The Issue The principal issue in this case is whether the Respondent, Dr. Livingston, is in violation of Section 458.331(1)(b), Florida Statutes, by reason of certain events which occurred in New Jersey. The Respondent has also raised several collateral issues, including issues concerning the validity of and the interpretation to be given to the cited statutory provision.
Findings Of Fact Based cn the exhibits received in evidence at the hearing in this case, I make the following findings of fact. The Respondent, Robert Michael Livingston, M.D., is a licensed medical physician, having been issued license number NE0009825 by the Florida Board of Medical Examiners. His last known address is 33 Southeast Third Street, Boca Raton, Florida 33432. Dr. Livingston has been licensed to practice medicine in both the State of Florida and the State of New Jersey for a number of years. The Dr. Livingston who is the Respondent in this case is the same Dr. Livingston who holds license number 18863 in the State of New Jersey and who was the subject of the administrative proceedings in the State of New Jersey which were resolved by a Final Order by Consent dated January 12, 1983. By an Administrative Complaint dated May 18, 1981, and an Amended Administrative Complaint dated September 17, 1981, the Attorney General of the State of New Jersey sought the suspension or revocation of Dr. Livingston's license to practice medicine in the State of New Jersey. The grounds alleged in the Amended Administrative Complaint included conduct which was asserted to constitute (a) the employment of unlicensed persons to perform work which may legally be done only by persons licensed to practice medicine and surgery; (b) gross malpractice and gross neglect in the practice of medicine; (c) professional incompetency; (d) lack of capability to discharge the functions of a medical licensee in a manner consistent with the health, safety and welfare of the public; and (e) habitual use of intoxicants. The allegations of the New Jersey Administrative Complaint and Amended Administrative Complaint were never proven in any proceeding in New Jersey. All of the allegations of the New Jersey Administrative Complaint were resolved by the entry of a Final Order by Consent dated January 12, 1983. The prefatory language of the Final Order by Consent contains the following relevant language: Subsequent to the filing of the complaint the parties have concluded that this dispute can be amicably resolved by means of this Final Order by Consent. In entering into this Final Order Dr. Livingston denies any malpractice, gross or otherwise, and this resolution of the dispute is therefore not to be construed as an admission by Dr. Livingston of any of the allega- tions contained in the complaint. The parties hereto acknowledge that the Board of Medical Examiners does not contend that Dr. Livingston is presently dependent upon controlled dangerous substances. In entering into this Final Order the Board of Medical Examiners relies upon Dr. Livingston's representation that he is not now practicing medicine and surgery in New Jersey, but is so practicing in the State of Florida. The dispositional language of the Final Order by Consent reads as follows: IT IS ORDERED AND AGREED, therefore, on this 12th day of January, 1983, that: Robert M. Livingston will not practice medicine and surgery in the State of New Jersey for a two-year period, that period having commenced on May 22, 1981. If at any time after the expiration of this two- year period he shall seek to practice medicine and surgery in New Jersey, he shall either personally appear before the Board of Medical Examiners or submit proof of his compliance with paragraph 2 of this Final Order. In addition, the Board of medical Examiners may in its discretion reguire Dr. Livingston to submit to a general psychiatric evaluation performed by a Board-certified psy- chiatrist designated by the Board of Medical Examiners to determine whether there exists any medically unjustified dependence upon con- trolled dangerous substances. Bobert M. Livingston will pay $2,500.00 as a sharing of the costs of the Board inquiry into the matters resolved by this Final Order. Robert Il. Livingston will pay the expert fee billed to Dr. Livingston by Dr. Leslie Iffy for Dr. Iffy's testimony during depo- sitions, and Dr. Livingston will be responsible for paying the cost of all transcripts of the depositions of Dr. Iffy, Kathleen M. Brancaccio and Nicholas Brancaccio. None of the provisions of this Final Order by Consent shall be deemed a disciplinary sanction or penalty under the Medical Practice Act. This Final Order by Consent consitutes resolution of all matters arising from the complaint as it pertains to Robert A. Livingston, and the complaint as it pertains to him is dismissed with prejudice. (Emphasis added.) Thereafter, effective July 1, 1953, Dr. Livingston's license to practice medicine in the State of New Jersey was renewed for a two-year period ending on June 30, 1955. ANALYSIS OF TUE ISSUES Issues Regarding Findings of Fact The Respondent has asserted that Petitioner's Composite Exhibit 2 constitutes hearsay evidence which would not be admis- sible over objection in a civil action and that, by operation of Section 120.55(1)(a), Florida Statutes, the exhibit is insufficient to support a finding of fact. Contrary to the assertions of the Respondent, it should be noted that Petitioner's Composite Exhibit 2 comes within the "public records exception to the hearsay