Lee Memorial Health System etc. v. State of Florida, Agency For Agency For Health etc.

FIRST DISTRICT COURT OF APPEAL
STATE OF FLORIDA
_____________________________
No. 1D16-1969
_____________________________
LEE MEMORIAL HEALTH SYSTEM
GULF COAST MEDICAL CENTER,
Appellant,
v.
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION,
Appellee.
_____________________________
On appeal from a Final Order of the Agency for Health Care
Administration.
Elizabeth Dudek, Secretary.
February 27, 2019
M.K. THOMAS, J.
Lee Memorial Health System Gulf Coast Medical Center
(“Gulf Coast”) challenges a final order of the Agency for Health
Care Administration (“the Agency”), which found it was overpaid
with Medicaid funds for in-patient emergency services rendered to
Medicaid eligible undocumented aliens. Gulf Coast argues the
Agency was without authority to order reimbursement as it was
barred from conducting retrospective audits on claims for
emergency in-patient services that were pre-authorized and paid.
We agree and reverse.
I. FACTS
In 2002, exercising authority under section 409.905(5)(a),
Florida Statutes, the Agency implemented a mandatory pre-
authorization program regarding Medicaid hospital in-patient
services, including emergency services provided to undocumented
alien recipients. The new program required medical providers to
acquire authorization either during or before provision of the
emergency medical services. Only those claims for hospital in-
patient services that had received pre-authorization with a pre-
authorization verification number could be submitted to the
Agency for payment. 1
In 2006, Gulf Coast entered into a Medicaid Provider
Agreement (“the Agreement”) with the Agency to participate in the
Florida Medicaid program. Gulf Coast billed Medicaid in 2007 for
emergency in-patient services provided to undocumented aliens.
Gulf Coast followed the required procedures, inclusive of
acquisition of pre-authorization for the medical services
subsequently provided and billed to Medicaid. As part of the pre-
authorization process, the Department of Children and Families
(“DCF”) provided Gulf Coast with a pre-authorization number
signifying each undocumented alien was qualified and eligible for
Medicaid, suffered from an emergency medical condition, and
approved the estimated duration of emergent care. The Agency
reviewed the claims submitted by Gulf Coast and issued payment.
In 2009, under its compliance and monitoring authority, the
Centers for Medicare and Medicaid Services (“CMS”), a federal
agency within the Department of Health and Human Services
1 Prior to 2002, medical providers were not required to obtain
pre-authorization of emergency in-patient hospital services in
order to ensure payment. Following provision of medical services,
but before making any payments to medical providers, the Agency
would review submitted claims to ensure, (1) the recipient was
Medicaid eligible per Florida’s Department of Children and
Families (“DCF”); (2) the services were medically necessary; and
(3) the services were for treatment of the emergency medical
condition previously approved by DCF.
2
(“HHS”), conducted a review of Florida’s Medicaid expense reports.
CMS concluded Florida was claiming federal funding for
emergency medical services “beyond what federal regulations
defined to be an emergency.” Specifically, the standard utilized by
the federal government to determine what constitutes an
“emergency medical condition” requiring “emergency medical
services” was more restrictive than that used by DCF. CMS
recommended the Agency review and re-determine the
allowability of claims for all emergency services for undocumented
aliens during fiscal years 2005, 2006, and 2007. Further, based on
this review and redetermination, CMS recommended the Agency
revise previous amounts claimed to reflect only emergency services
to undocumented aliens “to the point of stabilization.”
In response to the CMS federal audit, the Agency initiated the
Undocumented Alien Project (“the Project”). Under the flag of the
Project, the Agency began audits of all paid in-patient hospital
claims for emergency services provided to alien recipients in
Florida between July 2005 and June 2010.
In 2011, Gulf Coast received notice from the Agency, through
its Bureau of Medicaid Program Integrity (“MPI”), it would audited
regarding claims for in-patient hospital services provided to
undocumented aliens and billed to Medicaid in 2007. The purpose
of the audit, according to the Agency, was to determine whether
the claims were billed and paid in accordance “with Medicaid
policy.” Following review of the claims, the Agency issued a Final
Audit Report holding Gulf Coast was overpaid by $46,901.85 for
in-patient services rendered to Medicaid eligible undocumented
aliens post alleviation of an emergency medical condition and
found the overpayment to be subject to recoupment. 2
In response, Gulf Coast filed a petition for formal
administrative hearing to challenge the finding of overpayment.
