STATE OF FLORIDA act 1s C2 ~" DIVISION OF ADMINISTRATIVE HEARINGS LAKE WALES MEDICAL CENTER, Petitioner, v. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement on Sopbwhe 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 aT day of S or , 2002, in Tallahassee, Florida. - Wel fr Rhonda. Medows, MD, 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: Garnett Chisenhall, Esquire Agency for Health Care Administration (Interoffice Mail) W. David Watkins, Esquire Watkins & Caleen, P.A. 1725 Mahan Drive, Suite 201 Tallahassee, FL 32317-5828 Daniel Manry Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Kelly Bennett, Assistant Bureau Chief, Medicaid Program Integrity Debbie Lynn, 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 1S day of OGY, 2002. _ Chante Tho rtessn c*tealand McCharen, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS LAKE WALES MEDICAL CENTER, Petitioner, v. DOAH CASE NO.: 02-2905MPI AHCA Provider NO.: 010166400 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and LAKE WALES MEDICAL CENTER (“PROVIDER”), by and through the undersigned, hereby stipulate and agree as follows: 1. PROVIDER is a Medicaid provider in the State of Florida. 2. In its Final Agency Audit Report issued on May 17, 2002 (the "Audit Letter”) 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 $7,055.40. 3. In response to the Audit Letter, PROVIDER filed a petition for a formal administrative hearing that was assigned Case No. 02-2905MPI. 4. Subsequent to the audit that took place in this matter and in preparation for trial, AHCA re-reviewed the PROVIDER’S claims and evaluated additional documentation submitted by the PROVIDER. As a result, AHCA determined that the overpayment was $4,489.80. PROVIDER has agreed to pay $4,489.80 as full and complete resolution of this matter. 5. In order to resolve this matter without further administrative proceedings, PROVIDER and AHCA expressly agree as follows: (a) AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. (b) PROVIDER agrees to pay to AHCA, within 30 days after issuance of a Final Order, the sum of four thousand, four hundred and eighty-nine dollars and eighty cents ($4,489.80) to be made in one lump sum payment as full and complete settlement of all claims in the proceedings before the Agency and the Division of Administrative Hearings (Case No. 02- 2905MPI). (c) PROVIDER is responsible for ensuring timely delivery of the payment. Furthermore, failure to. timely. make. the. payment. will render the balance due and payable immediately, with interest, and interest will continue to accrue until the entire balance is paid. (d) AHCA reserves the right to seek ‘enforcement of this agreement by any legal means. (e) () (g) (h) (i) 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. No. 01-1175-000. 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. PROVIDER agrees that failure to make payment per the terms of this agreement may result in the Agency pursuing all legal means to enforce this agreement and may include a request for attorney fees and all costs associated with the enforcement of this agreement. PROVIDER also agrees that failure to make payment per the terms of this agreement may result in the Agency intercepting its Medicaid payments until the balance due is repaid. PROVIDER also agrees that failure to make payment per the terms. of this agreement. may..result in sanctions, which may include termination from the Medicaid program. 6. Payment shall be made payable to: AGENCY FOR HEALTH CARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 And payment shall clearly indicate that it is per a settlement agreement, shall reference the Case Number, and shall reference the C.J. Number. 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. The parties agree to bear their own attorney’s fees and costs, if any, except as expressly set forth in this agreement. 10. 