7] a4 1) a Fy 1, STATE OF FLORIDA CCT 15 G2 DIVISION OF ADMINISTRATIVE HEARINGS ACA OEPQTMENT CLERK MED-CARE INFUSION SERVICES, INC., Petitioner, 7 L clerec = vs. CASE NO. 00-1500 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Bl:4 Wd St 190 20 Respondent. sss FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement on Sepph nb 27, 2002, which is incorporated by reference. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. DONE and ORDERED on this the A] day of Sew, Abra. 2002, in Tallahassee, Florida. “y peti Medows, MD, Secretary freer for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS F INAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES, REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: L. William Porter II, Esquire Agency for Health Care Administration (Interoffice Mail) Bernard P. Coniff, Esquire 600 W. 20* Street Hialeah, Florida 33010 (U.S. Mail) Judy Hefren, Acting Bureau Chief, Medicaid Program Integrity Kathryn Holland, Medicaid Program Integrity Willie Bivens, Finance and Accounting od CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addressees by U.S. Mail on this the Jp aay of OCtOOW , 2002. pe COB ANC ealand McCharen, Troi Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 “4g MED-CARE INFUSION SERVICES, INC. DOAH No. 00-1500 Provider No. - 102454000 C.I. No. 97-0989-000-3 SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA’ or “the Agency”), and Med-Care Infusion Services, Inc. (‘PROVIDER’), by and through the undersigned, hereby stipulate and agree as follows: 1. This Agreement is entered into between the parties for the purpose of avoiding the costs and burdens of litigation, and neither party concedes the other’s position. 2. PROVIDER is a Medicaid provider in the State of Florida. 3. In its final agency audit report dated February 21, 2000, AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Integrity (MPI) indicated that, in its opinion, some claims in whole or in part were not covered by Medicaid. The Agency sought overpayment in the amount of $125,060.29. In response to the audit letter dated February 21, 2000, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No. 00-1500. 4. The PROVIDER submitted additional documentation and after a reviéw of~ that documentation, the overpayment was adjusted to $89,294.88. _The PROVIDER again submitted additional documentation, which was reviewed and the overpayment was adjusted to $82,012.13. Negotiations and document/inventory review continued and the overpayment was adjusted to $55,000. Med-Care Infusion Services, Inc. Settlement Agreement 5. In order to resolve this matter without further administrative Proceedings, PROVIDER did the AHCA expressly agree as follows: (1) | AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. (2) Within thirty days of receipt of the final order, PROVIDER agrees to make a lump sum payment of fifty five thousand dollars ($55,000.00) with a sanction of a 6-month follow-up review in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 00-1500). (3) PROVIDER and AHCA agree that full payment as set forth above will resolve and settle this case completely and release both parties from all liabilities arising from the findings in the audit referenced as C.1, 97-0989-000-3, (4) PROVIDER agrees that it will not rebill the Medicaid Program in any manner for claims that were not covered by Medicaid, which are the subject of the audit in this case. 6. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 - . ; . oe Tallahassee, Florida 32317-3749 + 7. PROVIDER agrees that failure to Pay any monies due and owing under the terms of this Agreement shall constitute PROVIDER'S authorization for the Agency, without further notice, to withhold the total remaining amount due under the terms of this agreement from any monies due and owing to PROVIDER for any Medicaid claims. Med-Care Infusion Services, Inc. Settlement Agreement 8. AHCA reserves the right to enforce this Agreement under the laws of the State of Florida, the Rules of the Medicaid Program, and all other applicable rutes and regulations. 9, This settlement does not constitute an admission of wrongdoing or error by either party with respect to this case or any other matter. 10. | Each party shall bear its own attorneys’ fees and costs, if any. 11. | The signatories to this Agreement, acting in a representative capacity, represent that they are duly authorized to enter into this Agreement on behalf of the respective parties. 12, This Agreement shall be construed in accordance with the provisions of the laws of Florida. Venue for any action arising from this Agreement shall be in Leon County, Florida. 13. This Agreement constitutes the entire agreement between PROVIDER and the AHCA, including anyone acting for, associated with or employed by them, concerning all matters and Supersedes any prior discussions, agreements or understandings; there are no promises, representations or agreements between PROVIDER and the AHCA other than as set forth herein. No modification or waiver of any provision shall be valid unless a written amendment to the Agreement is completed- and properly executed by the parties: 14. This is an Agreement of settlement and compromise, made in recognition that the parties may have different or incorrect understandings, information and contentions, as to facts and law, and with each party compromising and settling any potential correctness or incorrectness of its understandings, information and contentions Med-Care Infusion Services, Inc. Settlement Agreement as to facts and law, so that no misunderstanding or misinformation shall be a ground for rescission heréof. 