medicaid Program Integrity (“MPI”), Office of the AHCA Inspector General, during the period of January 1, 2008, through December 31, 2011, indicated that certain claims, in whole or in part, were inappropriately paid by Medicaid. The Agency for Health Care Administration v, Gulfside Regional Hospice, Inc. (C.1. No.: 13-0812-000) Settlement Agreement Page 1 of 7 Agency sought repayment of this overpayment, in the amount of forty-four thousand, eight hundred seventy dollars and thirty-five cents ($44,870.35). Additionally, the Agency applied sanctions in accordance with Sections 409.913(15), (16), and (17) Florida Statutes, and Rule 59G-9.070(7)(e) Florida Administrative Code. Specifically, the Agency assessed the following sanctions against PROVIDER: a fine in the amount of eight thousand, nine hundred seventy- four dollars and seven cents ($8,974.07) and costs in the amount of fifty-four dollars and sixteen cents ($54.16). The total amount due was fifty-three thousand, eight hundred ninety-eight dollars and fifty-eight cents ($53,898.58). 4. In response to the audit report dated March 18, 2013, PROVIDER filed a Petition for Formal Administrative Hearing. 5. Subsequent to the original audit that took place in this matter, the Agency agreed to relinquish the fine. The overpayment remains in the amount of forty-four thousand, eight hundred seventy dollars and thirty-five cents ($44,870.35). Additionally, the Agency assessed the following against the PROVIDER: costs in the amount of fifty-four dollars and sixteen cents ($54.16) pursuant to Section 409.913(23)(a), Florida Statutes. The total amount due is forty-four thousand, nine hundred twenty-four dollars and fifty-one cents ($44,924.51). 6. In order to resolve this matter without further administrative proceedings, PROVIDER and AHCA agree as follows: (1) | AHCA agrees to accept the payment set forth herein in settlement of the overpayment, fine, and costs arising from the above-referenced audit. Agency for Health Care Administration v. Gulfside Regional Hospice, Inc. (C.1. No.: 13-0812-000) Settlement Agreement Page 2 of 7 (2) Within thirty (30) days from the date of the execution of a Final Order adopting this Settlement Agreement, PROVIDER agrees to pay the Agency the sum of forty-four thousand, nine hundred twenty-four dollars and fifty-one cents ($44,924.51). (3) The amount due will be offset by any amount already received by the Agency in this matter. (4) | PROVIDER and AHCA agree that such payment as set forth above will resolve and settle this case completely and release both parties from all liabilities arising from the findings relating to the claims determined to have been overpaid in the audit referenced as C.1. Number 13-0812-000. (5) PROVIDER agrees that it will not rebill the Medicaid Program in any manner for claims that were not covered by Medicaid, which are the subject of the audit in this case. Payment shall be made to: AGENCY FOR HEALTH CARE ADMINISTRATION Medicaid Accounts Receivable 2727 Mahan Drive M.S. #14 Tallahassee, Florida 32308-5403 7. Payment shall clearly indicate it is pursuant to a settlement agreement and shall reference the audit number. 8. Overpayments owed to the Agency bear interest at the rate of 10 percent per year from the date of determination of the overpayment by the Agency; and payment arrangements must be made at the conclusion of legal proceedings, pursuant to Section 409.913(25)(c), Florida Statutes. Agency for Health Care Administration v. Gulfside Regional Hospice, inc. (C1. No.: 13-0812-000) Settlement Agreement Page 3 of 7 9. PROVIDER agrees that failure to pay any monies due and owing under the terms of this Agreement shall constitute PROVIDER’S authorization for the Agency, without further notice, to withhold the total remaining amount due under the terms of this agreement from any monies due and owing to PROVIDER for any Medicaid claims. 10. | AHCA reserves the right to enforce this Agreement under the laws of the State of Florida, the Rules of the Medicaid Program, and all other applicable rules and regulations. 11. This settlement does not constitute an admission of wrongdoing or error by either party with respect to this case or any other matter. 12. The signatories to this Agreement, acting in a representative capacity, represent that they are duly authorized to enter into this Agreement on behalf of the respective parties. 