2 The Agency first notified Gulf Coast of its preliminary audit
results estimating an overpayment amount of $100,588.07. This
was later amended to $79,917.50 inclusive of fines and costs. At
the time of hearing, the Agency asserted an overpayment amount
of $46,901.85.
3
Following the hearing, the administrative law judge (“ALJ”)
determined the Agency had exceeded the scope of its authority as
there was no provision in chapter 409, Florida Statutes, granting
the Agency the authority to decide whether the recipient had an
emergency medical condition – a decision exclusively within the
authority of DCF and which had been previously reviewed and
authorized. However, the Agency rejected the findings and
conclusions of the ALJ. The Agency held that overpayments in the
audit report, which were based on its determination of the
existence and duration of an emergency medical condition, were
recoverable pursuant to its Coverage and Limitations Handbook,
which limited eligibility to only duration of the emergency until it
was “alleviated.” The Agency ordered reimbursement by Gulf
Coast, plus interest. Gulf Coast appealed.
II. FEDERAL AND STATE
ADMINISTRATIVE STRUCTURE
“Medicaid is a jointly financed federal-state cooperative
program . . . States devise and fund their own medical assistance
programs, subject to the requirements of the Medicaid Act, and the
federal government provides partial reimbursement.” Moore ex rel.
Moore v. Reese, 637 F.3d 1220, 1232 (11th Cir. 2011) (citing 42
U.S.C. §§ 1396b(a), 1396d(b)). CMS is responsible for
administering the Medicaid Act, including setting state guidelines
and monitoring state compliance. Moore, 637 F.3d at 1235-36
(citing 42 U.S.C. § 1396a(b), 42 C.F.R. §§ 430.10, 430.15). CMS
may recoup from the state any overpayments that were made, even
if the state is unable to recover that amount from the provider. 42
C.F.R. § 433.300.
The U.S. government pays federal financial participation
(“FFP”) to participating states on a quarterly basis. For their part,
the states must submit quarterly expense reports to the U.S.
government, in effect claiming FFP or, more loosely, "billing" the
federal government for Medicaid costs. If the federal government
believes it has overpaid a state, it may disallow claims for FFP and
recover the amount of overpayment from the state. The state is
entitled to pursue an administrative appeal, before the
appropriate federal agency, of any disallowance it disputes. See 42
4
U.S.C. § 1316(e). Florida receives FFP funding to cover a
percentage of its Medicaid program expenditures.
Federal law broadly prohibits compensating a state through
FFP under the Medicaid program "for medical assistance
furnished to an alien who is not lawfully admitted for permanent
residence or otherwise permanently residing in the United States
under color of law." 42 U.S.C. § 1396b(v)(1). However, it permits
FFP for services provided undocumented aliens that "are
necessary to treat an emergency medical condition" if the
individual otherwise meets the conditions for participation in the
Medicaid program. 42 C.F.R. § 40.255(a); see also 42 U.S.C. §
1396b(v)(2). In fact, federal law mandates that state Medicaid
programs provide services necessary to treat an undocumented
alien’s emergency medical condition. 42 U.S.C. § 1396(b)v.
Florida enacted legislation consistent with federal law. See §§
409.902(2)(b), 409.904(4), Fla. Stat. Florida statutes and rules,
with minor variations, incorporate the federal standards limiting
the eligibility of undocumented aliens to treatment for emergency
medical conditions. Florida law sets forth “Provider Requirements”
and establishes that all Medicaid providers enrolled in the
Medicaid program and billing agents who submit claims to
Medicaid on behalf of an enrolled Medicaid provider must comply
with the provisions of the Florida Medicaid Provider General
Handbook. Fla. Admin. Code R. 59G-4.150. The “Handbook”
contains a section entitled “Emergencies: Medicaid for Aliens,” also
known as the “Statement on the Eligibility of Aliens for Services”
or “SEAS,” which provides, in pertinent part:
The Medicaid Hospital Services Program reimburses for
emergency services provided to aliens who meet all
Medicaid eligibility requirements except for citizenship
or alien status. Eligibility can be authorized only for the
duration of the emergency. Medicaid will not pay for
continuous or episodic services after the emergency has
been alleviated. (emphasis added).
