FH.Eo ga -@ 83 STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS MORALES PHARMACY #1 & #2, Petitioner, “P Lyn : Hl ere CASE No. 01-1969 ou Audit C.I. No. 01-0038-000-3 te iw Provider No. 102951700 Audit C.I. No. 01-0307-000-3 Provider No. 103903200 Rendition No. AHCA-03-e473-S-MDo vs. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement, 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 3! day of Ay , 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) Mr. J. Everett Wilson, Esquire Wilson, Suarez & Lopez Union Planters Building 2151 Le Jeune Road - Mezzanine Coral Gables, FL 33134 (U.S. Mail) Patricia Malono Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Tim Byrnes, Chief, Medicaid Program Integrity Kathryn Holland, Medicaid Program Integrity John Hoover, 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 ® day a) of LLLAC ! ti _, 2003. — Chari Uhmubocn 40€Lealand McCharen, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 Bafsessaas 14:56 nesdd5 7336 WILSUN SUSREZ LOPEZ PAGE - oa Al STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS ‘MORALES PHARMACY #1 & #2, Petitioner, WS. CASE NO. €1-1969 Audit C.-L NO. 01-0038-000-3 STATE OF FLORIDA, Provider NO. 102951700 AGENCY FOR HEALTH CARE Audit CI. NO, 01-0307-000-3 ADMINISTRATION, Provider NO. 103903200 Respondent. a SETILEMENT. AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and Morales Pharmacy #1 and #2 (“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 numbers 102951700 and 103903200 and was a provider during the audit period. 3. In its final agency audit report (final agency action) dated April 6, 2001, AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Integrity (MPD, Office of the Inspector General, indicated that certain claims, in whole ot in part, were not covered by Medicaid. The Agency sought recoupment of this overpayment in the amount of $20,646.58. In response to the audit letter dated April 6, 2001, PROVIDER filed a petition for a 82/87 Odea sags 1d: 58 B8Sdd67326 WILSON SUAREZ LOPEZ PASE — sal Morales Pharmacy #1 & #2 _ Ci. Nos, 01-0038-000 & 01-0307-000-3 Settiernent Agreement formal administrative hearing, which was assigned DOAH Case No. 01-1969. 4, Subsequent to the original audit, and in preparation for trial, AHCA re-reviewed the PROVIDER’s claims and evaluated additional documentation submited by the PROVIDER. As aresult, AHCA determined that the overpayment wes adjusted to $7,313.08. PROVIDER eubmitted additional documentation for review and the overpayment was adjusted to $6,697.37. 5, Duting the pendency of the case under CJ, 01-0038-000, another audit was being completed. Audit C.I. No. 01-0307-000-3 was initiated on October 2. 2000 at Morales Pharmacy #2 for the review period of January 1, 1999 through July 21, 2000. It was determined that review of Medicai¢ claims performed by Medicaid Program Integrity (MPI), Office of the Inspector General, indicated that certain claims, in whole or in part, were not covered by Medicaid. The Agency determined the overpayment to be in the amount of $4,176.89. 6. Tn order to resolve these two matters 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. (2) Within thirty days of receipt of the final order, PROVIDER agrees to make a lump sum payment of ten thousand sight hundred seventy four dollars and twenty-six cents ($10,874.26) in full and complete settlement of all claims in the audits referenced as C.1. 01-0038-000 and CJ. 01- 0307-000-3. AHCA retains the right to perform a 6-month follow-up review. Osa? Based 2693 1d ea 345446 733b WILSON SUAREZ LOPEZ PAGE Morales Pharmacy #1 & #2 C1. Nos. 01-0038-000 & 01-0307-900-3 Settlement Agreement (3) PROVIDER and AFICA agree that full payment as set forth above will resolve and settle these cases completely and release both parties from all liabilities arising from tbe findings in the audits referenced as C.I. C1- (038-000 and C.1. 01-0307-000-3. (4) PROVIDER and AHCA agree that fall payment as set forth above is final agency action for the audit referenced as CI. 01-0307-000-3 and that PROVIDER waives their right to a hearing. (3) PROVIDER agrces that it will not rebill tae Medicaid Program in any manner for claims that were not covered by Medicaid, which are the subject of the audit in this case. 7. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 8. PROVIDER agrees that failure to pay avy 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 ftom any monies due and owing to PROVIDER for any Medicaid claims. 9. AHCA reserves the right to enforce this Agreement under the laws cf the State of Florida, the Rules of the Medicaid Program, and all other applicable rules and regulations. 10. This settlement does not constitute an admission of wrongdoing ot ervor by either party with respect to this case or any other matter. 11, Each party shall bear its own attorneys’ fees and costs, if any. ud / OF O4/2d/ 2092 14:58 3654457336 WILSON SUAREZ LOPEZ PAGE Morales Pharmacy #1 & #2 S.A. Nos. 04-0038-000 & 01-0307-000-3 " Settiement Agreement 12 The signatories to this Agreement, acting in 4 representative capacity, represent that they are duly authorized to enter into this Agreement 07 pehalf of the respective parties. 13. This Agreement shall be construed in accordance with the provisions of the laws of Florida. Vere for any action arising from this Agreement shall be in Leon County, Florida. 14. This Agreement constitutes the entire agreement between PROVIDER and the AHCA, including anyone acting for, associated with or employed by them, conceming 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. 15. This is an Agreement of settlement apd 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 setting 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. 16. 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 ptaceeding 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 js consistent with the terms of this settlement agreement in any foram now of in the future available gfe? ds tds 2083 : 2h soe 14:58 2B54646 7336 WILSON SUAREZ LOPEZ PAGE BbS27 bia? Morales Pharmacy #1 & #2 _ C.). NOS. 01-0038-000 & 01-0307-000-3 Settlement Agreement to it, including the nght to any administrative proceeding, circuit or federal court action cr any appeal. 