STATE OF FLORIDA cen psn DIVISION OF ADMINISTRATIVE HEARINGS Li. SET BLAKE MEDICAL CENTER Tele CUES Petitioner, CASE NO: 01-4515 v. RENDITION NO.: AHCA~02- 0191-S-MDP JUDGE: W. F. QUATTLEBAUM AGENCY FOR HEALTH CARE ADMINISTRATION, Qa nr i) a Respondent. xz = OF! / Oe Fanaa Bnd oc ied Bae om t 52 =. Py FINAL ORDER oa * < 2 my THE PARTEES resolved all disputed issues and executed a settlement agreement watich is attached and 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 2/ day of por , 2002, in Tallahassee, Florida. ce : fv ah Medows, MD, Secretary on. 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: Jeanne Chaffin Blake Medical Center Post Office Box 25004 Bradenton, FL. 34209 (U.S. Mail) Anthony Conticello Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 | (Inter-office) William F. Quattlebaum Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway . Tallahassee, Florida 32399-3060 (U.S. Mail) Charlie Ginn, Chief” Medicaid Program Integrity Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #6 Tallahassee, Florida 32308 (Inter-office) Finance & Accounting (Inter-office) CERTIFICATE OF SERVICE LHEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addresses by U.S. Mail or Inter-office on this the fx _ day of psuk ; _, 2002. okt Daire, Esquire Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 (850) 922-5873 FILED STATE OF FLORIDA mm DIVISION OF ADMINISTRATIVE HEARINGS 02 APR IG AM 9:23 DIVISIGN BLAKE MEDICAL CENTER ADMIN'S | Arve HEARINGS Petitioner, CASE NO: 01-4515 Yv. JUDGE: W. F. QUATTLEBAUM AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), Blake Medical Center, (“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. 2. PROVIDER is a Medicaid provider in the State of Florida. 3. In its Final Agency Audit Reports issued on October 1, 2001 (the "Audit Letter") AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Integrity (MPI) 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 $ 27,140.35. In response to the Audit Letter, PROVIDER filed a petition for a formal administrative hearing that was assigned DOAH Case No 01-4515MPI. 4. Petitioner disputed only $16,425.19 of the stated overpayment total (the “Disputed Amount”), leaving $10,715.16 as an undisputed overpayment (the “Undisputed Amount’). Subsequent to issuance of the Audit Letter, PROVIDER submitted additional documentation to AHCA on the disputed claims. Upon review of the additional documentation and information supplied, AHCA determined that only $6,576.42 of the $16,425.19, Disputed Amounts properly classified as an overpayment. Therefore, AHCA agrees and stipulates that the overpayment total owed by PROVIDER in this matter is $17,291.58 ($6,576.42 + $10,715.16 = $17,291.58) (the “Amended Overpayment Total”). PROVIDER agrees to pay AHCA an additional $423.58, as investigative expenses and costs (the “Investigative Costs”). Thus, the entire balance due by PROVIDER to AHCA is $17,715.16 ($17,291.58 Amended Overpayment Amount + $423.58 Investigative Costs = $17,715.16). 5. In order to resolve this matter without further administrative proceedings, PROVIDER and AHCA expressly agree as follows: (a) | AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. (b) PROVIDER shall pay AHCA $7,000.00 in one lump sum payment by March 1, 2002, as complete settlement of all claims in this proceeding before the Division of Administrative Hearings (DOAH Case No 01- 4515MPI). This amount is broken down as set forth in this paragraph. In - November 2001 , PROVIDER paid AHCA the Undisputed Total tee ($10,715.16) of the entire Amended Overpayment Total ($17,291.58), leaving a balance of $6,576.42 still owing ($17,291.58 - $10,715.16 = $6,576.42). Thus, the balance due by PROVIDER to AHCA is $7,000.00 ($6,576.42 remaining Amended Overpayment Total, plus $423.58 Investigative Costs = $7,000.00). “() PROVIDER is responsible for ensuring timely delivery of the payment. Furthermore, failure to timely make the payment will render the balance due and payable immediately, with interest, and interest will continue to accrue until the entire balance is paid. AHCA reserves the right to seek enforcement of this agreement by any legal means. (d) PROVIDER and AHCA agree that full payment as set forth above will resolve and settle this case completely and release all parties from all liabilities arising from the findings in the audit referenced as: C.I. No. O1- 0550-029. (e) 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 And payment shall clearly indicate that it is per a settlement agreement, shall reference the DOAH Case Number, and shall reference the C.I. Number. 7. PROVIDER agrees that failure to pay any monies due and owing under the terms of this Agreement shall constitute PROVIDER 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. The parties agree to bear their own attorney’s fees and costs, if any. 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. Furthermore, PROVIDER agrees that its signature alone binds PROVIDER to make the payment as set forth in this agreement. PROVIDER shall furnish the actual signed Settlement Agreement to AHCA, however a facsimile copy shall be sufficient to enable AHCA to cancel the final hearing currently scheduled on this matter. 11. This Agreement shall be construed in accordance with the provisions of the laws of Florida. Venue for action arising from this Agreement shall be in Leon County, Florida. 12. 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. 13. Thisis 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. ° 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 tules of the Agency regarding this proceeding and any and all issues raised herein. PROVIDER further agrees that the Agency should issue a Final Order which is consistent with the terms of this settlement, that adopts this agreement and closes this matter. 15, Provider, 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 DOAH Case No. 01-4515MPI, C.I. No. 01-0550-029, 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. 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. PETITIONER: BLAKE MEDICAL CENTER (Fal. Dated: PI, A’ , 2002. : Jeanne Chaffin ITS: Director of Quality Utilization Management Place Corporate Seal Above AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 rn Inspector General WILLIAM ROBERTS Acting General Counsel NY L. CONTICELLO, ESQ. Assistant General Counsel Dated: 2/2 , 2002. Dated: > L. 22,2002. Dated: NXE SRL , 2002. 2002.

Docket for Case No: 01-004515MPI