Fey STATE OF FLORIDA DEC -) ag DIVISION OF ADMINISTRATIVE HEARINGS oe MOUNT SINAI MEDICAL CENTER, DERAR a Petitioner, TT OY an « vs. CASE NOv02-0020MPI = STATE OF FLORIDA, ca AGENCY FOR HEALTH CARE . : ADMINISTRATION, : 2 Respondent. / FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement on N CV. Lk » 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. is the LE Ndvew ince DONE and ORDERED on this the day of : ., 2002, in Tallahassee, Florida. Rhonda M. Medows, MD, 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: L. William Porter I], Esquire Agency for Health Care Administration (Interoffice Mail) Geoffrey D. Smith, Esquire Blank, Meenan & Smith 204 S. Monroe Street Tallahassee, Florida 32301 (U.S. Mail) J.D. Parrish Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Bob Maryanski, Medicaid Program Development Kathleen Cook, Medicaid Program Development 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 day of ( oop gi, 2002. ‘® 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 STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS MOUNT SINAI MEDICAL CENTER, Petitioner, vs. CASE NO. 02-0020MPI STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and Mt. Sinai 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 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 number 010046300. 3. In its final agency audit report (final agency action) dated November 15, 2001, AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Development (MPD), Office of the Inspector General, indicated that certain claims, in whole or in part, were not covered by Medicaid. The Agency sought recoupment of this overpayment, in the amount Mt. Sinai Medical Center 02-0020 Settlement Agreement of $137,384.70. In response to the audit letter dated November 15, 2001, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No. 02-0020. 4. Subsequent to the original audit that took place in this matter and in preparation for trial, AHCA re-reviewed the PROVIDER’s claims and evaluated additional documentation submitted by the PROVIDER. As a result, AHCA determined that the overpayment was $52,595.00. 5. In order to resolve this matter without further administrative proceedings, PROVIDER and the AHCA expressly agree as follows: (1) (2) AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPD review. Within thirty days of receipt of the final order, PROVIDER agrees to make a lump sum payment of fifty two thousand five hundred ninety five dollars ($52,595.00) in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 02- 0020}. As a sanction, MPI will do a re-audit in 6 months. 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. 01-1163-000. Mi. Sinai Medical Center 02-0020 Settlement Agreement (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 shail be in Leon County, Florida. Mt. Sinai Medical Center 02-0020 Settlement Agreement 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 law, and with each party compromising and settling any potential correctness or incorrectness of its understandings, information and contentions as to facts and Jaw, 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. Jct 16 02 03:43p Blank, Meenan&Smith,P.A.- 850-681-1003 _ — Mt. Sinai Medical Center 0.-v020 Settlement Agreement 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. MT. SINAI MEDICAL CENTER OX y Dated: , 2002 BY: Muy. Monde (Print name) ITS: sell, cf Mt. Sinai Medical Center 02-0020 Settlement Agreement AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 Bob Sharpe Deputy Secretary, Medicaid dé il ante Dated: 0" , 2002 aa Clark ae General Counsel Dated: [- , 2002 Assistant GeXeral Counsel STATE OF FLORIDA CA. AGENCY FOR HEALTH CARE AOMINISTRATION RHONDA M, MEDOWS, MO, FAAFP, SECRETARY JEB BUSH, GOVERNOR CERTIFIED MAIL - RETURN RECEIPT REQUESTED 7000 1670 0009 4949 2309 Date: November 15, 2001 Provider No. 0100463-00 - EXHIBIT Mount Sinai Medical Center ), Hospital Administrator 4300 Alton Road Miami, FL 33140-2849 RE: FINAL AGENCY AUDIT REPORT C.L 01-1163-000 Dear Administrator: On August 17, 2001, your hospital was issued a Preliminary Audit Report that determined the hospital was reimbursed $137,384.70 for services not covered by Medicaid. This was based on a retrospective medical record review by the Keystone Peer Review Organization (KePRO), wherein it was determined that either the inpatient admission or a portion of the length of stay was not medically necessary for Medicaid recipients. In response, your hospital did not request reconsideration of the denials. Accordingly, we have determined that your hospital was overpaid $137,384.70 for services not covered by Medicaid. This review and the determination of overpayment were made in accordance with the provisions of Florida Statutes Section 409.913. In determining payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, Medicaid Bulletins, Statements of Policy and the limitations and exclusions found in the Medicaid provider handbooks. 