RONALD CARSWELL, APPELLANT,
v.
BRODERICK CONSTRUCTION AND STATE FARM INSURANCE COMPANY, APPELLEES

Fla. 1st DCA | 1991-08-12
No. 90-3561
JOANOS, C.J., and SMITH, J., concur.
583 So. 2d 803 Florida District Court of Appeal, First District (1991) Positive Treatment
Cited by 15 cases

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Synopsis

In this workers' compensation appeal, the court affirmed the dismissal of a claim for medical benefits on jurisdictional grounds, holding that the Judge of Compensation Claims lacks jurisdiction to determine issues of medical overutilization, which must instead be reviewed by the Division of Workers' Compensation.


Holding

The Judge of Compensation Claims lacks jurisdiction to determine issues of medical overutilization or excessive treatment. Such determinations must be made by the Division of Workers' Compensation of the Department of Labor and Employment Security under section 440.13, Florida Statutes.


Headnotes

[1] A Judge of Compensation Claims lacks jurisdiction to determine the reasonableness and necessity of medical services when the employer/carrier rejects the quantity of thos…

[2] The determination of unjustified treatment, hospitalization, or office visits, and excessive charges for medical care in a workers' compensation case must be made by the…

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Key Quotes

“the determination of unjustified treatment, hospitalization or office visits and excessive charges for medical care in a particular claimant's case must be made by the Division of Workers' Compensation of the Department of Labor and Employment Security”

The core holding establishing that the Division, not the Judge of Compensation Claims, has jurisdiction over medical overutilization issues.

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Facts & Procedural History

An employer/carrier received medical bills exceeding $45,000 for hospital and doctor care. Following the carrier's policy of auditing bills over $5,00…

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Opinion of the Court
BARFIELD, Judge.

BARFIELD, Judge.

In this workers’ compensation appeal we review a decision of the Judge of Compensation Claims in which he dismissed on jurisdictional grounds a request for payment of medical benefits. The Judge of Compensation Claims took this action on his own motion, the employer/carrier having withdrawn any objection to jurisdiction.

The issue presented to this court is whether the judge of compensation claims has jurisdiction to determine the reasonableness and necessity of services provided by health care providers when the employer/carrier rejects the quantity of those services.

Employer/carrier received bills for hospital and doctor care exceeding $45,000. The employer/carrier’s policy is to have any bill over $5,000 subject to a medical audit, and Eagle Medical Review Enterprise was assigned the file for such review. Eagle rendered its report and based on that report the adjuster determined that the number of days for the hospital stay and services rendered were excessive. In reliance on Eagle’s report the employer/carrier paid approximately $28,000 of the accumulated bills. After hearing extensive argument on the issue of jurisdiction as well as the propriety of the medical care rendered, the Judge of Compensation Claims entered a final order concluding he did not have jurisdiction to determine the issue of “overutili-zation” and dismissed the claim with prejudice.

We affirm the dismissal by the Judge of Compensation Claims holding that the determination of unjustified treatment, hospitalization or office visits and excessive charges for medical care in a particular claimant’s case must be made by the Divi sion of Workers’ Compensation of the Department of Labor and Employment Security. The provisions of section 440.13, Florida Statutes (1991), dealing with the term “utilization review” and the reference to “overutilization” deal with the practices of a particular health care provider and give rise to deauthorization of that provider for treatment of any injured employees as well as denial of payment or requirement for reimbursement in a specific case.

It is not our purpose to differentiate between the Division and the Judge of Compensation Claims all of the various duties and responsibilities contemplated by section 440.13. The statute is no model of clarity, but in general the duties fall along two lines. The Judge of Compensation Claims 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. The Division establishes the fee schedule, determines compliance with the schedule, interprets procedures under the schedule and resolves disputes concerning gouging.

The issue in this case is excessive treatment, i.e., gouging.

AFFIRMED.

JOANOS, C.J., and SMITH, J., concur.


Cases With Similar Vibessemantic neighbors from the corpus


Citator

Cited By

  • Wolk v. Jaylen Homes, Inc., 593 So. 2d 1058 (Fla. 1st DCA 1992)
    …dispute between claimant and employer/carrier, (3) approve payment of medical bills presented in proper form, and (4) resolve conflicts between health care providers regarding a claimant’s medi [*1060] cal status. Carswell v. Broderick Construction, 583 So. 2d 803, 804 (Fla. 1st DCA 1991). When a claimant has established a satisfactory physician-patient relationship with an authorized physician, employer/carrier may not deauthorize that physician without the claimant’s prior agreement or without approval of…
  • Emerson Williams v. Triple J Enters. & Erc, Inc., 650 So. 2d 1114 (Fla. 1st DCA 1995)
    …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 p…
  • The Avalon Ctr. & Unisource Administrators v. Hardaway, 967 So. 2d 268 (Fla. 1st DCA 2007)
    …are provider”). Accordingly, the JCC lacks jurisdiction as in Furtick, Terners, 599 So. 2d 674 (holding that the JCC lacked jurisdiction over the disputed amount the claimant’s physician claimed was due from the E/C), Carswell v. Broderick Constr., 583 So. 2d 803 (Fla. 1st DCA 1991) (holding that the JCC lacked jurisdiction over the determination of unjustified treatment, hospitalization or office visits and excessive charges for medical care), and Atlantic Found. v. Gurlacz, 582 So. 2d 10 (Fla. 1st DCA 1991…

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