Florida law designates DCF as responsible for determining
eligibility for Medicaid. § 409.902(1), Fla. Stat. The Agency “is
designated as the single state agency authorized to make
5
payments” under Medicaid. § 409.902(1), Fla. Stat. Participating
medical providers seek reimbursement from the Agency for
services provided to Medicaid eligible patients. Id. Florida law
permits the Agency to review these claims two ways: by conducting
pre-payment reviews of provider claims before paying the provider;
and/or, by conducting post-payment reviews/audits to identify any
overpayments. § 409.13(3), (5), Fla. Stat. The latter method is
routinely referred to as the “pay and chase” method in which the
Agency reviews claims after payment using “peer reviews” by
medical professionals to determine whether the services provided
were medically necessary and otherwise permitted by Medicaid. §§
409.913(1)(d)-(e), (2), (5), (7); 409.9131(2)(b), (2)(d), Fla. Stat. As a
result of this pay and chase option, medical providers must
maintain records for a period of five years for the Agency to audit
for overpayment and seek reimbursement from medical providers.
§ 409.913(9), Fla. Stat.
Before and after the prior authorization program was
implemented in 2002, DCF has been responsible for making
Medicaid eligibility determinations based on information
submitted by providers. Conversely, the Agency’s assigned
Medicaid role is to determine the medical necessity of the services
rendered to treat the emergency medical condition. § 409.902, Fla.
Stat. Prior to 2002, if the Agency regarded the treatment as
medically necessary, the claims were approved and paid by the
Agency. In 2002, as required by statute, the Agency began a prior
authorization program for Medicaid inpatient hospital services.
The purpose was to determine, before payment, if services were
medically necessary. DCF assigned the limited eligibility period
for the duration of the emergency, which was the date of
admittance through the date of discharge. Until 2010, the Agency
accepted DCF's determination of the emergency medical condition
and the period of eligibility or duration of that emergency medical
condition. However, as a result of the CMS review and audit in
2009, the Agency changed its procedures. After July 1, 2010, the
Agency announced it would begin applying a new standard to
claims for undocumented aliens. Instead of reviewing solely for
“medical necessity,” the Agency would only reimburse for services
up to the patient reaching the point of “stabilization.” In essence,
the Agency announced it was expanding its evaluation to also
6
address duration of the emergency medical condition – a
determination historically made solely by DCF.
The Agency began audits and applied this new “stabilization
standard” retroactively to claims that had already been paid prior
to July 1, 2010, seeking to recoup money from the hospitals. In
response, the medical providers initiated litigation, arguing the
Agency was improperly operating under an unpromulgated rule by
applying a “stabilization standard.” See Bayfront v. AHCA, Case
No. 12-2757RU (Fla. DOAH Dec. 21, 2012), appeal dismissed,
AHCA v. Bayfront Medical Ctr., 145 So. 3d 888 (Fla. 1st DCA 2014)
(“Bayfront I”). The Agency defended by arguing the stabilization
standard was not new, but it simply began enforcing, at the
direction of the federal government, a reasonable interpretation of
existing law, which permits payment only for the “duration” of the
emergency and not past the point of “alleviation.” The Agency
asserted that until July 1, 2010, there was no system, procedure,
or practice for determining when the duration of an undocumented
alien's emergency ended or when the emergency was alleviated,
other than the initial determination of eligibility.
The Final Order in Bayfront I determined the Agency’s
application of the "stabilization standard" was an unadopted rule
and prohibited its further use. 3 The issue of jurisdictional confines
of DCF versus the Agency regarding the determination of
“duration” of the emergency medical condition was not specifically
addressed.
After Bayfront I, the Agency embarked upon a course of action
to conduct retrospective and prospective reviews of hospital in-
patient claims for Medicaid payments relying only on existing
statutes and rules. The Agency developed new guidelines for peer
reviewers. It provided peer reviewers with provisions of the
Florida Medicaid Handbooks that have been incorporated by
reference into the Agency's rules. The Agency expected the
3 The Agency appealed the determination; however,
ultimately voluntarily dismissed the appeal after oral argument,
but before an opinion was released. Bayfront Medical Ctr., Inc.,
145 So. 3d 888.
7
reviewers to apply their “education, clinical expertise, and
experience to determine if services provided were ‘emergency
services or treatment,’” as defined in section 409.901(11) for an
“emergency medical condition,” as defined in section 409.901(10).