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. Since this determination is final action by the Agency for Health Care Administration, you have the right to request a formal or informal hearing pursuant to Section 120.569, Florida Statutes. If a petition for formal hearing is made, the petition must be made in compliance with rule section 28-106.201, Florida Administrative Code. Please note that rule section 28-106.201(2) specifies that the petition shall conta 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. Failure to timely request a hearing shall be deemed a waiver of your right to a hearing. 2727 Mahan Drive « Mail Stop # Visit AHCA Online at www fdhe. state flus Tallahassee, FL. 32308 Mount Sinai Medical Cen. Page 2 It is important that a request for an informal hearing or petition for formal hearing be sent only to the following address: Mr. Charles Ginn, Chief Medicaid Program Integrity Office of the Inspector General ~ Agency for Health Care Administration 2727 Mahan Drive; Mail Stop #6 Tallahassee, FL 32308-5403 Do not send the request or petition to any other address. Ifa 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 concur with our findings, remit by check in the amount of $137,384.70. 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 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... Any questions you may have about this matter should be directed to: Hank Landis, Systems Project Analyst, Agency for Health Care Administration, Program Development, 2727 Mahan Drive, Building 3, Room 2354, Tallahassee, Florida 32308, telephone (850) 921- 8273. Sincerely, Mike Morton, Program Administrator KB/mm Enclosures ce: Area Medicaid Office. Medicaid Accounts Receivable Visit AHCA Online at 2727 Mahan Drive « Mail Stop # www fdhe. state. flus Tallahassee, FL 32308 Mount Sanai Medical Center Prov!'No. 0100463 00 KePRO Denials 07/31/2004 REC ORIG ID| REC CUR IO [RECI LAST [rec First [__sse [acm _[_oiscn Denled Days | Overpaid | PSY Credits Adj Overpay 811288968 |811288968 [ARTEAGA ORLANDO {591749211 | 03/21/1995] 04/14/1995 24| $22,793.04] $6,312.00] $16,481.04 751451706 |751451706 |CLARKE SHIRLEY 118444947 | 01/12/1996] 04/23/1996 3) $2,856.81 $2,856.81 810950631 |810950631 |CUFF |LoIs 262068392 | 08/23/1995! 09/13/1995 8| $7,745.28] $2,104.00 $5611.28 813099559 (813099559 |FERNANDEZ BRENDA 5817 16202 | 04/44/1996] 04/18/1996 2] $1,904.54 $1,904.54 758892974 |758892974 [FORTE __|ERNESTO [121507649 | oa/ar1998| oa/t6/1995 8| $7,745.28) $2,704.00] $6,611.28 811732034 |811732034 |GARCIA PERDO |RIGARDO ~ 590216081 | 02/03/1996] 02/07/1996 3] $2,856.81} $2,856.81 212043102 1212043102 |GIL JACQUELINE [267679170 | 04/16/1996] 05/09/1996 23] $21,902.21 | $21,902.21 096320663 [096320663 JGLASS MICHAEL 096320663 | 05/31/1996] 06/03/1996 3] $2,856.81 | $2,856.81 750143143 |750143143 IGLUZMAN LYUDMILA {595331885 | 10/25/1995] 10/30/1995 5] $4,822.05 $4,822.05 763457519 |763457519 [GONZALEZ THERESA __ {150566877 | 09/09/1996] 09/12/1996 3} $2,904.45 $2,904.45 744827027 1744827027 IGRU VLADIMIR [592232373 | 04/16/1996) 04/24/1996 i $952.27 $952.27 744827027 1744827027 [GRU __ VLADIMIR [592232373 | 05/14/1996] 05/16/1996 2| $7,904.54) $1,904.54 810435877 |8 10435877 [HERNANDEZ GLADYS 592487083 [oaririese 03/28/1996 2} $1,904.54 - $1,904.54 811337224 |811337224 [HERRERO JOSE 081785833 | 08/04/1995] 10/15/1995 11] $10,608.51 $10,608.51 759464218 |759464218 |ILYUTOVICH RAISA 591539813 | 01/03/1996] 04/11/1906 1 $952.27 $952.27 810244536 {810244536 [KING MARK 078245017 | 04/21/1996] 04/29/1996 1 $952.27 $952.27 756999406 |756999408 LLANOS EVELYN 107628942 | 09/13/1995] 09/27/1995 11] $10,608.51 $10,608.51 812498753 (812498753 IMANZANO RAMON 267956204 | 12/27/1995 12/30/1995 “3) $2,893.23 ~ | $2,893.23 146706291 |146706291 |MARTINEZ ABDENIA 146706291 | 11/23/1995 11/24/1995] i $964.44] $964.41 760564874 |760564874 [MEDINA _JASELA 194059361 | 05/02/1996} 05/15/1996 1 $952.27 $952.27 338428302 {338428302 |MUNK-KEGELER |BONITA 159367675 | 01/09/1996] 01/11/1996 2| $1,904.54 | $1,904.54 810330135 (810330135 [MUNOZ FABIOLA 065749375 | 04/29/1996] 06/14/1996 24| $22,854.48} $6,312.00| $16,542.48 810330135 (810330135 [MUNOZ FABIOLA 065749375 | 09/02/1996] 09/05/1996 3| $2,904.45] $789.00} $2,115.45 761793248 |761793248 [PITTA ANA 079660286 | 05/04/1996] 05/11/1996 2] $1,904.54 $1,904.54 263929785 |263929785 |RIVERAA (Romero) [MARIA TERE (263929785 02/06/1896] 02/08/1996 2| $1,904.54 | $1,904.54 227483602 |227483602 (SANCHEZ SANTA 083261057 | 11/21/1995} 11/25/1995 4| $3,857.64] $3,857.64 750914178 1750914178 (SANDLER SEMEN 593354990 | 10/17/1995] to/isii995| $1,928.82] ~~ $1,928.82 789977305 |759977305 [SHACKELFORD [FELIX 549467415 | 10/17/1995] 10/48/1995 1] $964.44) $964.41 812251223 [812251223 |TARAKHOVSKAY _ |YEVGENIYA 591453561 | 03/20/1996] 03/28/1996 2} $1,904.54 |__$1,904.54 266664388 (266664388 TRUJILLO CECILIA 266664388 | 08/29/1995] 09/11/1995 3} $2,893.23 | $2,893.23 749467258 |749467256 |TSIN SIMA 591334256 | 10/06/1995] 10/13/1995] 1 $964.41 [$964.41 Total Due Medicaid _, $155,005.70 $17,621.00 $137,384.70

Docket for Case No: 02-000020MPI