Florida Statute 409.9131 - Full Text and Legal Analysis

The 2025 Florida Statutes

Title XXX
SOCIAL WELFARE

Chapter 409
SOCIAL AND ECONOMIC ASSISTANCE

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409.9131 Special provisions relating to integrity of the Medicaid program.—

(1) LEGISLATIVE FINDINGS AND INTENT.—It is the intent of the Legislature that physicians, as defined in this section, be subject to Medicaid fraud and abuse investigations in accordance with the provisions set forth in this section as a supplement to the provisions contained in s. 409.913. If a conflict exists between the provisions of this section and s. 409.913, it is the intent of the Legislature that the provisions of this section shall control.

(2) DEFINITIONS.—For purposes of this section, the term:

(a) “Active practice” means a physician must have regularly provided medical care and treatment to patients within the past 2 years.

(b) “Medical necessity” or “medically necessary” means any goods or services necessary to palliate the effects of a terminal condition or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity, which goods or services are provided in accordance with generally accepted standards of medical practice. For purposes of determining Medicaid reimbursement, the agency is the final arbiter of medical necessity. In making determinations of medical necessity, the agency must, to the maximum extent possible, use a physician in active practice, either employed by or under contract with the agency, of the same specialty or subspecialty as the physician under review. Such determination must be based upon the information available at the time the goods or services were provided.

(c) “Peer” means a Florida licensed physician who is, to the maximum extent possible, of the same specialty or subspecialty, licensed under the same chapter, and in active practice.

(d) “Peer review” means an evaluation of the professional practices of a Medicaid physician provider by a peer or peers in order to assess the medical necessity, appropriateness, and quality of care provided, as such care is compared to that customarily furnished by the physician’s peers and to recognized health care standards, and, in cases involving determination of medical necessity, to determine whether the documentation in the physician’s records is adequate.

(e) “Physician” means a person licensed to practice medicine under chapter 458 or a person licensed to practice osteopathic medicine under chapter 459.

(f) “Professional services” means procedures provided to a Medicaid recipient, either directly by or under the supervision of a physician who is a registered provider for the Medicaid program.

(3) ONSITE RECORDS REVIEW.—As specified in s. 409.913(9), the agency may investigate, review, or analyze a physician’s medical records concerning Medicaid patients. The physician must make such records available to the agency during normal business hours. The agency must provide notice to the physician at least 24 hours before such visit. The agency and physician shall make every effort to set a mutually agreeable time for the agency’s visit during normal business hours and within the 24-hour period. If such a time cannot be agreed upon, the agency may set the time.

(4) NOTICE OF DUE PROCESS RIGHTS REQUIRED.—Whenever the agency seeks an administrative remedy against a physician pursuant to this section or s. 409.913, the physician must be advised of his or her rights to due process under chapter 120. This provision shall not limit or hinder the agency’s ability to pursue any remedy available to it under s. 409.913 or other applicable law.

(5) DETERMINATIONS OF OVERPAYMENT.—In making a determination of overpayment to a physician, the agency must:

(a) Use accepted and valid auditing, accounting, analytical, statistical, or peer-review methods, or combinations thereof. Appropriate statistical methods may include, but are not limited to, sampling and extension to the population, parametric and nonparametric statistics, tests of hypotheses, other generally accepted statistical methods, review of medical records, and a consideration of the physician’s client case mix. Before performing a review of the physician’s Medicaid records, however, the agency shall make every effort to consider the physician’s patient case mix, including, but not limited to, patient age. In meeting its burden of proof in any administrative or court proceeding, the agency may introduce the results of such statistical methods and its other audit findings as evidence of overpayment.

(b) Refer all physician service claims for peer review when the agency’s preliminary analysis indicates that an evaluation of the medical necessity, appropriateness, and quality of care needs to be undertaken to determine a potential overpayment, and before any formal proceedings are initiated against the physician, except as required by s. 409.913.

