Williams v. Triple J Enterprises, 94-1351

• Decision Date: 24 February 1995
• Docket Number: No. 94-1351,94-1351
• Citation: 650 So.2d 1114
• Parties: 20 Fla. L. Weekly D491 Emerson WILLIAMS, Appellant, v. TRIPLE J ENTERPRISES and Erc, Inc., Appellees.
• Court: Florida District Court of Appeals

Page 1114

650 So.2d 1114

20 Fla. L. Weekly D491

Emerson WILLIAMS, Appellant, v. TRIPLE J ENTERPRISES and Erc, Inc., Appellees.

No. 94-1351.

District Court of Appeal of Florida First District.

Feb. 24, 1995.

Brett K. Findler of Findler & Findler, P.A., and Randy D. Ellison, West Palm Beach, for appellant.

Kennie L. Edwards of Danielson, Clarke, Pumpian & Ford, P.A., West Palm Beach, for appellees.

DAVIS, Judge.

Emerson Williams appeals an order of the Judge of Compensation Claims (JCC) denying his claim for reimbursement for the cost of prescriptions ordered by his authorized treating physician. The denial is based upon a determination by the JCC that she lacked jurisdiction due to an ongoing overutilization review instigated by the employer and servicing agent (E/SA). We hold that the JCC erred in concluding that she lacked jurisdiction and reverse.

Mr. Williams was injured while acting in the course and scope of his employment on April 5, 1983, when he fell off a roof. There is no dispute over the fact that his physical injuries were compensable, as well as the emotional problems associated with his physical injuries. The parties stipulated that Mr. Williams reached maximum medical improvement (MMI) in January 1985. However, he has continued to receive care from a series of authorized psychiatrists, most recently Dr. Cunningham. Dr. Cunningham testified that he began treating Mr. Williams on February 5, 1990. Mr. Williams' treatment plan for approximately four years before the hearing below included nine different medications, costing approximately $626 a month. The employer and servicing agent initiated an overutilization review of claimant's prescriptions some time in 1993, although the exact date is not apparent from the record. As a part of the overutilization review process, Dr. Robert Mignone, a board certified psychiatrist, conducted a records review in June 1993, followed by an independent medical examination of the claimant and opined that the claimant was malingering, or faking his disorder. Thereafter the e/sa disallowed claimant's prescriptions but did not undertake to deauthorize the claimant's treating psychiatrist, Dr. Lowell Cunningham. In order to continue obtaining the prescriptions of his authorized treating psychiatrist, Mr. Williams had personally incurred expenses of approximately $1700 (using funds borrowed from his daughter) as of the time of the hearing.

Mr. Williams filed a claim seeking reimbursement for the cost of the prescriptions ordered by Dr. Cunningham. Although Mr. Williams asserts that this claim encompassed a request for payment of future prescriptions as well as reimbursement for the prescriptions already purchased, it is not possible to tell from the record on appeal whether the question of future prescriptions was presented to the JCC. The JCC did not rule on the claimant's entitlement to the prescriptions in the future. As to the request for reimbursement for the previously purchased prescriptions, she ruled:

The issue of the past prescriptions issued by Dr. Cunningham is one that is problematical for the undersigned. Based upon the testimony of that physician and the Claimant, he is clearly taking a large number of medications which Dr. Mignone believes are not indicated. The matter is or has been the subject of utilization review on the reasonableness and necessity of the prescriptions and accordingly the undersigned is without jurisdiction to resolve this dispute. Matters of utilization review and reimbursement pursuant to the medical and surgical fee schedule are solely within the province of the Division of Workers' Compensation. Accordingly, the provider (in this case Dr. Cunningham) would need to pursue any avenue that is available to him through the utilization review process as opposed to having this matter determined by the undersigned.

The JCC erred in characterizing this claim as a "matter of utilization review" and in declining to exercise jurisdiction over the claim presented to her. Once Mr. Williams filed his claim for reimbursement of these prescriptions and the e/sa defended against that claim based upon the contention that the medications were unnecessary, the medical necessity of that care was placed in issue before the JCC and should have been resolved by her. Carswell v. Broderick Construction, 583 So.2d 803, 804 (Fla. 1st DCA 1991) (the JCC "assures that the injured claimant receives appropriate medical treatment, authorizes health care providers in disputes between the claimant and the employer/carrier, approves payment of medical bills presented in proper form, and resolves conflicts between health care providers as to the medical status of the claimant...."). In Carswell v. Broderick Construction this court held that the JCC lacked jurisdiction over a dispute between a physician and a carrier concerning the amount of the doctor's bills.

The present case is more similar to, and is governed by, Wolk v. Jaylen Homes, Inc., 593 So.2d 1058 (Fla. 1st DCA 1992), in which this court held that the JCC had jurisdiction to resolve the issue of...