rule [see 90.803(8), Fla. Statutes] and is self-authenticating within the meaning of Section 90.902, Florida Statutes. Accordingly, the exhibit would be admissible over objection in a civil action and is, therefore, a sufficient basis for making findings of fact in this case. In making the foregoing findings of fact, I have, with the exceptions noted hereinafter, incorporated the text or substance of the vast majority of the findings of fact proposed by the parties. My reasons for not making certain findings proposed by the respondent are as follows. The last sentence of Respondent's proposed finding number 3 is not supported by competent substantial evidence. The penultimate sentence of Repondent's proposed finding number 4 is more in the nature of argument or a proposed conclusion of law than a proposed finding of fact. My reason for not making Petitioner's proposed finding of fact numbered 4 is that it is more in the nature of a conclusion of law than a proposed finding of fact--it is a proposed interpretation of the legal effect of the Final Order by Consent rather than a summary of the text of that order. The Delegation of Authority Issue At the hearing in this case, the Respondent also argued that Section 458.331(1)(b), Florida Statutes, constitutes an improper delegation of authority to officials of other states because by operation of the statute officials in other states are able to determine who shall be subject to discipline in the State of Florida. This argument has already been resolved contrary to the Respondent's contentions. See Bryan v. State Board of Medical Examiners of Florida, 381 So. 2d 1122 (Fla. 1st DCA 1979), affirmed, 398 So. 2d 1354 (Fla. 1981). The Sufficiency of the Statement of the Charges Against the Respondent The Respondent also asserts that a finding of guilt in this case would constitute a denial of due process because he was charged in the Administrative Complaint with having his license "acted upon" and was not charged, in the language of the statute, with having his license "acted against." There are, of course, cases in which a failure to charge in the statutory language could deprive a Respondent of his right to know the charges against him and have adequate opportunity to prepare his defense against them. But the Respondent is not entitled to a perfect statement of the charges against him. Rather, the standard which west be met by the language of the Administrative Complaint is that the . . . . grounds for revoking a license to practice medicine must be alleged with reasonable certainty and show the nature and cause of the accusa- tion and he must be given reasonable opportunity to defend against attempted proof of such charges. (Emphasis added.) State ex rel. Sbordy v. Rowlett, 190 So. 59 (Fla. 1939), at 62. Despite the failure of the Administrative Complaint in this case to track the exact language of the statute, the Respondent had full knowledge of the factual basis for the charge against him and was also fully aware of the legal basis for the charge. Therefore, he knew with "reasonable certainty" what the Petitioner would attempt to prove, and he had a "reasonable opportunity" to defend against the charge. The Principal Issue in the Case Turning at last to the heart of the matter, the principal issue which must be decided in this case is whether the actions of the Attorney General of the State of New Jersey or the Hoard of Medical Examiners of the State of New Jersey described in the findings of fact constitute, in the language of Section 455.331(1)(b), Florida Statutes: Having a license to practice medicine revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of another state, territory, or country. For the reasons explained below, I conclude that they do not. Part of the resolution of this issue turns on the interpretation to be given to the terms "suspended," "acted against," and "licensing authority," as used in Section 458.331(1)(b), Florida Statutes. None of these terms are defined in the statute. Accordingly, pursuant to well-established rules of statutory construction, these terms must be given their plain and ordinary meaning. See cases collected at Vol. 10-B, Florida Digest, Statutes, 188, of which the following is a modest sample. Crown Diversified Industries, Inc. v. Watt, 415 So.2d 803 (Fla. 1st DCA 1982); St. Petersburg Bank & Trust Co. v. Hamm, 414 So.2d 1071 (Fla. 1982); J. C. Vereen & Sons, Inc. v. City of Miami, 397 So.2d 979 (Fla. 3d DCA 1981); Gasson v. Gay, 49 So.2d 525 (Fla. 1951); Gaulden v. Kirk, 47 So.2d 567 (Fla. 1950). The term "licensing authority," as used in Section 458.331(1)(b), Florida Statutes, means the governmental entity in a foreign jurisdiction which possesses the power and authority to take final action to grant a license or to deny, revoke, or suspend a license, or to otherwise impose discipline on a licensee. In this case, the relevant "licensing authority" is the Board of Medical Examiners of the State of New Jersey. The Attorney General of the State of New Jersey is not a "licensing authority" within the meaning of Section 458.331(1)(b), Florida Statutes, because, although the Attorney General prosecutes complaints against licensees, nothing in this record shows that the Attorney General has the power and authority to grant, revoke, or suspend a license, or to impose any discipline on a licensee. Therefore, even if the actions of the Attorney General of the State of New Jersey described in the findings of fact were to be construed as action against a license, such action would not establish a violation of Section 458.331(b), Florida Statutes, because it would not be action by a "licensing authority." Accordingly, in order to establish a violation of the cited statute in this case, the Department must show that the Board of Medical Examiners of the State of New Jersey suspended or acted against the license of Dr. Livingston. 