FILED STATE OF FLORIDA oer +9 33 AGENCY FOR HEALTH CARE ADMINISTRATION KASH N KARRY FOOD STORES, INC., Petitioner, (SH -C ly> vs. CASE NO. 03-1193 oF PROVIDER NO. 105185700 STATE OF FLORIDA, AUDIT C.I. NO. 01-0488-000-3 AGENCY FOR HEALTH CARE Rendition No. AHCA-03-uoo-S-MD@ ADMINISTRATION, Respondent. / FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement. 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 5 _ day of Soplimbero , 2003, in Tallahassee, Florida. s, MD, Secretary 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) Robert S. Bolt, Esquire 601 Bayshore Blvd., Suite 700 Tampa, Florida 33606 (U.S. Mail) Carolyn Holifield Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Tim Byrnes, Chief, Medicaid Program Integrity Ramona Stewart, Medicaid Program Integrity John Hoover, Finance and Accounting CERTIFICATE OF SERVICE 1 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 thet day of Soe Au) 1 xs7p003. Cp tt 3 fa al nrglen xv Lealand McCharen, Esquire J 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 Tie Oe KASH N KARRY FOOD STORES, INC., Petitioner, DOAH CASE NO: 03-1193 provider no.: 105185700 audit no.: 01-0488-000-3 Vv. AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and Kash N Karry Food Stores, Inc. (“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 resolving the disputes between them and avoiding the costs and burdens of further litigation. Neither party concedes the other’s position. 2. PROVIDER is a Medicaid provider in the State of Florida, provider number 105185700 and was a provider during the audit period. 3. In its final agency audit report (final agency action) dated January 2, 2003, AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Integnty (MPI), Office of the Inspector General, indicated that certain claims, in whole or in part, were not covered by Medicaid. The Agency sought recoupment of this overpayment, in the amount of $143,553.61. In response to the audit letter dated January 2, 2003, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No. 03-1193MPI. Kash N Karry Food Stores, Inc. Cl 01-0488-000-3 — Settlement Agreement 4. Subsequent to filing the Petition for formal hearing, PROVIDER, submitted further documentation for review. The majority of the prescriptions and refills that had been at issue were resolved. The primary audit issue remaining was, by agreement between the parties, a matter of billing under the wrong provider number. The PROVIDER asserted that the billings were a computer error, whereby members of the PROVIDER chain were inadvertently using the same provider number, even though they had individual provider numbers issued. The actual overpayment for substantive erroneous billings was agreed between the parties to be $4,476.88. 5. PROVIDER and AHCA agree that, in addition to the reimbursement to the Medicaid program in the amount set forth in (4), PROVIDER agrees that they shall pay the amounts set forth in paragraph (7) as costs and penalties. The PROVIDER agrees that it shall, on future claims to Medicaid, properly invoice under the correct provider number and shall properly document and maintain records of the services or goods rendered and billed. 6. AHCA and the PROVIDER agree that the underlying facts of this matter show the integrity of the Medicaid program is best preserved by the resolution specified in paragraph , (7). 7. 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. Kash N Karry Food Stores, Inc. Cl 01-0488-000-3 — Settlement Agreement (2) (3) (4) Within thirty days of receipt of the final order, PROVIDER shall pay AHCA fifteen thousand and No/100 Dollars ($15,000.00) as compensation for the Agency’s costs of audit and investigation in this matter, three thousand eight hundred and No/100 Dollars ($3,800.00) in administrative costs, and four thousand four hundred seventy-six dollars and eighty-eight cents ($4,476.88) in overpayment for a single payment to AHCA of twenty three thousand two hundred seventy six dollars and eighty-eight cents ($23,276.88) in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 03-1193MPI). 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. 01-0488- 000-3. 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. 8. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 Kash N Karry Food Stores, Inc. Cl! 01-0488-000-3 — Settlement Agreement 9. 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. 10. 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. 11. This settlement does not constitute an admission of wrongdoing or error by either party with respect to this case or any other matter. 12. Each party shall bear its own attorneys’ fees and costs, if any. 13. 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. 14. 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. 15. 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. Kash N Karry Food Stores, Inc. Cl 01-0488-000-3 — Settlement Agreement 16. 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. 17. 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. 18. 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 ori ginating or preparing it. 19. 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. 20. | This Agreement shall inure to the benefit of and be binding on each party’s successors, assigns, heirs, administrators, representatives and trustees. 21. All times stated herein are of the essence of this Agreement. Kash N Karry Food Stores, Inc. Cl 01-0488-000-3 — Settlement Agreement 22. