The Issue The issue in this case is whether the Petitioner is entitled to have her bills paid for medical services rendered to her by Tallahassee Memorial Regional Medical Center, on January 12, 1997, through January 16, 1997, by the State of Florida, Group Health Self Insurance Plan.
Findings Of Fact The Petitioner was insured under the State of Florida Employees' Group Health Self Insurance Plan (Plan) at the time of her treatment which is in question and payment therefore was denied by the Respondent. Claims were processed at the time of the Petitioner's treatment by Unisys Corporation. The Division of State Group Insurance (DSGI) administers health coverage benefits for the Plan. The processing of the payment of claims by Unisys Corporation and now by Blue Cross/Blue Shield is based on the number of employees enrolled in the Plan. Neither Unisys or Blue Cross/Blue Shield have an economic interest in whether the claim is paid. Prior to midnight on January 12, 1997, the Petitioner went to Tallahassee Memorial Regional Medical Center (Hospital) and was seen in the hospital's emergency room (ER). The Petitioner gave statements regarding her complaint and her prior activities to several doctors and nurses at the hospital. Page 71 of Joint Exhibit 1 is the Psychiatric Center Psychiatric Emergency Response Preliminary (PERP) Assessment Form filled out on January 12, 1997, at 2250 hours. Of particular note on this form is the statement by the Petitioner of an overdose of thirty 500-milligram Tylenol PM eleven hours previously. See Presenting Problems Section, aforementioned form. The form states that the Petitioner was very cooperative, was clean and neat, and was appropriately attired. Her facial expression was sad, but her posture, gait, and motor activity were unremarkable. She had logical associations. Her language was normal. Under stream of mental activity, her productivity was marked spontaneous. At the time of the review by the PERP nurse, the nurse could not conclude that the Petitioner was suicidal. The conclusion of the medical staff was summed up in the note that suicidal ideations could not be ruled out. Page 16 of Joint Exhibit 1 is the report of the admitting physician, Dr. Broadway, who stated as follows at 0100 hours (1:00 a.m.) on January 13, 1997, (abbreviations and symbols have been written out for clarity): Twenty-seven year old white, female presents to emergency room twenty-three hours after ingesting thirty tablets of Tylenol PM. Patient had an argument with her boyfriend and started drinking wine. She began taking Tylenol tablets one after another until she had taken a whole bottle. Patient awoke with nausea and vomiting, didn't feel well and thought she should be checked. She denies any thoughts of suicide. Patient history: Bi-Polar Disorder, suicide attempt at age fifteen by shooting herself in the soft tissue of neck. Medications: Lithium, 600 milligrams daily followed [monitored] by doctor. Generally awake and alert and no apparent distress, Cooperative. Physical exam without focal findings - essentially normal. Anatomy/Physiology Tylenol OD not accidental. Will start Mucomyst protocol [treatment for Tylenol overdose]. Get PREP and Psych consults. Bi-Polar - continue regular dose of Lithium. On page 13 of Joint Exhibit 1, the patient's history and report of physical examination made by a physician whose name is illegible and at an unknown time prior to 0200 hours (2:00 a.m.) on January 13, 1997, states as follows in pertinent part (the abbreviations and symbols have been written out for clarity): Personal History: Twenty-seven year old White, Female presents approximately twenty-four hours after taking thirty Tylenol. She called her Psychologist, who told her to come to the emergency room, about which time she felt "funny." She denies protracted nausea and vomiting, loss of consciousness, or change in bowel or urine. She is a manic-depressive, presently treated with Lithium, who denies suicidal intentions. Medical History: Gun shot suicide attempt in neck at age fifteen; facial lacerations as small child. Family History: Non-Contributory Social History alcohol abuse. Medication: Lithium 600 milligrams daily. Allergies: No known drug allergies Page 14, of Joint Exhibit 1, appears to be a continuation of the preceding note made on January 13, 1997, at 0200 hours (2:00 a.m.). This charting records the results of a physical examination of the Petitioner and the results of laboratory values of blood work performed on the Petitioner. At the time of her first test, the level of acetaminophen level in the Petitioner's blood was 11.1 grams per liter; however, the time the blood was drawn is not noted. The note concludes that the diagnosis and prognosis are: 1. Tylenol overdose - treat four times with Mucomyst 7.6 gram load, then 3.8 gram x 4 x 17. Monitor LFT and acetaminophen level. 2. Bi-Polar Disorder - continue Lithium four times PERP consulted. Page 15, of Joint Exhibit 1, are the notes of the Psychiatric Consult performed by Dr. Sebastian on January 13, 1997, at an unknown hour. His notes read as follows (abbreviations and symbols have been written out for clarity): Cate Stoecklin, twenty-seven year old, White Female, who took overdose of (?) [Dr. Sebastian uses the question symbol mark in the note prior to the number of pills.] thirty Tylenol because her boyfriend left her. Patient says she has been feeling panicky. She came to emergency room about twenty-four hours after taking the Tylenol. Personal History: Suicidal attempt, manic depressive illness. Family history of suicide (grandfather). Observations: Alert, reportedly nervous, answers relevantly, denies suicidal thoughts/plans, evasive [note that the copy cuts off portions of the right margin and the note may be "not evasive"]. Diagnosis: Mental depressive illness, symptoms of depression. Recommendation: Transfer to Tallahassee Memorial Psychiatric. CHAST received or reviewed signed by Dr. Sebastian The first entry in the progress notes signed by Dr. Ward is on January 14, 1997, at 0900 hours. Dr. Ward's notes at that time read as follows (abbreviations and symbols are written out for clarity when understandable): Subjective: Patient wants to see Dr. Kagin, her Psychologist. He is coming this morning to see the patient with me; she had nausea while taking Mucomyst last evening. Observation: AF/vital signs stable no SI/HI today. Cardiovascular PRRØ M lungs CTA (B) abdomen soft, mild tenderness diffusely right upper quadrant