STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION > s NEIGHBORHOOD HEALTH PARTNERSHIP, =29 = Ti ine So exon INC, , Bae a . aie Beas er fl Petiti , > ae Petitioner, OER > cy vs CASE NO. 02-0587MPI™ =o PROVIDER NO. 015018500 ™ STATE OF FLORIDA, AUDIT C.I. NO. 97-1892-068 AGENCY FOR HEALTH CARE Rendition No. AHCA-06- -S-MDP ADMINISTRATION, i] to me Respondent. / FINAL ORDER ' ' THE,.PARTIES resolved all disputed issues and executed a Settlement Agreement. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. ih DONE and ORDERED on this the _/7 “day of Q#2Ze~ , 2006, in Tallahassee, Florida. Levine, 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 Agency for Health Care Administration (Interoffice Mail) Seann Frazier, Esquire , Greenberg Traurig, P.A. | Post Office Drawer 1838 Tallahassee, Florida 32302 (U.S. Mail) Florence Rivas Administrative Law Judge Division of Administrative:-Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Tim Byrnes, Chief, Medicaid Program Integrity Vickie Divens, Medicaid Program Integrity Maryann Alliegood, 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 ZAay tl + of _“Zare4 2006. Richard Shoop, Esquire ; Agency Clerk mo" State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 FILED ' STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS 208 HAR 23 A II: 03 NEIGHBORHOOD HEALTH . DIVISION OF PARTNERSHP, INC., ADMINISTRATIVE HEARINGS _ Petitioner, ' VS. ‘CASE NO. 02-0587MPI PROVIDER NO. 015018500 STATE OF FLORIDA, - AGENCY FOR HEALTH CARE ; ‘ ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and Neighborhood: Health Partnership, Inc. (“PROVIDER”), by and through the undersigned, hereby stipulate and agree as follows: 1. The two parties enter into this agreement for the purpose of memorializing the resolution to this matter. 2. PROVIDER is ‘a Medicaid provider in the State of Florida, provider number 015018500 and was a provider during the audit period. 3. In its Final Agency Audit Report. ‘final agency action) dated November 30, 2001, AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Integrity (MPI), Office of the ANCA Inspector General, indicated that certain claims, in whole or in part, has been inappropriately paid by Medicaid. The Agency sought recoupment of this overpayment, in the amount of $178,730.06. In response to the audit letter dated November 30, Neighborhood Health Partnership, Inc. Settlement Agreement 2001, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No. 02-0587. 4. In order to resolve this matter without further administrative proceedings, PROVIDER and the AHCA expressly agree as follows: 6. (1) ‘ 2) won, B) (4) ‘ AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. Within thirty days of entry of the final order, PROVIDER agrees to make a lump sum payment of one hundred sixty thousand eight hundred fifty seven dollars and five cents ($160,857.05) in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 02-0587). . 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. 97-1892- 068. 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. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 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 Neighborhood Health Partners, Inc. Settlement Agreement 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. 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, ifany. + 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, associatel 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. 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 and law, so that no misunderstanding or misinformation shall be a ground for rescission hereof. Neighborhood Health Partnership, Inc. 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 tules 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. t 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 ee shall not affect any other provision of this Agreement. . ( yeep 1 f ‘ 17. This Agreement shall inure to the benefit of and be binding on each party’s successors, assigns, heirs, administrators, representatives and trustees. 18. All times 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. Ce BY: Lun Ca ; bce besdert (Print name) ITS: Neighborhood Health Partnership, Inc. Settlement Agreement : ' ‘ AGENCY FOR HEALTH CARE ' ADMINISTRATION — + . 