a _ ee moro STATE OF FLORIDA! iLED AGENCY FOR HEATH CARE DBMINESTENT WR 1G AM 9: 31 Visidll bE ADMINISTRATIVE SOUTH BROWARD HOSPITAL HEARINGS DISTRICT, p/B/A MEMORIAL HOSPITAL WEST, Petitioner, vs. CASE NO. 01-4514 nalee cI # 01-1092-000 AGENCY FOR HEALTH CARE RENDITION NO.: AHCA-02- 0089-S-MDP ADMINISTRATION ' Respondent. / _ FINAL ORDER JVl- Clos THE PARTIES resolved all disputed issues and executed a vsettlement agreement”, which is incorporated by reference. The parties are directed to comply with the terms of the vsettlement agreement”. Based on the foregoing, this proceeding is CLOSED. DONE and ORDERED on this the Zl day of i , 2002, in Tallahassee, Florida. LEE Medows, M.D., Secretary inistration Agency for Health care Adm 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: Geoffrey D- Smith 204 South Monroe Street Tallahassee, Florida 32302 Kim A. Kellum, Esquire Attorney for Agency AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive Fort Knox Building 3, Mail Stop 3 Tallahassee, Florida 32308 J. G. Van Laningham Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Willie Bivens, Finance: and Accounting al Mike Morton, Medicaid Program Integrity CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above na d addressees by U.S. Mail on this the (xs day of , , 2002. Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3, Mail Stop 3 Tallahassee, Florida 32308-5403 STATE OF FLORIDA F L. E D AGENCY FOR HEALTH CARE ADMINISTRATION 02 APR I6 AM 9:31 DIVIS.Gh EF ADMINISTRATIVE SOUTH BROWARD HOSPITAL DISTRICT HEARINGS d/b/a MEMORIAL HOSPITAL WEST Petitioner, C.I. 01-1092-000 vs. Case No. 01-4514 AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / a SETTLEMENT AGREEMENT Respondent, the State of Florida, Agency for Health Care Administration, and Petitioner, South Broward Hospital District d/b/a Memorial Hospital West, by and through the undersigned individuals, hereby stipulate and agree as follows: : 1. This settlement agreement is entered into between the parties. in order to resolve a dispute that arose as the_ he mone result of a KePro review. 2. Ina final agency audit letter dated October 2, 2001, Petitioner was informed that the Agency sought recoupment in the amount of $9,338.45. A copy of the recoupment letter is attached to this agreement. 3, Petitioner challenged Respondent's action and requested a formal hearing regarding the claims in question. 4. Subsequently, the Respondent re-reviewed documentation and reduced the overpayment from $9,338.45 to $4,642.81. 5, The Agency agrees to allow the Petitioner, South Broward Hospital District, d/b/a Memorial Hospital West, to pay the Agency the total sum of $4,642.81 within sixty (60) days of execution of the Settlement Agreement. 6. In the event the Petitioner fails to make any payment due hereunder, the Respondent may, at its option and upon fifteen days written notice to Petitioner, declare Petitioner in default. Its provider number shall be suspended until such time as the Agency receives payment of the balance in full. 7. Payments shall be made to: AGENCY FOR HEALTH CARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, FL 32317-3749 8, This settlement does not constitute an admission of wrongdoing or error by either party. However, the parties believe that this matter should be settled. om * Lak 9. Both parties request that the Agency close the file in this case. 10. Each party shall bear its own attorney's fees and costs. 11. This agreement represents the entire agreement between the parties regarding settlement of this case. 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. The signatories to this agreement, acting in a representative capacity, represent that they are duly authorized to act on behalf of the parties to the agreement. Venue for any action arising from this agreement shall be in Leon County, Florida. 12. Petitioner for itself and for its attorneys, heirs, executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and AHCA's actions herein, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Facility. + Dated this ZL say of Harte of 2002. AGENCY FOR HEALTH CARE ADMINISTRATION kt lL William H: Roberts Acting General Counsel Agency for Health Care Administration 2727 Mahan Drive Ft. Knox Building 3 Tallah LZ hip 32308 RufusMNoble, Inspector General Agency for Health Care Administration 2727 Mahan Drive Ft. Knox Building 3 Tallahassee, Florida 32308 SOUTH BROWARD HOSPITAL DISCTRICT MEMORIAL HOSPITAL WE Hospital Administrator Memorial Hospital West 703 North Flamingo Road Pembroke Pines, Florida 33028 —_ . Blank, Meenan & Smith, P.A. von. Post Office Box 11068 Tallahassee, Florida 32302-3068 Cc: Mike Morton, Medicaid Program Integrity

Docket for Case No: 01-004514MPI