epee yd nt nae OG ATSB AARON OL ABE RIG CERIN NR aI . F j I E D AGENCY FoR STATE OF FLORIDA HEALTH SABE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION WEST KENDALL SURGICAL CENTER, manZ Saye /o Petitioner, SML- hee CASE NO 04-4262 a. AHCA CASE NO. 20040020807 ey vs. BMHC ID NO. 20040304 01 ea AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER Having reviewed the Determination Letter dated March 22, 2004 (Exhibit 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) finds and concludes as follows: FINDINGS OF FACT 4. On March 2, 2004, the Petitioner, West Kendall Surgical Center, filed with the Agency a petition (as defined in § 440.13(7)(a), Fla. Stat. (2003)) to contest the disallowance or adjustment of payment for treatment of a workers’ compensation claimant (hereinafter “Reimbursement Petition”). 2. The March 2 Reimbursement Petition did not include the following elements required by Section 440.13(7)(a), Florida Statutes and Florida Administrative Code Rule 59A-31.002: a. All bills submitted or resubmitted related to the services in question and their attachments b. Any pertinent or required health care records Final Order for West Kendall Surgical Center v. AHCA DOAH case no. 04-1262 - AHCA case no. 2004002980 Page 1 of 4 LA AMSAT RE SAE RES OE RON CE REE: EERE RE EEL RE A AE 3. On March 22, 2004, the Agency issued a Determination Letter dismissing the Reimbursement Petition for failure to satisfy the requirements of Section 440.13(7)(a), Florida Statutes (2003) and Florida Administrative Code Rule 59A-31.002 (Exhibit 1). The Determination Letter advised West Kendall Surgical Center of its right to request an administrative hearing. 4. On April 1, 2004, the Agency Clerk received a Petition for Hearing from West Kendall Surgical Center (Exhibit 2). West Kendall Surgical Center denied the allegations of fact contained in the Determination Letter and requested a formal proceeding pursuant to Section 120.57(3), Florida Statutes. 5. Subsequently, West Kendall Surgical Center withdrew its request for a hearing. The withdrawal is contained in the “Joint Response to Initial Order and Motion to Remand” (Exhibit 3). 6. Accordingly, the administrative law judge entered the Order Closing File on April 2, 2004 (Exhibit 4). 7. The facts as alleged and found, establish that: a. The Reimbursement Petition of West Kendall Surgical Center did not include the following: i. The provider bill that matched with the date of service in question ii. All pertinent health care records or reports b. Failure of a petitioner to submit such documentation to the agency results in dismissal of the Reimbursement Petition, pursuant to Section 440.13(7)(a), Florida Statutes (2003). Final Order for West Kendall Surgical Center v. AHCA DOAH case no. 04-1262 - AHCA case no. 2004002980 Page 2 of 4 0 cose akg A pha Am RRO URES SLE IES ABET ID NT OAR AREER 7 EE ara RR TS Se RR CONCLUSIONS OF LAW 8. The Agency has jurisdiction over West Kendall Surgical Center pursuant to Section 440.13(11)(c), Florida Statutes (2003). 9. As alleged in the Determination Letter, West Kendall Surgical Center did not file with its Reimbursement Petition all of the documents and records required by Section 440.13(7)(a). 10. Section 440.13(7)(a), Florida Statutes, states in relevant part: Any health care provider . . . who elects to contest the disallowance or adjustment of payment by a carrier . . . must, within 30 days after receipt of notice of disallowance or adjustment of payment, petition the agency to resolve the dispute. The petitioner must serve a copy of the petition on the carrier and on all affected parties by certified mail. The petition must be accompanied by all documents and records that support the allegations contained in the petition. Failure of a petitioner to submit such documentation to the agency results in dismissal of the petition. 