17. This Agreement is and shall be deemed jointly drafied and written by all parties to it and shall not be construed or interpreted against the party originating or preparing it. 18. To the extent that any provision of this Agreement is prohibited by Jaw for any reason, such provision shal] be effective to the cxtent not so prohibited, and such prohibition shall not affect any other provision of this Agreement. 19. This Agreement shall inure to the benefit of and be binding on cach party’s successors, assigns, heirs, administrators, representatives and trustees. 20, All times stated herein are of the esserce of this Acreement. 21. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. MORALES Morales Pharmacy #1 & #2 C.1. Nos. 01-0038-000 & 01-0307-000-3 Settlement Agreement AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 Dated: af RufasNoble Jaane: Here 7 General , 2003 Vdd Lil & Dated: Lobe Ar Valda Clark Christian General Cgunse, wo Dated: §-) Assistant General Counsel STATE OF FLORIDE ~AHCA "4 <2. eee AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH. GOVERNOR RUBEN J KING-SHAW. JR. SECRETARY April 6, 2001 CERTIFIED MAIL - RETURN RECEIPT NO. : 7000 0600 0023 5447 9412 Provider No. 1022517 00 License No. PHO013336 Jose C. Moreles, President Pharmovisa, inc. d/b/a Morales Pharmacy 55 S$.w. 137°* Avenue Miami, Florida 33183 #1 RE: FINAL AGENCY AUDIT REPORT C.I. No. C1-0038-000-3/H/KNH Dear Mr. Morales: An on-site audit of your pharmacy was initiated on September 2000. The Fiorida Medicaid Program through the agency for Health Care Administration has determined that you have be overpaid $20,646.58 in connection with claims submitted to Medicaid during the audit period(s) specified. This conclusion is supported by the audit results. is determinations were made in accordance with the provisions of Chapter 409 Plorida Statutes (F.S.), and Chapter 596, Florida Administrative Code (F.A.C.). In applying for Medicaid reimbursement, providers are required to follow the ae statutes, rules, Medicaid provider handbooks, mencs of Medicaid policy, and federal laws and reguia annot properly pay for claims that do not meet vequizements. Jnen a provider receives payment in ion of zhese provisions, those funds must be repaid. This review and the tions. REVIEW DETERMINATIONS included a judgmental sample review and a sep The audit é statistical analysis of a random sampling with the resul to the random sample universe of claims submitted during period The audit period for this review was irom Januar throug u , 2000. This review identified an overpay $20, 64 3 2 actual overpayment was calculated using 7 Mahan Drive © Mail Siop #6 Visit AHCA Online ai a we Sdire. siate. flies B08 + iM hassee. FL 3 2 Ta procedure that has been proven valid and is deemed admissible in administretive and law courts as evidence of the overpeyment. Attached are the overpayment calculations, @ summary of documented Giscrepancies, and an itemized listing of discrepancies noted in the review of the judgmental and random sample. The audit also included a comparison of your lawful documented Tne audi product acquisitions with your paid Medicaid claims. period for this review was from January 4, 1999, through July lied to Medicaid, in many instances, to 1, 2000. The drug quantity bill exceeded the quantity available to dispense to Medicaid recipients. This review identified an overpayment of $18,805.75. Attached are the overpayment calculations. Accordingly, we have determined at this time that you have been overpaid by the Medicaid program in the amount of $20,646.58. If you accept or concur with these findings, please send your checx in the amount of $20,646.58, for the identified overpayment, made payable to the Florida Agency for Health Care Administration, to: Agency for Health Care Administration Medicaid Accounts Receivable Post Office Box 12749 Tallahassee, Florida 32317-3749 (Note: The check must be payable to the Florida Agency for Health Care Administration, not to any employee of the agency.) To ensure proper credit, be sure that your provider number is shown on your check. Question regarding payment should be directed to Ms. Willie Bivens ac (850) 487-4298. You have the right to request a formal or informal hearing pursuant to section 120.569, F.S. Ifa petition for formal hearing is made, the petition must be made in compliance with rule section 28-106.201, F.A.C. Please note that rule section 26-106.201(2), F.A.C., speci thet the petition shall contain a@ concise Giscussion of speci items in dispute. Additionaily, vou are hereby informed that if a request for a hearing is made, the request or petition must be received within twenty-one (21) @ayvs of receipt of this ietter. Failure to timely request @ 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. Charles G. Ginn, Chief Medicaid Program Integrity Office of the Inspector General Agency for Health Care Administration 2727 Mahan Drive, Mail Stop # 6 Tallahassee, Florida 32308-5463 Do not send requests or petitions to any other address. Ifa hearing request is not received within 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 21-day period. Any questions that you may have regarding this matter should be directed to: Ms. Kathryn N. Holland, Senior Pharmacist, Agency for Health Care Administration, Medicaid Program Integrity, Office of the Inspector General, 2727 Mahan Drive, Mail Stop #6, Tallahassee, Florida 32308-5403, telephone number (850) 922- 4374, Sincerely, 4 (LAL ___— D. Kenneth Yon Program Administrator Medicaid Program Integrity DKY/knh Attachment(s) cc: Medicaid Program Integrity Administrative Section Medicaid Accounts Receivable, Attn: Willie Bivens Heritage Information Systems, Inc. Medicaid Program Development Area Medicaid Office H:\heritage\f-moralespny#i

Docket for Case No: 01-001969