ND, liver not enlarged, no guarding or rebound Anatomy/Physiology Acetaminophen overdose - patient to complete seventeen dose course of Mucomyst to finish Thursday; SGOT and PT continued to rise, VAK given to counteract rising PT; acetaminophen levels falling; continue to monitor patient. Bi-Polar Disorder, continue Lithium; level B is circled today. H/O suicide attempt age fifteen with gun- patient Baker Act Code 52, now although she claims this acetaminophen overdose was not suicide attempt; Dr. Sebastian recommends transfer to in-patient psychiatric facility when medically stable. Will see patient with Dr. Kagin this morning, signed Dr. Ward. The family practice faculty note of January 14, 1997, following Dr. Ward's notes indicates agreement with the care, indicates the patient prefers eating vegetables, and requests a dietitian interview the Petitioner. A family practice note by Dr. Ward for January 15, 1997, at 0745 hours, reads as follows (abbreviations and symbols are written out for clarity): Subjective: Patient without complaint of cough dysnia; has emesis [vomiting] with mucomyst sometimes. Objective: temperature 101 1/2. Vital signs stable. PE: unchanged, lungs clear Anatomy/Physiology: Acetaminophen overdose. Continue Mucomyst - finishes seventeenth dose tonight; continue to monitor LFT's. Baker Act Code 52- transferred to Tallahassee Memorial Psychiatric Center in morning per Dr. Sebastian. Bi-Polar Disorder - continue Lithium. Fever - twenty-four hours no symptoms of infection monitor closely. Dr. Ward's family practice note of January 16, 1997, at 0740 hours reads as follows (abbreviations and symbols are written out for clarity): Subjective: Patient without complaint of nausea and vomiting, abdominal pain, or yellow skin. Objective: Temperature 101 PE unchanged, Anatomy/Physiology: acetaminophen overdose, Mucomyst completed; check LFT's today and perhaps transfer to Tallahassee Memorial Psychiatric Center is patient stable medically; Patient still Baker Act Code 52. Bi-Polar Disorder: Continue Lithium Fever, resolving; PDB two hours probably due to acute hepaticdic damage. The physicians' orders of January 13, 1997, at 1130 hours state: Please change chart to Drs. Ward/Eastum. Transfer to private room. Arrange twenty-four hour sitter. Cannot rule out suicidal ideations. Begin Colace, 100 milligrams two times daily. The physician's order by Dr. Ward of January 13, 1997, at 1145 hours state: Please consult psychiatric emergency response preliminary assessment (in patient consult) Baker Act Code 52 patient The nursing notes and doctor's notes regarding the patient's history are inconsistent regarding when the Petitioner took the medication. It was initially reported as having been taken eleven hours prior to admission. In some instances, the record reflects that the medication was taken twenty-four hours prior to admission. When she took the medication is critical to the Rumack-Matthew Nomogram analysis. See Paragraph 21, below. The Petitioner's blood was drawn sometime after her admission and prior to the time the results of the blood test were recorded in the notes at 1400 hours, on January 13, 1997. The test reveal Petitioner had an acetaminophen level of 11.1. As part of the protocol, the Petitioner's liver function continued to be monitored over her stay in the hospital. The review of these liver functions reveals that the Petitioner suffered from acetaminophen toxicity upon presenting at the ER. Treatment was required. Petitioner was admitted and treated at Tallahassee Memorial Hospital for an acetaminophen overdose. This treatment consisted of the Mucomyst protocol which called for the administration of Mucomyst over a two-to three-day period. The expert called by the Respondent testified regarding his examination of the liver function tests of the Petitioner. His opinion was based upon the information obtained in the lab reports, commonly accepted facts concerning acetaminophen toxicity, and his professional experience. Paramount to the expert's testimony regarding how much Tylenol Petitioner took was Petitioner's acetaminophen level of 11.1 at admission. The expert found, using the Rumack-Matthew Nomogram, that the acetaminophen level of 11.1 on admission supported the taking of a large number of Tylenol PM Twenty-four hours prior to presenting. An acetaminophen level of 11.1 does not work out as toxic in a twelve hour scenario on the Nomogram. The cautions for the use of the Rumack-Matthew Nomogram with regard to acetaminophen poisoning includes the following caution: The graph should be used only in relation to a single acute ingestion and blood value taken within 24 hours. The time coordinates refer to the time of ingestion. Serum levels drawn before four hours may not represent peak levels. The testimony of the state expert is discounted because it was based upon the evidence of the Rumack-Matthew Nomogram and the Petitioner's lab values upon admission. The use of the Rumack-Matthew monogram is limited to a single acute dose and blood levels taken within twenty-four hours. The blood work, at best, was taken right at twenty-four hours from the alleged single ingestion or, perhaps twelve hours prior to admission, if one uses the eleven-hour statement taken down by the PERP nurse. However, a blood level of acetaminophen of 11.1, eleven hours after ingestion would not indicate a toxic dose. In sum, the twenty-four hour period is based upon the Petitioner's history which is not precise, and further no one knows when the blood sample was drawn. The course of the pathology of acetaminophen toxicity based upon a single ingestion of a toxic dose is as follows: Stage One (day one 0-24 hours): Anorexia, diaphoresis, lethargy, malaise, nausea and vomiting palor. Stage Two (day two 24-48 hours): Stage One symptoms disappear; hepaticdic necrosis begins; abdominal pain and tenderness occur, enlarged liver, elevated AST, ALT, bilirubin, and PT. Stage Three (days three-four 48-96 hours): Stage One symptoms reappear; hepaticdic necrosis peaks with jaundice, encephalopathy, acute renal failure, bleeding, and hypoglycemia. Stage Four (after day four 96 hours +): A resolution of symptoms and hepatic dysfunction. The patient either dies or gets better in stage four. Had Petitioner taken a massive dose twenty-four hours prior to presenting, she would have developed physical symptoms on January 13, 1997, and her blood and liver values would have been normal on admission. Petitioner had acetaminophen