(6) COST REPORTS.—For any Medicaid provider submitting a cost report to the agency by any method, and in addition to any other certification, the following statement must immediately precede the dated signature of the provider’s administrator or chief financial officer on such cost report:

“I certify that I am familiar with the laws and regulations regarding the provision of health care services under the Florida Medicaid program, including the laws and regulations relating to claims for Medicaid reimbursements and payments, and that the services identified in this cost report were provided in compliance with such laws and regulations.”

History.—s. 71, ch. 99-397; s. 62, ch. 2000-158; ss. 7, 24, ch. 2004-344; s. 29, ch. 2025-88.

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Amendments to 409.9131

Annotations, Discussions, Cases:

Cases Citing Statute 409.9131

Total Results: 4 | Sort by: Relevance | Newest First

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State v. Murciano, 163 So. 3d 662 (Fla. 1st DCA 2015).

Cited 3 times | Published | Florida 1st District Court of Appeal | 2015 Fla. App. LEXIS 6293, 2015 WL 1928555

...Following the hearing, the ALJ issued a Recommended Order dismissing the Final Audit Report because the ALJ concluded as a matter of law that the doctor who conducted the peer review of respondent’s claims, Dr. O’Hern, was not respondent’s “peer” as defined by section 409.9131(2)(e), Florida Statutes....

...*664 Upon receiving the Recommended Order, AHCA issued an order remanding the matter to the ALJ for additional factual findings, citing “exceptional circumstances.” AHCA found the ALJ should have deferred to AHCA’s reasonable interpretation of section 409.9131(2)(c), under which Dr....

...eed to be made by a peer reviewer. The ALJ entered an order declining remand. In response, AHCA entered a Partial Final Order and again remanded for factual findings. AHCA concluded as a matter of law that Dr. O’Hern was a “peer” as defined by section 409.9131(2)(c). Thus, AHCA remanded to the ALJ “to make factual findings regarding all the claims at issue in this matter with the understanding that Dr. O’Hern is a ‘peer’ of respondent as defined by Section 409.9131(2)(c), Florida Statutes.” The ALJ entered an order again declining remand....

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Lutheran Servs. Florida, Inc. v. Dep't of Child. & Families, 199 So. 3d 286 (Fla. 2d DCA 2015).

Published | Florida 2nd District Court of Appeal | 2015 Fla. App. LEXIS 17914, 2015 WL 7566262

...Zumaran testified, “Yes, it’s medically necessary.” The Department did not call any medical expert witnesses; rather it argued that a guardian fee is not a “medically necessary” expense pursuant to the definition of that term contained in section 409.9131(2)(b) and that therefore a guardian fee cannot be deducted from an individual’s income for purposes of determining his or her patient responsibility payment....

...erón is a medically necessary expense. LSF contends that the services it provides to the incapacitated ward, including the provision of consent to medical treatment, fall within the broad definition of “medically necessary” that is set forth in section 409.9131(2)(b)....

...In the instant case, the hearing officer concluded that LSF’s requested guardian fee satisfied the first, third, and fourth prongs of the test but failed to meet the second prong of the test because guardianship is not a medically necessary service under the statutory definition contained in section 409.9131(2)(b)....

...‘[Wjhen the language of the statute is clear and unambiguous and conveys a clear and definite meaning ... the statute must be given its plain and obvious meaning.’ ” (quoting Holly v. Auld, 450 So.2d 217, 219 (Fla.1984))). The plain language of section 409.9131(2)(b) states that the service at issue must be “provided in accordance with generally accepted standards of medical practice ” and that it must be reviewed for medical necessity by “a physician in active practice ......

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State of Florida, Agency For Health Care Admin. v. Alfred Ivan Murciano, M.D. (Fla. Dist. Ct. App. 2024).

Published | District Court of Appeal of Florida

Jenkins, did not qualify as a “peer” under section 409.9131(5)(b), Florida Statutes. In reaching this

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Murciano v. State, Agency for Health Care Admin., 208 So. 3d 130 (Fla. 3d DCA 2016).