41. The West Kendall Surgical Center expressly waived its right to a hearing and consented to the entry of a Final Order, adopting the allegations and conclusions set forth in the Determination Letter and imposing the dismissal of the Reimbursement Petition. Based on the foregoing findings of fact and conclusions of law, it is ORDERED: 41. The Petition for Reimbursement filed by West Kendall Surgical Center for services provided on November 5, 2003 is DISMISSED WITH PREJUDICE. DONE and ORDERED this 13 day of YY ) auf , 2004 in Tallahassee, Leori County, Florida. : LE lary Rét Moore, Interim Secretary Agency for Health Care Administration Final Order for West Kendall Surgical Center v. AHCA DOAH case no. 04-1262 - AHCA case no. 2004002980 Page 3 of 4 tp tales ene ANE neds APRS 6 PE ERE EBL SRE A NEN OE Se am OI ENTE SRE NM TY AGEN AR AEH RR EIT TE Tuna A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO 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 OF 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: THE HON STUART M LERNER MR MIGUEL MALDONADO DIVISION OF ADMIN HEARINGS WEST KENDALL SURGICAL CENTER THE DE SOTO BUILDING 41801 SW SOTH ST STE 202 1230 APALACHEE PKWY MIAMI FL 33186 TALLAHASSEE FL 32399-3060 ELIZABETH DUDEK WENDY ADAMS DEPUTY SECRETARY (INTEROFFICE MAIL) AGENCY FOR HEALTH CARE ADMINISTRATION 2727 MAHAN DRIVE BLDG #1 MS #9 TALLAHASSEE, FL 32308 (INTEROFFICE MAIL) JOANNA DANIELS ASSISTANT GENERAL COUNSEL (INTEROFFICE MAIL) CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true copy of the foregoing was served on the above- named person(s) by U.S. Mail, or the method designated, on LF day of 72 \ae __, 2004. (4) Te Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308 Final Order for West Kendall Surgical Center v. AHCA DOAH case no. 04-1262 - AHCA case no. 2004002980 Page 4 of 4 this eee een eee FORA AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH, GOVERNOR ' MARY PAT MOORE, INTERIM SECRETARY DIVISION OF HEALTH QUALITY ASSURANCE BUREAU OF MANAGED HEALTH CARE WORKERS’ COMPENSATION UNIT. March 22, 2004 CERTIFIED MAIL: 7001 0360 0003 3761 8340 4" Mr. Miguel Maldonado i West Kendall Surgical Center X PAGES 11801 Southwest 90" Street, Suite 202 Miami, FL 33186 RE: Injured Emplioyee: maa SSN Accident Date: 11/15/2001 BMHC Case ID: 20040304-001 Dear Mr. Maldonado: The Agency received your March 2, 2004 request for reimbursement dispute resolution regarding services provided by West Kendall Surgical Center to the above referenced injured employee on November 5, 2003. | am dismissing this petition for the following reasons. Pursuant to s. 440.13(7), F.S., the petition for dispute resolution must be accompanied by all documents and records that support the allegations contained in the petition. Failure of a petitioner to submit such documentation to the Agency results in dismissal of the petition. Based on Rule 59A-31.002, Florida Administrative Code, the supporting documentation is a copy of: 1. All bilis submitted or resubmitted that are related to the services in questicn and their attachments. VY Q 2. Allapplicable Explanations of Medical Benefits. 13. All correspondence between the carrier and provider relevant to the disputed . & reimbursement. 4. Any notations of phone calls regarding authorizations. 7S. All pertinent or required health care records or reports or carrier medical opinions. You failed to submit the provider bill that matches with the date of service in question and ail pertinent health care records or reports. Visit AHCA online at 2727 Mahan Drive * Mail Stop #26 www fdhe. state. fius Tallahassee, FL 32308 > RRS ACO A SRE TCE SE ERE IR | A SA AGP tReet cctv Nt aN He Re Not ’ . . Miguel Maidonado March 22, 2004 Page 2 Under the Florida Administrative Procedures Act, you have the right to an administrative hearing to challenge the Agency's determination in this matter. You may request either a formal or an informal hearing in accordance with section 120.569, Florida Statutes. Your request for such a hearing must be received by the Agency within 21 days from the date you receive this letter. A request for an informal hearing must be submitted in writing. A request for a formal hearing must be in the form of a petition and in compliance with Rule 28-106.201, F.A.C. Either request must be substantive and clearly state the specific actions to which you object and the basis for your objections. A request for an informal hearing or a petition for a formal hearing must be sent to the following address: Lealand McCharen, Agency Clerk Agency for Health Care Administration , ‘4 Office of the General Counsel yy 2727 Mahan Drive, Building 3, M.S.