FILED STATE OF FLORIDA _ ARCA AGENCY FOR HEALTH CARE ADMINISTRATION — AGENCY CLERK AGENCY FOR HEALTH GARE 1001 JUN -1 A & Ob ADMINISTRATION, Petitioner, vs. CASE NO. 07-648MPI z C.I. NO. 07-5250-000 wk, ALPHA DENTAL SERVICES, JUDGE CAROLYN S. H FIELD “ RENDITION NO.: AHCA“STCZAG -S2MDO 2. 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 4 day of Hare , 2007, in Tallahassee, Florida. Andrew C. Agwuriohi/M.D., 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: William M. Blocker, II, Esquire Jeffries H. Duvall, Esquire Agency for Health Care Administration (Interoffice Mail) Jennifer Hammond, Esquire Chaires Hammond, P.L. Altamonte Lakeside Park 283 Cranes Roost Bivd., Suite 165 Altamonte Springs, FL 32701 (U.S. Mail) The Honorable Carolyn S. Holifield Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399 (U.S. Mail) Linda Keen, Inspector General Agency for Health Care Administration (Interoffice Mail) Tim Byrnes, Bureau Chief, MPI Agency for Health Care Administration (Interoffice Mail) Finance & Accounting Agency for Health Care Administration (Interoffice Mail) CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addressees by U.S. Mail and/or Interoffice Mail on this the “day of Jane-——_, 2007. ae Richard Shoop, Esquire Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308-5403 Tel: (850) 922-5873 Fax: (850) 921-0158 STATE OF FLORIDA . AGENCY FOR HEALTH CARE ADMINISTRATION <.") ALPHA DENTAL SERVICES, INC., Pit} Petitioner, L Case Nos.: 07-648MPI ‘“ C.J. Nos.: 07-5250-000 vs. : Provider No.: 075685700 AGENCY FOR HEALTH CARE ADMINISTRATION., Respondent. / SETTLEMENT AGREEMENT The STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter, “AHCA” or “the Agency”), and Alpha Dental Services, Inc., by and through the undersigned, hereby stipulate and agree as follows: . 1. The parties enter into this agreement for the purpose of memorializing the resolution to this matter. 2. Alpha Dental Services, Inc., is a Medicaid provider in the State of Florida, provider number 075685700. Alpha Dental Services, Inc., was a provider during the periods of the audit referenced as C.I. 07-5250-000. 3. In the Final Agency Audit Report dated January 1 1, 2007, AHCA notified Alpha Dental Services, Inc., that a review of the Medicaid claims for the audit period of January 1, 2004 through September 30, 2006, performed by the Office of Medicaid Program Integrity (MP1) of the AHCA Inspector General indicated that certain claims, in whole or in part, had been inappropriately paid by Medicaid. The Agency sought repayment of this overpayment in the amount of $48,234.85, and fines in the amount of Alpha Dental Services, Inc., Settlement Agreement $1000.00. Alpha Dental Services, Inc., responded by filing a petition for formal administrative hearing, which was assigned DOAH case number 07-648MPI. 4. After further documentation review for the audit AHCA has determined that the overpayment amount should be adjusted to $45,744.15, and that the fine should. remain at $1,000.00. . 5. In order to resolve this matter without further administrative proceedings, . Alpha Dental Services, Inc., and 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 in these cases. (2) Alpha Dental Services, Inc,, agrees to pay AHCA a total overpayment amount of $45,744.15, total sanctions of $1,000.00, with statutory interest over a six (6) month period. If the amount is paid in full during this six month period then costs will be waived. Alpha Dental Services, Inc., will make an initial payment of $25,000, due on May 25, 2007. All subsequent payments will be of an equal amount, to be determined by AHCA’s Financing and Accounting Department, and will be due on the 15th of each month for the remainder of the six (6) month payment period. Specific payment arrangements shall be completed by AHCA’s Finance and Account Department. Alpha Dental Services, Inc., also agrees to submit a corrective action plan in the form of a Provider Acknowledgement Statement in this case, as attached. Alpha Dental Services, Inc., Settlement Agreement (3) Alpha Dental Services, Inc., and AHCA agree that full payment, as set forth above, will resolve and settle this case completely and will release both parties from all liabilities arising from the findings in the audit. (4) Alpha Dental Services, Inc., agrees that it will not rebill the Medicaid Program in any manner for claims that were not covered by Medicaid and which are the subject of the audit referenced as C.I. 07-5250-000. 