13. This Settlement Agreement shall be construed in accordance with the provisions of the laws of Florida. 14. Venue for any action arising from this Settlement Agreement shall be in Leon County, Florida. 15. This Agreement constitutes the entire agreement between PROVIDER and AHCA, including anyone acting for, associated with or employed by them, concerning all matters and supersedes any prior discussions, agreements or understandings; there are no promises, representations or agreements between PROVIDER and AHCA other than as set forth herein. No modification or waiver of any provision shall be valid unless a written amendment to the Agreement is completed and properly executed by the parties. 16. This is an Agreement of Settlement and Compromise, made in recognition that the parties may have different or incorrect understandings, information and contentions, as to facts and law, and with each party compromising and settling any potential correctness or Agency for Health Care Administration v. Gulfside Regional Hospice, Inc. (C.I. No: 13-0812-000) Settlement Agreement Page 4 of 7 incorrectness of its understandings, information and contentions as to facts and law, so that no misunderstanding or misinformation shall be a ground for rescission hereof. 17, | PROVIDER expressly waives in this matter its right to any hearing pursuant to sections 120.569 or 120.57, Florida Statutes, the making of findings of fact and conclusions of law by the Agency, and all further and other proceedings to which it may be entitled by law or rules of the Agency regarding this proceeding and any and all issues raised herein. PROVIDER further agrees that it shall not challenge or contest any Final Order entered in this matter which is consistent with the terms of this settlement agreement in any forum now or in the future available to it, including the right to any administrative proceeding, circuit or federal court action or any appeal. 18. | PROVIDER does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter, AHCA’s actions herein, including, but not limited 10, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement. 19. | This Agreement is and shall be deemed jointly drafted and written by all parties to it and shall not be construed or interpreted against the party originating or preparing it. 20. To the extent that any provision of this Agreement is prohibited by law for any reason, such provision shall be effective to the extent not so prohibited, and such prohibition shall not affect any other provision of this Agreement. 21. This Agreement shall inure to the benefit of and be binding on cach party’s successors, assigns, heirs, administrators, representatives and trustees. Agency for Health Care Administration v. Gulfside Regional Hospice, Inc. (C.1. No.: 13-0812-000) Settlement Agreement Page 5 of 7 22. All times stated herein are of the essence of this Agreement. 23. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. 24. The parties agree to bear their own attorney’s fees and costs, if any. THE REMAINDER OF THIS PAGE IS INTENTIONALLY BLANK. Agency for Health Care Administration v. Gulfside Regional Hospice, Inc. (C.L No.: 13-0812-000) Settlement Agreement Page 6 of 7 GULFSIDE REGIONAL HOSPICE, INC. Yemf ¢ § Provider’s Representative KZ Couns. rovider STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 tuakt Williams General Counsel Kron Ow Kim Kellum Chief Medicaid Counsel ws ater bh: A aden Tracie L. Hardin Assistant General Counsel Dated: U/r ¥ , 2014 Dated: 2; 28 214 Dated: 2014 Dated: Ss 20 , 2014 F Dated: , 2014 Dated: ,2014 i Agency for Health Care Administration y. Gulfside Regional Hospice, Inc. (C.1. No.: 13-0812-000) Settlement Agreement Page 7 of 7 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RICK SCOTT a ELIZABETH DUDEK GOVERNOR Better Health Care for all Floridians SECRETARY FEDERAL EXPRESS MAIL No.: 8027 0367 2785 March 18, 2013 Provider No: 087570800 NPINo: 1144328881 License No.: 5005096 GULFSIDE REGIONAL HOSPICE, INC. 6117 TROUBLE CREEK RD NEW PORT RICHEY, FL 34653-5240 In Reply Refer to FINAL AUDIT REPORT C.I.No.: 13-0812-000 Dear Provider: The Agency for Health Care Administration (Agency), Office of Inspector General, Bureau of Medicaid Program Integrity, has completed a review of claims for Medicaid reimbursement for dates of service during the period January 1, 2008 through December 31, 2011. A preliminary audit report dated January 18, 2013 was sent to you