The Agency’s amended guidelines for peer reviewers lead to
the inevitable sequel to Bayfront I. Bayfront Medical Ctr., et al. v.
AHCA, DOAH Case No. 14-4758RU (Fla. DOAH June 28, 2016),
aff’d, Bayfront v. AHCA, 192 So. 3d 472 (Fla. 1st DCA 2016)
(“Bayfront II”). In Bayfront II, the medical providers again
challenged the Agency’s methods as unpromulgated rules.
However, the ALJ found that the use of an “alleviation standard”
by peer reviewers was discernably different from the prior
“stabilization standard,” in that it was not treated as an unadopted
rule throughout the Agency. The new alleviation standard was
allowed where it was applied in a plain and ordinary sense and
was not enforced by the Agency as a hardline standard.
In this case, we further analyze the scope of Agency authority,
albeit limited in context to Agency review of claims for emergency
inpatient hospital services that were pre-authorized and paid.
III. ANALYSIS
On January 8, 2019, the newly enacted article V, section 21,
of the Florida Constitution took effect. According to the
amendment, “[i]n interpreting a state statute or rule, a state court
or an officer hearing an administrative action pursuant to general
law may not defer to an administrative agency’s interpretation of
such statute or rule, and must instead interpret such statute or
rule de novo.” Art. V, § 21, Fla. Const. (2019). Prior to the passage
of article V, section 21, administrative agencies were afforded wide
discretion in the interpretation of a statute, and an agency’s
interpretation of a statute it has authority to administer was not
overturned on appeal unless clearly erroneous. Amerisure Mut.
Ins. Co. v. Fla. Dep’t of Fin. Servs., 156 So. 3d 520, 529 (Fla. 1st
DCA 2015); Sullivan v. Fla. Dep’t of Envtl. Prot., 890 So. 2d 417,
420 (Fla. 1st DCA 2004). We recognize that questions may arise
as to whether the newly enacted amendment should be
retroactively applied. Here, we decline to address the question as
it is not necessary to our legal analysis, because even if deference
8
were provided to the Agency’s interpretation of the statute,
“judicial adherence to the Agency’s view is not demanded when it
is contrary to the statute’s plain meaning,” as is the case here.
PAC for Equality v. Dep’t of State, Fla. Elections Comm’n, 542 So.
2d 459, 460 (Fla. 2d DCA 1989), quoted in Werner v. Dep’t of Ins.
& Treasurer, 689 So. 2d 1211, 1214 (Fla. 1st DCA 1997); see also
Kessler v. Dep’t of Mgmt. Servs., Div. of State Grp. Ins., 17 So. 3d
759, 762 (Fla. 1st DCA 2009) (“Judicial deference never requires
that courts adopt an agency’s interpretation of a statute or rule
when the agency’s interpretation cannot be reconciled with the
plain language of the statute. . .”).
A. Retrospective Review is Contrary to the Plain Language of
Section 409.905(5)(a), Florida Statutes.
Section 409.905 was amended to provide the Agency, for the
first time, the authority to condition payment for inpatient
hospital services upon a pre-payment review, which was referred
to as prior authorization. The statute, as amended, specifically
provides:
The agency shall pay for all covered services provided for
the medical care and treatment of a recipient who is
admitted as an inpatient by a licensed physician or
dentist to a hospital licensed under part I of chapter 395.
However, the agency shall limit the payment for
inpatient hospital services for a Medicaid recipient 21
years of age or older to 45 days or the number of days
necessary to comply with the General Appropriations Act.
(a) The agency may implement reimbursement and
utilization management reforms to comply with any
limitations or directions in the General Appropriations
Act . . . Upon implementing the prior authorization
program for hospital inpatient services, the agency shall
discontinue its hospital retrospective review program.
§ 409.905(5), Fla. Stat. (emphasis added). Prior to this grant of
authority, the Agency paid claims prior to any review; however, it
later conducted a retrospective review on a percentage of all claims
to determine if they had been properly paid. If upon retrospective
9
review the Agency suspected fraud or abuse, the claim was
referred to its MPI office, which only conducted reviews on claims
that appeared to be outliers or had abnormal billing patterns.
MPI’s function was to investigate possible Medicaid abuse; MPI
did not conduct general retrospective reviews.
Section 409.905, clearly advises that for hospital inpatient
services, upon implementing the new authorization program, “the
agency shall discontinue its hospital retrospective review program.”
