STATE OF FLORIDA AGENCY FOR HEATH CARE ADMINISTRATION! L - CHARLOTTE REGIONAL MEDICAL CENTER, 4 wh co Petitioner, vs. CASE NO. 01-4507 CI 97-1306-091 , AGENCY FOR HEALTH CARE RENDITION NO.: AHCA-02- { vO-s-mpp ADMINISTRATION, Respondent. / NU FINAL ORDER THE PARTIES resolved all disputed issues and executed a “settlement agreement”, which is incorporated by reference. The parties are directed to comply with the terms of the “settlement agreement”. Based on the foregoing, this proceeding is CLOSED. DONE and ORDERED on this the ZS day of a Jor , 2002, in Tallahassee, Florida. pe nda/M. bt M.D. Secretary frBees 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: Dalton Tininenko Charlotte Regional Medical Center 733 East Olympia Avenue Punta Gorda, FL 33950-3898 Kim A. Kellum, Esquire Attorney for Agency AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive Fort Knox Building 3, Mail Stop 3 Tallahassee, Florida 32308 Lawrence P. Stevenson Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Willie Bivens, Finance and Accounting Mike Morton, Medicaid Program Integrity 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 AZ: day of Te 2002. Lebuth 0M hu. Lealand McCharen, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3, Mail Stop 3 Tallahassee, Florida 32308-5403 , STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLOTTE REGIONAL MEDICAL CENTER Petitioner, C.I. 97-1306-091 vs. Case No. 01-4507 AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / eee SETTLEMENT AGREEMENT Respondent, the State of Florida, Agency for Health Care Administration, and Petitioner, Charlotte Regional Medical Center, by and through the undersigned individuals, hereby stipulate and agree as follows: 1. This settlement agreement is entered into between the parties in order to resolve a dispute that arose as the result of a First Mental Health review. 2. Ina final agency audit letter dated February 25, 1999, Petitioner was informed that the Agency sought recoupment in the amount of $63,729.12. A copy of the recoupment letter is attached to this agreement. 3. Petitioner challenged Respondent's action and requested a formal hearing regarding the claims in question. 4. Subsequently, the Respondent ro-reviewed the documentation and the actual overpayment is $6,536.32. 5. The Agency agrees to allow the Petitioner, Charlotte Regional Medical Center, to pay the Agency the total sum of $6,536.32 within sixty (60) days of execution of the Settlement Agreement. 6. In the event the Petitioner fails to make any payment due hereunder, the Respondent may, at its option and upon fifteen days written notice to Petitioner, declare Petitioner in default. Its provider number shall be suspended until such time as the Agency receives payment of the balance in full. 7. Payments shall be made to: AGENCY FOR HEALTH CARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, FL 32317-3749 8. This settlement does not constitute an admission of wrongdoing or error by either party. However, the parties believe that this matter should be settled. 9. Both parties request that the Agency close the file in this case. 10. Each party shall bear its own attorney's fees and costs. 1. This agreement represents the entire agreement between the parties regarding settlement of this case. 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. The signatories to this agreement, acting in a representative capacity, represent that they are duly authorized to act on behalf of the parties to the agreement. Venue for any action arising from this agreement shall be in Leon County, Florida. Dated this V/A day of LpruL of 2002. AGENCY FOR HEALTH CARE ADMINISTRATION William H. Roberts Acting General Counsel Agency for Health Care Administration 2727 Mahan Drive Ft. Knox Building 3 Tallahassee, Florida 32308 M— Rufvis NoBle, Inspector General Agency for Health Care Administration 2727 Mahan Drive Ft. Knox Building 3 Tallahassee, Florida 32308 Charlotte Regiona 733 East Olympia Avenue Punta Gorda, Florida 33950 Cc: Mike Morton, Medicaid Program Integrity

Docket for Case No: 01-004507MPI