blood level of 11.1 on admission, as stated above. The acetaminophen level of 11.1 is not per se toxic unless it is the residual reading after a prior massive dose as determined by reference to the Nomogram. The only scenario which explains acetaminophen toxicity upon presenting with the late on-set of observed physical symptoms and the Petitioner's acetaminophen blood levels on admission is the history given by Petitioner. The facts do not support a single massive dose, but a slower, although excessive, dosage rate. However, this latter scenario, in the absence of other supporting evidence, cannot be concluded to show an intent to harm oneself. There is no such credible evidence. The patient notes are inconsistent. The deposition of Dr. Melanie Ward, at page 9, reflects that the only physical symptom of acetaminophen overdose which she observed was tenderness in the right upper quadrant in the area of her liver. This was at 0900 hours on January 14, 1997, fifty-seven hours after the supposed overdose. On page 11 of Dr. Ward's deposition, she states that she could not say 100% whether the Petitioner really intended to hurt herself; however, they had to take the episode seriously even though the Petitioner stated she was not intending to hurt herself. Dr. Ward explains on pages 16 and 17 of her deposition, the terms PT and PTT. PT is the Prothrombin Time and activated Partial Thromboplastin Time. The doctor explains that these are liver function tests in the general sense and that an elevated PT tends to suggest that the liver is not working as well as it should. On Page 18 of Dr. Ward's deposition, she states that the Petitioner's PT values are elevated on the first test, explaining that normal value should be no higher than 12.5 and that the first value was 14.5. The doctor indicates that it then went up to 17.3 and then started trending downward. On page 21 of her deposition, Dr. Ward indicates that the Petitioner's liver enzyme tests were elevated upon admission. On page 27 of the medical records, the SGPT shows a very significant rise. On page 74 of the transcript of Dr. Ward's testimony in the hearing, the doctor indicates that the elevated enzyme readings are consistent with the Petitioner ingesting excessive amounts of acetaminophen. However, Dr. Ward states that she cannot determine how many Tylenol would have been necessary to create the toxicity. Petitioner testified by deposition. The Petitioner had had some difficulty sleeping because of breaking up with her boyfriend, and had been taking Tylenol PM, as a sleeping aid, for several days prior to her hospitalization. She reported this at the ER and that she had exceeded the maximum recommended dosage with this medication. In the twenty-four hours preceding her hospitalization, the Petitioner reported further difficulty sleeping, and taking increasing doses of acetaminophen in order to sleep while drinking the remainder of a bottle of wine which she had in her apartment. When she awoke from sleeping around 2100 hours on January 12, 1997, she was nauseated and was vomiting. Feeling poorly, she called her psychologist fearing that she was suffering from a Lithium-induced problem; however, when the psychologist learned that the Petitioner had been taking acetaminophen in combination with alcohol, he recommended that the Petitioner seek emergency treatment. It was under these circumstances that the Petitioner presented herself for treatment at the emergency room.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is RECOMMENDED: That the Plan pay the medical bills of the Petitioner. DONE AND ENTERED this 26th day of February, 1999, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 26th day of February, 1999. COPIES FURNISHED: Dr. Sara Stoecklin 1559 Christobal Drive Tallahassee, Florida 32303-5625 Joan Van Arsdall, Esquire Department of Management Services 4050 Esplanade Way, Suite 260 Tallahassee, Florida 32399-0950 Paul A. Rowell, General Counsel Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950 Thomas D. McGurk, Secretary Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950
Findings Of Fact Petitioner resigned from State Government on July 23, 1987. At the time of his resignation, Petitioner was covered under the Florida State Group Health Insurance Plan. His wife, who is a diabetic, was also covered under Petitioner's insurance. Upon termination Petitioner was eligible for continuation of coverage benefits under the federal COBRA Act. However, prior to receiving any notice of his COBRA rights, Petitioner elected to continue his State Employees' Insurance for two months from July 1, 1987 and then begin coverage under his new employer's insurance plan. 2/ Petitioner made advance payment on the 2 months additional coverage. The payments carried his State Employees' health insurance through September 1, 1987 when it was terminated. DOA notified Petitioner on August 27, 1987, of his right to elect continuation of coverage under the COBRA Act. This notice complied with the notice requirements under the COBRA Act. COBRA provides continued health insurance coverage for up to (18) months, after a covered employee leaves employment. However, coverage does not continue beyond the time the employee is covered under another group health plan. COBRA simply fills the gap between two different employers group health insurance plans so that an employee's group health insurance does not lapse while the employee changes jobs. Petitioner's new employer's health coverage began around September 1, 1987. After Petitioner had begun coverage under his new insurance plan, he discovered that his wife's preexisting diabetic condition would not be covered. However, no evidence was presented that Petitioner, within 60 days of September 1, 1987 requested the Division of State Employee's Insurance to continue his insurance coverage pursuant to COBRA. Moreover, Petitioner's COBRA rights terminated when he began his coverage under his new employer's health plan.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Administration enter a Final Order denying Petitioner's request for continuation of coverage under COBRA. DONE and ENTERED this 5th day of April, 1989, in Tallahassee, Florida. DIANE CLEAVINGER 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, 1989.
The Issue The issues in this case are whether Respondent violated Subsections 456.072(1)(gg), 456.072(1)(y), and 460.413(1)(q), Florida Statutes (2005),1 and, if so, what discipline should be imposed.