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. Furthermore, PROVIDER agrees that his signature alone binds him to make the payment as set forth in this agreement. The parties further agree that a facsimile or photocopy reproduction of this agreement with PROVIDER’S signature alone shall be sufficient for the Agency to enforce the agreement and to cancel the. hearing. in. this.. matter... Furthermore,.. PROVIDER agrees. that. upon. receipt of the monies due and owing under this agreement, and upon PROVIDER’S signature on the agreement, AHCA shall file a notice and motion. canceling the hearing in this matter. 11, 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. 12. In the event PROVIDER breaches this Agreement, and enforcement of this Agreement or recovery of damages for breach hereof is obtained by law or by legal proceedings through an attorney at law, all costs of collection or enforcement, including reasonable attorneys’ fees and costs, shall be paid by PROVIDER to AHCA. 13. This Agreement constitutes the entire agreement between PROVIDER and 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 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. 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 the Agency should issue a Final Order which is consistent with the terms of this settlement, that adopts this agreement and closes this matter. 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. LAKE WALES MEDICAL CENTER Petitioner/Provider Dated: ? _ LY — ,2002 (signature) By its: President Dated: 7/#/oL , 2002 W. David Watkins, Esquire Attorney for Petitioner AGENCY-FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 Inspector General Valda Clark Christian General Counsel Sarreht ChrcocAl Garnett Chisenhall Assistant General Counsel Dated: G/L? , 2002 Dated: thst vA , 2002 Dated: 9 / /€/ , 2002 = = FLORA AGENCY FOR MEATH CARE ADM ISTRATICN <{23. SfOKe ¢ RHONDA M. MEDCWS, MO, FAAFP, SECAETARY JEB BUSH, GOVERNOR : pry — May 17, 2002° CERTIFIED MAIL ~ 7001 0320 0004 6781 6939 Provider No. 010166400 | Ms. Phyllis Fitzwater Director, Case Management ‘ R cE C F ; ; Lake Wales Medical Center ? 410 South 11th Street I V Ep Wales, FL, 33859 Lake Wales JUN 07 0000 MEDI RE: FINAL AGENCY AUDIT REPORT Ie ROGRAM CI. 01-1175-000 Dear Administrator. Please refer to our provisional agency audit report dated August 15, 2001, wherein we made a preliminary determination that you were overpaid $7,055.40, for services not covered by Medicaid. This was based on retrospective medical record 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. We have received no response from you regarding this provisional agency audit letter. T erefore, the agency has determined that you were overpaid $7,055.40 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 pursuarit 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. ; . Pursuant to Florida Administrative Code 59G-4.150 (06/09/96) and Florida.Medicaid Hospital Coverage and Limitations, January 1999, Appendix J, under Notice of Adverse Determination, request for reconsideration of an initial adverse determination was to be made in writing to the PRO within sixty calendar days after receipt of the denial notice. ‘Of the attached (see Visit AHCA ontine ar www fire. state flius Exhibit | 2727 Mahau Drive * Mail Stop #6 Tallahassee, FL 32308 Lake Wales Medical Cevter - Page 2 attachment) 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 0 claim(s), Therefore, 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. Because of FMQAI’s termination of their Medicaid contract with AHCA, adverse determinations that were dated for June thru September 1999 will be granted hearing rights. For the remaining claim(s), you have the right to request a formal or informal hearing pursuant to section 120.569, F.S. If a request for forma! hearing is made, the petition must be made in compliance with rule section 28-106.201, Florida Administrative Code (F.A.C.). Ifa request for an informal hearing is made, the petition must be made in compliance with rule section 28-106.301, F.A.C. Please note that rule section 28-106.201 (formal hearing) and 28-106.301 (informal hearing), F.A.C., specify 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 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 toa 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. Charles G. Ginn, 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. 