6. Payment shall be made.to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 7. Alpha Dental Services, Inc., agrees that failure to pay any monies due and owing under the terms of this Agreement shall, without further notice, constitute its authorization for the Agency to withhold the total remaining amount due under the terms of this Agreement from any monies due and owing to it by AHCA for any unpaid 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. This settlement does not constitute an admission of wrongdoing or error by either party with respect to this case or any other matter. Alpha Dental Services, Inc., Settlement 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. . 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: This Agreement constitutes the entire agreement between Alpha Dental Services, Inc., and AHCA, including anyone acting for, associated with or employed by them, concerning all matters, and this Agreement supersedes any prior discussions, agreements or understandings; there are no promises, representations or agreements between Alpha Dental Services, Inc., 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. . 13. 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, 14. Alpha Dental Services, inc, expressly waives in this matter its’ right to . any hearing pursuant to Sections 120.569 or 120.57, Florida Statutes, any making of findings of fact and conclusions of law by the Agency, and all further and other proceedings to which he may be otherwise be entitled to under the law or the rules of the Alpha Dental Services, Inc., Settlement Agreement Agency regarding this proceeding and the issues raised herein. Alpha Dental Services, Inc., 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 available to it now or in the future, including its’ right to any administrative proceeding, circuit or federal court action, or any appeal. 15. | 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. . 16. _ 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. 17. This Agreement shall inure to the benefit of and be binding on each party’s successors, assigns, heirs, administrators, representatives and trustees. 18. All times stated herein are of the essence in this Agreement. 19. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. _A LPir Owe S80 ceF (provider’s name) CWwistna Laud man Dated: > 2007 Printed Representative’s Name (provider/ representative’s signature) Alpha Dental Services, Inc., Settlement Agreement ae [lu 2007 , Esquire Attorney for Petitioner AGENCY FOR HEALTH CARE — ADMINISTRATION 2727 Mahan Drive, Bldg. 3, Mail Stop #3 Tallahassee, FL 32308-5403 2007 | a Linda Keen Inspector General 2007 } ; : Craig Smith KimKelu 9 TT Chief Medicaid Counsel Dated: S 01 > Dated: al avo Dated: Dated: 5, oa Jo? Corrective Action Plan — Acknowledgement Statement A “corrective action plan” is the process or plan by which the provider will ensure future compliance with state and federal Medicaid laws, rules, provisions, handbooks, and policies. For purposes of this matter, the sanction of a corrective action plan shall take the form of an “acknowledgement statement”, which is a written document submitted to the Agency within 30 days of the date of the Agency action that brought rise to this requirement. An acknowledgement statement: identifies the areas of non- compliance as determined by the Agency in this Final Audit Report (FAR); acknowledges a requirement to adhere to the specific state and federal Medicaid laws, rules, provisions, handbooks, and policies that are at issue in the FAR; and, must be signed by the provider or its president, director, or owner. The acknowledgement statement is due to Medicaid Program Integrity within 30 days of the issuance of this FAR. Please sign the enclosed statement and return it to: Mr. Glen Stone Agency for Health Care Administration Medicaid Program Integrity 2727 Mahan Drive, Mail Stop # 6 Tallahassee, FL 32308-5403 Phone (850) 921-1802 Facsimile (850) 410-1972 Failure to comply with the requirements set forth above may result in the imposition of additional sanctions, which may include monetary fines, suspension, or termination from the Medicaid program. Corrective action plan -- Acknowledgement Statement Final Agency Audit Report January 11, 2007 C.I. 07-5250-000 PROVIDER ACKNOWLEDGEMENT STATEMENT I CirkisPrautr Cvormry __, 0 on behalf of Alpha Dental Services, Inc. (insert printed full name here) a Medicaid provider operating under provider number 0756857 