15. PROVIDER expressly waives in this matter its right to any hearing pursuant to sections 120.569 or 120.57, Florida Statutes, the making of findings of fact and conclusions of law by the Agency, and all further and other proceedings to which it may be entitled by law or rules of the Agency regarding this proceeding and any and all issues raised herein. PROVIDER further agrees that it shall not challenge or contest any Final Order entered in this matter which is consistent with the terms of this settlement agreement in any forum now or in the future available to it, including the right to any administrative proceeding, circuit or federal court action or any appeal. 16. This Agreement is and shall be deemed jointly drafted and written by all parties to it and shall not be construed or interpreted against the party originating or preparing it. 17. To the extent that any provision of this Agreement is Prohibited by law for any reason, such provision shall be effective to the extent not so prohibited, and such prohibition shall not affect any other provision of this Agreement. 18. This Agreement shall inure to the benefit of and be binding on each party’s “2 successors, assigns, heirs, administrators, representatives and trustees. 19. All.times stated herein are of the essence of this Agreement. 20. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. ‘Med-Care Infusion Services, Inc. Settlement Agreement MED-CARE INFUSION SERVICES, INC. hi wy NKrceeter Dated: G/6/2 > , 2002 BY: W/AFREK RAB CR RGIS (Print name) ITS: PRESIQENT AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 Loaf lhe Dated: i 27 , 2002 Rufus Ndble Inspector General / : Dated: 0/157 / , 2002 Valda Clark Christian General Counsel ow re Dated: CE 1} __ 2002 L. William Porter i! Assistant General Counsel Z\) © “ig EXHIBIT A i STATE OF HCA RECE IVED _ FES 95 ang AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH, GOVERNOR RUBEN J. KING-SHAW, JR., EXECUTIVE OIRECTOR February 21, 2000 CERTIFIED MAIL - RETURN RECEIPT NO. Z 082 986 407 ae nna Provider No. 1024540 00 License No. PH0012474 Wilfred Braceras, President Med-Care Infusion Services, Inc. 590 West 20th Street Hialeah, Florida 33010 RE: FINAL AGENCY AUDIT REPORT C.I. No. 97-0989-000-3/KNH Dear Mr. Braceras: Medicaid Program Integrity has completed a review of your paid Medicaid claims with dates of service from February 1, 1996, through December 31, 1997. We have also reviewed your product purchase/acquisition documentation and other documentation received on January 19, March 11, and April 9, 1999. Every explanation received from January 19, 1999, through April-9, 1999, for the billing of one drug and/or strength and the dispensing of another drug and/or strength has been considered thus resulting in changes to the identified overpayment. We have applied your explanations to the review although your prescription/compound records were non-supportive of the substitutions. You have failed to: 1) provide adequate by a certain National Drug Code (NDC) that were billed to’ and reimbursed by Medicaid and 3) provide documentation to support the claim quantity reimbursed by Medicaid for certain claims. You are hereby notified that we have determined that Med-Care Infusion Services, Inc., was overpaid $125,060.29 for claims that in whole or in Part are not covered by Medicaid. . The total amount due is $125,060.29. ‘The above action and your right of appeal are discussed below. _ RECEIVED MAR 16 2000 Visit AHCA Onli t MEDICAID PROGRAM dic. srare.r1-us INTEGRITY. 2727 Mahan Drive » Mail Stop # 6 Tallahassee, FL 32308 Wilfred Bracera:t President { Page 2 The Medicaid Provider Agreement states that the provider agrees to participate in the Florida Medicaid program under the terms and conditions specified in the provider agreement. This includes, but is not limited to, complying with federal and state laws, regulations, rules, Medicaid handbooks and policies, Section 409.913(7), Florida Statutes (F.S.), provides that a provider is responsible for the preparation and submission of a claim that is true and accurate and is for goods and services that are provided in accordance with applicable provisions of all Medicaid rules, regulations, handbooks, policies, federal, state, and local laws. Section 409.913(8), F.S., requires a Medicaid provider to retain medical, professional, financial, and business records pertaining to goods and services furnished to a Medicaid xecipient for a period of five years after the date of furnishing the goods and services. We have required that you submit invoices from your suppliers to substantiate the availability of drugs and drug package sizes that you billed to Medicaid. You have not fully substantiated such availability. The Medicaid Provider Reimbursement Handbook, “Pharmacy”, pages 5-1 and 5-2, effective February 1996, and the Medicaid Provider Coverage, Limitations, and Reimbursement