Findings Of Fact The Department is the state agency charged with the regulation of chiropractic medicine pursuant to Chapters 20, 256 and 460, Florida Statutes. Dr. Guerriero is a licensed chiropractic physician with the State of Florida, having been issued license number CH 6373 on or about August 21, 1991. The Professional Resource Network (PRN) is the impaired practitioners program for the Board of Chiropractic Medicine pursuant to Section 456.076, Florida Statutes. PRN is an independent program that monitors the evaluation, care, and treatment of impaired healthcare professionals. PRN oversees random drug screens and provides for the exchange of information between treatment providers and the Department for the protection of the public. On or about October 26, 2005, Dr. Guerriero was admitted to the Center for Drug Free Living, Inc., for detoxification related to opiate and benzodiazepine use. On October 31, 2005, he self-reported to PRN that he was discontinuing the use of benzodiazepines and opiates prescribed by his doctor and that he had entered the Center for Drug Free Living, Inc., to be weaned from these prescription medications. PRN arranged for Dr. Guerriero to be evaluated by Chowallur Dev Chacko, M.D. (Dr. Chacko), who is a psychiatrist. The evaluation was made to determine whether Dr. Guerriero's addiction problems prevented him from practicing chiropractic medicine with reasonable skill and safety to patients. Dr. Chacko saw Dr. Guerriero on November 7, 2005. Dr. Guerriero admitted to continuing the use of prescription medications containing opioids and benzodiazepines after his recent detoxification. Dr. Chacko diagnosed Dr. Guerriero as having opioid and benzodiazepine dependence, as well as suffering from alcohol abuse. It was Dr. Chacko's opinion that Dr. Guerriero was not able to practice chiropractic medicine with reasonable skill and safety. He recommended that Dr. Guerriero receive inpatient substance abuse treatment. After PRN received the evaluation performed by Dr. Chacko, there were several unsuccessful attempts to contact Dr. Guerriero. However, Dr. Guerriero did talk with his case manager on December 16, 2005, to discuss options for treatment. Dr. Guerriero maintained that he could not afford the inpatient treatment. His case manager informed him that one option would be an intensive outpatient program with no less than nine hours a week of therapy. During the therapy, Dr. Guerriero would not be allowed to practice chiropractic medicine. After the treatment was completed, Dr. Guerriero would be required to be evaluated to determine if he could practice chiropractic medicine with reasonable skill and safety to patients. Dr. Guerriero did not provide PRN with any evidence that he had completed any treatment program. PRN received no further contact from Dr. Guerriero until May 2, 2006. Dr. Guerriero indicated that he wanted to get a second opinion. On July 31, 2006, Martha E. Brown, M.D. (Dr. Brown), who is board-certified in psychiatry and addiction psychiatry, saw Dr. Guerriero for an evaluation. During the evaluation, Dr. Guerriero indicated that he was taking Dalmante, which had been prescribed for him as a sleep-aid. He admitted to drinking from one-to-two glasses of wine three times a week. Dr. Guerriero was given a drug test during the evaluation, and he tested positive for alcohol, opioid, and benzodiazepine use. Dr. Brown's diagnosis of Dr. Guerriero was that he was alcohol dependent, opiate dependent, and sedative hypnotic dependent. It is Dr. Brown's opinion that Dr. Guerriero cannot practice chiropractic medicine with reasonable skill and safety. She recommended that he enter a detoxification program and then a residential long-term treatment program, that he see a pain management specialist to look at his pain issues, that he see a psychiatrist acceptable to PRN to help him with his sleep difficulties, that he abstain from all mood altering substances including alcohol, and that he be in PRN for long-term monitoring. Dr. Guerriero did not provide PRN with proof that he had completed an inpatient program. He did not execute a contract with PRN. PRN sent Dr. Guerriero contracts to sign, but the contracts were returned as unclaimed. The last contact that Dr. Guerriero had with PRN was on August 31, 2006. Jerome M. Gropper, D.D.S. (Dr. Gropper), is a clinical network coordinator at PRN. He is a practicing dentist and has a master's degree in counseling. Based on his review of the PRN file of Dr. Guerriero, he is of the opinion that Dr. Guerriero could not practice chiropractic medicine with reasonable skill and safety and that Dr. Guerriero will need long-term residential treatment before he could safely return to practice. Based on the opinions of Drs. Chacko, Brown, and Gropper, Dr. Guerriero cannot practice chiropractic medicine with reasonable skill and safety to his patients due to his dependence on drugs and alcohol. In order to be able to return to practice chiropractic medicine, Dr. Guerriero will need long- term residential treatment and will need to enter into a monitoring contract with PRN.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered finding that Dr. Guerriero violated Subsections 456.072(1)(y), 456.072(1)(gg), and 460.413(1)(q), Florida Statutes; imposing a $1,000 administrative fine; and suspending his license until such time the following conditions are satisfied: Dr. Guerriero executes a PRN advocacy contract, Dr. Guerriero successfully completes a six-month period in which he complies with all of PRN's treatment recommendations, PRN appears before the Board and advocates for Dr. Guerriero's return to active practice during a Board meeting in which Dr. Guerriero is present, and (4) the Board determines that Dr. Guerriero is able to practice with reasonable skill and safety. DONE AND ENTERED this 7th day of May, 2007, in Tallahassee, Leon County, Florida. S SUSAN B. HARRELL Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 7th day of May, 2007.
The Issue The issue for determination in this case is whether certain provisions of the Florida Title XIX Long-Term Care Reimbursement Plan, as adopted in Rule 59G-6.010, Florida Administrative Code, which are relied upon by the AGENCY FOR HEALTH CARE ADMINISTRATION to apply a fair rental value system of property reimbursement to Petitioner are invalid under Section 120.56, Florida Statutes (1995). Petitioner also asserts a state and federal constitutional equal protection challenge to the existing rule provisions. (Petitioner’s constitutional issues are preserved, but are not determined in this proceeding.)
