STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS TOTAL FAMILY CARE CENTER Petitioner, - . ; CASE NO: 03-0319MPI Vv. . CI. No. 97-1140-00 ; JUDGE: Errol H. Powell STATE OF FLORIDA, AGENCY FOR Medicaid Provider No.: 375713700 HEALTH CARE ADMINISTRATION, Respondent. > =] , / az =e 7 mSEs See Bae se ff ; Spe mM FINAL ORDER ae FR < = Petitioner withdrew its request for Final Hearing. As a result the Petitioner’s acfidns, the Agency for Health Care Administration enters this Final Order adopting the November 19, 2002 Final Agency Audit Report findings in their entirety. A true and correct copy of the Final Agency Audit Report is attached and incorporated into this Final Order. The overpayment amount is due together with interest from the date of the Final Agency Audit Report, and the Agency imposes the sanction of a comprehensive follow-up review in six months. The Petitioner is directed to comply with the terms of this Final Order. Based on the foregoing, this file is CLOSED. we DONE and ORDERED on this the /7/7_ day of (#7254 , 2006, in Tallahassee, Florida. AYES 2g I Alaff Levine, Secretary | Agency for Health Care Administration t 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: Chris Parella, Anthony C. Vitale, P.A Attorney for Petitioner 799 Brickell Plaza, Suite 700, Miami, FL 33131 Erroll H. Powell Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399 Anthony L. Conticello, Esquire Agency for Health Care Administration (Interoffice Mail) James D. Boyd, Inspector General Agency for Health Care Administration (Interoffice Mail) Timothy Byrnes, Bureau Chief Medicaid Program Integrity Agency for Health Care Administration (Interoffice Mail) Bureau of Finance and Accounting Agency for Health Care Administration (Interoffice Mail) 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 wa of ABs , 2006. Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: JEB BUSH, GOVERNOR ‘ RHONDA M, MEDOWS, MD, FAAP, SECRETARY Division of Administrative Hearings CERTIFIED MAIL — RETURN RECEIPT No. 7002 0860 1001 5385 9922 November 19, 2002 a3 0 Provider No: 3757137 00 Total Family Care Center 7650 West Flagler Street Miami, Florida 33144 O> DIG me L In Reply Refer to AMENDED FINAL AGENCY AUDIT REPORT CI. No. 97-1140-000 Dear Provider: On May 28, 1998, the Agency for Health Care Administration, Medicaid Program Jntegrity issued a Preliminary Audit Report notifying you of an overpayment in the amount of $323,033.07. Based upon a subsequent review, on December 9, 1999, the Agency issued a Final Agency Audit Report with an overpayment in the amount of $289,588.15. This report was rescinded on January 31, 2000 and replaced by a Final Agency Audit Report issued on August 8, 2000 detailing an overpayment of $307,340.39. By agreement of the parties, the matter was not set for hearing and the Agency agreed to conduct further review of the documentation. Based upon the agreed review, Medicaid Program Integrity amends its Final Agency Report dated August 8, 2000, respecting Medicaid claims for the procedures specified below for dates of service during the period September 1, 1995 through September 17, 1997. The overpayment is adjusted to $286,261.53 for certain claims that are not covered by Medicaid. Pursuant to Section 409.913, F.S., this letter shall serve as notice of the following sanction(s): The provider is subject to a comprehensive follow-up review in six months. In determining the appropriateness of Medicaid payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, limitations and requirements found in the Medicaid provider handbooks and Florida Statutes Section 409.913. 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, billing bulletins, and the Medicaid provider agreement. Medicaid cannot pay for services that do not meet these guidelines. Visit AHCA online at 2727 Mahan Drive # Mail Stop #6 wwwifdhe. state fl.us Tallahasses, FL 32308 Total Family Care Center’ ', Page 2 The following is our assessmenit of why certain claims paid to your provider number do not meet Medicaid requirements. The audit work papers detailing the claims affected by this assessment are attached. \ i] REVIEW DETERMINATION (S) in Medicaid policy requires services performed be medically necessary for the diagnosis and treatment of an illness. You billed and received paymenits 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. Medicaid policy specifies how medical records must be maintained. A review of your medical records revealed that some services for which you billed and received payment were not documented. Medicaid requires documentation of the services and considers payments made for services