Handbook, “Prescribed Drug Services”, pages 5-1 through 5-3, effective November 1997, state that it is a violation of Medicaid regulations to intentionally or unintentionally submit claims for services not provided or not fully provided, to submit a higher paying NDC than the one you actually provided, or to create unnecessary cost(s) to the Medicaid program from improper billings. The Medicaid Provider Reimbursement Handbook, “Pharmacy”, page 6-19, effective February 1996, and the Medicaid Provider Coverage, Limitations, and Reimbursement Handbook, “Prescribed Drug Services", page 6-23, effective November 1997, state that the provider should enter on claims the NDC for the drug dispensed as it appears on the bottle or package from which® the. drug. was dispensed. This includes the manufacturer number, item number, and package size number. Billing a NDC other than the one on the package from which the drug was dispensed is-a-— violation of Medicaid policy. = Section 409.913(10),-F.S., states: “The Agency may require repayment for inappropriate, medically unnecessary, or excessive goods or services from the person furnishing them, the person under whose supervision they were furnished, or the person causing them to be furnished.” R FE C E V E D MAR 16 2000 MEDICAID PROGRAM INTEGRITY Wilfred Braceras. President Page 3 Sections 409.913(14) (e),(h), and (n), F.S., state: “The agency may seek any remedy provided by law, including, but not limited to, the remedies provided in subsections (12) and (15) and s. 812.035, if:” kok “(e) The provider is not in compliance with provisions of Medicaid provider publications that have been adopted by xeference as rules in the Florida Administrative Code; with provisions of state or.federal laws, rules, or regulations; with provisions of the provider agreement between the agency and the provider; or with certifications found on claim forms or on transmittal forms for electronically submitted claims that are submitted by the provider or authorized representative, as such provisions apply to the Medicaid program; x ok “(h) The provider or an authorized representative of the provider, or a person who ordered or prescribed the goods or services, has submitted or caused to be submitted false or a pattern of erroneous Medicaid claims that have resulted in overpayments to a provider or that exceed those to which the provider was entitled under the Medicai — program; ” REC E i V ED k ok o* MAR 16 2000 “(n) The provider fails to demonstrate that it had available during a specific audit or review period MEDICAID PROGRAM sufficient quantities of goods, or sufficient time in #MtEGRITY case of services, to support the provider's billings to the Medicaid program;” . Failure to Substantiate Goods and Services Billed “y Billing Medicaid for drugs that have not been demonstrated as available-for dispensing is a violation of Medicaid laws and regulations and has resulted in the finding that you have -been overpaid by the Medicaid program. The overpayment identified is calculated for those instances in which you have failed to provide adequate documentation to substantiate the drug quantities and services billed to and paid for by Medicaid. The overpayment of $118,647.28 identified in overpayment summary #1 is with regard only to Immu Globulin, Gamma 5GM and comprehends only the period audited, namely February 1, 1996, through December 31, 1997. Allowance was given for the explanation that Immu Globulin, Gamma 10% was dispensed at times when Immu Globulin, Gamma 5% was billed/paid for by Medicaid and Immu Wilfred Braceras, President ‘ Page 4 Globulin, Gamma 5GM was dispensed at times when Immu Globulin, Gamma 6GM was billed/paid for by Medicaid. A review of Immu Globulin, Gamma 5GM, comparing purchases and claims on a time- line, determined that inventory was unavailable at times during the review period although the total units purchased during the review period were sufficient to cover billings to Medicaid. The shaded areas of overpayment summary #1 indicate the units unavailable. The paid claims in the shaded areas were summed to $118,647.28 as demonstrated in overpayment summary #1. A printout identifying all relevant claims involved in the overpayment and a copy of the drug purchase/acquisition review are attached. Failure to Substantiate Package Sizes Billed Billing Medicaid for drug quantities of package sizes that have not been demonstrated as available for dispensing is a violation of Medicaid laws and regulations and has resulted in the finding that you have been overpaid by the Medicaid program. The overpayment identified is calculated for those instances in which you have failed to provide adequate documentation to substantiate the availability in sufficient drug quantities of package sizes billed. Although you billed Medicaid for certain drugs identified by a given NDC, the last two digits of the noc billed did not accurately reflect the product packaging that you had available for dispensing. The inappropriate billings resulted in reimbursement amounts greater than that to which you were entitled. The overpayment of $524.80 identified in overpayment summary #2 is with regard only to Procrit 10000u/ml and comprehends only the period audited, namely, February 1, 