CopyCited 9 times | Published | Florida 4th District Court of Appeal
...Merkle's claims under section
641.513(5) and for declaratory relief fail to state a cause of action because section
641.513(5) does not authorize a private cause of action for its violation. Thus, Merkle must assert his claims through an alternative dispute resolution process provided for in section
408.7057, Florida Statutes....
...The HMOs argue further that the only avenues for vindication of Merkle's rights under section
641.513(5) are either (1) filing a claim under ERISA, the federal Employee Retirement Income Security Act, or (2) participating in the alternative dispute resolution process established in section
408.7057, Florida Statutes. We decline to address ERISA's applicability to this case, as the issue was not discussed or raised below, and we disagree with the HMOs' contention that dispute resolution under section
408.7057 is mandatory. Section
408.7057(2)(a), Florida Statutes (2005), provides in pertinent part, that: [T]he [Florida Agency for Health Care Administration (AHCA)] shall establish a program by January 1, 2001, to provide assistance to contracted and noncontracted provid...
...n. The agency shall contract with a resolution organization to timely review and consider claim disputes submitted by providers and health plans and recommend to the agency an appropriate resolution of those disputes. *1198 There is no indication in section 408.7057 that the dispute resolution process is mandatory....
...In Adventist Health, the court noted the following: We disagree that anything in the language of the statute manifests an intent by the Legislature to confer upon [AHCA] exclusive jurisdiction to resolve this dispute, nor do we agree that the statutory, voluntary dispute resolution process established pursuant to section 408.7057, Florida Statutes (2005), must first be exhausted....
...pecific payment amounts would comply with Section
641.513(5)(b), Florida Statutes. . . .'" Instead, the AHCA directed the parties to bring this issue before a `court of competent jurisdiction or the provider dispute resolution program as outlined in section
408.7057.'
934 So.2d at 604 n....
...Health v. Garcia-Rivera, M.D.,
814 So.2d 537, 538 (Fla. 3d DCA 2002) (finding that class action proceedings may be appropriate despite arbitration provisions in agreements between providers and HMOs). Thus, while the dispute resolution process under section
408.7057 may provide an adequate review of a non-participating provider's claims under section
641.513(5), [3] it is not the only avenue of review....
...[3] The HMOs argue correctly that the dispute resolution process results in final agency orders that may be appealed to the district courts of appeal, and that AHCA can order HMOs to make additional payments to providers on disputed claims submitted to the dispute resolution program. See §
408.7057, Fla. Stat. (2005); §
120.68(1), Fla. Stat. (2005); Fla. Admin. Code R. 59A-12.030(3)(4) (2006); Fla. R.App. P. 9.030. [4] Merkle argues also that the dispute resolution process cannot be the exclusive remedy because the enabling statute, section
408.7057, was passed years after section
641.513(5)....
CopyCited 3 times | Published | Florida 1st District Court of Appeal
...dopted the recommendations of the fact-finder, Maximus, Inc., an independent third-party claim-dispute-resolution entity, selected by AHCA to review claim disputes between health providers and managed care organizations pursuant to the provisions of section 408.7057, Florida Statutes (2002)....
...ntractual charge at each BayCare facility. Health Options responded by instead paying BayCare at 120 percent of the Medicare reimbursement rate. In order to resolve the controversy, BayCare utilized the claim-dispute-resolution procedure provided in section 408.7057, and, after the parties' submission of evidence in five of the eight cases, Maximus made recommendations in four cases that were generally favorable to Health Options' reimbursement position....
...had been completed. We begin our analysis with adherence to the rule that in construing a statute's terms, the polestar that guides a court's inquiry is the legislative intent. McLaughlin v. State,
721 So.2d 1170 (Fla.1998). The express language of section
408.7057 itself sheds very little light on *852 whether the legislature intended the resolution-dispute mechanism to be binding. BayCare defends the orders by pointing out that section
408.7057(4) requires AHCA to adopt the recommendation of the resolution organization within 30 days after its receipt....