Published | Florida 3rd District Court of Appeal | 2016 Fla. App. LEXIS 13176

...Murciano”) appeals an amended order of the Agency for Health Care Administration (“AHCA”), requiring him to repay AHCA $1,265,741.45 for Medicaid overpayments, following a peer review audit. We affirm, and hold, on the central issue raised, that AHCA correctly construed the statutory definition of “peer” under section 409.9131(2)(c), Florida Statutes (2013). BACKGROUND Dr....

...13). AHCA referred the matter to the Division of Administrative Hearings (“DOAH”), which was assigned to Administrative Law Judge Todd P. Resavage (“the ALJ”). The formal hearing took place on January 21, 2014, and May 22, 2014. 1 Under section 409.9131(5)(b), Florida Statutes (2013), in determining that a Medicaid overpayment has been made to a physician, AHCA must “[r]efer all physician service claims for peer review when the agency’s preliminary analysis indicates that an evaluation of the medical necessity, appropriateness, and quality of care needs to be undertaken to determine a potential overpayment, and before any formal proceedings are initiated against the physician, except as required by s. 409.913.” Pursuant to section 409.9131(2)(b), a “peer” is defined as follows: “Peer” means a Florida licensed physician who is, to the maximum extent possible, of the same specialty or subspecialty, licensed under the same chapter, and in active...

...O’Hern) who did not meet the statutory definition of “peer” as required by Florida law for a determination of overpayment, and that therefore, AHCA’s case must be dismissed. AHCA filed timely exceptions to the ALJ’s Recommended Order, asserting that Dr. O’Hern was a peer of Dr. Murciano as defined by section 409.9131 and further, that the ALJ was required to defer to AHCA’s interpretation of the term “peer” as this was a conclusion of law....

...o DOAH for a de novo hearing. Thereafter, AHCA’s agency clerk remanded the matter back to the ALJ, finding the ALJ departed from the essential requirements of the law by concluding Dr. O’Hern did not meet the definition of a peer under section 409.9131; by failing to give deference to AHCA’s interpretation of the statute; and by failing to make 4 specific factual findings on the claims at issue....

...1D14-3836), asserting there were exceptional circumstances for AHCA’s remand because the ALJ refused to make necessary factual findings based solely on his erroneous conclusion that Dr. O’Hern did not meet the definition of “peer” under section 409.9131(2)(c)....

...ngs of Fact” rather than under “Conclusions of Law,” where it had been located in its previous order), and accordingly, the ALJ found that an appropriate peer review was not conducted before formal proceedings were initiated, as required by section 409.9131(5)(b). However, recognizing the directives set forth in the First District’s opinion, the ALJ nevertheless made findings of fact as to the claims of overpayment....

...and the ALJ’s other factual findings, this court should affirm the Amended Final Order. ANALYSIS The central question raised by this appeal is whether AHCA erred in determining that Dr. O’Hern met the statutory requirements of a “peer” under section 409.9131(2)(b)....

...application of that statute to the undisputed facts, all that remains is the legal determination of whether, under the statute and these undisputed facts, Dr. O’Hern is, “to the maximum extent possible, of the same specialty or subspecialty.” As stated above, section 409.9131(2)(b) defines a “peer” as follows: “Peer” means a Florida licensed physician who is, to the maximum extent possible, of the same specialty or subspecialty, licensed under the same chapter, and in active practice. Dr....

...ve, and normally indicates that alternatives were intended. Sparkman v. McClure, 498 So. 2d 892, 895 (Fla. 1986); Piper Aircraft Corp. v. Schwendemann, 564 So. 2d 546, 548 (Fla. 3d DCA 1990). Applying this general rule to the plain language of section 409.9131(2)(b), we hold that Dr....

...Further, the statutory language “to the maximum extent possible” provides some deference to AHCA to implement its peer review process and exercise its discretion, given that it must select its peer reviewer from a finite list of medical professionals who contract with AHCA to perform peer reviews. See § 409.9131(5)(b), Fla....