indicating that we had determined you were overpaid $44,870.35. Since no documentation was produced to refute these billings, all the claims are considered overpayments. We have determined that you were overpaid $44,870.35 for services that in whole or in part are not covered by Medicaid. A fine of $8,974.07 has been applied. The cost assessed for this audit is $54.16. The total amount due is $53,898.58. Be advised of the following: (1) In accordance with Sections 409.913(15), (16), and (17), Florida Statutes (F.S.), and Rule 59G-9.070, Florida Administrative Code (F.A.C.), the Agency shall apply sanctions for violations of federal and state laws, including Medicaid policy. This letter shall serve as notice of the following sanction(s): e A fine of $8,974.07 for violation(s) of Rule Section 59G-9.070(7) (e), F.A.C. (2) Pursuant to Section 409.913(23) (a), F.S., the Agency is entitled to recover all investigative, legal, and expert witness costs. 2727 Mahan Drive, MS# 6 Tallahassee, Florida 32308 Visit AHCA online at http://ahca.myfiorida.com Nursing Home Diversion Waiver — Fee for Service Match Page 2 The Medicaid program is authorized by Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations. The Florida Medicaid Program is authorized by Chapter 409, F.S., and Chapter 59G, F.A.C. This review and the determination of overpayment were made in accordance with the provisions of Section 409.913, F.S. In determining the appropriateness of Medicaid payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, limitations and requirements found in the Medicaid provider handbooks and Section 409.913, F.S. In applying for Medicaid reimbursement, providers are required to follow the guidelines set forth in the applicable rules and Medicaid fee schedules, as promulgated in the Medicaid policy handbooks (in accordance with Chapter 59G, F.A.C.), billing bulletins, and the Medicaid provider agreement. Medicaid cannot pay for services that do not meet these guidelines. Below is a discussion of the particular guidelines related to the review of your claims, and an explanation of why these claims do not meet Medicaid requirements. The audit work papers are attached, listing the claims that are affected by this determination. REVIEW DETERMINATION(S) A Medicaid Provider is required to comply with Medicaid policy requirements (e.g. laws, rules, regulations, handbooks, policy). These requirements include, but are not limited to, providing goods and services in accordance with provisions of Medicaid policy and retaining medical, financial, and business records pertaining to the goods and services furnished. This review included a review of your claims reimbursed to you by Medicaid for goods and services to determine compliance with Medicaid policy. Payments for goods or services that are not documented and/or not billed in accordance to Medicaid policy are deemed to be overpayments. Our review has determined that you have failed to comply with Medicaid policy as outlined below. e Medicaid fee-for-service payments have been identified for recipients while they were enrolled in the Medicaid Nursing Home Diversion Waiver Program. Medicaid providers are required to verify Medicaid recipient eligibility prior to rendering Medicaid services. The fee-for-service payments, shown on the attached work papers, were for services that were to be covered by the recipient’s Nursing Home Diversion Waiver Provider. The total amount reimbursed to you for these fee-for-service payments has been identified as an overpayment. If you are currently involved in a bankruptcy, you should notify your attorney immediately and provide a copy of this letter for them. Please advise your attorney that we need the following information immediately: (1) the date of filing of the bankruptcy petition; (2) the case number; (3) the court name and the division in which the petition was filed (e.g., Northern District of Florida, Tallahassee Division); and, (4) the name, address, and telephone number of your attorney. If you are not in bankruptcy and you concur with our findings, remit by certified check the total amount reflected on page one, paragraph one, of this letter which includes the overpayment amount as well as any fines imposed and assessed costs. The check must be payable to the Florida Agency for Health Care Administration. Questions regarding procedures for submitting payment should be directed to Medicaid