00, do hereby acknowledge the obligation of Alpha Dental Services, Inc., to adhere to state and federal Medicaid laws, rules, provisions, handbooks, and policies. Additionally, Alpha Dental Services, Inc., acknowledges that Medicaid policy requires: The Dental Services Coverage and Limitations Handbook states in Chapter 2-2, Covered Services, Service Requirements: “Medicaid reimburses for services that are determined medically necessary and do not duplicate another provider’s service.. In addition the services must meet the following criteria: e The services must be individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient’s needs; . The services cannot be experimental or investigational; The services must reflect the level of services that can be safely furnished, and for which no equally and more conservative or less costly treatment is available statewide; and - e The services must be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a covered service.” The Medicaid Dental Services Coverage and Limitations Handbook states in Chapter 2-24, “Description”: “All radiographs must be of diagnostic quality. Corrective action plan -- Acknowledgement Statement Final Agency Audit Report January 11, 2007 C.I. 07-5250-000 The Medicaid Dental Services Coverage and Limitations Handbook states in Chapter 2-1, Oral Evaluations: “Evaluation Limitations: Evaluations for adults are limited to determining the need for dentures or for emergency services. “Evaluation Exclusions: A second evaluation will not be reimbursed when the recipient retums on a later date for follow-up treatment subsequent to either a comprehensive or periodic evaluation.” The Medicaid Dental Services Coverage and Limitations Handbook states in Chapter 2-29, Removable Prosthodontics: “Non-immediate Dentures: A non-immediate denture must include: e The reimbursement for the seating; e All necessary adjustments and corrections, including relines, for- six months after seating; and All adjustments for six months after seating. “An Immediate and a non-immediate denture are billed using the same procedure code.” “Immediate Dentures: An immediate denture procedure must include: e The reimbursement for the seating; e All necessary adjustments and corrections, including relines, for three months after seating; and : e All adjustments for three months after seating. “An immediate denture is billed using the same procedure code as a non- immediate denture.” The Medicaid Dental Services Coverage and Limitations Handbook states in Chapter 2-30, Removable Prosthodontics, Denture Billing Date: “A claim for dentures may not be submitted until the dentures are actually seated. Use the date the dentures were seated as the date of service.” The Florida Medicaid Provider General Handbook states in Chapter 5-4, Provider Responsibility: “When presenting a claim for payment under the Medicaid program, a provider has an affirmative duty to supervise the provision of, and be responsible for, goods and services claimed to have been provided, to supervise and be responsible for preparation and Corrective action plan -- Acknowledgement Statement Final Agency Audit Report January 11, 2007 C.I. 07-5250-000 submission of the claim, and to present a claim that is true and accurate and that is for goods and services that: By: Have actually been furnished to the recipient by the provider prior to submitting the claim; Are Medicaid-covered services that are medically necessary; Are of a quality comparable to those furnished to the general public by the provider’s peers; : Have not been billed in whole or in part to a recipient’s responsible party, except for such co-payments, coinsurance, or deductibles as are authorized by AHCA; Are provided in accord with applicable provisions of all Medicaid rules, regulations, handbooks, and policies and in accord with federal, state, and local law; and . . Are documented by records made at the time the goods or services were provided, demonstrating the medical necessity for the goods or services rendered. Medicaid goods or services are excessive or not medically necessary unless the medical basis and the specific need for them are fully documented in the recipient’s medical record.” CR (2 Pas Date: “4-16-07 (signature) Olu ern (title) ee Return completed acknowledgement statement to Medicaid Program Integrity. ee Corrective action plan -- Acknowledgement Statement Final Agency Audit Report January 11, 2007 C.1. 07-5250-000

Docket for Case No: 07-000648MPI