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. KASH N KARRY FOOD STORES, INC. Sl Bu BY: Shellen GC. Reocader (Print name) ITS: Veesrsewk COO AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 Judith’. Hefr' Actin’Anspector General “ki Lb, Valdé Clark Christian General Counsel Ww - L. William Porter II Assistant General Counsel Dated: Pus ost \)\ , 2003 Dated: Septtonn tr, S__, 2003 Dated: lags QE __, 2003 BAA , 2003 Dated: FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RHONDA M. MEDOWS, MD, FAAFP, JEB BUSH, GOVERNOR fe a ptil: CERTIFIED MAIL — RETURN RECEIPT No. 7001 0360 0003 8771 2470 January 2, 2003 Provider No: 105185700 License No.: PH0010464 Kash N’ Karry # 881 d/b/a Medicine Shoppe #1646 2460 East Bay Drive Largo, Florida 33771 O oe (¢ In Reply Refer to FINAL AGENCY AUDIT REPORT C.L No. 01-0488-000-3/H/RDS Dear Provider: Medicaid Program Integrity has completed the review of your Medicaid claims for the: procedures specified below for dates of service during the period January 12, 1999 through October 20, 2000. A provisional agency audit report, dated, December 18, 2001, was sent to you indicating that we had determined you were overpaid $143,553.61. Based upon a review of all documentation submitted, we have determined that you were overpaid $143,553.61 for services that in whole or in part are not covered by Medicaid. Pursuant to Section 409.913, Flonda Statutes (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 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, billing bulletins, and the Medicaid provider agreement. Medicaid cannot pay for services that do not meet these guidelines. The following is our assessment of why certain claims paid to your provider number clo not meet Medicaid requirements. The audit work papers detailing the claims affected by this assessment are attached. Visit AHCAcontiine at 2727 Mahan Drive « Mail Stop #6 www fdhe.siate flus Tallahassec, FL 32308 03 ap setae PH L- 25 Kash N’Karry #882 Page 2 REVIEW DETERMINATION(S) statistically valid random sample taken from the population of uring the audit period. The overpayment found ir. the random sample was extended to the population using generally accepted statistical formulas and methods. The audit period for this review was from January 12, 1999, through October 20, 2000. This review identified an overpayment of $143,553.61. Attached are the overpayment calculations, a summary of f discrepancies noted in the review of the random The audit included the review ofa paid claims with dates of service d documented discrepancies, and an itemized listing 0 sample. If you are currently involved in a bankruptcy, you should notify your attomey 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 petition was filed (e.g., Northern District of Florida, Tallahassee Division); and, (4) the name, address, and telephone number of your attommey. If you are not in bankruptcy and you concur with our findings, remit by check in the amount of $143,553.61. The check must be payable to the Florida Agency for Health Care Administration. Questions regarding payment should be directed to Medicaid Accounts Receivable, (850) 488-5869. To ensure proper credit, be certain your provider number and the audit number (beginning with C.I.) 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), F.S. Furthermore, pursuant to Sections 409.913(24) and 409.913(14), F.S., 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, (850) 488-5869. 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, Florida Administrative Code (F A.C.) and mediation may be available. If a 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. Kash N’Karry #881 Page 3 na Stewart, Senior Pharmacist, Agency for Health Office of Inspector General, 2727 5403, telephone (850) 922-4374. Questions should be directed to: Ramo Care Administration, Medicaid Program Integrity, Mahan Drive, Mail Stop #6, Tallahassee, Florida 32308- Sincerely, L by D. Kenneth Yon AHCA Administrator DKY/rds Attachment cc: Medicaid Accounts Receivable Medicaid Program Integrity Chief (FAR) Kash N’Karry #881 Page 4 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 forma] administrative hearing pursuant to Section 120.57(1), Florida Statutes. If 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: Assistant Bureau Chief Medicaid Program Integrity Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #6 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 th 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 A demand for relief. 2 ND WEY » 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 50 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. If a written request for an administrative hearing is not timely received you will have waived your ri ight 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. MEE Pepe pegs pap ps m mentee OALIC URL LZ LZ ¢ dno1y yo My Ausaquy weso1g propay a es g WIUIMIPY aED yyeay 10) Aouasy Ty g0¢ze 1 ‘sasseyeyey, 9sSW- U; (I O1-9 ‘ON Wuuagy SENDER: COMPLETE THIS SECTION ™ Compiete items 1, 2, and 3. Also complete item 4 if Restricted Delivery fs desirad, ™ Print your name and address on the reverse 90 that we can return tha card to you. ™ Attach this card to the back of the mallpiece, Or on the front If space permits. _T. Atticla Addressed to: WE3/ROS AAL 01-04 FY +000 Kash N’ Karry #881 d/b/a Medicine Shoppe #1646 2460 East Bay Drive Largo, Florida C. I. No. 01-0488-000-3/H/RDS 2. Article Number (Transfer from service labef) PS Form 381 1, August 2001 2470 Postage 27 Certitied Fes Return Recalpt Fee (ncersement Required) Rastricted Detvery Fes (Endorsement Required} a sash N’ Karry #881 d/b/a Medicine Shoppe #1646 Siasi4¢ 2460 East Bay Drive Largo, Florida C. I. No. 01-0488-900-3/H/RDS FOMHAS Wisod Saivig a3LING, ant To 704 0340 poo3 a ity, Stats Sgsn PIEY S084 P afieysog NEW Sse1D-j815 “it YES, enter detivery acess be O1 No. TT 0 203 égisterad O Return Receipt for Merchandise O insured Ma? = 6.0.0. 4. Restricted Delivery? (Extra Fee) 7001 0360 0003 4771 2470 Comestic Retum Receipt 102595-01-M-2500

Docket for Case No: 03-001193MPI