...Resolution, on the other hand, is defined as a "formal expression of an opinion, intention, or decision by an official body or assembly...." BLACK'S LAW DICTIONARY at 1313. Clearly, the term resolution has a far greater imprimatur of authority than that accorded mediation. Given the history of section 408.7057, we cannot accept the argument that the legislature decided to reject a dispute mechanism which was clearly nonbinding, only to replace it with another nonbinding process whose only difference was the language used in its final version. When one indulges the presumption that the legislature knows existing law as well as the judicial constructions placed thereon, the legislative intent becomes even more evident. As reflected in the historical development of section 408.7057, the legislature drafted and later rejected language in subsection (4), requiring AHCA *853 "to issue a final order subject to the provisions of chapter 120." The reference to the Administrative Procedure Act (APA) is no longer conta...
...5th DCA 1988): "After the fact-finder retires to deliberate the outcome, it is too late under Rule 1.420(a) [Florida Rule of Civil Procedure 1.420(a)] to take a voluntary dismissal." Id. at 1169. [4] Although the resolution-dispute process now provided in section
408.7057 is not expressly required to comply with chapter 120, we find it highly persuasive that the legislature, presumed to be cognizant of APA procedures and aware of the judicial interpretations placed on them, initially considered and thereafter rejected modeling an agency's review powers after those in section
120.57, with the result that a recommendation of the resolution organization must be accepted, under the provisions *854 of section
408.7057(4), as the agency's final order....
...[2] Judicial deference to an agency's construction of a statute is not required if the statute is unrelated to the regulatory functions of the agency. See Chiles v. Dep't of State, Div. Of Elections,
711 So.2d 151, 155 (Fla. 1st DCA 1998). Thus, if a statute, such as section
408.7057, which prescribes only a procedure for the resolution of disputed health-care claims, involves no policy "considerations for which" an agency has been entrusted "special responsibility," McDonald v....
...1st DCA 1977), the agency "is in no better position than the court to interpret such a statute." Chiles,
711 So.2d at 155. We therefore reject AHCA's argument that we should apply the clearly erroneous review standard to its interpretation. [3] Pursuant to section
408.7057(2)(a), AHCA was required to establish the dispute resolution program by January 1, 2001....
CopyCited 2 times | Published | Florida 1st District Court of Appeal | 2006 Fla. App. LEXIS 424, 2006 WL 141052
...This matter arises from a claims dispute resolution process between the parties. In December 2004, the Agency for Health Care Administration ("AHCA") received a recommended order from Maximus, the organization under contract with AHCA for the dispute resolution process, in favor of appellee. Pursuant to section 408.7057, Florida Statutes (2004), AHCA issued a final order, adopting Maximus' recommendation....
...mit the parties to request AHCA, the proper forum, to vacate the order. After jurisdiction was relinquished, AHCA denied the joint motion, stating: Unfortunately, while the parties' arguments in support of their Motion are laudable, [AHCA] concludes section 408.7057, Florida Statutes (2005), the statutory scheme governing this matter, allows AHCA no discretion to vacate the Final Order. Specifically, Section 408.7057(4) states that within 30 days after receipt of the resolution organization's recommendation, the "agency shall adopt the recommendation as a final order." Because administrative agencies are creatures of statute and only have those p...
...However, when jurisdiction over this matter returns to the First District Court of Appeal, [AHCA] respectfully suggests the Parties renew their request *621 for the Court to vacate the Final Order. While AHCA is merely a tribunal in proceedings under section
408.7057, the Court appears to be the only tribunal with the legal authority to grant the relief sought by the Parties. Moreover, if AHCA's interpretation of section
408.7057 is erroneous, then the Court has the authority under section
120.68(7), Florida Statutes (2005), to set aside the agency action at issue. (Citation omitted). AHCA's interpretation of section
408.7057 is not one that we need give deference. See Health Options, Inc. v. Agency for Health Care Admin.,
889 So.2d 849, 851 & n. 2 (Fla. 1st DCA 2004). Section
408.7057(2)(a), Florida Statutes (2005), directs AHCA to establish a dispute resolution program to "provide assistance to contracted and non-contracted providers and health plans for resolution of claim disputes that are not resolved by the provider and the health plan." (Emphasis added). By the plain language of the statute, the dispute resolution program only applies to unresolved claim disputes. Because the parties have resolved their claim disputes at issue, section
408.7057(4) does not prohibit AHCA from vacating its prior final order to facilitate the parties' settlement....
