A Florida court recently ruled on a healthcare dispute involving T.B., a patient represented by Teri Berket, and Humana Medical Plan, Inc. The court's decision addressed whether the Agency for Health Care Administration (AHCA) had jurisdiction to hear Berket's claims regarding payment for additional service hours. This ruling is significant as it clarifies the limits of AHCA's jurisdiction in healthcare payment disputes.
The case, T.B. c/o Teri Berket v. Humana Medical Plan, Inc., was filed on June 10, 2020, under docket number 1D19-1249. Teri Berket, acting on behalf of T.B., challenged a previous decision made by a hearing officer. Berket argued that Humana had reduced the number of service hours T.B. was eligible to receive and refused to pay for an additional sixteen hours of services she provided. This situation led to the appeal, as Berket sought a fair hearing on the matter.
The dispute began when T.B. received healthcare benefits from UnitedHealthcare in 2018. UnitedHealthcare had authorized T.B. to receive forty hours of services from Berket, plus an additional sixteen hours that needed to be performed by outside servicers. In 2019, T.B. switched to Humana for healthcare coverage. Humana informed Berket that it would continue to provide the same services previously authorized by UnitedHealthcare. However, Humana also stated that the additional sixteen hours of service would have to come from outside providers.
Berket's appeal to the court centered on whether AHCA had the authority to hold a hearing regarding her claims. The court reviewed the hearing officer's determination and found no error in the decision. The court noted that AHCA has jurisdiction to hold a hearing only when a fee-for-services recipient has their authorized services reduced, suspended, or denied. Since Humana did not change the services T.B. was authorized to receive, AHCA did not have jurisdiction to hear Berket's claims.
The court ruled, "Because Humana had not changed the services that T.B. was previously authorized to receive or denied T.B. additional services, AHCA did not have jurisdiction to hold a hearing on this matter." This statement highlights the court's reasoning in affirming the hearing officer's decision.
Additionally, the court addressed Berket's claim for payment for the sixteen hours of services she provided. The court found that Berket's request for payment was not within the jurisdiction of AHCA. The record showed that Berket had requested payment from Humana for these additional hours, but such requests are not among the circumstances that allow AHCA to hold a hearing.
The court stated, "A request for payment by a service provider is not one of the enumerated circumstances over which AHCA has jurisdiction." This further solidified the court's position that AHCA could not hear Berket's claim for payment.
The ruling has implications for similar cases involving healthcare payment disputes in Florida. It clarifies that AHCA's jurisdiction is limited to specific circumstances, particularly when authorized services are reduced or denied. This decision may affect how service providers and caregivers approach payment disputes with healthcare plans in the future.
Going forward, this ruling may set a precedent for future cases involving jurisdictional challenges in healthcare disputes. It emphasizes the importance of understanding the specific circumstances under which AHCA can intervene. As healthcare plans continue to evolve, caregivers and service providers must be aware of their rights and the limitations of agency jurisdiction.
As for the next steps, Berket may consider whether to appeal the decision. The court's ruling is not final until the disposition of any timely and authorized motion under Florida Rules of Appellate Procedure. However, details regarding any potential appeal were not available in the court filing.