Petitioner: TENDER HOME CARE
Respondent: AGENCY FOR HEALTH CARE ADMINISTRATION
Judges: STUART M. LERNER
Agency: Agency for Health Care Administration
Locations: Tallahassee, Florida
Filed: Nov. 29, 2000
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Wednesday, October 24, 2001.
Latest Update: Dec. 23, 2024
STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS ATCA
pane HEN? CLERK
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TENDER HOME CARE,
Petitioner, RQ
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vs. aA:
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AGENCY FOR HEALTH CARE nn ed
ADMINISTRATION, “os
Respondent.
/
FINAL ORDER
THE PARTIES resolved all disputed issues and executed a Settlement
Agreement on , 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 %0_ day of Sypfab--a000, in
Tallahassee, Florida.
fP Aecnce nolo MD, Secretary
fP recney 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:
L. William Porter II, Esquire
Agency for Health Care
Administration
(Interoffice Mail)
Stuart Lerner
The Division of Administrative Hearings
The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-30060
Anthony C. Vitale, Esquire
799 Brickell Plaza, Suite 700
Miami, Florida 33131
Judy Hefren, Acting Bureau Chief, Medicaid Program Integrity
Adolfo Garcia, 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 WDaay
of OCiok WN _, 2002.
is
4% CLealand McCharen, Esquire
Agency Clerk
State of Florida
Agency for Health Care Administration
2727 Mahan Drive, Building #3
Tallahassee, Florida 32308-5403
(850) 922-5873
2°
ALG-23-2282 8:23
TENDER HOME CARE DOAH No. 00-4766
Provider No. 678913800 C.1. No. 00-0438-000
SETTLEMENT AGREEMENT
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION
(‘AHCA" or "the Agency’), and Tender Home Care ("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
avoiding the costs and burdens of litigation, and neither party concedes the other's
position.
2. PROVIDER Is a Medicaid provider in the State of Florida.
3. In its final agency audit report dated October 6, 2000, AHCA notified
PROVIDER that review of Medicaid claims performed by Medicaid Program Integrity
(MP)) 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 $621,801.32. in response
to the audit letter dated October 6, 2000, PROVIDER filed a petition for a formal
administrative hearing, which was assigned DOAH Case No, 00-4766.
4. The provider submitted additional documentation and & revi of that
documentation resulted In the amount being adjusted to $531,526.97. nea
5. 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.
TOTAL P.@2
ETIG-@SE (SOE) JO 3OISS0 MYT HLIWWAH SHL WYBT FOOT
2002 S32
gnu
(2) Within thirty days of receipt of the final order, PROVIDER agrees to
~ make the first installment to repay four hundred ninety thousand
dollars ($490,000.00) to be made in eighteen (18) equal monthly
payments in full and complete settlement of all claims in the
proceedings before the Division of Administrative Hearings (DOAH
Case No. 00-4766).
(3) 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. 00-0438-000.
(4) 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.
6. Payment shall be made to:
AGENCY FOR HEALTHCARE ADMINISTRATION
Medicaid Accounts Receivable
Post Office Box 13749
Tallahassee, Florida 32317-3749
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. This settlement does not constitute an admission of wrongdoing or error
by either party with respect to this case or any other matter.
10. Each party shall bear its own attorneys’ fees and costs, if any.
11. 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.
12. 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.
13. 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.
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 jaw, 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 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.
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.
19. All times stated herein are of the essence of this Agreement.
20. This Agreement shall be in full force and effect upon execution by the
respective parties in counterpart.
TENDER HOME CARE
BY: 2h fr.
Print nanfe)
ITS: fee Sin Zus- ‘
FLORIDA AGENCY FOR HEALTH CARE
ADMINISTRATION
2727 Mahan Drive, Mail Stop #3
Tallahassee, FL 32308-5403
apo Dated: IP o000
Rufus Nowe
Inspector Genera!
o/s Dated: « 18 , 2002
Valda Clark- Christian
General Counsel .-°-.-.::
hylleen _ Dated: | 2b -9r 2002
L. William Porter II
Assistant General Counsel
Dated: O¢ ‘fay , 2002
)
)
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
JEB BUSH, GOVERNOR RUBEN J. KING-SHAW, JR., SECRETARY
October 6, 2000 7
CERTIFIED MAIL - RETURN RECEIPT No. 7000 0600 0026 2895 3211
Provider No. 6769136 00
553 SH 87" Avene >
A iS
Suite A venwe REC E I V E D
Miami, Florida 33174
OCT 31
In Reply Refer to 34 2000
FINAL AGENCY AUDIT REPORT MEDIC.