1996, through December 31, 1997. During the period, February 1, 1996, through February 11, 1997, there was a $0.8000 reimbursement price difference per unit between the package size billed/paid for and the package size documented as purchased. During this period, 656 units were billed using a NDC not supported by the provider’s purchase documentation. Therefore, 656 units multiplied by $0.8000/unit equals a $524.80 overpayment as demonstrated in overpayment summary #2. A printout identifying all relevant claims for this portion of the review and a copy of the drug purchase/acquisition review afe -- attached. . Failure to Substantiate Quantities Billed — . oe Billing Medicaid for overstated drug quantities is a violation of Medicaid laws and regulations and has resulted in the finding that you have been overpaid by the Medicaid program. The overpayment idehtified is calculated for those instances in which you identified (January 19, 1999) another quantity other than the claim quantity as the correct quantity dispensed. The quantity discrepancies resulted in reimbursement amounts greater than that to which you were entitled. The overpayment of $5,888.21 identified in overpayment summary #3 is "RECEIVED MAR 16 2959 MEOIOGIN PROG TAM ei On . Wilfred Bracerag. President a Page 5 ‘ only to Immu Globulin, Gamma 10GM and comprehends only the period audited, namely, February 1, 1996, through December 31, 1997. Eight claims were identified by you to have an error in the claim quantity. A correct payment was determined based on an identical paid claim for the same drug and quantity on the same date of service or within two days of the date of service using the correct quantity you supplied on January 19, 1999, For each claim, the correct Payment was subtracted from the amount paid to determine the overpayment and the overpayments were summed to $5,888.21 as demonstrated in overpayment summary #3. A printout identifying all relevant claims for this portion of the review is attached. All overpayment calculations are based upon the assumption that all stock that you have demonstrated as available during the period was exclusively dispensed to Medicaid recipients; this is undoubtedly not the case and the assumption serves to reduce the amount of the calculated overpayment. All Medicaid payments that have been substantiated by documented inventory are assumed to be valid; and payments in excess of that amount are regarded to be invalid. Accordingly, as shown in overpayment summaries #1, #2, and #3, we have determined at this time that you have been overpaid by the Medicaid program in the amount of $125,060.29. TF additional overpayments are found subsequently, you will be notified. If you accept or concur with these findings, please send your check in the amount of $125,060.29, for the identified overpayment, made payable to the Florida Agency for Health Care Administration, to: Agency for Health Care Administration Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 (Note: The check must be payable to the Florida Agency for Health Care Administration, not to any employee of the ,agency.) To ensure proper credit, be sure that your - provider number is Shown on your check. Questions regarding payment should be directed to Ms. Willie: Bivens at (850) 487-4298, = You have the right to request a formal or informal hearing pursuant to section 120.569, F.S. If a petition for formal hearing is made, the petition must be made in compliance with rule section 28-106.201, Florida Administrative Code (F.A.C.). Please note that rule section 28-106.201(2), F.A.C., specifies that the petition shall contain a concise discussion of specific items in dispute. Additionally, you are hereby informed that if &@ request for a hearing is made, the request or PORE ERY E D MAR 16 2000 MEDICAID PROGRAM INTEGRITY Wilfred Braceras President . Page 6 received within twenty-one (21) days of receipt of this letter, Failure to timely request a hearing shall be deemed a waiver of your right to a hearing. It is important that a request for an informal hearing or a petition for a formal hearing be sent only to the following address: Mr. John A. Owens, Chief Medicaid Program Integrity Office of the Inspector General Agency for Health Care Administration 2727 Mahan Drive . Tallahassee, Florida 32308-5403 Do not send requests or petitions to any other address. If a hearing request is not received within 21 days from the date of receipt of this letter, the right to such hearing is waived, and repayment of the above-stipulated overpayment will be due and payable at the end of that 21-day period. Any questions. that you may have regarding this matter should be directed to: Ms. Kathryn N. Holland, Senior Pharmacist, Agency for Health Care Administration, Medicaid Program Integrity, Office of the Inspector General, 2727 Mahan Drive, Tallahassee, Florida 32308-5403, telephone number (850) 922-4374. Sincerely, Lilty— D. Kenneth Yon Program Administrator Medicaid Program Integrity DKY/knh ie Attachments cc: Medicaid Program Integrity Administrative Section Willie Bivens, Medicaid Accounts Receivable — L Medicaid Program Development Area Medicaid Office . O:\docs\f-medcareinfusion RECEIVED MAR 16 2000 MEDICAID FROGRAM INTEGRITY

Docket for Case No: 00-001500MPI