UNITED HEALTH, INC., D/B/A AMELIA ISLAND DEVELOPMENTAL CENTER, APPELLANT,
v.
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES, APPELLEE
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United Health, operating an intermediate care facility for the mentally retarded, appealed HRS's disallowance of approximately $75,000 in Medicaid reimbursements, including a fee paid to an orthopedic surgeon. The court affirmed in part and reversed in part, holding that reimbursement for the orthopedic surgeon's services was permissible where no Medicaid-participating physician was available to treat the facility's injured resident.
The court held that the orthopedic surgeon's fee was reimbursable under the ICF/MR program despite Rule 10C-7.049(3)(b)3 because the facility was obligated to provide necessary medical care and no Medicaid-participating physician was willing to accept payment, making strict application of the rule impractical under the circumstances.
[1] An agency's interpretation of its own rule is entitled to deference, but such deference is not absolute.
[2] A facility operating under the ICF/MR program may be reimbursed for necessary medical services provided to a resident, even if those services are theoretically reimbursab…
Previewing 2 of 4 headnotes on this case. FLexlaw’s editorially structured points of law — every proposition, pinpointed — are reserved for members.
Join FLexlaw to unlock all legal intelligence“While theoretically only the services of a physician willing to accept payment under the Medicaid Physician Services program should have been obtained, it is uncontroverted that appellant was compelled to provide necessary medical treatment for its injured resident, yet no physician could be found willing to accept payment through that program.”
Establishes the court's rationale that strict application of the reimbursement rule was impractical given the facility's obligation to provide care and the unavailability of participating providers.
Previewing 1 of 3 key quotes on this case — the court’s exact language, pinpointed for members.
Join FLexlaw to unlock all legal intelligenceUnited Health operates an intermediate care facility for the mentally retarded and filed a 1985 Medicaid cost report seeking reimbursement for various…
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SMITH, Judge.
Appellant, which operates an intermediate care facility for the mentally retarded, challenges a final order disallowing certain Medicaid reimbursements. We affirm, in part and reverse in part.
The Department of Health and Rehabilitative Services (HRS), the appellee, disallowed approximately $75,000 in items claimed in the 1985 Medicaid cost report filed by appellant for the purpose of reimbursement under the ICF/MR (Intermediate Care Facilities for the Mentally Retarded Services) program. Among the items disallowed was the fee paid to an orthopedic surgeon who treated a resident of appellant’s facility who suffered a broken leg. The appellant filed for a hearing following which the DO AH hearing officer found that appellant could not “reasonably arrange” for medical treatment, and that the orthopedic surgeon who treated the resident of appellant’s facility was “the only physician reasonably available to perform the services.” The hearing officer found further that while the physician used “was eligible for payment through the Physician Service’s Medicaid, he refused to accept payment except from [appellant].” Further still, the hearing officer found that appellant had an obligation to provide medical care to its injured resident, and so concluded as a matter of law that the fee paid to this non-Medicaid physician was reimbursable under the ICF/MR program.
Contrary to the hearing officer’s recommended order, HRS denied reimbursement for this item on the authority of Rule 10C-7.049(3)(b)3., Florida Administrative Code, which provided that services “reimbursable” under any other Medicaid program are not subject to reimbursement under the ICF/MR program. HRS ruled that since the orthopedic surgeon’s services could have been reimbursed under the Physician Services Program, reimbursement under the ICF/MR program should not be approved.
We conclude that the recommendation made by the hearing officer was correct under the particular facts of this case. While theoretically only the services of a physician willing to accept payment under the Medicaid Physician Services program should have been obtained, it is uncontro-verted that appellant was compelled to provide necessary medical treatment for its injured resident, yet no physician could be found willing to accept payment through that program. Thus, we conclude, in agreement with the hearing officer, that HRS’ contention that the services' of the orthopedic surgeon were reimbursable “ignores the facts of this case.” We are well aware that an agency’s interpretation of its own rule is entitled to great deference. See, Reedy Creek Improvement District v. State of Florida, 486 So. 2d 642 (Fla. 1st DCA 1986). But such deference need not be absolute. Woodley v. Dept. of HRS, 505 So. 2d 676 (Fla. 1st DCA 1987).
The remaining items disallowed by HRS were approved by the hearing officer. We find no basis in the record or in the authority cited to disturb these findings. Accordingly, the final order is AFFIRMED in part and REVERSED in part.
NIMMONS and ZEHMER, JJ., concur.
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Citator
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- Reedy Creek Improvement Dist. v. State of Fla. Dep't OF Env't Reg. & Cent. Fla. Utils., Inc., 486 So. 2d 642 (Fla. 1st DCA 1986)
- Birdie Woodley v. Dep't OF Health & Rehabilitative Servs., 505 So. 2d 676 (Fla. 1st DCA 1987)