Findings Of Fact Petitioner, CONSULTING MANAGEMENT AND EDUCATION, INC., d/b/a GULF COAST NURSING AND REHABILITATION CENTER (CME), is the licensed operator of a 103-bed nursing home in Clearwater, Florida, which is presently known as GULF COAST NURSING AND REHABILITATION CENTER (GULF COAST). CME participates in the Florida Medicaid Program as an enrolled provider. Respondent, AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA), is the agency of the State of Florida authorized to implement and administer the Florida Medicaid Program, and is the successor agency to the former Department of Health and Rehabilitative Services, pursuant to Chapter 93-129, Laws of Florida. Stipulated Facts Prior to 1993, the GULF COAST nursing home facility was known as COUNTRY PLACE OF CLEARWATER (COUNTRY PLACE), and was owned and operated by the Clearwater Limited Partnership, a limited partnership which is not related to CME. In 1993 CME agreed to purchase, and did in fact purchase, COUNTRY PLACE from the Clearwater Limited Partnership. Simultaneous with the purchase of COUNTRY PLACE, CME entered into a Sale/Leaseback Agreement with LTC Properties, Inc., a Maryland real estate investment trust which engages in the financing of nursing homes. The Purchase and Sale Agreement between Clearwater Limited Partnership and CME was contingent upon the Sale/Leaseback Agreement and the proposed Lease between CME and LTC Properties, Inc. On September 1, 1993, CME simultaneously as a part of the same transaction purchased COUNTRY PLACE, conveyed the facility to LTC Properties, Inc., and leased the facility back from LTC Properties, Inc. As required, CME had notified AHCA of the proposed transaction. AHCA determined that the transaction included a change of ownership and, by lease, a change of provider. CME complied with AHCA's requirements and became the licensed operator and Medicaid provider for COUNTRY PLACE. Thereafter, CME changed the name of the facility to GULF COAST. After CME acquired the facility and became the licensed operator and Medicaid provider, AHCA continued to reimburse CME the same per diem reimbursement which had been paid to the previous provider (plus certain inflation factors) until CME filed its initial cost report, as required for new rate setting. In the normal course of business, CME in 1995 filed its initial Medicaid cost report after an initial period of actual operation by CME. Upon review of the cost report, AHCA contended that the cost report was inaccurate and engaged in certain "cost settlement" adjustments. During this review, AHCA took the position that CME's property reimbursement should be based on FRVS methodologies rather than "cost" due to the lease. In November of 1995, CME received from AHCA various documents which recalculated all components of Petitioner's Medicaid reimbursement rates for all periods subsequent to CME's acquisition of the facility. In effect, AHCA placed CME on FRVS property reimbursement. The practical effect of AHCA's action was to reduce CME's property reimbursement both retroactively and prospectively. The retroactive application would result in a liability of CME to AHCA, due to a claimed overpayment by AHCA. The prospective application would (and has) resulted in a reduction of revenues. CME is substantially affected by AHCA's proposed action and by Sections I.B., III.G.2.d.(1), V.E.1.h., and V.E.4. of the Florida Medicaid Plan. Additional Findings of Fact The Florida Medicaid Plan establishes methodologies for reimbursement of a nursing home's operating costs and patient care costs, as well as property costs. The dispute in this matter relates only to reimbursement of property costs. CME as the operator of the GULF COAST nursing home facility is entitled to reimbursement of property costs in accordance with the Florida Medicaid Plan. CME as the operator of the GULF COAST facility entered into a Florida Medicaid Program Provider Agreement, agreeing to abide by the provisions of the Florida Medicaid Plan. The Sale/Leaseback Agreement entered into by CME and LTC Properties Inc. (LTC) specifically provides for a distinct sale of the nursing home facility to LTC. LTC holds record fee title to GULF COAST. LTC, a Maryland corporation, is not related to CME, a Colorado corporation. The Florida Medicaid Plan is intended to provide reimbursement for reasonable costs incurred by economically and efficiently operated facilities. The Florida Medicaid Plan pays a single per diem rate for all levels of nursing care. After a nursing home facility's first year of operation, a cost settling process is conducted with AHCA which results in a final cost report. The final cost report serves as a baseline for reimbursement over the following years. Subsequent to the first year of operation, a facility files its cost report annually. AHCA normally adjusts a facility's reimbursement rate twice a year based upon the factors provided for in the Florida Medicaid Plan. The rate-setting process takes a provider through Section II of the Plan relating to cost finding and audits resulting in cost adjustments. CME submitted the appropriate cost reports after its first year of operation of the GULF COAST facility. Section III of the Florida Medicaid Plan specifies the areas of allowable costs. Under the Allowable Costs Section III.G.2.d.(1) in the Florida Title XIX Plan, a facility with a lease executed on or after October 1, 1985, shall be reimbursed for lease costs and other property costs under the Fair Rental Value System (FRVS). AHCA has treated all leases the same under FRVS since that time. AHCA does not distinguish between types of leases under the FRVS method. The method for the FRVS calculation is provided in Section V.E.1.a-g of the Florida Medicaid Plan. A “hold harmless” exception to application of the FRVS method is provided for at Section V.E.1.h of the Florida Medicaid Plan, and Section V.E.4 of the Plan provides that new owners shall receive the prior owner’s cost-based method when the prior owner was not on FRVS under the hold harmless provision. As a lessee and not the holder of record fee title to the facility, neither of those provisions apply to CME. At the time CME acquired the facility, there was an indication that the Sale/Leaseback transaction with LTC was between related parties, so that until the 1995 cost settlement, CME was receiving the prior owner’s cost-based property method of reimbursement. When AHCA determined that the Sale/Leaseback transaction between CME and LTC was not between related parties, AHCA set CME’s property reimbursement component under FRVS as a lessee. Property reimbursement based on the FRVS methodology does not depend on actual period property costs. Under the FRVS methodology, all leases after October 1985 are treated the same. For purposes of reimbursement, AHCA does not recognize any distinction between various types of leases. For accounting reporting purposes, the Sale/Leaseback transaction between CME and LTD is treated as a capital lease, or “virtual purchase” of the facility. This accounting treatment, however, is limited to a reporting function, with the underlying theory being merely that of providing a financing mechanism. Record fee ownership remains with LTC. CME, as the lease holder, may not encumber title to the facility. The Florida Medicaid Plan does not distinguish between a sale/leaseback transaction and other types of lease arrangements. Sections IV.D., V.E.1.h., and V.E.4., the “hold harmless” and “change of ownership” provisions which allow a new owner to receive the prior owner’s method of reimbursement if FRVS would produce a loss for the new owner, are limited within the Plan’s organizational context, and within the context of the Plan, to owner/operators of facilities, and grandfathered lessee/operators. These provisions do not apply to leases executed after October 1, 1985. Capital leases are an accounting construct for reporting purposes, which is inapplicable when the Florida Medicaid Plan specifically addresses this issue. The Florida Medicaid Plan specifically addresses the treatment of leases entered into after October 1985 and provides that reimbursement will be made pursuant to the FRVS method. The Florida Medicaid Plan is the result of lengthy workshops and negotiations between the agency and the nursing home industry. The Florida Medicaid Plan complies with federal regulations.
The Issue Whether Petitioner's laser in situ keratomileusis (LASIK) surgery is a covered service for which he is entitled payment/reimbursement under the State of Florida's Self-Insured Group Health Insurance Program.
