STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS LEONICO G. SANCHEZ, M.D., Petitioner, it D p C line A vs. CASE NO. 01-4080 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement on deck be , 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 *%_ day of BAL n— , 2002, pcibiti Medows, MD, — fF Reine for Health Care Administration in Tallahassee, Florida. 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 Il, Esquire Agency for Health Care Administration (Interoffice Mail) Anthony C. Vitale, Esquire 799 Brickell Plaza, Suite 700 Miami, Florida 33131 (U.S. Mail) Kelly Bennett, Assistant Bureau Chief, Medicaid Program Integrity Bonnie Mills-Herrera, 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 \Waay of OCtoOlic , 2002. Cheats TAG ep vhs So*Lealand McCharen, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 AUB-He-SENe Lett : . Lycee tae, . my uee LEONCIO G. SANCHEZ, M.D. DOAH No. 01-408? _, aa Provider No. 375576200 . ; C.1, No. 98-1 596+ 000 “yr 2, wed “lg SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA" or “the Agency’), and Leoncio G. Sanchez, M.D. (‘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 August 7, 2001, 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 $64,642.13. In response to the audit letter dated August 7, 2001, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No. 01-4080. 4. In its amended final agency audit report dated March 11, 2002, AHCA notified PROVIDER that the amount of the overpayment had been reduced to $61,983.70. Dey AUG-BE SHS Laat Leoncio G. Sanchez, M.D. Settlement Agreement 5. in order to resolve this matter without further administrative proceedings, PROVIDER and the AHCA expressly agree as follows: fon (1) (2) (3) (4) (5) AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. Within thirty days of receipt of the final order, PROVIDER agrees to make a lump sum payment of fifty thousand dollars ($50,000.00) in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 01-4080), 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. 98-1596-000. 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. As a concurrent condition, AHCA will require PROVIDER to complete training in coding/billing procedures and provide AHCA with documentation when required training has been completed. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 AUG-HE-Sa PE ’ Pe P.B4 86 Leoncio G. Sanchez, M.D. Settlement Agreement 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. 410. Each party shall bear its own attorneys’ fees and costs, if any. 41. The signatories to this Agreement, acting in a representative capacity, represent that they are duly authorized to enter into this Agreement on behaif 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. 43. 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. AUR-BS-Shee lees ; : Pas /a6 Leoncio G. Sanchez, M.D. Settlement Agreement 14. This is an Agreement of settlement and compromise, made in recognition that the parties may have different or incorrect. understandings, inforrnation and contentions, as to Tacts And 1aW, 4Na WITT Bai! party Curiproruonig cums sewn sory 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 rascission hereof. 45. 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, PROVIDEK turner agrees tat It sual NUL Giianeys UE WWI neoe 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. 46. 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 affective 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. AUIS lk 2s ‘ PBB te . . YE MEE: Leoncio G. Sanchez, M.D. Settlement Agreement 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. LEONCIO G. SANCHE MD. Dated: 2-AX% -A009. , 2002 FLORIDA AGENCY FOR HEALTH CARE AOMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 _ Aft Dated: ft _, 2002 Rufus Noble Inspector General Dated: 9 /. A7___., 2002 ~Leee” “ylidden MN Mal A» Dated: By [ o7 2002 L. Willam Porter tI Assistant General Counsel! res ~92 SANTA CLARA MED. 38S 8264616 P “4OBO O { oO; Mie . STATE OF FLORIDA , ; PA + AGENGY FOR HEALTH CARE ADMINISTRATION JER BUSH, GOVERNOR "| RHONDA M. MEADOWS, MD; FAAS Provider No. 3755762 00 a io . Leoncio G. Sanchez, MD R E C EJ V ED 155 West 49° Street Hialeah, Florida 33012 , AUG 2 9 2001 tr. Reply Refer to FINAL AGENCY AUDIT REPORT MEDICAID PROGRAM INTEGRITY C.1. 