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 concur with the amount of the overpayment, please send your check in the amount shown in the first paragraph of this letter. 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. Please mail to: Agency for Health Care Administration Medicaid Accounts Receivable Attention: Ms. Willie Bivens P.O. Box 13749 Tallahassee, Florida 32317-3749 If payment is not received or arranged for, within 30 days of receipt of this letter, the Agency may withhold Medicaid payments in accordance with the provisions of Chapter 409.913(26), F.S. Questions regarding payment should be directed to Ms. Willie Bivens, Medicaid Accounts Receivable, (850) 487-4298. Lake Wales Medical C ‘er a ' 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, (ir fos Mike Morton AHCA Administrator MVM:djl Enclosures ce: Medicaid Program Development Area Medicaid Office Willie Bivens Medicaid Accounts Receivables LAKE WALES MEDICAL CENTER FMOA! Hospital Denials Provider No. 0101664 00__ DENIAL ADMIT DISCHARGE BEGIN DENIAL DENIAL OVERPAYMENT RECIPIENT NO LAST NAME FIRST NAME DATE DATE DATE END DATE DAYS ADVERSE DETERMINATION - (June - September 1999} LENGTH OF STAY/ADMISSION DENIAL 8106307115 Bousman David 12/01/1997 12/09/1997 12/07/1997 12/09/1997 2 $1,282.80 7630102453 Ganzalez Ciara ~ 01/13/1998 01/15/1998 01/13/1998 01/15/1998 2 $1,282.80 7545160444 Jacobs Thessalonina 03/01/1998 03/07/1998 03/06/1998 03/07/1998 1 $641.40 8113477977 Otiver Dorothy 03/05/1998 03/10/1998 02/08/1998 03/10/1998 2 $1,282.80 2116491134 Velez Eduardo 06/08/1998 06/11/1998 06/08/1998 06/11/1998 3 $1,924.20 RECONSIDERATION DETERMINATION 7349698208 Spradiey Linda 04/07/1998 04/09/1998 04/08/1998 04/09/1998 1 $641.40 ae $7,055.40 FLORIDA AGENCY FOR HEALTH CARE ADMINGTRATION JE8 BUSH, GOVERNOR FHONOA M, MEOOWS, MD, FAAFP, SECRETARY PLEASE INCLUDE THIS REMITTAN CE FORM WITH YOUR PAYMENT Date: May 17, 2002 C.I.No.: 01-1175-000 Provider No. 010166400 Name of Entity: Lake Wales Medical Center Address: 410 South 11th Street Lake Wales, FL, 33859 Payment Due to the Agency for Health Care Administration: Managed Care Fine Notice of Intent- MC&HQ Final Order - MC&HQ $7,055.40 Medicaid Overpayment Administrative Complaint - MC&HQ Medicaid Fine Other Investigative Cost eee SEND PAYMENT TO: Agency for Health Care Administration Medicaid Accounts Receivable Attention: Willie Bivens P. O. Box 13749 Tallahassee, Florida 32317-3749 Amount Enclosed: Attomey: NA Preparer: MPI, djl Investigator: Debbie Lynn, Human Services Program Specialist Visit AHCA online at 2727 Mahan Drive + Mail Stop #6 www. fdhestateflius Tallahassee, FL 32308 CERTIFIED MAIL RECEIPT @orestic Mall Only: No lnstiralive Coverage b vides o- : | m yO es | ” vy BR 6 ea Postage | $ & S ay : wo : - . ~ Certified Fee Postmark “ Hera Return Receipt Fee =r (Endorsement Required) ao 5 Stowe Phyllis Fitzwater mm [Sear Director, Case Management 7 | a Lake Wales Medical Center ; ‘Street A th S eee410 South 1" Stect ‘ = |" Lake Wales, FL 33859 } PS Form 3800, Janvary 2001 tee tte us * +: See Revetse fot tnstitetions SENDER: COMPLETE THis SECTION *® Compiete items 1, 2, and 3, Also complete item 4 if Restricted Delivery is desired. ™ Print your name and address on the reverse se “Sat we can return the card to you, uy; ‘this card to the back of the mailpiece, Or uni the front if Space permils, 1. Articte Addressed to: D - Phyllis Fitzwater C Director, Case Mahagement Lake Wales Medical Center 410 South 11" Street Lake Wales, FL 33859 0. Is delivery address Gifterent trom item 17 CJ Yes W YES, enter delivery address below: ONo 3. Service Type #Xcertinn Mail © Express Mait O Registered OC Return Recei O insured Mat = COD. ipt for Merchandise 4. Resticted Oelivery? (Extra Fee) OD Yes 7001 0329 Oooy 678) 6934 Domestic Return Receipt Article Number Mansfer trom Service label) 3 Form 3811, August 2001

Docket for Case No: 02-002905MPI