Accounts Receivable, (850) 412-3901. To ensure proper credit, be certain you legibly record on your check your Medicaid provider number and the C.I. number listed on the first page of this audit report. Please mail payment to: Nursing Home Diversion Waiver — Fee for Service Match Page 3 Medicaid Accounts Receivable - MS # 14 Agency for Health Care Administration 2727 Mahan Drive Bldg. 2, Ste. 200 Tallahassee, FL 32308 Pursuant to section 409.913(25)(d), F.S., the Agency may collect money owed by all means allowable by law, including, but not limited to, exercising the option to collect money from Medicare that is payable to the provider. Pursuant to section 409.913(27), F.S., if within 30 days following this notice you have not either repaid the alleged overpayment amount or entered into a satisfactory repayment agreement with the Agency, your Medicaid reimbursements will be withheld; they will continue to be withheld, even during the pendency of an administrative hearing, until such time as the overpayment amount is satisfied. Pursuant to section 409.913(30), F.S., the Agency shall terminate your participation in the Medicaid program if you fail to repay an overpayment or enter into a satisfactory repayment agreement with the Agency, within 35 days after the date of a final order which is no longer subject to further appeal. Pursuant to sections 409.913(15)(q) and 409.913(25)(c), F.S., a provider that does not adhere to the terms of a repayment agreement is subject to termination from the Medicaid program. Finally, failure to comply with all sanctions applied or due dates may result in additional sanctions being imposed. You have the right to request a formal or informal hearing pursuant to Section 120.569, F.S. If a request for a formal hearing is made, the petition must be made in compliance with Section 28-106.201, F.A.C. and mediation may be available. If a request for an informal hearing is made, the petition must be made in compliance with rule Section 28-106.301, F.A.C. Additionally, you are hereby informed that if a request for a hearing is made, the petition must be received by the Agency within twenty-one (21) days of receipt of this letter. For more information regarding your hearing and mediation rights, please see the attached Notice of Administrative Hearing and Mediation Rights. Any questions you may have about this matter should be directed to: Sheri Creel, Auditor, Agency for Health Care Administration, Medicaid Program Integrity, 2727 Mahan Drive, Mail Stop #6, Tallahassee, Florida 32308-5403, telephone (850) 412-4600, facsimile (850) 410-1972. Sincerely, Pamela Fante Program Administrator Office of Inspector General Medicaid Program Integrity PF/SC/SG Enclosure(s) Copies furnished to: Finance & Accounting Health Quality Assurance (Interoffice mail) (E-mail) Nursing Home Diversion Waiver — Fee for Service Match Page 4 NOTICE OF ADMINISTRATIVE HEARING AND MEDIATION RIGHTS You have the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If you disagree with the facts stated in the foregoing Final Audit Report (hereinafter FAR), you may request a formal administrative hearing pursuant to Section 120.57(1), Florida Statutes. If you do not dispute the facts stated in the FAR, but believe there are additional reasons to grant the relief you seek, you may request an informal administrative hearing pursuant to Section 120.57(2), Florida Statutes. Additionally, pursuant to Section }20.573, Florida Statutes, mediation may be available if you have chosen a formal administrative hearing, as discussed more fully below. The written request for an administrative hearing must conform to the requirements of either Rule 28- 106.201(2) or Rule 28-106.301(2), Florida Administrative Code, and must be received by the Agency for Health Care Administration, by 5:00 P.M. no Sater than 21 days after you received the FAR. The address for filing the written request for an administrative hearing is: Richard J. Shoop, Esquire Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop # 3 Tallahassee, Florida 32308 Fax: (850) 921-0158 Phone: (850) 412-3630 The request must be legible, on 8 % by 11-inch white paper, and contain: 1. Your name, address. telephone number, any Agency identifying number on the FAR, if known, and name, address, and telephone number of your representative, if any; 2. An explanation of how your substantial interests will be affected by the action