98-1596-000-BMH Dear Provider: tre 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 August 1, 1997, through August 24, 1999. A Provisional Agency Audit Report dated, August 30, 2000, was sent to you indicating that we had determined you were overpaid $75,817.54. In response to the provisional letter, you sent documentation to validate your claims. We have performed a subsequent review, in Jight of the additional evidence you provided, it has been determined that you were overpaid $64,642.13 for claims that in whole or in part are not covered by Medicaid. . 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. lar guidelines related to lanation of why these claims Bn attached computer ffected by this Below ig a discussion of the particu our review of your claims and an exp do not meet Medicaid requirements. puintout lists the claims that are a determination. Steadquarters # 6 2727 Mahan Drive Sallabassee, FL 32308 Medicaid Program Integrity PO Box 52-2804 Miami, FL 33152 aru tdhe cinta thie ceppreee nce: oa ay | f. : SANTA CLARA MEDB.7 S3Q5 8264616 PLoS roe i t a ¥ t Leoncio G. Sanchez, MD. : R E Cc E V E 5 ' Pege 2 AUG 2 9 D004 i REVIEW DEVERMINATIONS _ MEDICAID PROGRAM - . INTEGRITY rc Following review determinations were made by applying © : Medicaid policy to the documentation obtained from your office by the Medicaid Program Integrity office, Agency for Heal, ‘Care, Acministration. a> oor) Medicaid policy defines the varying levels of care ane: expertise required for the evaluation and management’ ~ procedure codes for office visits. The documentation you provided supports a lower level of office visit than the one for which you billed and received payment. The difference between the amounts you were paid and the correct payment for the appropriate level of service is considered an overpayment. oe = wo _— Medicaid policy requires that payinents be made only for those services listed in the provider handbook. You billed f and received payment for services that, when reviewed by a : physician consultant, indicated the service was not ! Medicaid covered. Payments made to you for these services ace considered overpayments, — se ms Taam Medicaid policy requires services performed be medically necessary for the diagnosis and treatment of an illness. You billed and received payments for services for which the medical records, when reviewed by a Medicaid physician consultant, indicated that the services provided did not meet the Medicaid criteria for medical necessity. The claims, which were considered medically unnecessary, were disallowed and the money you were paid for these procedures is considered an overpayment. She overpayment was calculated as follows: A random sample of 38 recipients for whom you submitted’ 587 claims was reviewed. For those claims in the sample, which have detes of service from August 1, 1997, through August 24, 1999, an overpayment of $3,424.11 or $5.83323682 per claim was found, as indicated on the accompanying schedule. Since you were paid for a total (population) of 14,239 claims for that period, the point estimate of the total overpayment is $5,83323682 x 14,239 = $83,059.46. There is a fifty percent (50%) probability that the overpayment to you is that amount or more, sone Cy oa SANTA CLARA MED.- B@S 8264616 ey jeoacio G. Sanchez, MD. Qa ; . Page 3 lop os . - . a & ; Senin SO ot We therefore used the following statistical formula fr’ clusteky sampling: ae & pling Mg /> fon ee Avuaenaumant a Ro- > [PWM S$(4 —YB.Y Where: : bs La i = point estimate of overpayment = ASaiSa\) $83,059.46 fel ist = number of claims in the population = SB, 14,239 total overpayment in sample cluster " RECEIV ED = number of claims in sample cluster = number of clusters in the population, 976 AUG 29 2001 N = number of clusters in the random sample, 38 Y MEDICAID PROGRAM Se 5 R fd N = mean overpayment pex claim = ALY B $5.83323682 . INTEGRITY tol to) t = t value from the Distribution of t Table, 1.687.934 The values of overpayment and number of claims respecting each companying schedvle. anarally accPpbrgohls this purpose, we have calculated that the overpayment (95%) probability that at Jf you concur with the amount of the overpayment, send your check for $64,642.13. The check must be payable to the Florida Agency for Health Care Administration, not to any employee of tha agency. TY 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 directed to Ms, Willie ment should be (850) 921-4396. Questions regarding pay 3ivens, Medicaid accounts receivable, 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. Please note that rule section 28-106.201(2) specifies that the petition crow ore SANTA CLARA MED. 3Q@5 8264616 P.e5 Leoncio G. Sanchez, MD. 2 Fage 4 i : ey “py ES shall contain a concise discussion of specific items in dispute.