CopyCited 1 times | Published | Florida 2nd District Court of Appeal
...by Health Options, Inc., a health maintenance organization that is a wholly owned subsidiary of Blue Cross/Blue Shield of Florida, Inc. The AHCA's orders were entered based upon the results of a voluntary dispute resolution process, provided for by section
408.7057, Florida Statutes (2002). Consistent with the requirements of section
408.7057 and the holding of the First District in Health Options, Inc. v. Agency for Health Care Administration,
889 So.2d 849 (Fla. 1st DCA 2004), the orders adopt the recommendation of Maximus Center for Health Dispute Resolution (Maximus CHDR), an "independent third-party claim-dispute-resolution entity." See §
408.7057(1)(c), (4). Baycare asks this court to hold section
408.7057 and the AHCA's rules implementing this dispute resolution process unconstitutional....
...In large part, the dispute between the parties centered on the reimbursement rates for emergency medical care. To resolve this dispute, Baycare filed a series of claims with Maximus CHDR, the third-party claim-dispute-resolution organization with which the AHCA has contracted pursuant to section 408.7057 to resolve claims between medical service providers and insurers....
...commendation to deny the majority of Baycare's claims for reimbursement from Health Options and four orders denying Baycare any further administrative process before the AHCA. II. THE LIMITED EFFICACY OF THE DISPUTE RESOLUTION PROCESS ESTABLISHED BY SECTION 408.7057 Section 408.7057 authorizes certain parties to elect to use a nonjudicial forum to resolve health insurance claim disputes....
...arge class of pending claims. The undisclosed panel of decision-makers utilized by Maximus CHDR ruled against Baycare, and Baycare has been trying ever since to obtain a second opinion from a court. This case demonstrates that the process created by section 408.7057 is not an adequate method to resolve legal issues of first impression that involve the payment of millions of dollars....
...Health Options and the AHCA, however, have not focused their arguments on the validity of the legal determination ultimately made by Maximus CHDR. [7] Instead, Health Options and the AHCA assert that Baycare voluntarily invoked the alternative third-party claim-dispute-resolution process of section
408.7057; that the AHCA's adoption of Maximus CHDR's recommendation was mandated first by section
408.7057 and confirmed by the First District in Health Options,
889 So.2d 849; that the shortcomings of the voluntary dispute resolution process do not implicate due process; and that our limited scope of review under section
120.68 does not permit this court to reverse the AHCA's orders, which were essentially ministerial. We agree. III. DUE PROCESS Baycare argues that section
408.7057 and the rules implementing the alternative third-party claim-dispute-resolution forum established by the statute are facially unconstitutional because they improperly delegate quasi-judicial power to Maximus CHDR without imposing adequate standards, guidelines, or criteria as to how to exercise that power....
...ue process protections would apply, the state did not deprive Baycare of its due process rights; Baycare chose to forego them, perhaps in the hopes of a more expedient resolution to its claims. Baycare seeks to impose upon the process established by section
408.7057 the due process requirements normally afforded to administrative proceedings under sections
120.569 and
120.57(1). However, nothing in the statutes supports this argument. Section
408.7057 creates a voluntary process that is an alternative to the formal administrative process, as evinced by the requirement in section
408.7057(4) that the agency receiving a recommendation from the resolution organization "shall adopt the recommendation as a final order." Further, as discussed above, due process does not require more....
...THIS COURT'S REVIEW OF THE AHCA ORDERS Under section
120.68(7), Florida Statutes (2002), this court may set aside an *570 agency action or remand a case for further proceedings only under specific circumstances. Baycare argues that the AHCA's orders erroneously interpret section
408.7057, were entered without a hearing, and are unsupported by competent, substantial evidence. Section
408.7057(4) states that the AHCA "shall" adopt Maximus CHDR's "recommendation as a final order." The First District concluded that this required the entry of the final orders now on appeal....