-3 Tallahassee, Florida 32308 Please send a copy of your request to me as well. Pursuant to Rule 28-106.111, F.A.C., any person who fails to request a hearing within twenty-one (21) days, shall have waived his right subsequently to request a hearing. If a petition for hearing is not filed within twenty-one (21) days of receipt of this determination, your right to such a hearing will be WAIVED and this determination will be the final Agency action. If you have any questions regarding this letter, you may contact me at (850) 410-1072. Sincerely, LZ. . ‘Filerke. Phavure Merle Barnett Registered Nurse Specialist PANE A ES ARNT. RRA TE ARO AE RARER RRR Cn RRA RMR S AES Oe ERIE ene memeay A) tf =fo2 A _2 FiLtar, a ht to. » . = Fl % nt ty 4 Strcica- Ce AGE 03-29-2004 CERTIFIED MAIL: 7003-2260-0005-9534-4350 Lealand McCharen, Agency Clerk Agency for Health Care Administration Office of the General Counsel 2727 Mahan Drive, Building 3, M.S.-3 Tallahassee, F1.32308 Re: Request for Hearing Section 120.569 Florida Statutes. We had filed a claim base on the documentation we had at our facility. As of this day we still have not received the payment that is reflected on the EOR provided for your review. We would like at this time to request a hearing as to the determination of this claim with this agency for Non Compliance of the FS 440.13. We may also file an additional complaint for reimbursement issues. We have today faxed to Fireman’s Fund Foundation request for payment. Sincerely, Migfiel Maldonado f Medial Claims Auditor WKSC Cc: Fireman’s Fund Foundation NS Marke Barnaht, 11801 Southwest 90th Street, Suite 202, Miami, FL 33186 Telephone: (30S) 595-2414, Facsimile: (305) 595-5140 West Kendall Surgical Center ~ 150 SW 12" Avenue Suite:201 Pompano Beach, FI 33069 Phone No. 954-781-450 ext 110 facsimile transmittal Oe Ys To: Attention: Claims Appeals -F@:-=——4972-829-4518 Mb, O , | i Sa From: Miguel Maldonado Date: 03/29/04 Re: Pages: 7 ce: 21 Urgent O For Review O Please Comment 0 Please Reply DO Please Recycle Attention: Department Paton ts apa ID# DOS 11-05-2004 We will hold this claim (15)day from this fax. Thank You : Miguel Maldonado This fax contains legally protected medical information intended only for the individual or entity named within the message. If the reader of this message is not the intended recipient, or a person responsible to delive* it to the intended recipient, you are hereby notified that any review, dissemination, distribution or copying of this communication is prohibited. If this communication was received in error, please notify us by reply fax or phone call and physically destroy the original message and all attachments Ci i a a i awe. Received Event (Event Succeeded)... cece neces scene me wenrinsssonmganenns ve ee EEOC CEC) Date: 4/20/2004 Time: 4:36 PM Pages: 1 Duration: 0 min 35 sec Sender: 850 921 0158 Company: Fax Number: Subject: Type: Fax APR-28-2084 16:45 AGENCY HEALTH CARE ADMIN EXHIBIT Fax To: Miguel Maldonado (954) 786-3502 & DOAH Clark (850) 921-684) April 20, 2004 STATE OF FLORIDA 1 PASE. DIVISION OF ADMINISTRATIVE HEARINGS WEST KENDALL SURGICAL CENTER, SVL Petitioner, DOAH CASE NO 04-1262 AHCA CASE NO. 2004002980 vs, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / JOINT RESPONSE TO INITIAL ORDER & MOTION TO REMAND Respondent, AGENCY FOR HEALTH CARE ADMINISTRATION (“Respondent”), by and through its undersigned attomey, submits this Joint Response to Initial Order dated April 13, 2004 and states: 1. Counsel for Respondent has conferred with the Representative for Petitioner, WEST KENDALL SURGICAL CENTER and Respondent is authorized to file this response. 2. There are no related cases before the Division of Administrative Hearings. 3. On Thursday, April 15, 2004 and today, the Petitioner’s Representative advised Respondent’s counsel that the Petitioner has decided to not pursue a formal hearing. 4. WHEREFORE, the partics request that the Court remand this case to the Agency for final disposition. Respectfully submitted on Tuesday, April 20, 2004. canna Daniels FL BAR #0118321 Agency for Health Care Administration 2727 Mahan Drive, MS #43 Tallahassee, FL 32308 (850) 922-5873 (850) 921-0158 (fax) CERTIFICATE OF SERVICE Thereby certify that a true and correct. copy of the foregoing has been firmished on Tuesday, April 20, 2004 by XJ FACSIMILE = -954/7118-5502 to Mr. Miguel Maldonado West Kendall Surgical Center 11801 Southwest 90th Street, Suite 202 Miami, FL 33186 JOANNA DANIELS TOTAL P.@2

Docket for Case No: 04-001262