2/ The plain meaning of the term "suspend" is "to render temporarily void" or "to punish by temporary exclusion." See The Random House Dictionary. And the plain and ordinary meaning of "against," in the context in which it appears in the subject statute, is "in opposition or hostility to." Id. A careful review of the Final Order by Consent reveals that the action taken by the Board of Medical Examiners of the State of New Jersey did not suspend Dr. Livingston's license and did not constitute any action against Dr. Livingston's license. The Final Order by Consent does not purport to suspend Dr. Livingston's license and does not purport to impose any other form of discipline against him. This is evidenced by the penultimate paragraph of the order, which specifically states: "None of the provisions of this Final Order by Consent shall be deemed a disciplinary sanction or penalty under the Medical Practice Act." (Emphasis added.) Further, there is nothing in the Final Order by Consent which purports to order Dr. Livingston to do anything or to refrain from doing anything. Quite to the contrary, the dispositive action of the New Jersey Board in the final paragraph of the Final Order by Consent was to dismiss, with prejudice, the complaint against Dr. Livingston. The Department argues that the language of paragraph number 1 of the Final Order by Consent constitutes a suspension of, or action against, Dr. Livingston's New Jersey license and that paragraphs number 2 and 3 of that order also constitute action against Dr. Livingston's New Jersey license. Paragraph number 1 of the Final Order by Consent does state that Dr. Livingston "will not" practice medicine in the State of New Jersey for a specified period and paragraphs number 2 and 3 of that order do state that Dr. Livingston "will pay" certain expenses related to the case. But those paragraphs cannot be interpreted as having the legal effect urged by the Department, because to do so would be to belie the express language of paragraph number 4 of the same document (which states that nothing in the order constitutes "a disciplinary sanction or penalty") and to ignore the operative language of the order, which is to dismiss the complaint with prejudice. It would be a total contradiction to say, on the one hand, that the New Jersey Board dismissed the complaint against Dr. Livingston and did not impose any disciplinary sanction or penalty and to then conclude that the New Jersey Board had suspended Dr. Livingston's license and had otherwise acted against his license. Furthermore, nothing in paragraphs number 1, 2, or 3 of the Final Order by Consent prohibits Dr. Livingston from doing anything or orders Dr. Livingston to do anything. Those paragraphs simply state that Dr. Livingston will not do this and will do that. The clear import of the statements in these three paragraphs is that they recite what Mr. Livingston has agreed to do and not to do. It is noteworthy that these three paragraphs are immediately preceeded by a statement reading "IT IS ORDERED AND AGREED." Inasmuch as the three subject paragraphs do not order Dr. Livingston to do or refrain from doing anything, they can only be construed as manifestations of what Dr. Livingston agreed to do and to refrain from doing. Thus, these paragraphs constitute action taken by Dr. Livingston, not action taken by the Board. Finally, this interpretation of paragraphs number 1, 2, and 3 is compelled by the fact that it would be incongruous to conclude that the New Jersey Board was, in a single act, both penalizing Dr. Livingston (which the order specifically disavows) and dismissing all charges against him. Reduced to the vernacular, the New Jersey Board made a deal with Dr. Livingston that if he would agree to do this and not do that, they would not take any action against him, and the Final Order by Consent is the implementation of that deal. And in this regard it is important to take cognizance of the fact that the Final Order by Consent was not a consent to the entry of an order against Dr. Livingston. Quite to the contrary, it was a consent to a dismissal of all charges. The Department also argues by analogy that the New Jersey consent order in this case is as sufficient a basis for finding a violation of Section 458.331(1)(b) as was the consent order entered by the Composite State Board of Medical Examiners of the State of Georgia, which was relied on in Department of Professional Regulation, Board of Medical Examiners v. Ralph C. Lee, M.D., 4 FALR 2388A (1982) The analogy fails because of the following notable differences. In the Lee case, Dr. Lee's consent in the Georgia case included an admission of some or all of the charges brought against him. Here, Dr. Livingston's consent in the New Jersey case incorporates an express denial of the charges against him. In the Lee case, the Georgia Hoard revoked Dr. Lee's license and then put Dr. Lee on probation. Here the New Jersey Hoard dismissed with prejudice all charges against Dr. Livingston. In the Lee case, a clear violation of Section 485.331 (1)(b) , Florida Statutes, was established. Here, there was no such