Opinion
Nos. 1D19-1631 1D19-1632 1D19-1633 1D19-1634 1D19-1635 1D19-1636 1D19-1637 1D19-1638
05-24-2021
1D19–1631, PREMIER BEHAVIORAL SOLUTIONS OF FLORIDA, INC. d/b/a Suncoast Behavioral Health Center ; 1D19–1632, Wekiva Springs Center, LLC d/b/a Wekiva Springs ; 1D19–1633, Windmoor Healthcare, Inc.; 1D19–1634, Fort Lauderdale Hospital; 1D19–1635, La Amistad Residential Treatment Center, LLC d/b/a Central Florida Behavioral Hospital ; 1D19–1636, La Amistad Residential Treatment Center, LLC; 1D19–1637, Emerald Coast Behavioral Hospital, LLC; 1D19–1638, University Behavioral, LLC d/b/a University Behavioral Center, Appellants, v. MAGELLAN COMPLETE CARE, Appellee in All Cases.
Geoffrey D. Smith, Susan C. Smith, and Stephen B. Burch of Smith & Associates, Melbourne, for Appellants. Stephen A. Ecenia and Jennifer Forshey Hinson of Rutledge Ecenia, P.A., Tallahassee, for Appellee.
Geoffrey D. Smith, Susan C. Smith, and Stephen B. Burch of Smith & Associates, Melbourne, for Appellants.
Stephen A. Ecenia and Jennifer Forshey Hinson of Rutledge Ecenia, P.A., Tallahassee, for Appellee.
Kelsey, J.
These consolidated appeals involve the costs of using an optional statutory process to resolve health care payment disputes. See § 408.7057, Fla. Stat. (2018). Appellants provide in-patient mental health services. Appellee Magellan is a health plan that processes and pays claims for Appellants’ services provided to Magellan's members. The parties disagreed about reimbursement amounts. They agreed to use the statutory process, which resolved many of the disputed claims, the merits of which are not at issue here. The issue is how much the dispute-resolution company charged for its services, and specifically whether Appellants should have had a chance to challenge costs after the company finished its review and submitted its recommended resolutions to the Florida Agency for Health Care Administration (AHCA) for approval. We reject Appellants’ arguments, and affirm.
Governing Statutes and Rule.
Section 408.7057 requires AHCA to "establish a program to provide assistance to contracted and noncontracted providers and health plans for resolution of claim disputes that are not resolved by the provider and the health plan." § 408.7057(2)(a), Fla. Stat. The statute requires AHCA to contract with a third-party dispute-resolution company to handle disputes like this. Id. AHCA contracted with Maximus, Inc. (Maximus) (which is not a party here) to serve as the statutory dispute-resolution organization.
The statute also mandates that the losing party pay the resolution organization's costs. § 408.7057(6), Fla. Stat. ("The entity that does not prevail in the agency's order must pay a review cost to the review organization, as determined by agency rule."). The statute required AHCA to adopt a rule to apportion costs if both parties prevail in part. Id. AHCA promulgated such a rule, requiring costs to be apportioned in proportion to the final judgment, based on the disputed claim amount, if both parties prevail in part. Fla. Admin. Code R. 59A-12.030(4)(b). Neither the statute nor the rule addresses any further details about costs.
Finally, and importantly for these cases, the statute expressly mandates that AHCA "shall adopt" the recommended order as a final order: "Within 30 days after receipt of the recommendation of the resolution organization, the agency shall adopt the recommendation as a final order." § 408.7057(4), Fla. Stat. The statute and rule do not provide for exceptions or further review by AHCA. The sole review authorized in section 408.7057(4) is judicial review pursuant to section 120.68 of the Florida Statutes (governing administrative appeals). Id.
Costs Charged.
Appellants retained a third party to handle this dispute-resolution process. That third party submitted "filing cover sheets" for each Appellant's claims, providing basic information, and checking "yes" to request a fee estimate for each Appellant. Maximus responded with letters stating a maximum fee for each batch of claims, noting that the initial quote was based on preliminary review and could increase based on the issues raised. Maximus stated that it would advise Appellants if the fee were to increase, and give them the chance to withdraw from the process. Maximus advised Appellants that it would allocate costs to each filing party (provider) based on the percentage of the amount in dispute awarded to the provider. Maximus asked each Appellant to indicate whether it wished to withdraw at that point; or, alternatively, to accept the quote at the amount of the maximum, which was specified on each form, and proceed to review of the case. Each Appellant checked the box that stated, "I accept the quote of [specified maximum dollar amount] and wish to proceed with the review of this case." Appellants proceeded to submit their disputed claims to Maximus.