...gency's factual findings. Our jurisdiction and our standards of review in administrative law are, as a general rule, issues that are established by the legislature through the enactment of a general statute. See art. V, § 4(b)(2), Fla. Const. Under section 408.7057, neither we nor the AHCA may review the merits of the decision of Maximus CHDR so long as it was entered in accordance with the statute. Because the alternative dispute resolution process offered by section 408.7057 is completely voluntary, and because Baycare elected to initiate that process and forego the rights it otherwise would have had to a civil action in circuit court, Baycare has not been deprived of due process of law. Further, the AHCA has complied with section 408.7057 and the mandate of Health Options I, and there is no basis for us to set aside its orders....
CopyPublished | Florida 1st District Court of Appeal | 2011 WL 1449514
...Scott Warburton of Adams, Coogler, Watson, Merkel, West Palm Beach, for Outpatient Surgery Center of St. Augustine, LLC., Appellee. DODSON, CHARLES W., Associate Judge. These consolidated appeals challenge the constitutionality of the dispute resolution process established by section 408.7057, Florida Statutes (2009), as applied to a respondent....
...to direct payment from Blue Cross. They bill their patients (in these cases Blue Cross customers), who are reimbursed by Blue Cross. In these cases the Providers claimed underpayment by Blue Cross and submitted their disputes to Maximus. Pursuant to section 408.7057 and the applicable administrative rule, Maximus obtained documentation from Blue Cross and the Providers. After review of that documentation, Maximus applied its procedure for determining the reimbursement amount and made its recommendation to AHCA. That recommendation was adopted by AHCA, as required by section 408.7057(4), and a final order entered....
...1976) ("[T]he legislature is presumed to have intended to enact a valid and constitutional law and ... we will construe a statute, if possible, in such a manner as will be conducive to its constitutionality."). The courts have consistently referred to the procedure outlined in section
408.7057 as "voluntary." See Baycare Health Sys., Inc. v. Agency for Health Care Admin.,
940 So.2d 563, 569 (Fla. 2d DCA 2006) (concluding that section
408.7057 "creates a voluntary process that is an alternative to the formal administrative process"); Merkle v. Health Options, Inc.,
940 So.2d 1190 (Fla. 4th DCA 2006) (finding "no indication in section
408.7057 that the dispute resolution process is mandatory"); Adventist Health Sys./Sunbelt, Inc. v. Blue Cross and Blue Shield,
934 So.2d 602, 604 n. 2 (Fla. 5th DCA 2006) (denying that "the statutory, voluntary dispute resolution process established pursuant to section
408.7057, Florida Statutes (2005), must first be exhausted"). The statute provides at section
408.7057(2)(b)6 that the resolution organization shall review disputed claims unless the claim "is the basis for an action pending in state or federal court." Thus, after these claims were filed with Maximus by the Providers, Blue Cross could...
...AFFIRMED. DAVIS, J., concurs, and WETHERELL, J., Dissents with Opinion. WETHERELL, J., dissenting. I agree with the underlying premise implicit in the majority's opinion that, in order to pass constitutional muster, the dispute resolution process in section 408.7057, Florida Statutes, must be voluntary, not mandatory....
...ble to an interpretation that would make participation in the process voluntary for the respondent (here, Blue Cross). Accordingly, I respectfully dissent from the decision to affirm the final orders in these cases. The dispute resolution process in section 408.7057 is without question voluntary in the sense that a provider may chose to utilize that forum to resolve its dispute with the health maintenance organization (HMO) instead of filing suit in an appropriate court....
...drawing its claim. See id. at 851. This court held that once the review organization issued its recommendation, the fact-finding process was complete and the party could not withdraw its claim. Id. In reaching that decision, the court explained that section 408.7057 was intended to provide a binding dispute resolution process and that the process would be turned into a "moot court endeavor" if the party faced with an adverse recommendation could simply withdraw its claims to avoid entry of a final order by AHCA....
...Likewise, the Second District's decision in Baycare Health System and the Fourth District's decision in Merkle provide no support for the majority's decision in this case. In Baycare Health System, the court rejected the provider's constitutional challenges to section
408.7057 because the provider voluntarily selected the forum provided by the statute to adjudicate its dispute with the HMO.
