STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: ;, MEMORIAL HOSPITAL OF TAMPA, Petitioner, vs. CASE NO. 02-0585 AUDIT CL. NO. 00-1477-000 RENDITION NO.: AHCA-02-0143-S-MDP STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / { SYN) C (06 FINAL ORDER The Respondent, AGENCY FOR HEALTH CARE ADMINISTRATION, issued the Petitioner, MEMORIAL HOSPITAL OF TAMPA, a final agency audit report dated October 5, 2001 advising Petitioner of an alleged overpayment in the amount of $29,924.26. Petitioner has paid this amount to the Agency’s Finance and Accounting Department on January 16, 2002. A copy of the check and final agency action report is incorporated by reference. Based on the foregoing, the alleged overpayment has been paid and the file is CLOSED. DONE and ORDERED on this the @/ day of wa. , 2002, in Tallahassee, Florida. f ond& Medows, 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 II, Esquire Assistant General Counsel Agency for Health Care Administration (Interoffice Mail) Elizabeth Sports Memorial Hospital of Tampa 2901 Swann Avenue Tampa, Florida 33609-4057 (U.S. Mail) Daniel Manry Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Willie Bivens, Finance & Accounting (Interoffice Mail) Charlie Ginn, Chief, Medicaid Program Integrity (Interoffice Mail) Kathleen Brown, Medicaid Program Development (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnishe the above-named addressees by the means indicated on this the[ I day of me We , 2002. LepheundldW Ota, Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 MEMORIAL HOSPITAL OF TAMPA “ DOAH No. 02-0585 ee) Provider No. 011279800 - C.I. No. 00-1477-000 ~ SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA” or “the Agency"), and Memorial Hospital of Tampa (“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 5, 2001, 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 $29,924.26. In response to the audit letter dated October 5, 2001, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No. 02-0585. 4. in order to resolve this matter without further administrative proceedings, PROVIDER and the AHCA expressly agree as follows: (41) AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. Memorial Hospital of Tampa Settlement Agreement (2) PROVIDER has paid to the”’Agency the amount of twenty nine thousand nine hundred twenty-four dollars and twenty-six cents ($29,924.26) in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 02-0585). (3) | PROVIDER and AHCA agree that full payment as set forth above will resolve and settle this case completely and release both parties from ail liabilities arising from the findings in the audit referenced as C.|. 00-1477-000. (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. 5. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 6. 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. 7. 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. Memorial Hospital of Tampa Settlement Agreement 8. This settlement does not constitute“an admission of wrongdoing or error by either party with respect to this case or any other matter. 9. Each party shall bear its own attorneys’ 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. 11. | 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. 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. 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 ahd law, so that no misunderstanding or misinformation shall be a ground for rescission hereof. Memorial Hospital of Tampa Settlement Agreement 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 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. 15. 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. 16. 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. 17. | This Agreement shall inure to the benefit of and be binding on each party’s successors, assigns, heirs, administrators, representatives and trustees. 18. Alltimes stated herein are of the essence of this Agreement. 19. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. NM nist prive» Mail stop #3 FL 57308-540° zs 2002 hi BMCA FINENCE AND GCCT ina Bid sed SEDs P.S1/ay stn er Dsisenhore wR UUUS45526 chakra 3138 $5ad6 o TWENTY —-NEN THOUSAND NINE HUNDRED THENTY=EQUR OILLARS Twovry ‘ -STX cent oy Yo the ordar of Date Amount 1 Fl AGENCY FAR HEALTH CAQF ADMTST OL~16-92 #€#68029, 925596 ‘ MEDICAL” ACCOUNT RECFYVaals . i PY AIX 13769 Vaid afer 180 doy: TALLAHASSER FL 323173769 1 4 ‘ Ths Bank of New York (Delaware) ", ss, : ae / Newark, Delage vor FR ' ‘s , , oo “OOOS8GSI26H O31 10035 % woO30051081 208 Remittance Advica, Patient Refund Oote Chock No. " [f N fF | P.O, Box 809074, Dallas, TX 75360-9074 1-15-02 909865426 ae Ps FL AGENTY ©n2 yea ry CARS ADMTST 3334 795419 Bs : [Gross Amount Hopitat/Clinic Nome #3920K 2010493 lavoioa Number 10602 MEM 495? OF TawPa | MENTCATO RFETMIIRSEM=VT] Pp FINANCE pu Won] -—._ ACCOUNTS RECE TMAH ELEVA a IN ie | TOTALS b Z pig ee 7 TOTAL P.@1

Docket for Case No: 02-000585MPI