STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS ATCA pane HEN? CLERK at uebin hae TENDER HOME CARE, Petitioner, RQ F4 nom ate vs. aA: Lea} : ~m fe AGENCY FOR HEALTH CARE nn ed ADMINISTRATION, “os Respondent. / FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement on , 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 %0_ day of Sypfab--a000, in Tallahassee, Florida. fP Aecnce nolo MD, Secretary fP recney 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: L. William Porter II, Esquire Agency for Health Care Administration (Interoffice Mail) Stuart Lerner The Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-30060 Anthony C. Vitale, Esquire 799 Brickell Plaza, Suite 700 Miami, Florida 33131 Judy Hefren, Acting Bureau Chief, Medicaid Program Integrity Adolfo Garcia, Medicaid Program Integrity Willie Bivens, 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 the WDaay of OCiok WN _, 2002. is 4% CLealand McCharen, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 2° ALG-23-2282 8:23 TENDER HOME CARE DOAH No. 00-4766 Provider No. 678913800 C.1. No. 00-0438-000 SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA" or "the Agency’), and Tender Home Care ("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 October 6, 2000, AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Integrity (MP)) 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 $621,801.32. in response to the audit letter dated October 6, 2000, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No, 00-4766. 4. The provider submitted additional documentation and & revi of that documentation resulted In the amount being adjusted to $531,526.97. nea 5. In order to resolve this matter without further administrative proceedings, PROVIDER and 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. TOTAL P.@2 ETIG-@SE (SOE) JO 3OISS0 MYT HLIWWAH SHL WYBT FOOT 2002 S32 gnu (2) Within thirty days of receipt of the final order, PROVIDER agrees to ~ make the first installment to repay four hundred ninety thousand dollars ($490,000.00) to be made in eighteen (18) equal monthly payments in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 00-4766). (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.I. 00-0438-000. (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 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. 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 rules 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 jaw, and with each party compromising and settling any potential correctness or incorrectness of its understandings, information and contentions as to facts and law, so that no misunderstanding or misinformation shall be a ground for rescission hereof. 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 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. TENDER HOME CARE BY: 2h fr. Print nanfe) ITS: fee Sin Zus- ‘ FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 apo Dated: IP o000 Rufus Nowe Inspector Genera! o/s Dated: « 18 , 2002 Valda Clark- Christian General Counsel .-°-.-.:: hylleen _ Dated: | 2b -9r 2002 L. William Porter II Assistant General Counsel Dated: O¢ ‘fay , 2002 ) ) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH, GOVERNOR RUBEN J. KING-SHAW, JR., SECRETARY October 6, 2000 7 CERTIFIED MAIL - RETURN RECEIPT No. 7000 0600 0026 2895 3211 Provider No. 6769136 00 553 SH 87" Avene > A iS Suite A venwe REC E I V E D Miami, Florida 33174 OCT 31 In Reply Refer to 34 2000 FINAL AGENCY AUDIT REPORT MEDIC. C.I. 00-0438-000 NTE ROGRAM Dear Provider: The Agency for Health Care Administration, Medicaid Program Integrity office has completed the review of your Medicaid claims for the procedures specified below for dates of service during the period January 1, 1999, through June 15, 2000. A Provisional Agency Audit Report dated, July 6, 2000, was sent to you indicating that we had determined you were overpaid $621,801.32. In response to the provisional letter, you sent documentation to validate your claims. We have performed a subsequent review, in light of the additional evidence you provided; the overpayment amount will remain $621,801.32. In determining payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, limitations and exclusions found in the Medicaid provider handbooks, and Section 409.913, F.S. 