violation. A Collateral Issue Which Need Not Be Decided Here A final issue which need not be decided here, but which nevertheless warrants brief attention, is the Respondent's contention that his due process rights will be violated unless Section 458.331(1)(b), Florida Statutes, is construed quite narrowly. He argues that Section 458.311(1)(b) should be construed . . . . as requiring the allegation, substan- tiated by competent substantial evidence, that a licensee has had his license revoked, suspended or otherwise acted against by the licensing authority of another state, territory, or country, for conduct which would constitute a violation of 458.331, Florida Statutes, if that conduct were committed in Florida. Petitioner replies to the foregoing by arguing that the Respondent's due process arguments involve constitutional issues which are beyond the scope of the Hearing Officer's authority. In view of the foregoing conclusions about the effect of the Final Order by Consent, it is not necessary in this case to embark upon a lengthy analysis of the extent to which the proper interpretation of Section 358.331(1)(b) , Florida Statutes, may be colored by constitutional considerations. 4/ Nevertheless, because occasion to address this issue may arise at some later stage in these proceedings, I commend to the parties' attention the following comments from Hotel, Motel, Restaurant Employees and Bartenders Union, Local 737 v. Escambia County School Board, 3 FALR 2122A (1981) at 2125A--2126A, affirmed, 426 So.2d 1017 (Fla. 1st DCA 1983): Prior to embarking upon a discussion of the constitutional ramifications of the issues at hand we hasten to acknowledge that we are well aware of the limitations upon an adminis- trative agency's role in matters which involve the application or interpretation of our State Constitution. As noted in Barr v. Watts, 70 So.2d 347 (Fla. 1953) , and State ex rel. Atlantic Coast Line Railroad Co. v. State Board of Equalizers, 94 So. 681 (ala. 1922) the "right to declare an act unconstitutional cannot be exercised by the officers of the executive department under the guise of the observance of their oath of office to support the Constitution." But the fact that we are without authority to rule upon the constitutionality of statutes does not mean that we must ignore the Constitution. To the contrary, where the meaning of a statute is colored by provisions in the Constitution our hope of reaching the correct understanding of that meaning lies in part in a consideration of those constitutional consequences. * * * * And while we may not, in the course of ourefforts to construe applicable statutory provisions, declare a statute to be unconstitutional, neither are we required to fumble around in some pretended ignorance of reality. if we are to act responsibly, we must act in full contemplation of the inescapable consequences of what the courts have already said about similar statutes . . . And even though we lack the power of a court with regard to the ruling upon the validity of a statute, we owe to the Legislature certainly no less duty than is owed by the courts to respect the enactments of that body. In this regard it seems especially appropriate for us to follow the same rules as are followed by the courts in their construction of statutory pro visions which skate near the thin ice of constitutional invalidity particularly in light of the fact that in the event of judicial review of this order notions of stare decisis make it most likely that any reviewing court would also resort to the same time-tested rules of construction. (Word in square brackets added.) See also: Florida Education Association/United v. Public Employees Relations Commission, 346 So.2d 551 (Fla. 1st DCA 1977), at 553. In Brief Summary In sum: The Final Order by Consent issued by the Hoard of Medical Examiners of the State of New Jersey on January 12, 1983, does not constitute a suspension of Dr. Livingston's license to practice medicine in that state, nor does it constitute action against such license. There is no competent substantial evidence in the record of any other revocation, suspension, or action against Dr. Livingston's license to practice medicine in New Jersey. Therefore, the violation charged in the Administrative Complaint in this case has not been proved and the Administrative Complaint should be dismissed.
Recommendation Based upon all of the foregoing, I RECOMMEND that the Florida Board of Medical Examiners enter a Final Order in this case dismissing in its entirety the Administrative Complaint against Dr. Livingston. DONE and ORDERED this 28th day of June, 1984, at Tallahassee, Florida. MICHASEL M. PARRISH Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 28th day of June, 1984.
