STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION LAKE WALES MEDICAL CENTER, tac =, Petitioner, my Vs. Case No. 00-4334 WwW Rc - Audit No. CI00-0616-000 STATE OF FLORIDA, AGENCY FOR Clceed HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER On August 29, 2000, Respondent Agency for Health Care Administration notified the Petitioner that it sought to recoup an overpayment in the amount of $3,178.80. On October 24, 2000 the Agency issued a corrected final agency audit report reducing the overpayment to $1,907.28. On November 14, 2000, the Petitioner filed a Notice of Voluntary Dismissal. On November 16, 2000, DOAH issued an Order Closing File. Based on the foregoing, the petition filed in the above- styled cause is dismissed, and the Agency’s file is hereby closed. DONE and ORDER this 4 day of , 2001, in Tallahassee, Leon County, Floridy. uben J. King-Shaw, Jr., Secretary Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL 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: Moses E. Williams, Esquire Assistant General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building 3 Tallahassee, Florida 32308 W. David Watkins, Esq. 1725 Mahan Drive, Suite 201 Tallahassee, Florida 32317-5828 William R. Cave Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 John Owens, Medicaid Program Integrity Willie Bivins, Finance and Accounting 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 ah day o gee 300. R.S. wer, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Dr., Bldg. 3, MS# 3 Tallahassee, Florida 32038 (850) 922-5873 t a el 7 Wx c STATE OF FLORIDA c ¢ . eV TT ‘paca wt "nov 0 1 2000 ’ oe ts AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE JEB BUSH, GOVERNOR RUBEN J. KING SEMIDHSTRAFTON-LEGAL CERTIFIED MAIL — 7000 0600 0027 1515 3043 October 24, 2000 Provider No. 010166400 Lake Wales Medical Center C/O Mr. David Watkins Attorney at Law 1725 Mahan Drive, Suite 201 P. O. Box 15828 : Tallahassee, FL, 32317-5828 i RE: FINAL AGENCY AUDIT REPORT - CORRECTED C.I. 00-0616-000 Dear Administrator: Please refer to our provisional agency audit report dated May 22, 2000, wherein we made a ' preliminary determination that you were overpaid $3,178.80, for services not covered by _ Medicaid, This was based on retrospective medical zecord review by the Florida Medical Quality Assurance, Inc. FMQAD, wherein it was determined that either the inpatient admission or a portion of the length of stay was not medically necessary for Medicaid recipients. In i response to the preliminary letter, you sent additional documentation to validate your claims. I The agency has performed a subsequent review, in light of the additional evidence you provided. Therefore, it has been determined that you were overpaid $3,178.80 for claims that in whole or in part are not covered by Medicaid. . On September 19, 2000, your facility requested a formal hearing and a complete review of all medical records. After reviewing the records, it has been determined that you were overpaid $1,907.28 for claims that in whole or in part are not covered by Medicaid. This review and the determination of overpayment were made in accordance with the provisions of Florida Statutes Section 409.913. In determining payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, Medicaid Bulletins, Statements of Policy and the limitations and exclusions found in the Medicaid provider handbooks. In applying for Medicaid reimbursement, providers are required to follow the guidelines set forth in the applicable rules and Medicaid fee schedules, as promulgated in the Medicaid policy handbooks and billing bulletins. Medicaid cannot pay for services that do not meet these guidelines. ; Visit AHCA Online at 2727 Mahan Drive ~ Mail Stop #1 www.fdhe.state.fl.us Tallahassee, FL 32308 ae: CO C Lake Wales Medical Center page 2 Of the attached (see attachment) 2 claim(s) reviewed, according to our records your hospital did not submit a timely request for reconsideration by Florida Medical Quality Assurance, Inc. (FMQAI) on 2 claim(s). Therefore, pursuant to Florida Medicaid Hospital Coverage and Limitations, January 1999, Appendix J, under Notice of Adverse Determination, you waived your rights to an administrative hearing. If you have additional documentation supporting a timely request for reconsideration, please submit within 21 days or submit payment for these claims. For the remaining 0 claim(s), you have the right to request a formal or informal hearing pursuant to Section 120.569, F.S. Ifa petition for formal hearing is made, the petition must be made in compliance with rule section 28-106.201, Florida Administrative Code. Please note that rule section 28-106.201(2) specifies that the petition shall contain a concise discussion of specific items in dispute. Additionally, you are hereby informed that if a request for a hearing is made, the request or petition must be 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 Inspector General Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #6 Tallahassee, Florida 32308-5403 Do not send requests or petitions to any other address. Ifa hearing request is not received within twenty-one (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 twenty-one (21) day period. If you concur with the amount of the overpayment, send your check for $1,907.28. 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 certain your provider number is shown on your check. lease mail to: Agency for Health Care Administration Medicaid Accounts Receivable P.O. Box 13749 Tallahassee, Florida 32317-3749 Questions regarding payment should be directed to Ms. Willie Bivens, Medicaid accounts receivable, (850) 487-4298. Lake Wales Medical Center page 3 - Any questions you may have about this matter should be directed to: Debbie Lynn, Human Services Program Specialist, Agency for Health Care Administration, Medicaid Program Integrity, 2727 Mahan Drive, MS #6, Tallahassee, Florida 32308, telephone (850) 488-8194. Sincerely, Drurbm Mike Morton Program Administrator MVM:djl Enclosures cc: Medicaid Program Development Area Medicaid Office LAKE WALES MEDICAL CENTER FMQAI DENIALS PROVIDER NUMBER 0101664 00 DENIAL RECIPIENT AOMIT DISCHARGE DENIAL DENIAL NO LAST NAME FIRST NAME DATE DATE ee END DATE DAYS OVERPAYMENT ADVERSE DETERMINATION - LENGTH OF STAY/ADMISSION DENIAL 8141983085 BRADWAY BARBARA qIMAN997 «1479341997 11/11/1997 11/13/1997 2 $1,271.52 761282125 GRINER WILLIS 10/01/1997 10/03/1997 10/02/1997 10/03/1997 1 $635.76 —————— $1,907.28 C C STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS LAKE WALES MEDICAL CENTER, Petitioner, v. . DOAH CASE NOS: 00-4334 AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent, / LAKE WALES MEDICAL CENTER'S NOTICE OF VOLUNTARY DISMISSAL LAKE WALES MEDICAL CENTER , by and through its undersigned counsel, hereby gives notice of the voluntary dismissal of its Petition for Formal Administrative Hearing filed on September 19, 2000. This dismissal is pursuant to the Agency for Health Care Administration's issuance of the Corrected Final Agency Audit Report dated October 24, 2000. Respectfully submitted this 14th day of November, 2000. Watkins & Caleen, PA. . 1725 Mahan Drive, Suite 201 P. O. Box 15828 ‘ Tallahassee, Florida 32317-5828 (850) 671-2644 pEcaivEg W. DAVIDIWATKINS, Esq. NOV 15 2000 Florida Bar No. 437190 ~~ General Ccunel's Office Attorneys for Lake Wales Medical Center ee ia ae aT a are we Se

Docket for Case No: 00-004334