Colonnade Medical Center, Inc. v. State, 4D02-1026.

• Decision Date: 23 April 2003
• Docket Number: No. 4D02-1026.,4D02-1026.
• Citation: 847 So.2d 540
• Parties: COLONNADE MEDICAL CENTER, INC., Appellant, v. STATE of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, Appellee.
• Court: Florida District Court of Appeals

847 So.2d 540

COLONNADE MEDICAL CENTER, INC., Appellant, v. STATE of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, Appellee.

No. 4D02-1026.

District Court of Appeal of Florida, Fourth District.

April 23, 2003.

Richard A. Serafini, Chris M. Morrison, and Teri L. DiGiulian of Broad and Cassel, Fort Lauderdale, for appellant.

Garnett W. Chisenhall, Assistant General Counsel, Tallahassee, for appellee.

STONE, J.

Colonnade Medical Center, Inc. (Colonnade) appeals a final order of the Agency for Health Care Administration (AHCA) ordering it to remit $49,965.30 in Medicaid overpayments. We affirm.

Colonnade operates a nursing home. Under chapter 7 of the institutional provider handbook, a nursing home may apply for supplemental payment for Medicaid recipients with AIDS, known as "H" supplemental payments, provided that certain prerequisites are met. The individual must be diagnosed as HIV positive, have laboratory confirmation of a reactive screening test for HIV antibodies, and must be receiving active treatment for a condition that meets the Center for Disease Control definition of AIDS. As a pre-condition to receiving "H" supplemental payment, a nursing home must request and receive prior authorization from Medicaid. A request for prior authorization must contain: (1) a letter from the facility requesting the "H" supplemental payment; (2) a copy of the admission cover sheet; (3) a confirming HIV test; and (4) a signed physician letter or statement documenting current treatment for an opportunistic AIDS-related disease.

During the audit period in question, Colonnade billed for and received from Medicaid $49,965.30 in "H" supplemental payments without first seeking prior authorization or having the AHCA perform a prior authorization review in violation of chapter 7. The AHCA sent Colonnade an audit report indicating it had determined that the amount constituted overpayment and ordered repayment of same.

After a formal administrative hearing, the administrative law judge (ALJ) held that the payments at issue constitute "overpayments" as defined by section 409.913(1)(d), Florida Statutes. The ALJ construed section 409.913(14) as conferring upon the AHCA the authority to demand a repayment of an overpayment. The ALJ ruled that Colonnade's argument that the AHCA lacked the authority to demand repayment was based on an overly narrow construction of the statute and should be rejected. The AHCA issued a final order and adopted the findings of fact and conclusions of law set forth in the recommended order and ordered Colonnade to remit $49,965.30 in Medicaid overpayments to the AHCA.

Colonnade asserts that the AHCA's interpretation of section 409.913 is erroneous. We conclude that the plain meaning of the statute dictates that it is within the AHCA's power to demand repayment.

Section 409.913, Florida Statutes, charges the AHCA with oversight of the integrity of the Medicaid program. Further, section 409.913(14) provides that:

[t]he agency may seek any remedy provided by law, including but not limited to, the remedies provided in subsections (12) and (15) and s. 812.035, if:

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(d) The provider has failed to maintain medical records made at the time of service, or prior to service if prior authorization is required, demonstrating the necessity and appropriateness of the goods or services rendered;

(e) The provider is not in compliance with provisions of Medicaid provider publications that have been adopted by reference as rules in the Florida Administrative Code, with provisions of state or federal laws, rules, or regulations; with provisions of the provider agreement between the agency and the provider; or with certifications found on claim forms or on transmittal forms for electronically submitted claims that are submitted by the provider or authorized representative, as such provisions apply to the Medicaid program.

Colonnade failed to maintain and provide the necessary medical records in order for AHCA to conduct a prior authorization. Furthermore, Colonnade failed to comply with Medicaid provider publications, i.e., chapter 7 of the institutional provider handbook, by not requesting and receiving prior authorization from Medicaid. Under the statute, the AHCA could seek "any remedy provided by law." Recovery of the overpayment...