Findings Of Fact On May 10, 1983, the Petitioner Florida Psychiatric Centers submitted two letters of intent to the Respondent Department of Health and Rehabilitative Services to construct psychiatric hospitals in Palm Beach and Marion Counties. On June 10, 1983, the Petitioner timely submitted both applications for certificates of need to the Department. On February 11, 1983, the Department imposed an administrative moratorium with respect to the construction of new hospitals or the addition of new beds to existing hospitals. As a result, letters of intent for hospital projects involving new beds which were filed prior to February 11, 1983, which pursuant to Rule 10-5.08, Florida Administrative Code, would normally have an application deadline of March 15, were extended to a June 15 deadline with a review in September. Letters of intent which were received after February 14 and prior to May 16, which pursuant to the Department rules would have had a deadline of June 15, were instructed to file applications by August 15 to receive a November review. The moratorium, which was administratively imposed by the Department, had the effect of changing the application deadline the Petitioner's batching cycle from June 15, 1983, to August 15, 1983. In the absence of the Department's administrative moratorium, the Petitioner's applications would have been reviewed in the June 15 batch cycle pursuant to Rule 10-5.08, Florida Administrative Code. As a result of the administrative moratorium, the Department developed a letter of instructions which was forwarded to each of the 71 applicants who filed letters of intent between February 14 and May 16. The letter informed the applicants of the moratorium, the inapplicability of the June 15 deadline specified in the Department's rules, and requested applicants to file applications with the Department and appropriate local health council by August 15, 1983. The Department responded to Petitioner's letters of intent by forwarding letters of instruction dated May 18, 1983 and May 19, 1983. These two instruction letters were mailed to the Petitioner in the ordinary course of business by Ms. Diane Spooner, secretary to the certificate of need application review coordinator for the Department. Notwithstanding his receipt of the letters of instruction, the Petitioner forwarded his applications to the Department for review under cover letter dated June 10, 1983. These applications were received by the Department of June 15, 1983 and returned to the Petitioner. The Petitioner, however, did not receive the returned applications with cover letters or the application fees of $4,000 each from the Department. Subsequently, the Petitioner became aware that the applications were not included in the June or August batch and sent a letter to the Department requesting that the applications be included in the August batch. Neither the Department's rule nor Chapter 381, Florida Statutes, restrict an applicant from filing an early application. Accordingly, by filing its application on June 15, the Petitioner complied with the rules by filing on or before August 15. Had the Petitioner's applications been included in the August 15 batch cycle, its applications would have been comparatively reviewed with applications from Horsham Corporation in Palm Beach County and Citrus Community in Marion County.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That a final order be entered by the Department placing the Petitioner within the batching cycle for which applications were due by August 15, 1983, and within ninety days, comparatively review the Petitioner's applications with those competitive applications filed and accepted by the Department for the August 15, 1983 batch. DONE and ENTERED this 6th day of June, 1984, in Tallahassee, Florida. SHARYN L. SMITH Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 FILED with the Clerk of the Division of Administrative Hearings this 6th day of June, 1984. COPIES FURNISHED: Kenneth G. Oertel, Esquire Oertel and Hoffman 646 Lewis State Bank Building Tallahassee, Florida 32301 Doug Mannheimer, Esquire Post Office Drawer 591 Tallahassee, Florida 32302
Findings Of Fact At all times pertinent to the issues herein either the Florida Department of Health and Rehabilitative Services, (Department), or the Florida Agency for Health Care Administration, (Agency), its successor agency, operated the Medicaid Program in Florida, a state and federally funded program to provide medical services to indigent and eligible individuals, including children, in Florida. Petitioner, Neonatology Associates, Inc., (NAI), is a provider to the Medicaid Program of the State of Florida, and is located in St. Petersburg, Florida. Its Medicaid provider number is 067920-01. It has been a Medicaid provider for approximately thirty years. Medicaid and Children's Medical Services (CMS) were, at one time, both separate components of the Department of Health and Rehabilitative Services. On July 1, 1993, responsibility for Medicaid was assigned to the Agency for Health Care Administration. Medicaid, and its fiscal agent, FMMIS, are not now and never have been a part of either Children's Medical Services or Regional Perinatal Intensive Care Center (RPICC) and neither CMS nor RPICC have ever been a part of Medicaid or its fiscal agent. RPICC serves only peripherally to Medicaid as a claims transmittal agency or billing agent. That relationship was formalized by a contract which is considered by FMMIS as a billing agent contract. The parties stipulated prior to the hearing that the medical services, which are represented by Petitioner to have been performed were actually performed and rendered, and that all of the patients for the disputed claims are assumed to be Medicaid eligible. The parties stipulated at the hearing that the five claims were submitted by Petitioner to RPICC in a timely manner; that the five claims were received by RPICC within a twelve month period from the date of service; that there was a problem at RPICC which precluded the transmittal of these five claims in a timely manner to the Florida Medicaid Management Information System, (FMMIS), the office with which they were to be filed for payment; and that there was communication by telephone and in person between