described in the FAR: 3. A statement of when and how you received the FAR; 4. For a request for formal hearing, a statement of all disputed issues of material fact; 5. For a request for formal hearing, a concise statement of the ultimate facts alleged, as well as the rules and statutes which entitle you to relief; For a request for formal hearing, whether you request mediation, if it is available; For a request for informal hearing, what bases support an adjustment to the amount owed to the Agency; and 8. A demand for relief. A formal hearing will be held if there are disputed issues of material fact. Additionally, mediation may be available in conjunction with a formal hearing. Mediation is a way to use a neutral third party to assist the parties in a legal or administrative proceeding to reach a settlement of their case. If you and the Agency agree to mediation, it does not mean that you give up the right to a hearing. Rather, you and the Agency will try to settle your case first with mediation. If you request mediation, and the Agency agrees to it, you will be contacted by the Agency to set up a time for the mediation and to enter into a mediation agreement. If a mediation agreement is not reached within 10 days following the request for mediation, the matter will proceed without mediation. The mediation must be concluded within 60 days of having entered into the agreement, unless you and the Agency agree to a different time period. The mediation agreement between you and the Agency will include provisions for selecting the mediator, the allocation of costs and fees associated with the mediation, and the confidentiality of discussions and documents involved in the mediation. Mediators charge hourly fees that must be shared equally by you and the Agency. If a written request for an administrative hearing is not timely received you will have waived your right to have the intended action reviewed pursuant to Chapter 120, Florida Statutes, and the action set forth in the FAR shall be conclusive and final. Nursing Home Diversion Waiver — Fee for Service Match Page 5 If you are in agreement with this audit and wish to make payment, please return this form along with your check. Complete this form and send along with your check to: Agency for Health Care Administration Medicaid Accounts Receivable 2727 Mahan Drive, Mail Stop #14 Tallahassee. Florida 32308 CHECK MUST BE MADE PAYABLE TO: FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Provider Name GULFSIDE REGIONAL HOSPICE, INC. Provider ID 087570800 MPI Case Number 13-0812-000 Overpayment Amount $ 44,870.35 Fine Amount $ 8,974.07 Costs Assessed L $ 54.16 Total Amount Due $ 53,898.58 Check Number Payment for Medicaid Program Integrity Audit
The Issue The issue in this case is whether notice was accorded the patient, as contemplated by section 766.316, Florida Statutes (2012).
Findings Of Fact Ashley Lamendola first presented to Gulf Coast OB/GYN on the morning of December 16, 2011, for a prenatal visit. This visit constituted the beginning of her professional relationship with the physicians who were part of the Gulf Coast OB/GYN group, which included Dr. Calderon and Dr. Shamas.1/ Violet Lamendola, Ms. Lamendola’s mother, accompanied Ms. Lamendola to that visit. When she arrived at Gulf Coast OB/GYN, Ms. Lamendola was given information and forms to fill out by the receptionist. According to both Ms. Lamendola and her mother, the materials included a NICA brochure in Spanish and an acknowledgment of receipt of the NICA form. While reviewing the materials, Ms. Lamendola, who does not speak Spanish, noted that the NICA brochure given to her was in Spanish. She asked her mother to take the brochure back to the receptionist. When Ms. Lamendola’s mother asked the receptionist about the Spanish brochure, the receptionist told her that the office had run out of NICA brochures printed in English, but that she would obtain one from another office and give it to Ms. Lamendola at the end of her appointment. Ms. Lamendola was instructed to sign and did sign the acknowledgment form so that she could see the physician. The acknowledgment form advised that all physicians in the Gulf Coast OB/GYN, P.A., were participating physicians in the NICA program. Ms. Lamendola received a black-and-white facsimile copy of the NICA brochure on her way out of the office along with other materials relating to prenatal and infant care. The