A.C. v. Agency for Health Care Admin.
| Decision Date | 08 July 2020 |
| Docket Number | No. 3D19-365,3D19-365 |
| Parties | A.C. c/o V.R., Appellant, v. Agency for Health Care Administration, Appellee. |
| Court | Florida District Court of Appeals |
Not final until disposition of timely filed motion for rehearing.
An Appeal from the Florida Agency for Health Care Administration, Office of Fair Hearings.
Jacksonville Area Legal Aid, Inc., and James A. Kowalski, Jr. (Jacksonville); Florida Health Justice Project, Inc., and Katy DeBriere (Jacksonville), for appellant.
Tracy Lee Cooper George, Chief Appellate Counsel, and Nicholas A. Merlin, Senior Attorney (Tallahassee), for appellee.
Before SALTER, LINDSEY and MILLER, JJ.
A.C., a disabled 13-year-old child, through her mother and authorized representative below, V.R., appeals a final order of the Florida Agency for Health Care Administration ("AHCA"), which dismissed her request for a Medicaid fair hearing. A.C.'s request concerned AHCA's termination of A.C.'s occupational therapy services. We reverse and remand the case for further proceedings because the final order is not supported by competent and substantial evidence in this record.
A.C. has been enrolled in Florida's Medicaid Prescribed Pediatric Extended Care (PPEC) program1 and has received medically necessary benefits since June of 2015.2 Her treating physician reported a diagnosis of "encephalopathy, left sided schizencephaly and cerebral palsy which is manifested by right sided weakness and motor impairments." The occupational therapy services requested, and at issue inthis appeal, are to help her perform various motor skills and communicate effectively.
On September 6, 2018, A.C.'s PPEC provider, Children's Rehab Network3 (CRN), submitted a request to eQHealth Solutions, Inc.—AHCA's contractor for medical necessity determinations for Medicaid benefits—for occupational therapy services. On October 24, 2018, eQHealth denied A.C.'s request in part because of a "Technical Reason" and also because the information submitted "does not support the medical necessity for [the] requested services." Specifically, the request for dates of service from September 6, 2018 through October 4, 2018, was denied because the request was submitted too late. The request for dates of service from October 5, 2018 through March 4, 2019, was denied because "no dated physician signature or clarification of the hours requested was submitted." The notice informed A.C. of her right to reconsideration of the decision and her right to request a Medicaid fair hearing. The notice was signed by a physician who reviewed the request and made the decision "based on the information provided." Two days later, A.C.'s medical provider CRN faxed a 17-page follow-up confirming that a total of 364 unit hours of therapy were requested. The documents faxed to AHCA included a dated physician signature authorization for the therapy services on the last page.On the facsimile memo page, the provider included the following: "Reconsideration—Total units should be 364 units (units missing)."
On October 28, 2018, eQHealth sent its notice of reconsideration determination upholding its denial of the requested services. The notice explained that, The "medical basis" for the reconsideration decision was that (1) records showed A.C. "was receiving [Occupational Therapy] services from another provider also," (2) the provider was asked "to provide clarification" on the issue and did not provide such clarification, and (3) a proper review cannot be done.4 The notice again informed A.C. of her right to request a Medicaid fair hearing to challenge the decision. The reconsideration notice was signed by the same physician who made the initial decision to deny the occupational therapy services, despite the above-quoted language providing that a different physician had reviewed the materials as part of the reconsideration review process.
On November 1, 2018, A.C., through her mother, V.R., filed a request for a Medicaid fair hearing to challenge AHCA's denial of her request for occupational therapy services. Thereafter, on November 19, 2018, AHCA's hearing officer, assigned to A.C.'s case, issued an order requesting "documentation to show cause why the request for Fair Hearing should not be dismissed for failure to file a written authorization" for designation of an authorized representative on A.C.'s behalf. V.R. timely complied with the order to show cause and faxed the requested written authorization designating herself as A.C.'s authorized representative. V.R. also faxed AHCA a "Letter of Appeal" from A.C.'s occupational therapist at CRN confirming A.C.'s numerous disabilities and that she is "an excellent candidate for continuation of skilled [Occupational Therapy] services."