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. The following is our assessment of why certain claims do not meet Medicaid requirements. A computer printout detailing the claims affected by this assessment is attached. Visit AHCA Online at 2727 Mahan Drive « Mail Stop # 6 www. fdhe.state.flus Tallahassee, FL 32308 . -_~ oN Tender Home Care Page 2 -- : REVIEW DETERMINATIONS The following review determinations were made by applying Medicaid policy to the documentation obtained from your office by the Medicaid Program Integrity office, Agency for Health Care Administration. - Subsection 409.9013(5), F.S., states: “(7) When presenting a claim for payment under the Medicaid Program, a provider has an affirmative duty to supervise the provision of, and be responsible for, goods and services claimed to have been provided, to Supervise and be responsible for preparation and submission of the claims, and to present a claim that is true and accurate and that is for goods and services that: (e) are provided in accord with applicable provisions of all Medicaid rule, regulations, handbooks and policies and in. __ accordance with federal, state and local law.” R FCE | V E D The Project AIDS Care (PAC) Waiver Services. Coverage and OCT 21 209 Limitations Handbook, Chapter 1, Waiver Services Provider “eu Qualifications, Introduction, dated April 1999, states: MEICAIA OG “AR nab wre “PAC waiver providers must meet the general Medicaid provider qualifications that are contained in Chapter 2 of the Medicaid Provider Reimbursement Handbook, Non- Institutional 081. In addition, PAC waiver providers must meet the specific provider qualifications listed on this section for the services that they provide.” The section subtitled Home-Delivered Meals Providers states: “To provide Medicaid PAC waiver home-delivered meal services providers must be: ‘ ¢ Meal preparation and delivery businesses licensed by the Department of Health in accordance with Chapter 509, F.S., ® Restaurants licensed by the Department of Health in accordance with Chapter 500, F.S. or e Federal Older Americans Act providers contracted for home delivered meals.” RE C E i} V E D OCT 31 2000 MEDICAID PROGRAM INTEGRITY ‘ . -_ o™ Tender Home Care Page 3 The section subtitled Pest Control Providers states: “To provide Medicaid PAC waiver pest control services, providers must be pest control businesses licensed by the Department of Agriculture and Consumer Services according to Chapter 482, F.S.” The amount of the unauthorized services for-which you billed and were paid for Medicaid claims foy..Home Delivered Meals, procedure codes W9991 and Pest Control, procedure code w9953 is considered an overpayment. In addition, Medicaid Home and Community-Based Services, waiver services for PAC recipients were rendered for Specialized Medical Equipment and Supplies, procedure code W9994, without Service Authorization being issued for the recipients in this review. The Project AIDS Care (PAC) Waiver Services. Coverage and Limitations Handbook, Chapter 2, Covered Services, Limitations and Exclusions, Plan of Care, April 1999, page 2-9 states: “Services not specified in the plan of care are not considered approved or authorized. Medicaid reimbursements for services furnished, but not specified in the plan of care for that specific time period are subject to recoupment.” Chapter 2, Covered Services, Limitations and Exclusions, Service Authorization Components, April 1999, page 2-10 further states: “All service authorizations for PAC waiver services must include: : @¢ Claim authorization number;, @® Provider name and Medicaid identification number; ® Recipient’s name, birth date, and Medicaid identification number; e Recipient’s address e Case management agency name and address; @ Name and telephone number of the case manager who authorized services on the plan of care; . e Specials instructions; @ Services to be furnished with corresponding proceduag Etre | V E D OCT 312077 MEDICAID PROGRAM INTEGRITY ‘ , “~ ~~ Tender Home Care Page 4 e Frequency and amount of service; ® Cost of service (maximum authorized expenditures); and @ ~Puration of services. The amount of the unauthorized services for which you billed and were paid for Medicaid claims for procedure code w9994, Specialized Medical Equipment and Supplies, is considered an overpayment. - . If you concur with the amount of the overpayment, send your check for $621,801.32. The check must be payable to the Plorida 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. Please 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) 921-4396. 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 28-106.21, 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 a request for a hearing is made, the request or petition must be received within twenty-one (21) days of receipt of this letter, and 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 Agency for Health Care Administration Medicaid Program Integrity R . 2727 Mah Dri Tallahassee, Florida 32308 ECEIVED OCT 31 2009 MEDICAID PROGRAM INTEGRITY ‘Tender Home Care Page 5 Do not send requests or petitions to any other address. If a 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 have any questions about this matter, contact Adolfo Garcia, Medical/Health Care Analyst, Agency for Health Care Administration, Madicaid Program Integrity, Office of the Inspector General, P.O. Box 52-2804, Miami, Florida 33152-2804, telephone (305) 470-5862. Medicaid Program Integrity Sincerel Nie John A. Owens, Chief JAO:ALG: def Enclosures cc: Medicaid Accounts Receivable Medicaid Program Development Medicaid Program Integrity Administration Medicaid Program Integrity Work Group Five Area Medicaid Office RECEIVED OCT 3 1 2000 MEDICAID PRocRaM INTEGRITY

Docket for Case No: 00-004766