C.I. 00-0438-000 NTE ROGRAM
Dear Provider:
The Agency for Health Care Administration, Medicaid Program
Integrity office has completed the review of your Medicaid
claims for the procedures specified below for dates of service
during the period January 1, 1999, through June 15, 2000. A
Provisional Agency Audit Report dated, July 6, 2000, was sent to
you indicating that we had determined you were overpaid
$621,801.32. In response to the provisional letter, you sent
documentation to validate your claims. We have performed a
subsequent review, in light of the additional evidence you
provided; the overpayment amount will remain $621,801.32.
In determining payment pursuant to Medicaid policy, the Medicaid
program utilizes procedure codes, descriptions, policies,
limitations and exclusions 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 and billing
bulletins. Medicaid cannot pay for services that do not meet
these guidelines.
The following is our assessment of why certain claims do not
meet Medicaid requirements. A computer printout detailing the
claims affected by this assessment is attached.
Visit AHCA Online at
2727 Mahan Drive « Mail Stop # 6
www. fdhe.state.flus
Tallahassee, FL 32308
. -_~ oN
Tender Home Care
Page 2
-- : REVIEW DETERMINATIONS
The following review determinations were made by applying
Medicaid policy to the documentation obtained from your office
by the Medicaid Program Integrity office, Agency for Health Care
Administration. -
Subsection 409.9013(5), F.S., states:
“(7) 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 submission of the claims,
and to present a claim that is true and accurate and that
is for goods and services that:
(e) are provided in accord with applicable provisions of all
Medicaid rule, regulations, handbooks and policies and in. __
accordance with federal, state and local law.” R FCE | V E D
The Project AIDS Care (PAC) Waiver Services. Coverage and OCT 21 209
Limitations Handbook, Chapter 1, Waiver Services Provider “eu
Qualifications, Introduction, dated April 1999, states: MEICAIA OG “AR
nab wre
“PAC waiver providers must meet the general Medicaid
provider qualifications that are contained in Chapter 2 of
the Medicaid Provider Reimbursement Handbook, Non-
Institutional 081. In addition, PAC waiver providers must
meet the specific provider qualifications listed on this
section for the services that they provide.”
The section subtitled Home-Delivered Meals Providers states:
“To provide Medicaid PAC waiver home-delivered meal services
providers must be: ‘
¢ Meal preparation and delivery businesses licensed by the
Department of Health in accordance with Chapter 509, F.S.,
® Restaurants licensed by the Department of Health in accordance
with Chapter 500, F.S. or
e Federal Older Americans Act providers contracted for home
delivered meals.” RE C E i} V E D
OCT 31 2000
MEDICAID PROGRAM
INTEGRITY
‘
. -_ o™
Tender Home Care
Page 3
The section subtitled Pest Control Providers states:
“To provide Medicaid PAC waiver pest control services,
providers must be pest control businesses licensed by the
Department of Agriculture and Consumer Services according
to Chapter 482, F.S.”
The amount of the unauthorized services for-which you billed
and were paid for Medicaid claims foy..Home Delivered Meals,
procedure codes W9991 and Pest Control, procedure code w9953
is considered an overpayment.
In addition, Medicaid Home and Community-Based Services, waiver
services for PAC recipients were rendered for Specialized
Medical Equipment and Supplies, procedure code W9994, without
Service Authorization being issued for the recipients in this
review.
The Project AIDS Care (PAC) Waiver Services. Coverage and
Limitations Handbook, Chapter 2, Covered Services, Limitations
and Exclusions, Plan of Care, April 1999, page 2-9 states:
“Services not specified in the plan of care are not considered
approved or authorized. Medicaid reimbursements for services
furnished, but not specified in the plan of care for that
specific time period are subject to recoupment.”
Chapter 2, Covered Services, Limitations and Exclusions, Service
Authorization Components, April 1999, page 2-10 further states:
“All service authorizations for PAC waiver services must
include: :
@¢ Claim authorization number;,
@® Provider name and Medicaid identification number;
® Recipient’s name, birth date, and Medicaid identification
number;
e Recipient’s address
e Case management agency name and address;
@ Name and telephone number of the case manager who authorized
services on the plan of care; .
e Specials instructions;
@ Services to be furnished with corresponding proceduag Etre | V E D
OCT 312077
MEDICAID PROGRAM
INTEGRITY
‘
, “~ ~~
Tender Home Care
Page 4
e Frequency and amount of service;
® Cost of service (maximum authorized expenditures); and
@ ~Puration of services.