On December 10, 2018, AHCA's Office of Fair Hearings issued an order scheduling a telephonic hearing on January 29, 2019, at 9:00 a.m., regarding A.C.'s request for occupational therapy services. The order specified that the hearing will be governed by Rule 59G-1.100, Florida Administrative Code. It ordered AHCA to "send any documents they intend to present as evidence at the Fair Hearing." The order provided information on rescheduling the hearing if the recipient or authorized representative cannot appear at the scheduled date and time. And it specified that, "[i]f the Recipient or Authorized Representative fails to appear for the hearing as scheduled in this Order, without good cause, the request for hearing will beconsidered abandoned." Lastly, the recipient or authorized representative was ordered "to send any documents they intend to present at the Fair Hearing to the Hearing Officer" at the mailing or e-mail address specified "no later than ten (10) days prior to the hearing date." The record shows that, on December 12, 2018, two days after the hearing was scheduled, AHCA received a letter from a neurologist at Neuro Network Partners about A.C.'s medical diagnosis stating, "it is essential for her to receive occupational therapy." The record also shows that eQHealth submitted 200 pages for the hearing on behalf of AHCA. The package included call-in instructions, notices of the hearing, A.C.'s prior authorization clinical information, documents of the initial and reconsideration decisions, and additional information in eQHealth's file regarding A.C.'s request for therapy services.
In eQHealth's 200-page submission there is a letter from V.R. confirming that her daughter: (1) had been attending CRN since August 27, 2018, (2) had stopped attending her previous PPEC provider on August 17, 2018, and (3) was evaluated for occupational, physical, and speech therapy at CRN. V.R.'s letter concluded with a plea to have her daughter begin her therapy sessions "as soon as possible" at CRN for "the 6 month period beginning on 9/6/18 to 3/4/19." V.R. signed and dated her letter October 11, 2018. While there is no stamped date of receipt by AHCA on the copy of V.R.'s letter in the record, it appears eQHealth received the letter since it was made part of the documents submitted for the hearing on behalf of AHCA.V.R.'s letter appears to have been sent in response to eQHealth's request for additional information prior to its reconsideration decision upholding its denial of the occupational therapy services.5
On January 29, 2019, the hearing officer issued an order to show cause after V.R. failed to appear at the scheduled telephonic hearing. The hearing officer ordered V.R. to "submit . . . on or before February 8, 2019, an explanation to show cause why the request for a Fair Hearing should not be dismissed for failure to appear at the scheduled Fair Hearing." The order specified that failure to comply would result in dismissal of the case.
On February 8, 2019, V.R. provided the requested explanation by e-mail. She explained that she had become disabled and had a Supplemental Security Income appointment "at the very same hour and day and was not notified." A stamp appears on a copy of the e-mail message in the record showing that it was received by AHCA on February 11, 2019. Florida Administrative Code Rule 59G-1.100(5)(a) provides that, "[a]ny pleading or paper received by the Office before 5:00 p.m. on a business day shall be filed as of that day." V.R. sent her explanation by e-mail on a businessday before 5:00 p.m. and thus, it is deemed timely filed and in compliance with the hearing officer's order to show cause.
On February 18, 2019, the hearing officer issued a final order concluding that A.C.'s fair hearing request was deemed abandoned and closing the case. The final order specifies that, "[o]n February 11, 2019, the Office received a written communication from [A.C.]'s authorized representative [V.R.] that she had another appointment on the same date and time of the hearing." The hearing officer concluded that V.R.'s explanation did not establish "good cause" under Rule 59G-1.100(2)(n), Florida Administrative Code. This appeal followed.
On July 31, 2019, before the case was fully briefed, AHCA filed a motion to determine whether A.C.'s mother, V.R., is legally authorized to represent A.C. in the instant appeal. On September 11, 2019, the Court issued an order on AHCA's motion concluding that V.R. was authorized to proceed on behalf of her disabled minor child "absent further order or guidance from The Florida Bar or Florida Supreme Court." A.C. v. Agency for Health Care Admin., 44 Fla. L. Weekly D2279 (Fla. 3d DCA Sept. 11, 2019). The Court also abated the case for sixty days "to allow a non-profit legal service provider or Florida-licensed attorney to volunteer pro bono assistance" to A.C. Id.
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