Findings Of Fact At all times pertinent to these proceedings, Petitioner was a state employee covered under the State of Florida Self- Insured Group Insurance Plan. The provisions of the "State Employees' PPO Plan Group Health Insurance Plan Booklet and Benefit Document" applies to the issues herein. The State of Florida's third party administrator, Blue Cross and Blue Shield of Florida denied prior authorization for Petitioner's LASIK surgery. The Division of State Group Insurance, which administers the State Plan, upheld Blue Cross and Blue Shield's denial of prior authorization by proposed agency action letter dated July 11, 2000. Petitioner timely requested a formal hearing. Petitioner proceeded with LASIK surgery without prior authorization. Petitioner here requests that charges for his LASIK surgery be reimbursed by the State Plan. LASIK surgery is a treatment in which part of the cornea of each eye is removed and reshaped to correct myopia (nearsightedness) or hyperopia (farsightedness). Prior to his LASIK surgery, Petitioner suffered from myopia, a refractive disorder of the eyes. Petitioner's myopia was not the result of an accident or cataract surgery. The evidence is unrefuted and substantial that Petitioner experienced difficulty in his job because of his vision. He had difficulty reading multiple computer screens and documents. His difficulty was acute when shifting his gaze back and forth from one computer screen to another or back and forth from a document to a computer screen. Petitioner's employment performance suffered as a result of his vision problems, and he got headaches. Petitioner attributed his difficulty to the inadequacy of his vision, as corrected by glasses. He tried both bifocals and "sophisticated bifocals," but he felt he lost considerable peripheral vision with any glasses. Petitioner consulted with two optometrists, Dr. Douglas Jones and Dr. Thomas Barnard. Prior to the LASIK surgery, Dr. Jones and Dr. Barnard agreed that Petitioner's vision was functionally correct to 20/20, with glasses. However, both suggested that LASIK surgery would be beneficial for Petitioner. Only this information was provided with Petitioner's authorization request to Blue Cross and Blue Shield for prior authorization. Petitioner is 50 years old and had the LASIK surgery approximately two months prior to the formal hearing. Petitioner's ability to function in his job improved after the LASIK surgery. By his testimony at formal hearing, Dr. Barnard testified that one of Petitioner's eyes was not correctable with glasses exactly to 20/20 but was, in fact, "20/20-", which meant that Petitioner may have been able to read most of the letters on the 20/20 line but may have missed one or two of them. Nonetheless, Dr. Barnard agreed that this status or diagnosis is considered functional. Dr. Barnard also testified that any person with myopia is going to have some loss of peripheral vision with the use of glasses, depending on the prescription. Further, he testified that as we age the difficulty in getting a good correction at different distances is just something that people have to put up with after the age of forty. Dr. Barnard has a preference for LASIK surgery over glasses. According to Dr. William Cobb, ophthalmologist, most people with myopia benefit from LASIK surgery when it is successful. The designation of "20/20" vision means that the judgment of acuity of vision is made at a distance of 20 feet. In ophthalmology, all visions are measured by 20/20, which gives a basis for comparison. Glasses can be made to allow for acuity of vision at any stated distance for any specific function. Most people using a computer must have trifocals or special lenses to use with the computer. If trifocal lenses are not adequate, then progressive lenses can be used for multiple focusing distances. In Dr. Cobb's opinion, Petitioner should have been able to obtain glasses to solve his visual problems at specific distances. LASIK surgery corrects vision in the same functional way as glasses, in that it is performed to focus the eyes at one specified distance. The pertinent provision of the "State Employees' PPO Plan Group Health Insurance Plan Booklet and Benefit Document" provides: The following services and supplies are excluded from coverage under this health insurance plan unless a specific exception is noted. Exceptions may be subject to certain coverage limitations. * * * 11. Services and supplies for treating or diagnosing refractive disorders (vision errors which can be corrected with glasses) including eye glasses, contact lenses, or the examination for the prescribing or fitting of eye glasses or contact lenses, unless required because of an accident or cataract surgery that occurred while covered by this health insurance plan. This health insurance plan will cover the first pair of eye glasses or contact lenses following an accident to the eye or cataract surgery. The Division of State Group Insurance has uniformly interpreted this provision to exclude any payment for contact lenses, glasses, or LASIK surgery. The only exception to the exclusion is the stated provision for glasses or contact lenses following cataract surgery or following an accident that affected vision. State employees may purchase supplemental insurance that covers vision care and provides reimbursement for LASIK surgery.
Recommendation Upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Department of Management Services, Division of State Group Insurance, issue a final order determining that Petitioner is not entitled to payment for LASIK surgery and dismissing his petition. DONE AND ENTERED this 11th day of December, 2000, in Tallahassee, Leon County, Florida. ELLA JANE P. DAVIS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 11th day of December, 2000. COPIES FURNISHED: Kenneth E. Gesser Apartment D-23 4100 Southwest 20th Avenue Gainesville, Florida 32607 Julie P. Forrester, Esquire Department of Management Services 4050 Esplanade Way, Suite 260 Tallahassee, Florida 32399-0950 Thomas D. McGurk, Secretary Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950 Bruce Hoffmann, General Counsel Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950
The Issue Whether Petitioner's Medicaid provider number should be cancelled for the reason stated in Respondent's October 1, 1995, letter to Petitioner?
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Petitioner is a provider of community mental health services. It provides these services to residents of Palm Beach County and the surrounding areas. Some of the services it provides are unique to the area it serves. Petitioner provides services to Medicaid recipients pursuant to a Medicaid provider agreement dated September 6, 1994, paragraphs 8 and 9 of which provide as follows: The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. The agreement may be terminated upon thirty days written notice by either party. The Depart- ment may terminate this agreement in accordance with Chapter 120, Florida Statutes. Petitioner has attempted to enter into a contract with the Department of Health and Rehabilitative Services' Alcohol, Drug Abuse and Mental Health office (hereinafter referred to as "ADM"), but to date has been unable to do so because ADM has not had the money to fund such a contract.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered terminating Petitioner's provider agreement and cancelling its provider number on the grounds that it "does not have a contract with the [Department of Health and Rehabilitative Services] ADM [Alcohol, Drug Abuse and Mental Health] office." DONE and ENTERED this 26th day of February, 1996, at Tallahassee, Leon County, Florida. STUART M. LERNER, Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 SC 278-9675 Filed with the Clerk of the Division of Administrative Hearings this 26th day of February, 1996. COPIES FURNISHED: Darlene Silvernail, Esquire Forest Hill Counseling Center 2624 Forest Hill Boulevard West Palm Beach, Florida 33406 Gordon B. Scott, Esquire Agency for Health Care Administration 2727 Mahan Drive, Fort Knox Number 3 Tallahassee, Florida 32308-5403 Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Fort Knox Number 3 Tallahassee, Florida 32308-5403 Sam Power, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Fort Knox Number 3 Tallahassee, Florida 32308-5403
The Issue Is Petitioner entitled to reimbursement under the State of Florida Employees Group Health Self Insurance Plan for $300.00 she spent for chiropractic treatment between 11/16/83 and 01/23/84?