not appropriately documented an overpayment. Medicaid policy defines the varying levels of care and 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. \ The overpayment was calculatéd as follows: A random sample of 34 recipients for whom you submitted 603 claims was reviewed. For those claims in the sample, which have dates of service from September 1, 1995 through September 17, 1997, an overpayment of $15,400.21 or $25.53932024 per claim was found, as indicated on the accompanying schedule. Since you were paid for a total (population) of 13,057 claims for that period, the point estimate of the total overpayment is $25.53932024 x 13,057 = $333,466.90. There is a fifty percent (50%) probability that the overpayment to you is that amount or more. We therefore used the following statistical formula for cluster sampling: ULU-N) & Overpayment = E —t SOU -¥B,)’ Where: Nv N £= point estimate of overpayment = F’ b A, > 3,| , $333,466.90 de] jal u F = number of claims in the population = > B,, 13,057 f=] A, = total overpayment in sample cluster, $15,400.21 B, = number of claims in sample cluster, 603 Total Family Care Center _ Page3 U = number of clusters in the population, 1,077 W = number of clusters in the random sample, 34 vv N { ¥ = mean overpayment per claim = 7 4, / 5" B, , $25.53932024 ial dul ‘=f value from the Distribution of t Table, 1.6923602 fi All of the claims relating to a recipient represent a cluster. Aj is the overpayment relating to the jth recipient in the sample, and B; is the number of claims relating to the ith recipient in the sample. The values of overpayment and number of claims respecting each recipient in the sample are shown on the accompanying schedule. From this statistical formula, which is generally accepted for this purpose, we have calculated that the overpayment to you is $286,261.53 with a ninety-five percent (95%) probability that it is that amount or more. IF you are currently involved in a bankruptcy, you should notify your attorney immediately and provide them with a copy of this letter. Please advise your attorney that we need the following information immediately: (1) the date of filing of the bankruptcy petition (2) the case number (3) the court.name and the division in which the pétition was filed (e.g., Northern District of Florida, Tallahassee Division) and, (4) the name, address, and telephone number of your attorney. If you are not in bankruptcy and you concur with our findings, remit by check in the amount of $286,261.53. The check must be payable to the Florida Agency for Health Care Administration. Questions regarding payment should be directed to Medicaid Accounts Receivable, (850) 921-6999. To ensure proper credit, be certain your provider number and the audit number (beginning with C.1.) are shown on your check. Please mail to: Agency for Health Care Administration ', =» Medicaid Accounts Receivable 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), Florida Statutes, Furthermore, pursuant to Sections 409.913(24) and 409.913(14), Florida Statutes, failure to pay in full, or enter into and abide by the terms of any repayment schedule set forth by the Agency may result in termination from the Medicaid Program. Questions regarding payment should be directed to Medicaid Accounts Receivable at (850) 921-6999, You have the right to request a formal or informal hearing pursuant to section 120.569, F.S. Ifa request for a formal hearing is made, the petition must be made in compliance with Section 28- 106.201, F.A.C. and mediation may be available. Ifa request for an informal hearing is made, the petition must be made in compliance with rule section 28-106.301, F.A.C. Additionally, you are hereby informed that if a request for a hearing is made, the petition must be received by the Agency within twenty-one (21) days of receipt of this letter. For more information regarding your hearing and mediation rights, please see the attached Notice of Hearing and Mediation Rights. Total Family Care Center |" Page 4 ' Any questions you may have about this matter should be directed to: Bonnie Mills-Herrera, Medical/Health Care Program Analyst, Agency for Health Care Administration, Medicaid Program Integrity, Office of the Inspector General, P.O. Box 52-2804, Miami, Florida 33152-2804, telephone (305) 470-5862. ‘ Sincerely, in Magda Rosales! , : , AHCA Administrator MNR/BMH/def Attachment cc: Medicaid Accounts Receivable ; Medicaid Program Integrity Chief (FAR) ; Anthony C, Vitale, Esquire : Anthony L. Conticello, Esquire Total Family Care Center Page 5 ‘NOTICE OF ADMINISTRATIVE HEARING AND MEDIATION RIGHTS You have