§ 409.905(5)(a), Fla. Stat. (emphasis added). 4 Pursuant to the new
statutory bar to retrospective reviews, the Agency stopped
conducting general retrospective reviews of hospital in-patient
claims in 2002, but continued to permit MPI to conduct limited
retrospective reviews where fraud or abuse was suspected. It is
clear that in 2002, the Agency understood that general
retrospective reviews were prohibited under the amended statute
when it advised all providers, “[t]he new inpatient prior
authorization program will involve concurrent review . . . thus
rendering obsolete the retrospective reviews.” The Project, however,
was a review of “all the alien . . . claims for all hospital providers
during this time period” not specifically targeted to fraud or abuse
and contrary to the plain reading of the statute.
Thus, the ALJ’s conclusion that the Agency’s retrospective
audit on claims for emergency in-patient services provided to
undocumented aliens was the type of review prohibited by section
409.905(5)(a) is not only supported by a plain reading of the
statute, but is also supported by the record evidence of the
Agency’s claim review history. The Agency acknowledges that the
Project was a review of all inpatient claims for undocumented
aliens, but it opines section 409.905(5)(a) is not controlling because
the retrospective review was conducted by MPI. Yet, the statute
does not distinguish among the Agency’s different offices nor does
4 Of note, the prohibition of section 409.905(5)(a) applies only
to claims for in-patient hospital services. Ex post facto audits of
paid Medicaid claims are commonplace but unlike the typical
retrospective review, the Project involves the attempted re-
adjudication of claims that were previously authorized on a
prospective basis.
10
the office that conducts the review necessarily dictate the type of
audit being conducted. Here, the plain reading of the statute
makes clear that the Agency is barred from conducting general
retrospective reviews of claims, which the Project commanded. 5
We find no ambiguity in the prohibition on retrospective review in
section 409.905(5)(a).
B. Section 409.913, Florida Statutes, Does not Provide the Agency
Authority to Conduct General Retrospective Reviews.
The Agency also argues on appeal it had authority to conduct
the retrospective audit pursuant to section 409.913. 6 The Agency
interprets section 409.913 as requiring it to seek reimbursement
of any overpayment to providers, and this can only be
accomplished via retrospective audits. However, overpayment is
defined as “any amount not authorized to be paid by the Medicaid
program, whether paid as a result of inaccurate or improper cost
reporting, improper claiming, unacceptable practices, fraud, abuse
or mistake.” § 409.913(1)(e), Fla. Stat. (emphasis added). Post
2002, the amended statute required medical providers to obtain
pre-authorization from the Agency before the inpatient medical
services were provided to undocumented aliens. Following
treatment, the medical provider sent the Agency the bill for the
pre-approved services. The Agency then reviewed the bill and
issued payment. Essentially, the Agency now argues another
5 We note that it is appropriate for the Agency to determine
whether, for example, the services for which payment is sought is
medically necessary to treat the emergency medical condition.
However, the Agency must accept DCF’s finding that the
recipient’s condition was an emergency medical condition, as well
as all other findings in support of eligibility, including the duration
of the emergency medical condition.
6 Section 409.913 provides in pertinent part: “The Agency
shall operate a program to oversee the activities of Florida
Medicaid recipients, and providers and their representatives, to
ensure that fraudulent and abusive behavior and neglect of
recipients occur to the minimum extent possible, and to recover
overpayments and impose sanctions as appropriate.” Section
409.913, Fla. Stat.
11
review or repetitive audits are allowable under 409.913. While we
agree section 409.913 does allow retrospective audits, it is only in
the context of claims not previously reviewed and where
fraudulent acts are suspected.
Although we recognize section 409.913 provides the Agency
the authority to audit claims under certain circumstances, it does
not provide the Agency the authority to implement a sweeping
retrospective review plan inclusive of hospital inpatient services to
undocumented aliens. See Diaz v. State of Fla., Agency for Health
Care Admin., 65 So. 3d 78, 82 (Fla. 3d DCA 2011) (holding that to
further the objectives of 409.913 the Legislature requires agencies
to respond when a provider engages in fraudulent or abusive
practices). We do not address what factors trigger an audit under
section 409.913 as that is not necessary for our analysis or
conclusion given no allegations of fraud or abuse were raised. 7
We reject the Agency’s argument that its duty to maintain
Medicaid program integrity would be seriously undermined if
administrative finality prevented it from auditing paid claims.