officials of Petitioner, RPICC, and the Department/Agency, (CMS), in an effort to resolve the filing difficulty. These claims relate to five patients, M.H., M.C., C.J., B.A. and R.W. Claims which are not received by Medicaid or its fiscal agent within twelve months of service may not be paid pursuant to law described in the trade as the "twelve month rule." The five claims in issue here were transmitted electronically to RPICC by NAI's agent, Ms. Chandler, the RPICC billing clerk at All Children's Hospital, where the service was rendered, for subsequent re- transmittal by RPICC to FMMIS. This procedure is authorized by the Agency. However, due to technical problems not further identified, the claims were never received by FMMIS. RPICC, a part of the Department's Children's Medical Services, and operated by the University of Florida, does not adjudicate claims but merely gathers and analyzes neonatology data for statistical reporting. FMMIS, Medicaid's fiscal agent since July 1, 1993, is operated by a private vendor. The contract between Medicaid and the University under which RPICC data services are provided, and that between NAI and Medicaid, which provides for medical services, both contain the same "boiler plate" clauses. Both NAI and RPICC transmit electronic claims to Medicaid for adjudication, but neither is a party of or agent of Medicaid. FMMIS is Medicaid's agent for payment. RPICC data processing services charges are paid to the University of Florida by Children's Medical Services under their contract. Medicaid pays only for the actual medical care provided to indigent mothers and their sick newborn children. NAI has a contract with Medicaid. RPICC has a contract with Medicaid. Children's Medical Services has a contract with RPICC at the University of Florida. These are the only formal agreements involved in this situation. The contract between NAI and Medicaid provides that NAI will submit Medicaid claims "in accordance with program policies." Medicaid policy provides that receipt of electronic claims submission to Medicaid or its fiscal agent, FMMIS, takes place only upon acceptance and confirmation by FMMIS. Acceptance occurs when each claim is assigned its own identification number. Medicaid policy also provides that submittal of a claim to RPICC does not constitute receipt of the claim by Medicaid or its fiscal agent, and submittal of a claim to RPICC does not toll the running of time accounted for under the twelve month rule. The relationship between Medicaid and the RPICC data center may be likened to that of RPICC's being a billing transmittal agent for FMMIS. RPICC does not process claims submitted to it but merely forwards those it receives to the fiscal agent which operates the FMMIS. Medicaid, by letter from Mr. Thomas Arnold, dated March 5, 1990, authorized FMMIS to receive Medicaid claims from RPICC. That letter does no more than offer providers an option to have RPICC bill the fiscal agent for them, thereby creating a "billing agent" status for RPICC. It does not state that submittal of claims by providers to RPICC constitutes filing a claim with Medicaid or the fiscal agent so as to toll the running of the twelve months limit. The Medicaid Physician Provider Handbook made available to all providers expressly states that all claim inquiries be made to Consultec, a private computer services provider. Both Mr. Blasioli and the Agency's regional claims representative noted that NAI did not contact Consultec regarding the computer problems regarding the instant claims prior to the expiration of the twelve month claim filing limit. Neither did NAI make use of RPICC's internal claims tracking system during the period in issue. The evidence establishes that NAI experienced difficulty in submitting the five claims in issue. Nonetheless, within a month of being employed by NAI, its billing administrator advised Medicaid that he had addressed the problem and had established procedures with RPICC's data center to prevent future claims from exceeding the twelve month limit. NAI's difficulty with the five claims in issue were first brought to the attention of Medicaid personnel after the twelve month filing limit had expired. Though the claims in issue here were submitted electronically, NAI could have submitted these claims directly to FMMIS by traditional paper claim, omitting the RPICC channel and its potential for technical problems. It chose not to do so. The "twelve month rule" provides for exceptions which are expressly limited to those claims which are delayed by either legal action or lack of proof of recipient eligibility. An additional exception is afforded claims delayed by "crossovers" with Medicare. The rule does not provide for extension of time due to computer system error unless such error relates to processing errors which arise subsequent to Medicaid's acknowledgment of claim receipt. In essence, to justify an exception to the twelve month rule, the computer error must be Medicaid's. The Medicaid program cannot deviate from federally imposed requirements. Should it do so, it faces the potential loss of federal expenditure reimbursement which constitutes fifty-five percent of all money spent by Florida in its operation of the Medicaid program. The program processes 100,000,000 claims annually from more than 60,000 providers, paying out approximately $6,700,000,000 each year. Even minor exceptions to the rules governing the adjudication process could have extensive impact on and consequences to the program and the benefits it imparts to the indigent health care recipients it serves.