940 So.2d at 569-70. In Merkle, the court rejected the HMO's argument that the provider was required to pursue its claims in the dispute resolution process under section
408.7057 and that the provider's circuit court action was barred because it failed to do so.
940 So.2d at 1198; see also Adventist Health Sys./Sunbelt, Inc. v. Blue Cross & Blue Shield,
934 So.2d 602, 604 n. 2 (Fla. 5th DCA 2006) (rejecting HMO's argument that section
408.7057 gives AHCA exclusive jurisdiction over disputes between providers and HMOs or that the provider must exhaust the dispute resolution process under the statute before bringing a civil action against the HMO)....
...vider. The interpretation given to the statute by the majoritythat the HMO can "opt out" of the dispute resolution process at any time by filing a judicial actionis, in my view, at odds with the statute and the implementing rule adopted by AHCA. Section 408.7057(2)(a) requires AHCA to contract with a dispute resolution organization to review and consider claim disputes between providers and HMOs. The organization, Maximus, is required to review the dispute unless one of the statutory exceptions applies. § 408.7057(2)(b), Fla. Stat. ("The resolution organization shall review claim disputes ....") (emphasis added). One exception is that the claim "[i]s the basis for an action pending in state or federal court." § 408.7057(2)(b)6., Fla....
...The majority *956 construes this exception as providing the HMO the right to "opt out" of the dispute resolution process at any time by filing an action in an appropriate court. [1] The rule adopted by AHCA to implement the dispute resolution process belies the majority's interpretation of section 408.7057(2)(b)6....
..."application process" to "review all requests for claim dispute resolution within 10 days after receipt to determine whether the request meets the statutory and rule criteria for submission to the resolution organization as specified in subsections 408.7057(2)(b)1....
...Code R. 59A-12.030(4)(a) (emphasis added). Moreover, once Maximus determines that the documentation submitted in support of the claim is sufficient, the HMO is required to respond to the claim by submitting all documentation in support of its position. § 408.7057(2)(f), Fla....
...("An appeal of a decision by the board to the circuit court by a consumer or a manufacturer shall be by trial de novo."). By contrast, the suit that the majority concludes may be filed by the HMO to "opt out" of the dispute resolution process under section 408.7057 is not seeking to re-litigate a claim that has already been decided in the provider's favor....
...e arbitration process would be relegated to "a procedural impediment to the consumer prior to accessing the circuit court without the counterbalancing benefit to which the prevailing party in arbitration should be entitled"). In my view, not only is section 408.7057(2)(b)6 not susceptible to the reading given to it by the majority, but the majority's interpretation of the statute is inconsistent with, and undermines, the purpose of the dispute resolution process....
...itigation that the statute was designed to avoid. *958 Accordingly, in light of the majority's decision, I suggest that the Legislature consider revising the entire dispute resolution process. Indeed, it seems to me that the public policy underlying section 408.7057 would be better served, and more fairly effectuated, by a process that culminates in AHCA adopting the Maximus recommendation as a proposed order that can be challenged in an administrative hearing (perhaps a summary hearing under se...
...Like the majority, I recognize that courts are obligated to construe statutes in a manner that renders them constitutional if at all possible. However, I cannot join the majority's decision upholding the dispute resolution process because it is based on an interpretation of section 408.7057(2)(b)6 in isolation without giving due regard to the context in which the statute applies, as reflected in the implementing rule adopted by AHCA....
...Rather, I read the opinion to construe the statute to require the HMO to file an action in an appropriate court in order to "opt out" of the dispute resolution process. [2] See Baycare Health System,
940 So.2d at 569 (concluding that the state did not deprive the provider of its due process rights through section
408.7057 because, although the provider had the option of bringing its claim in court, it "chose to forego [its due process rights], perhaps in the hopes of a more expedient resolution of its claims"). [3] Id. at 568 n. 8 (observing that "`Maximus' may be oddly named because the process by which it resolves claims might more aptly be described as `de minimus'"). [4] The Second District held that "[u]nder section
408.7057, neither [the appellate court] nor the AHCA may review the merits of the decision of Maximus [] so long as it was entered in accordance with the statute." Baycare Health System,
940 So.2d at 570....