Administrative finality should not bar the retrospective review of
all paid claims; rather, in the absence of fraud or abuse, it bars the
reopening of all adjudicated paid claims, which were previously
determined on the merits to be compensable. When the Agency
determines compensability for prior authorization, it is not
expected to simultaneously investigate the provider for possible
wrongdoing, such as fraud or misrepresentation. These matters
are clearly distinguishable, and such matters may be explored by
the Agency retrospectively in connection with adjudicated claims.
In that section 409.905’s prohibition only applies to hospital
inpatient services that are subject to prior authorization review,
the ALJ’s interpretation leaves intact the Agency’s authority to
conduct retrospective reviews for all other matters, including
reviews of prior authorized claims to determine if the claim for
prior authorization was materially false. § 409.913(15)(i), (16)(c),
7The Agency did not argue the audit was conducted on a
random basis pursuant to section 409.913(2), Florida Statutes.
12
Fla. Stat. As such, the ALJ’s interpretation does not render the
review function meaningless and preserves both statutes. 8
C. Statute of Limitations.
Gulf Coast argues the audits for overpayment are barred by
Chapter 95, Florida Statutes, which requires an action arising out
of statutory liability to be brought within four years of the date the
cause of action accrues. § 95.11(3)(f), Fla. Stat. A cause of action
accrues when the last element of the action has been met. §
95.031(1), Fla. Stat. Here, Gulf Coast’s final bill for the claims at
issue was submitted approximately eight years prior to the
Agency’s retrospective determination it had overpaid. The Agency
defends that Chapter 95 does not apply to administrative
proceedings unless the action is a direct substitute for a civil
action. That exception does not apply here. There is no federal or
state statute that requires Medicaid overpayments to be audited
within a certain period of time. See Horta v. Dep’t of Children
Families, 911 So. 2d 139, 140 (Fla. 3d DCA 2005). We hold the
statute of limitations does not apply, because the instant case is a
quasi-judicial administrative proceeding. The case is similar to
Horta, in that an overpayment of federal funds was alleged, and
the recovering entity sought recovery of the overpayment. Further,
applying a statute of limitations to review of claims allowed under
section 409.913 would be inequitable. Actual instances of fraud or
abuse of the Medicaid system could take significant amounts of
time to discover and allege, and federal Medicaid funds could
reasonably go unrecovered as a result.
8 The Agency also argues it has the ability to conduct
retrospective reviews pursuant to SEAS to evaluate “alleviation”
of an emergency medical condition and deny payment for medical
services falling outside its determined timeline – a determination
not usurping that of DCF under “eligibility” review. This issue
need not be addressed as it is rendered moot by section
409.905(5)(a), which clearly forbids retrospective reviews of paid
inpatient hospital claims for undocumented aliens. The validity of
the Agency’s retrospective audit of paid claims in cases not
involving inpatient hospital services to undocumented aliens is not
before us.
13
Notwithstanding the foregoing, even if Chapter 95’s statute of
limitations were applicable, the audit would not be time-barred.
The cause of action does not accrue until the last element
constituting the cause of action occurs. In overpayment actions,
the final element is the identification of the overpayment amount,
which occurs with the initiation of the Final Audit Report. In the
instant case, the statute of limitations never actually began
running because the last element and the initiation of the action
occurred simultaneously.
IV. CONCLUSION
In conclusion, the Agency erroneously relied upon section
409.913 as providing it authority to conduct general retrospective
reviews of claims for emergency in-patient services provided to
undocumented aliens that had previously been authorized and
paid. The plain language of section 409.905(5)(a), as well as the
Agency’s claim review history, specifically bars such retrospective
reviews. Thus, the Agency was without authority to conduct the
retrospective review and to order Gulf Coast to reimburse what the
Agency considered to be overpayment. Accordingly, we reverse the
order on appeal.
REVERSED and REMANDED for entry of an order consistent
with this opinion.
B.L. THOMAS, C.J., and JAY, J., concur.
_____________________________
Not final until disposition of any timely and
authorized motion under Fla. R. App. P. 9.330 or
9.331.
_____________________________
Joanne B. Erde and Donna Holshouser Stinson of Duane Morris
LLP, Miami, for Appellant.
Tracy Cooper George of the Agency for Health Care
Administration, Tallahassee, for Appellee.
14