Findings Of Fact Petitioner is and has been an employee of the State of Florida for a number of years. In February of 1974, she subscribed to the general group health insurance plan offered by the State of Florida Employees Group Health Self Insurance Plan under contract no. 264158282. Blue Cross of Florida Inc. and Blue Shield of Florida Inc. are the designated claims agent/administrator for the general plan and its options/addenda. Petitioner was first treated by Dr. Steven M. Willis, D.C., in January, 1983. She did not initially present to Dr. Willis, a chiropractor, for trauma but for symptoms of chronic sciatica and leg pain. She was treated the remainder of that month for sciatica but did not subscribe to the state group health plan until February 1, 1983. Although her application for chiropractic coverage was not offered or admitted in evidence, Petitioner testified that she answered all questions thereon and Respondent did not affirmatively raise any issues of lack of coverage due to effective date of coverage, or due to addendum changes, or due to concealment or due to fraud and on the basis of Petitioner's exhibits as a whole, I find that she acquired chiropractic coverage during a period of open enrollment and that from February 1, 1983 on, the plan took her as it found her and provided complete chiropractic coverage. In dispute in this cause are a series of chiropractic treatments and charges incurred by the Petitioner with Dr. Willis. Claims for the following dates of treatment were made in the name of a health care provider, Robert G. Hildreth, D.C." Dr. Hildreth made the formal claims upon Petitioner's assignment to the Centerville Road Chiropractic Clinic in which both chiropractors are partners. There is no dispute that the following treatments were rendered by Dr. Willis and properly assigned for payment by Petitioner: 11/16/83 - $20.00 12/21/03 - $6.44 11/22/83 - $20.00 12/29/83 - $20.00 11/28/83 - $20.00 01/03/84 - $20.00 12/05/83 - $20.00 01/06/84 - $20.00 12/09/83 - $20.00 01/13/84 - $20.00 12/14/83 - $20.00 01/17/84 - $20.00 12/19/83 - $20.00 01/19/84 - $20.00 12/21/83 - $20.00 01/23/84 - $20.00 Claims for some or all of these treatments/amounts were submitted by the chiropractors a number of times and rejected by Blue Cross/Blue Shield as the state administrator a number of times. Petitioner conceded at hearing that the 12/21/83 charge in the amount of $6.44 was properly rejected for lack of coverage of supplies costs. The first rejection of some of the other charges was for failure of the doctors' bookkeeper to include the correct diagnosis and procedure codes on the claims forms. This was corrected and resubmitted and thereafter all of the charges for treatment were rejected (either together or piecemeal) for payment upon grounds that 26 visits had already been paid for and that after the maximum number of 26 visits has been paid the state plan pays for no more chiropractic visits. Blue Cross/Blue Shield resumed paying for chiropractic treatment for the chronic back and leg problems on 1/27/84. In light of Blue Cross/Blue Shield's earlier response, Petitioner and Dr. Willis concluded that this must be because a new year was beginning and a new 26 visits would be paid annually. However, Respondent stipulated at hearing, that although private Blue Cross/Blue Shield insurance plans may have such a maximum, the state plan has no such 26 visits annual maximum. Petitioner and Dr. Willis questioned Blue Cross/Blue Shield about its 26 visit annual maximum reason for rejection, so Blue Cross/Blue Shield sent a "review sheet" asking Dr. Willis to justify his diagnosis and treatment. His justification was supplied on the review sheet (R-1) dated February 27, 1984. After review, Blue Cross/Blue Shield advised Petitioner and Dr. Willis that payment for these treatments had been determined not to be "medically necessary" by its chiropractic board of review. Petitioner responded with a timely request for Section 120.57(1) hearing. Petitioner eventually paid for the treatments in question out of her own pocket. In support of her position that her treatments (all of which may be generically described as "spine adjustments") are "medically necessary, Petitioner offered the testimony of Dr. Willis, the treating chiropractor. In addition to relating facts, I find Dr. Willis by education, training, and experience is capable of giving expert opinions in the field of chiropractic medicine. Dr. Willis testified that he first saw Petitioner on 1/12/83 for sciatic pain in both legs. After taking a complete history revealing previous orthopedic treatment locally with Dr. Haney and previous podiatric treatment locally with Dr. Merritt, treatment with another doctor in Orlando and with another podiatrist in Texas, Dr. Willis initially diagnosed acute lumbosacral neuralgia and treated Petitioner 3 times per week for 6 weeks. He opined that Petitioner's case was unusual in that Petitioner wanted to remain as athletically active as possible, including but not limited to running 10-50 miles per week and participating in a number of sports. Dr. Willis subsequently revised his diagnosis to make it bilateral sacrilization at the L-5/S-1 vertebrae, anterior gravitational syndrome and hyperimbrication at the L4/L5 vertebrae. Put into laymen's terms, Petitioner's L-4 / L-5 vertebrae do not have full range of motion and this results in Petitioner's low back pain at that level. In Dr. Willis' opinion, due to a congenital abnormality, in Petitioner, her condition is not fully correctable. On 4/5/83, Petitioner came to Dr. Willis with back pain which he diagnosed as the result of a trauma occurring as a result of weight lifting Petitioner had done on 4/4/83, and subsequently she suffered a trauma to the unstable back while windsurfing. On 10/28/83, Petitioner reported pain in the medial aspect of her left foot which Dr. Willis diagnosed as tendonitis. In January, 1984 he referred her to Dr. Merritt, a local podiatrist for a severe left shin/ankle/ metatarsal problem. These various diagnoses, treatments, and referrals, are important to the instant issue involving spine adjustment treatments between 11/16/83 and 01/23/84 for chronic back pain at L-4 through S- 1 because they serve to illustrate diagnosis and treatment differences between trauma situations and continuing treatment for exacerbations of the chronic back and foot/leg problems for which cost of treatment reimbursement is sought. "Apparently, however, there was no problem with payment of any fees charged until 11/16/83 (the twenty-seventh visit in 1983), and clearly payments resumed as soon as the calendar rolled over to 1984. Dr. Willis further diagnosed concluded that there is pedal instability of Petitioner's foot resulting in ankle and shin problems and that these problems in turn create an imbalance; the imbalance in turn causes great wear and tear in the lumbar (low back) region. The low back is again exacerbated by increased periods of activity. During these periods of exacerbation he treats Petitioner's chronic back pain with spine adjustments. There may be long periods between exacerbations when treatments are not necessary. It is for the periods of exacerbation that the treatments in question were administered and for which Petitioner seeks reimbursement. Although Dr. Willis conceded on cross-examination that frequency of treatment in a case like Petitioner's is a matter of chiropractic judgment and also that opinions among health care providers and especially chiropractors may differ as to whether the treatments he has provided to Petitioner are medically necessary or not, he states emphatically that in his professional opinion they are medically necessary. Upon consideration of all the testimony and evidence, I find the treatments between 11/16/83 and 01/23/84 to be remedial as opposed to merely palliative in nature due to the considerable instability of both the back and foot which continued to be exacerbated by Petitioner's particular lifestyle. Both Petitioner and her doctor testified that chiropractic treatment sessions in her case have always included preventive counselling as well as therapeutic treatment. The goal of such counselling is to substitute non-exacerbating or less-exacerbating recreational activities for those Petitioner would otherwise pursue (i.e. weight training and swimming in place of running and wind surfing).