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Agency for Health Care Administration enter a final order denying as untimely Petitioner's five claims in issue. DONE and ENTERED this 22nd day of May, 1996, in Tallahassee, Florida. ARNOLD H. POLLOCK, 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 22nd day of May, 1996. APPENDIX TO RECOMMENDED ORDER, CASE NO. 95-3049 To comply with the requirements of Section 120.59(2), Florida Statutes (1993), the following rulings are made on the parties' proposed findings of fact: Petitioner's Proposed Findings of Fact. 1. - 3. Accepted and incorporated herein. First sentence accepted. Balance accepted as definitions, not Findings of Fact. - 12. Accepted. Merely a restatement of testimony in support of Petitioner's position. Not a proper Finding of Fact. Accepted. Rejected as no more than a comment on the evidence and a statement of party position. - 20. Accepted as a statement of position, but rejected as probative of any material factual issue. 21. - 24. Accepted. Accepted. & 27. Not Findings of Fact but citations of statute. 28. & 29. Accepted. Not Findings of fact but cites of agency rule. A restatement of Handbook matter. Accepted. - 35. Accepted. Accepted but non-probative argument. Rejected as contra to the weight of the evidence. - 43. Accepted. Not a Finding of Fact but a restatement of testimony. - 49. Accepted. 50. & 51. Accepted and incorporated herein. 52. - 55. Accepted. 56. - 58. Accepted. 59. & 61. Accepted, but no evidence exists that RPICC's actions constitute receipt of the claim. The evidence of record better suggests that RPICC receives information from providers based upon which it acts as billing agent for the provider and it remains incumbent upon the provider to insure it gets the pertinent information to RPICC in sufficient time for the claim to be billed within the tweleve month constrains. 62. - 65. Rejected as contra to the better evidence of record. Respondent's Proposed Findings of Fact. 1. & 2. Accepted and incorporated herein. Not a Finding of Fact but a restatement of the issue. - 7. Accepted and incorporated herein. 8. & 9. Accepted. 10. - 14. Accepted. Accepted. - 18. Accepted. 19. & 20. Accepted and incorporated herein. Not a Finding of Fact but a restatement of and comment on testimony. & 23. Accepted and incorporated herein. 24. Accepted but not probative of any material issue of issue of fact. COPIES FURNISHED: Frank P. Rainer, Esquire Ruden, McClosky, Smith, Schuster, and Russell, P.A. 215 South Monroe Street, Suite 815 Tallahassee, Florida 32310 Mark S. Thomas, Esquire Agency for Health Care Administration 2727 Mahan Drive, Suite 3407 Tallahassee, Florida 32308 Sam Power Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Tallahassee, Florida 32308 Jerome W. Hoffman General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32309
Findings Of Fact Based upon the record evidence, the following findings of fact are made: Okeechobee Health Care Facility (OHCF) is a licensed nursing home facility located in Okeechobee County, Florida. OHCF was formerly owned and operated by Okeechobee Health Care Facility, Ltd. (Okeechobee). Okeechobee was a limited partnership. Faye Williamson and her husband were its general partners. In March, 1988, Okeechobee was granted, pursuant to its request, a certificate of need (CON 5454) to add a 30-bed wing to OHCF at a cost of $810,000.00. On December 8, 1989, Okeechobee filed its final project cost report with Respondent. The report reflected that actual expenditures had exceeded the approved cost of the project by more than $650,000.00. By letter dated December 13, 1989, Respondent advised Okeechobee that it was necessary for Okeechobee "to request an expedited review for a cost overrun on this project." On February 22, 1990, Okeechobee filed a certificate of need application (CON application 6150) seeking such expedited review. The application was accompanied by a check in the amount of $750.00. Ms. Williamson, who submitted the application on behalf of Okeechobee, did so thinking that the application was complete. Following her submission of the application, she awaited Respondent's response. Based upon her prior experiences with Respondent in these matters, it was her understanding that if Respondent determined that the application was incomplete, it would so notify her. On or about March 2, 1990, Williamson, who was identified on the application as Okeechobee's authorized representative and contact person, was telephoned by an employee of Respondent's who advised her that she needed to remit an additional $1,990.04 on behalf of Okeechobee to cover the full application filing fee. Immediately following this telephone conversation, Williamson wrote out a check in the amount of $1,990.04 and mailed it to Respondent. On or about April 11, 1990, Williamson was informed that, notwithstanding what she had been telephonically advised the previous month, the $2,740.04 that already had been remitted did not constitute payment in full of the application filing fee and another $1,990.00 was still required. Upon being provided this information, Williamson sent a third check, in the amount of $1,990.00, to Respondent. In the aggregate, Respondent received $4,730.04 from Okeechobee in connection with the filing of CON application 6150. On or about April 23, 1990, Respondent, by certified mail, sent to Williamson at the address indicated on the application as her mailing address (Post Office Box 728, Okeechobee, Florida 34973), an "omissions" letter, which read in pertinent part as follows: Your application on behalf of Okeechobee Health Care Facility, Ltd. has been received for a certificate of need for a cost overrun on Certificate of Need Number 5454, to be located in Okeechobee, Florida. Certain specified elements are omitted from your proposal which are nee to implement formal review. Please respond to the items noted below. For an existing health care facility, HMO or hospice, audited financial statements of the applicant for the two previous years. (The applicant's most recent complete fiscal years of operation immediately preceding the 120 day period described above). Update for period ending December 31, 1989. 