brochure, received by Ms. Lamendola from Gulf Coast OB/GYN, bears a facsimile transmission header dated December 16, 2011, at 9:47 a.m. The brochure prepared by NICA is a color brochure which contains the following text in white letters on a light-to-medium green background on the back of the brochure: Section 766.301-766.316, Florida Statutes, (“NICA Law”) provides rights and remedies for certain birth-related neurological injuries and is an exclusive remedy. This brochure is prepared in accordance with the mandate of Section 766.316, Florida Statutes. A copy of the complete statute is available free of charge to completely inform patients of their rights and limitations under the application provision of Florida law. Since 1989, numerous court cases have interpreted the NICA law, clarifying legislative intent. The above-quoted language is absent from the facsimile copy of the brochure that Ms. Lamendola received from Gulf Coast OB/GYN. Apparently because the letters in the original brochure were white, the letters did not transmit. It is noted that on the front of the brochure, white lettering that appears on the green background of the color brochure did not transmit on the copy that Ms. Lamendola received. The majority of the information contained in Ms. Lamendola’s facsimile copy of the brochure is contained in the color copy of the brochure. The facsimile copy informed Ms. Lamendola that the statutes provide an exclusive remedy and a copy of the statutes may be obtained from NICA. The facsimile outlined the rights and limitations provided in the statutes. The only things that are not contained in the original brochure are that a copy of the statutes is available free of charge, the preparation of the brochure was mandated by section 766.316, and court cases have interpreted the statutes. St. Petersburg General Hospital offers a tour of its obstetrical department to expectant mothers and their families. Ms. Lamendola’s mother called St. Petersburg General Hospital to register for a tour. The hospital employee who was scheduling the tour asked to speak to Ms. Lamendola to obtain pertinent biographical information. Ms. Lamendola provided the information to the hospital employee. The tour is an informational tour and attendance at the tour does not constitute pre-registration at St. Petersburg General Hospital for the delivery of a baby. Ms. Lamendola and her mother, along with 12 other couples, attended the tour on March 22, 2012. During the tour, Ms. Lamendola received a tour packet, which contained a document titled Preadmission and Financial Information. This document instructed Ms. Lamendola to fill out the pre-admission form and return it to the hospital. Ms. Lamendola filled out the pre- admission form, but did not return it to St. Petersburg General Hospital. Ms. Lamendola did not pre-register for admission to the hospital. On April 3, 2012, Ms. Lamendola presented to St. Petersburg General Hospital with complaints of vaginal bleeding. Ms. Lamendola was told by a hospital employee that she was already in the system and that additional information would not be necessary. Ms. Lamendola signed a “Consent to Treat” form and was treated in the labor and delivery unit of the hospital. A short time later, she was given informational materials relating to prenatal and infant care and released. She was not given a NICA brochure during the visit on April 3, 2012. It was the hospital’s policy to give a NICA brochure to a patient only when the patient was being admitted as an inpatient for delivery of her baby. Ms. Lamendola’s professional relationship with St. Petersburg General Hospital relating to her pregnancy began with her visit on April 3, 2012. At 20:19 on June 26, 2012, Ms. Lamendola presented to St. Petersburg General Hospital. She had been experiencing contractions for six hours prior to her arrival at the hospital. She had been placed on bed rest for gestational hypertension five days prior to coming to the hospital. When she arrived at the hospital, she had hypertension. Normally when a patient is 37 to 39 weeks gestation, her physician will bring the prenatal records to the hospital or the physician’s office will send the records to the hospital by facsimile transmission. When Ms. Lamendola arrived at St. Petersburg General Hospital, her prenatal records from her physicians’ office were not on file. Megan Muse, R.N., was on duty when Ms. Lamendola