the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If you disagree with the facts stated in the foregoing Final Agency Action Report (hereinafter FAAR), you may request a formal administrative hearing pursuant to Section 120.57(1), Florida Statutes. Lf you do not dispute the facts stated in the FAAR, but believe there are additional reasons to grant the relief you seek, you may request an informal administrative hearing pursuant to Section 120.57(2), Florida Statutes. Additionally, pursuant to Section 120.573, Florida Statutes, mediation may be available if you have chosen a formal administrative hearing, as discussed more fully below. \ : The written request for an administrative hearing must conform to the requirements of either Rule 28-106.201(2) or Rule 28-106.301(2), Florida Administrative Code, and must be received by the Assistant Bureau Chief by 5:00 P.M. no later than 21 days after you received the FAAR. The address for filing the written request for an administrative hearing is: mi Assistant Burean Chief “Medicaid Program Integrity Agency for Health Care Administration ; 2727 Mahan Drive, Mail Stop #6 pow Tallahassee, Florida 32308 The request must be legible, on 8 4% by 11-inch white paper, and contain: 1. Your name, address, telephone number, any Agency identifying number on the FAAR, if known, and name, address, and telephone number of your representative, if any; An explanation of how your substantial interests will be affected by the action described in the FAAR; A statement of when and how you received the FAAR; For'a request for formal hearing, a statement of all disputed issues of material fact; For a request for formal hearing, a concise statement of the ultimate facts alleged, as well as the rules and statutes which entitle you to relief; _ For a request for formal hearing, whether you request mediation, if it is available; For a request for informal hearing, what basis support an adjustment to the amount owed to the Agency; and 8. A demand for relief. ND wane A formal hearing will be held if there are disputed issues of material fact. Additionally, _mediation may be available in conjunction with a formal hearing. Mediation is a way to use a neutral third party to assist the parties in a legal or administrative proceeding to reach a settlement of their case. If you and the Agency agree to mediation, it does not mean that you give up the right to a hearing. Rather, you and the Agency will try to settle your case first with mediation. If you request mediation, and the Agency agrees to it, you will be contacted by the Agency to set up a time for the mediation and to enter into a mediation agreement. If a mediation agreement is not reached within 10 days following the request for mediation, the matter will proceed without mediation. The mediation must be concluded within 60 days of having entered into the agreement, unless you and the Agency agree to a different time period. The mediation agreement between you and the Agency will include provisions for selecting the mediator, the allocation of costs and fees associated with the mediation, and the confidentiality of discussions and documents involved in the’ mediation. Mediators charge hourly fees that must be shared equally by you and the Agency. Ifa written request for an administrative hearing is not timely received you will have waived your right to have the intended action reviewed pursuant to Chapter 120, Florida Statutes, and the action set forth in the FAAR shall be conclusive and final. DEC-11-2882 10°13 MEDICAID PROGRAM INT 385 478679S P. 82-87 : a COMPLETE Teil. SEN! D ER: COMPLETE THIS SECTION “EC HON Ofe Di wey <-> Lteliisizoanes Jc, Zeke petvey . ” Wed os? D. is delve hives Gea Toa enh LT Yes ~ ‘ SSwonter delivery addesss below: CINo oti a Complete i items 1, 2, and 3. Also complete item 4 if Rastricted Delivery Is desired, @ Pant your name and address on the raverso So that we can return tha card to you, tT Attach this card to the back of the matpicil or oa the front if space permits. 4. Article Addressed ta: Total Family Care Center“ 7650 West Flagler Street 2 Miami, Florida 33144 4, Sarvica Type “Wl Conified Mat 1 Express Mal O Registered D Ratum Receipt for Merchandise Clinsured Mai =. 6.0.0, 2 Aristo Number, : 7002 O860 0002 S233 4ne2 (ransfer trom séevies laba) —_—— SS eee PS Form 9811, August 2001 Domestic Retum Racelpt 102895-02.0.0999 * Sender. Please print Hattie. AGENCY FOR HEALTH CARE ADMINISEN ED MEDICAID PROGRAM INTEGRITY . P.O. BOX 52-2804 Nov 21 MRE MIAMI, FLORIDA 33152-2804 QERENED ne ema an hualloyelfonallatslenaleeleMocaDeverbadlbeseballabl sypytst cite Sdasereae, ts

Docket for Case No: 03-000319MPI