7B. Please furnish a certified copy of the resolution of the board of directors pursuant to 381.709(1)(c), Florida Statutes. Conditions predicated upon award. 2C1. Terms of Financing (Appendix 5(2C1)). Letter of commitment omitted. Section 381.709(3)(a), Florida Statutes, requires that you respond to the above omissions by May 14, 1990. Failure to provide responses by this date may result in your application being deemed incomplete and administratively withdrawn from further consideration. The United States Postal Service delivered this "omissions" letter on April 27, 1990. Kasee Wherrell was the person to whom delivery was made. At the time, Wherrell was an employee of Professional Accounting Systems of Okeechobee (PASO), which had contracted with Okeechobee to perform certain clerical and administrative services in connection with the operation of OHCF. Among Wherrell's duties as an employee of PASO was to go to the post office, pick up the regular mail in the OHCF post office box, bring it back to the OHCF business office and distribute it to the appropriate person(s). She was not authorized, however, to sign for and receive any certified mail. Wherrell never gave Williamson the "omissions letter she had retrieved from the post office. Consequently, neither Williamson nor any other Okeechobee representative responded to the letter within the time frame specified in the letter. Not having received such a response, Respondent sent Williamson the following letter, dated May 25, 1990: In accordance with the provisions of Section 381.707 and 381.709, Florida Statutes, you were given until May 14, 1990 to respond satisfactorily to the omissions noted in the correspondence from this office dated April 23, 1990 relative to your proposal for a cost overrun on Certificate of Need Number 5454. Because of your failure to provide a detailed listing of the needed capital expenditures, including sources of funds; and a certified copy of a resolution by the board of directors, your proposal has been withdrawn from further consideration, effective May 14, 1990. You have the right to request an administrative hearing on this decision under the provisions of Florida's Administrative Procedure Act, Chapter 120, Florida Statutes, and under Department Rule 10-5.010, Florida Administrative Code. A request for hearing, if any, must be actually received by this department within 21 days of the first day of publication of notice of the withdrawal in the Florida Administrative Weekly. A request for hearing must contain the information required in Rule 28-5.201, Florida Administrative Code, and must make reference to the "CON Action Number" referred to in this lit The original and one copy of each request for hearing may be filed with or mailed to the following location: Sam Power, Agency Clerk, Assistant General Counsel, Department of HRS, 1323 Winewood Blvd., Building 1, Suite 406, Tallahassee, Florida 32399-0700. Upon receiving this letter, Williamson contacted her attorney, who in turn telephoned Amy Jones, Respondent's Deputy Assistant Secretary for Regulation and Health Facilities, to explain the circumstances surrounding Okeechobee's failure to timely respond to the "omissions" letter. After Williamson's attorney made his presentation, Jones advised him that, if he desired to have Respondent formally consider the matter, he would have to submit a petition for an administrative hearing in accordance with the May 25, 1990, letter that had been sent to Williamson. Such a petition was filed with Respondent's Agency Clerk on June 21, 1990. Okeechobee no longer owns or operates OHCF. The current owner and operator of the facility is Lifestyles and Healthcare, Ltd., (Lifestyles) which acquired the facility from Okeechobee in the spring of 1990, following the submission of CON application 6150. Okeechobee was dissolved upon Lifestyles' acquisition of OHCF. On or about September 14, 1990, Lifestyles was issued a license by Respondent's Office of Licensure and Certification authorizing Lifestyles to operate OHCF. The effective date of the license, as indicated on its face, was June 19, 1990.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Department of Health and Rehabilitative Services enter a final order (1) dismissing the instant petition on the ground that the issue raised therein has become moot as a result of Okeechobee's voluntary withdrawal of CON application 6150, and (2) declining to refund the certificate of need application filing fee paid by Okeechobee in connection with the submission of CON application 6150. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 28th day of December, 1990. STUART M. LERNER 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 28th day of December, 1990.