presented at St. Petersburg General Hospital. Because Ms. Lamendola’s records were not on file, Ms. Muse requested that Bayfront Hospital send Ms. Lamendola’s records to St. Petersburg General Hospital. The evidence did not establish how Ms. Muse knew that the prenatal records were at Bayfront Hospital. Ms. Lamendola’s prenatal records, consisting of 11 pages, were sent by facsimile transmission to St. Petersburg General Hospital beginning at 21:35 on June 26, 2012. Ms. Muse recorded in her notes that Ms. Lamendola’s prenatal records were received from Bayfront Hospital at 21:45 on June 26, 2012. Although Ms. Lamendola’s prenatal records may have been sent to Bayfront Hospital, it was never Ms. Lamendola’s intention to deliver her baby at Bayfront Hospital. She took the informational tour offered by St. Petersburg General Hospital and went to St. Petersburg General Hospital in April 2012 when she had a problem related to her pregnancy. At 20:33, Dr. Javate admitted Ms. Lamendola to St. Petersburg General Hospital for the delivery of her infant. Ms. Lamendola was examined by Emanuel Javate, M.D., at approximately 21:35. At 22:02, Ms. Lamendola signed the hospital’s Condition of Admission form. At 22:10 the hospital gave Ms. Lamendola the brochure prepared by NICA, and Ms. Lamendola signed the acknowledgment form, acknowledging that she had received the brochure. Ms. Lamendola gave birth to Hunter Lamendola (Hunter) on June 27, 2012, at St. Petersburg General Hospital, which is a licensed Florida Hospital. At birth, Hunter weighed in excess of 2,500 grams and was a single gestation. Ashley Lamendola received obstetrical care from Guillermo Calderon, M.D. Dr. Calderon was a “participating physician” as defined in section 766.302(7). Christina Shamas, M.D., provided obstetrical services in the course of labor, delivery, and resuscitation in the immediate post-delivery period. Dr. Shamas was a “participating physician” as defined in section 766.302(7).
The Issue The issue presented is whether Petitioners are entitled to additional benefits pursuant to the State of Florida Employees Group Health Self Insurance Plan.
Findings Of Fact At all times material hereto, Petitioner Della G. Sphaler (hereinafter "Petitioner") has been an employee of the State of Florida with health insurance coverage under the State of Florida Employees Group Health Self Insurance Plan (hereinafter "the Plan"). The Plan is administered by Blue Cross and Blue Shield of Florida, Inc. (hereinafter "Blue Cross/Blue Shield"), pursuant to an Administrative Services Agreement between the State and Blue Cross/Blue Shield. On or about November 14, 1989, Petitioner's doctor recommended that she be admitted to Humana Hospital-Palm Beaches for psychiatric services on an emergency basis. At the time, Petitioner knew that Humana was not a Preferred Patient Care Provider (hereinafter "PPC") under the Plan. A PPC provider has an agreement with Blue Cross/Blue Shield to provide health care services at set fees to individuals under the Plan. The Plan provides higher benefits when PPC providers are used. Petitioner told her doctor that Humana was a non-PPC provider and that she did not want to go to a hospital unless her bill would be paid by her insurance. However, her doctor wanted her to go to Humana specifically, and she agreed. Thereafter, Petitioner and William Sphaler (hereinafter "husband") went to Humana Hospital. They spoke to an employee at Humana regarding Petitioner's insurance coverage under the Plan, and that unidentified employee telephoned Blue Cross/Blue Shield. Petitioner was not a party to the conversation between the Humana Hospital admissions clerk and the unidentified employee of Blue Cross/Blue Shield, and her husband heard none of the conversation. Further, neither Petitioner nor her husband personally made any contact with Blue Cross/Blue Shield or Respondent regarding the existence or extent of any insurance coverage under the Plan if Petitioner were admitted at Humana. After her conversation, the clerk at Humana told Petitioner that Blue Cross/Blue Shield would pay 80 percent for the first three days of admission and 100 percent thereafter, according to Petitioner's and her husband's testimony. Petitioner was admitted to Humana on November 14, 1989, with an admitting diagnosis of major depression. She remained there until her discharge on December 8, 1989. As a result of the