Court Opinion

ID: 2748597
Source: CourtListenerOpinion
Date Created: 2014-11-06 16:02:52.55315+00
Date Added: 2024-06-11T13:05:37.275184
License: Public Domain

IN THE DISTRICT COURT OF APPEAL
                                    FIRST DISTRICT, STATE OF FLORIDA

FLORIDA HOSPITAL                    NOT FINAL UNTIL TIME EXPIRES TO
ORLANDO,                            FILE MOTION FOR REHEARING AND
                                    DISPOSITION THEREOF IF FILED
      Appellant,
                                    CASE NO. 1D14-178
v.

STATE OF FLORIDA,
AGENCY FOR HEALTH CARE
ADMINISTRATION,

      Appellee.

_____________________________/

Opinion filed November 6, 2014.

An appeal from an order of the Agency for Health Care Administration.
Elizabeth Dudek, Secretary.

John D. Buchanan, Jr. and Joseph V. Gardner of Henry, Buchanan, Hudson, Suber,
& Carter, P.A., Tallahassee, for Appellant.

Tracy Lee George, Assistant General Counsel, and Cynthia L. Hain, Assistant
General Counsel, Agency for Health Care Administration, Tallahassee, for
Appellee.

PER CURIAM.

      This appeal arises out of a Medicaid integrity audit of Florida Hospital

Orlando’s (“Hospital”) inpatient services claims. As a result of the audit, the

Agency for Health Care Administration (“AHCA”) determined it had reimbursed
the Hospital for services submitted to Medicaid which were not “medically

necessary.” See § 409.913(1)(d), Fla. Stat. (2013). After a hearing, AHCA issued a

Final Order adopting the administrative law judge’s findings of fact, conclusions of

law, and recommendation that the Hospital repay certain overpayments, as well as

a small fine and costs.

      On appeal, the Hospital asserts that AHCA and its auditor unlawfully

reviewed entire patient files to determine whether each patients’ inpatient

admission was a “medical necessity,” without limiting the audit to just the

information that was available to the Hospital at the time that the patient was

admitted. The Hospital asserts that it is unlawful and unfair for AHCA’s auditors

to deny reimbursements based on hindsight analyses of entire patient files, which

give greater and better information than was available to the Hospital’s doctors

when they made the real-time decisions to admit their patients to the hospital.

      The Hospital is correct about how “medical necessity” must be determined

for purposes of section 409.913(1)(d). The statute is perfectly clear that

“[d]eterminations of medical necessity . . . must be based upon information

available at the time the goods or services are provided.” § 409.913(1)(d), Fla.

Stat. (emphasis added). It gives no room for evaluating medical necessity

determinations post hoc, using later-available information “from a post-discharge

standpoint,” as the Hospital alleges here.

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      Nevertheless, with respect to the fourteen subject patients at issue in this

appeal, the Hospital has not shown that AHCA and its auditor relied on hindsight

information in penalizing the Hospital’s admission decisions. Rather, the record

supports the administrative law judge’s finding adopted by AHCA that the claims

were “described and evaluated based upon the medical documentation available to

the treating physician at the time the services were rendered.” And so we must

affirm.

      AFFIRMED.

WOLF, ROBERTS, and OSTERHAUS, JJ., CONCUR.

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