After completing its reviews of eligible claims (which were fewer than the number submitted), Maximus invoiced the parties for its costs. The invoiced costs ranged from a low of $3,510 for twelve claims with an amount in dispute of $35,900, to a high of $19,110 for a set of ninety-eight claims involving $281,250. Costs were allocated in inverse proportion to percentage of success. Taking just one example from the record, where Maximus awarded the provider only six percent of the amount in dispute, Maximus charged the provider ninety-four percent of the review cost, charging Magellan the remaining six percent of the cost. The total costs charged equaled the maximum amount Maximus had quoted previously, to which each Appellant had agreed, through its representative. Appellants nevertheless confronted Maximus about its decision to charge the maximum. Maximus responded that its "actual labor exceeded the estimated quote." Maximus did not provide any further explanation or detail as to its labor.
Simultaneously with invoicing the parties for its costs of review, Maximus submitted to AHCA written recommendations describing its resolution of the claims and reflecting the review costs imposed. These recommendations did not make findings of fact about the costs or about the number of claims reviewed out of those initially submitted.
Appellants wanted to challenge the costs and wanted more information about how Maximus arrived at the costs charged. They sent correspondence to AHCA's Deputy Secretary; AHCA declined to respond. AHCA entered final orders as required by statute, incorporating Maximus's written recommendations and the associated invoices. Appellants moved to vacate the final orders, which AHCA denied. Appellants paid the invoiced costs, which would have been subject to statutory penalties if not paid promptly. See § 408.7057(6), Fla. Stat. This appeal followed.
Analysis.
On appeal, Appellants challenge AHCA's final orders as not being supported by competent, substantial evidence. They also argue that they were deprived of due process because they had no way to challenge the costs Maximus imposed in its simultaneous invoices and written recommendations. We must reject both arguments, because the process Appellants elected to use comported with statutory requirements and our prior holdings upholding the statutes. Appellants are not entitled to relief on appeal.
CSE.
Appellants argue that AHCA's final orders violate section 120.68 of the Florida Statutes because the orders are not supported by competent, substantial evidence. § 120.68(7)(b), Fla. Stat. (permitting this Court to reverse if agency action "depends on any finding of fact that is not supported by competent, substantial evidence in the record of a hearing conducted pursuant to ss. 120.569 and 120.57"). Here, however, because Appellants elected the statutory dispute-resolution process rather than administrative litigation, they were not entitled to an evidentiary hearing under the Administrative Procedure Act, and none was held. Thus, there is no administrative hearing record in this or any similar cases. Section 120.68 does not provide any basis for us to reverse AHCA's orders.
Further, the only agency action before us is AHCA's entry of final orders, which is an act the statute expressly mandates without requiring or allowing AHCA to conduct any review or fact-finding. § 408.7057(4), Fla. Stat. ("Within 30 days after receipt of the recommendation of the resolution organization, the agency shall adopt the recommendation as a final order."). This is consistent with the private, voluntary procedure for resolving these disputes, which Appellants elected to follow.
Finally, AHCA had Maximus's invoices, and incorporated them into its final orders. The sole agency acts we review—entry of final orders—complied with the statute. See Baycare Health Sys., Inc. v. Agency for Health Care Admin. , 940 So. 2d 563, 570 (Fla. 2d DCA 2006) (finding this private dispute-resolution process a voluntary relinquishment of constitutional protections that would attach to state action, which were available but not utilized). We therefore reject Appellants’ competent-substantial-evidence argument.
Due Process.
Appellants also argue that their inability to challenge the costs after Maximus issued its written recommendations deprived them of due process. We have rejected this argument before, and we reject it again. See Blue Cross Blue Shield of Fla. v. Outpatient Surgery Ctr. of St. Augustine , 66 So. 3d 952, 953–54 (Fla. 1st DCA 2011) (finding this statutory process is constitutional and expressly rejecting a due-process challenge against it); see also Baycare , 940 So. 2d at 568–70 (acknowledging that the process may be minimal and afford minimal protections, but the provider voluntarily selected it, thereby selecting any "inadequacies"; and equating the process to voluntary arbitration where whatever limits exist are known and selected). We recognize, and are not unsympathetic to, Appellants’ argument that they received from Maximus insufficient detail about how costs would be and were calculated. But the record reflects that Maximus offered to provide a quote, and did so, quoting a maximum to each Appellant. This information did not provide the detail Appellants now claim they wanted, yet Appellants did not pursue the matter with Maximus at that time or, as far as our record reveals, in civil litigation. Instead, Appellants expressly agreed to pay the maximum cost Maximus quoted each of them (subject to proration between the prevailing and non-prevailing parties pursuant to the statute and rule). That is the cost Maximus charged. Appellants had a "point of entry" to get that information from Maximus up front, or to withdraw from the process, and they did not do either.
Conclusion.
We emphasize that this is an elective, alternative dispute resolution process. By the terms of its statutory creation, it eliminates procedures and remedies that would be available in typical administrative or civil litigation. Appellants opted into this process, and expressly agreed to the maximum cost quotes without requesting or securing any additional information or terms about calculation of costs or contingent developments in the review process. To the extent they do not like this valid dispute-resolution process as it exists under the statute, their remedy is to decline to use it, or to address their concerns to the Florida Legislature.
AFFIRMED .
Ray, C.J., and B.L. Thomas, J., concur.