phone call from Humana, on November 14, 1989, the Blue Cross/Blue Shield computer generated a form letter to Petitioner advising her that under the Hospital Stay Certification component of the Plan Petitioner's emergency hospital stay was certified for three days and that contact by the hospital would be necessary to recertify the admission for additional days. That letter further advised as follows: We remind you that the review was limited to determining the appropriate length of stay for the emergency admitting diagnosis and did not question medical necessity. We further remind you that payment of benefits is still subject to the terms of your Health Insurance Policy. Neither Petitioner nor her husband contacted Blue Cross/Blue Shield to verify or ascertain benefits upon their receipt of that letter. Petitioner's total bill for her stay at Humana was $17,652.53. The bill was primarily for room charges. Humana charged $463 a day for eleven days in a semi-private room and $713 a day for an additional thirteen days in a semi- private room. Blue Cross/Blue Shield paid a total of $6,751.50 of Petitioner's hospital bill. That payment covered portions of Petitioner's bill for the entire stay. Since Humana is a non-PPC hospital, payment for services is controlled by Section II.A.1. of the Plan's Benefit Document, amended effective July 1, 1988, which covers non-PPC hospital inpatient room and board services as follows: When confined to a semi-private or private room or ward, 80 percent of the hospital's average semi-private room rate shall be paid but not to exceed an actual payment of one-hundred and fifty-two dollars ($152.00) per day. The Benefit Document also establishes deductibles under the Plan in Section VI.C. as follows: "Two hundred dollars ($200.00) per admission to a non-PPC provider hospital, specialty institution or residential facility." The Hospital Stay Certification component of the Plan, like the Pre- admission Certification component, if complied with, does not increase the benefits payable under the Plan. Rather, Section XXIV.C. of the Benefit Document provides that the benefits set forth in Section II.A. will be paid if an elective admission to a non-PPC hospital is certified and will not be paid if the admission is not certified. Since Petitioner obtained certification, she was entitled to benefits as provided in Section II.A., i.e., a maximum of $152 per day for room charges. Blue Cross/Blue Shield properly calculated and paid the benefits to which Petitioner is entitled. Petitioner is entitled to no additional benefits under the Plan.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered denying Petitioners' claim for additional benefits for the November 14, 1989, Humana hospitalization. DONE and ENTERED this 5th day of April, 1994, at Tallahassee, Florida. LINDA M. RIGOT 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 Division of Administrative Hearings this 5th day of April, 1994. APPENDIX TO RECOMMENDED ORDER DOAH CASE NO. 93-5971 Petitioners' proposed findings of fact numbered 1-4 and 6 have been adopted either verbatim or in substance in this Recommended Order. Petitioners' proposed finding of fact numbered 5 has been rejected as not being supported by the weight of the competent evidence in this cause. Respondent's proposed findings of fact numbered 1-5 and 8-10 have been adopted either verbatim or in substance in this Recommended Order. Respondent's proposed finding of fact numbered 6 has been rejected as being unnecessary to the issues involved herein. Respondent's proposed findings of fact numbered 7, 11, and 12 have been rejected as not constituting findings of fact but rather as constituting argument of counsel, conclusions of law, or recitation of the testimony. COPIES FURNISHED: John P. Marinelli, Esquire John P. Marinelli, P.A. 1615 Forum Place Suite 4-B, Barristers Building West Palm Beach, Florida 33401 Augustus D. Aikens, Jr., Esquire Chief, Benefit Programs and Legal Services Division of State Employees' Insurance 2002 Old St. Augustine Road, B-12 Tallahassee, Florida 32301-4876 William H. Lindner, Secretary Department of Management Services Knight Building, Suite 307 Koger Executive Center 2737 Centerview Drive Tallahassee, Florida 32399-0950 Paul A. Rowell, General Counsel Department of Management Services Knight Building, Suite 307 Koger Executive Center 2737 Centerview Drive Tallahassee, Florida 32399-0950