Recommendation Upon the foregoing findings of fact and conclusions of law it is RECOMMENDED that the Department of Administration enter a Final Order finding Petitioner's treatments in question "medically necessary and ordering the plan administrator (Blue Cross/Blue Shield) to reimburse her $300.00 therefor (amount claimed less the admittedly "not covered" $6.44 supplies charge on 12/21/83.). DONE and ORDERED this 2nd day of May, 1985, in Tallahassee, Florida. ELLA JANE P. DAVIS 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 2nd day of May, 1985. COPIES FURNISHED: Dara Houliston 2308 Notley Court Tallahassee, Florida 32308 Daniel C. Brown, Esquire General Counsel Department of Administration 435 Carlton Building Tallahassee, Florida 32301 Gilda Lambert, Secretary Department of Administration 435 Carlton Building Tallahassee, Florida 32301
Findings Of Fact Petitioner, Patricia A. Wotring, is an employee of the Department of Health and Rehabilitative Services. At all times relevant hereto she was enrolled as a member of the State of Florida Employees Group Health Self Insurance Plan (Plan). The State of Florida is a self-insurer. It has contracted with Blue Cross - Blue Shield to act as its administrator in processing and paying all claims by employees under the Plan. Claims are suppose to be paid-in accordance with coverage requirements, limitations and exclusions that have been adopted by the State. These requirements are set forth in the Employees Group Health Self Insurance Booklet (Booklet) which has been received in evidence as respondent's exhibit 1. Between November, 1982 and January, 1983 petitioner submitted five claims for benefits with Blue Cross - Blue Shield. The claims totaled $633, of which $620 were for mental health services provided by a Tallahassee clinical psychologist and $13 for laboratory services performed by a Tallahassee physician. Although Blue Cross - Blue Shield had been "instructed" to not pay this type of claim, the claims were nonetheless honored in early 1983 and Wotring received checks at that time for $633. Upon advice from respondent, Department of Administration, Blue Cross - Blue Shield requested reimbursement from petitioner in June, 1983 for $633. That request prompted the instant proceeding. As a basis for claiming reimbursement, Blue Cross - Blue Shield relied upon Section H of the Exclusions portion of the Booklet. That section reads as follows: No payment shall be made under the Plan for the following: H. Services, care, treatment, and supplies furnished by a person who ordinarily resides in the Insured's home or by any person or institution not otherwise defined in the Definitions section of this booklet. (Emphasis Added) It then referred to page 39 of the Booklet which defines a "physician" as follows: "Physician" shall mean the following: a doctor of medicine (M.D.), doctor of osteopathy (D.O.), doctor of surgical chiropody (D.S.C.) or doctor of podiatric medicine (D.P.M.), who is legally qualified and licensed to practice medicine and perform surgery at the time and place the service is rendered; a licensed chiropractor acting within the scope of his/her license, provided the insured receiving his/her services is covered under the chiropractic coverage option of the Plan and the proper premium has been paid; a licensed dentist who performs specific surgical procedures covered by the Plan, or who renders services due to injuries resulting from Accidents, provided such procedures or services are within the scope of the dentist's professional license; a licensed optometrist who performs procedures covered by the Plan provided such procedures are within the scope of the optometrist's professional license. A clinical psychologist is not defined within the Definitions section of the Plan. Because a clinical psychologist does not fall within the definition of a physician, and is not otherwise defined within that section, the services received by Wotring were properly excluded from coverage by the Plan. Effective October 1, 1983, the Legislature amended the law to require that services rendered by a clinical psychologist be covered by the Plan. In the event payments are made in error, the Department's policy is to instruct its Administrator (Blue Cross - Blue Shield) to request reimbursement from the insured. Petitioner acknowledged that the five claims were paid in error. However, she contended that the claims were submitted in good faith over a period of time and were honored. Accordingly, she argues it is wrong to now require her to repay those amounts.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that petitioner repay respondent $613 for payments previously received in error that are not covered by the Plan. It is further RECOMMENDED that in view of the size of the amount owed, petitioner be allowed to repay that amount on an installment basis over a six-month period, if she so chooses. It is further RECOMMENDED that she not be required to repay $20 to respondent if all deductibles for the appropriate calendar year have been met. DONE and ENTERED this 18th day of November, 1983, in Tallahassee, Florida. DONALD R. ALEXANDER 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 18th day of November, 1983. COPIES FURNISHED: Patricia A. Wotring 1833 Mayfair Road Tallahassee, Florida 32303 Daniel C. Brown, Esquire 435 Carlton Building Tallahassee, Florida 32301 Nevin G. Smith, Secretary Department of Administration Room 435, Carlton Building Tallahassee, Florida 32301