The amount of the unauthorized services for which you billed and
were paid for Medicaid claims for procedure code w9994,
Specialized Medical Equipment and Supplies, is considered an
overpayment. - .
If you concur with the amount of the overpayment, send your
check for $621,801.32. The check must be payable to the Plorida
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 .
P.O. Box 13749
Tallahassee, Florida 32317-3749
Questions regarding payment should be directed to Ms. Willie
Bivens, Medicaid accounts receivable, (850) 921-4396.
You have the right to request a formal or informal hearing
pursuant to Section 120.569, F.S. If a petition for formal
hearing is made, the petition must be made in compliance with
rule section 28-106.21, Florida Administrative Code (F.A.C.).
Please note that rule section 28-106.201(2), F.A.C., specifies
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 request or 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 to a 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. John A. Owens, Chief
Agency for Health Care Administration
Medicaid Program Integrity R .
2727 Mah Dri
Tallahassee, Florida 32308 ECEIVED
OCT 31 2009
MEDICAID PROGRAM
INTEGRITY
‘Tender Home Care
Page 5
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 have any questions about this matter, contact Adolfo
Garcia, Medical/Health Care Analyst, Agency for Health Care
Administration, Madicaid Program Integrity, Office of the
Inspector General, P.O. Box 52-2804, Miami, Florida 33152-2804,
telephone (305) 470-5862.
Medicaid Program Integrity
Sincerel
Nie
John A. Owens, Chief
JAO:ALG: def
Enclosures
cc: Medicaid Accounts Receivable
Medicaid Program Development
Medicaid Program Integrity Administration
Medicaid Program Integrity Work Group Five
Area Medicaid Office
RECEIVED
OCT 3 1 2000
MEDICAID PRocRaM
INTEGRITY
Docket for Case No: 00-004766
Issue Date |
Proceedings |
Oct. 15, 2002 |
Final Order filed.
|
Oct. 24, 2001 |
Order Closing File issued. CASE CLOSED.
|
Oct. 22, 2001 |
Motion for Remand (filed by Respondent via facsimile).
|
Aug. 21, 2001 |
Order Continuing Case in Abeyance issued (parties to advise status by October 22, 2001).
|
Aug. 20, 2001 |
Joint Motion to Hold Case in Abeyance (filed via facsimile).
|
Jul. 13, 2001 |
Order Continuing Case in Abeyance issued (parties to advise status by August 13, 2001).
|
Jul. 13, 2001 |
Joint Status Report (filed via facsimile).
|
May 10, 2001 |
Order Continuing Case in Abeyance issued (parties to advise status by July 9, 2001).
|
May 09, 2001 |
Status Report (filed by Respondent via facsimile).
|
Mar. 09, 2001 |
Order Continuing Case in Abeyance issued (parties to advise status by May 8, 2001).
|
Mar. 08, 2001 |
Second Joint Motion to Hold Case in Abeyance (filed via facsimile).
|
Jan. 22, 2001 |
Order Granting Continuance and Placing Case in Abeyance issued (parties to advise status by February 7, 2001).
|
Jan. 18, 2001 |
Joint Motion to Hold Case in Abeyance (filed via facsimile).
|
Dec. 14, 2000 |
Order of Pre-hearing Instructions issued.
|
Dec. 14, 2000 |
Notice of Hearing issued (hearing set for February 2, 2001; 9:00 a.m.; Tallahassee, FL).
|
Dec. 06, 2000 |
Respondent`s Request for Admissions (filed via facsimile).
|
Dec. 06, 2000 |
Notice of Service of Interrogatories (filed via facsimile).
|
Dec. 06, 2000 |
Notice of Service of Expert Interrogatories (filed via facsimile).
|
Dec. 06, 2000 |
Respondent`s First Request for Production of Documents (filed via facsimile).
|
Nov. 29, 2000 |
Initial Order issued. |
Nov. 29, 2000 |
Petition for Formal Hearing filed.
|
Nov. 29, 2000 |
Final Agency Audit Report filed.
|
Nov. 29, 2000 |
Notice filed by the Agency.
|