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 ' . ' . " _ Lawserpiored Dated: 3 ~/ 7 ‘2006 James D, Boyd : Inspector General , Clrcfa Cetauced Dated: 3/5 , 2006 Christa Calamas General Couns Dated: 1- L | « , 2006 L. William P ; Assistant General Counsel \ , } FILED STATE OF FLORIDA DIVISION OF ADMINISTRATIVE: ) HEARINGS _ 2005 MA R23 Allg 03. NEIGHBORHOOD HEALTH OVS] OF PARTNERSHP, INC., ADMINS A Oye HEARINGS , Petitioner, ; : VS. , CASE NO. :02-0587MPI . PROVIDER NO. 015018500 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, ; Respondent. i : / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and Neighborhood Health Partnership, Inc. (“PROVIDER”), by and through the undersigned, hereby stipulate and agree as follows: my “ The two parties enter into this agreement for the purpose of memorializing the resolution to this matter. 2. PROVIDER is a Medicaid provider in the State of Florida, provider number 015018500 and was a provider during the audit period. 3. In its Final Agency Audit Report (final agency action) dated November 30, 2001, AHCA notified PROVIDER that review of Medicaid claims performed by. Medicaid Program Integrity (MPI), Office of the AHCA Inspector General, indicated that certain claims, in whole or in part, has been inappropriately paid by Medicaid. The Agency sought recoupment of this overpayment, in the amount of $178,730.06. In response to the audit letter dated November 30, Neighborhood Health Partnership, Inc. Settlement Agreement 2001, PROVIDER filed a petition for a formal administrative hearing, which was assigned DOAH Case No. 02-0587. ! 4. 4 In order to resolve this matter without. further administrative proceedings, PROVIDER and the AHCA expressly agree as follows: 6. (1) (2) (3) (4) AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. ‘ Within thirty days of entry of the final order, PROVIDER agrees to make a lump sum payment of one hundred sixty thousand eight hundred fifty seven dollars and five cents ($160,857.05) in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 02-0587). ‘ 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. 97-1892- 068. 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. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee,. Florida 32317-3749 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 Neighborhood Health Partnership, Inc. Settlement Agreement 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. 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 and law, so that no misunderstanding or misinformation shall be a ground for rescission hereof. Neighborhood Health Partnership, Inc. 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 t 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. All times 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. Dated: iw 2/2006 sy: [amon Gero Nee bresden (Print name) Neighborhood Health Partnership, Inc. Settlement Agreement AGENCY FOR HEALTH CARE ' ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 Dated: z-/ 7 _» 2006 es D. Boyd Inspector General mot Cuswite. Calacean Dated: 3) 15 , 2006 Christa’ Calamas General Counsel o~ -h ; 2006 L.. AW: Porter II Assistant General Counsel AGENCY FOR HEALTH CARE ADMINISTRATION hae . - : i SiOk be JEB BUSH, GOVERNOR ' RHONDA M. meow6 SiS KARR: BE i yaRY EARINGS © November 30, 2001 CERiIFIED MAIL - RETURN RECEIPT REQUESTED Provider No. 015018500 Neighborhood Health’Plan, Inc. ye 7600 Corporate Center Drive Og . O S Miami, FL 331260000 ; 6 In Reply Refer to FINAL AGENCY AUDIT REPORT C.I. No. 97-1892-068/WG4/VSD ’ Dear Provider: ‘ The Medicaid Program Integrity Office has reviewed Medicaid claims for all newborns whose mother was enrolled in a health maintenance organization at the time of birth for dates of service July 1, 1996, through June 30, 2000. Based on this review and the documentation submitted by you in response to the Preliminary Agency Audit letter, we have made a final determination that Medicaid paid claims in the amount of $178,730.06 for services for newborns who were the responsibility of your HMO, which is accordingly responsible for that amount. In determining payment pursuant to Medicaid policy, the Medicaid program follows provisions of Sections 409.907, 409.913, and 641.31, Florida Statutes, and provisions of applicable policy manuals and the contract for Medicaid prepaid health plans. The Medicaid Prepaid Health Plan contract states that all Medicaid eligible newborns of enrollees are the responsibility of the plan for a period of at least three months from the date of birth unless the mother voluntarily disenrolls the newborn from the plan, the newbom loses Medicaid eligibility, or the newborn is enrolled by the mother in Children’s Medical Services. For the purposes of this review, we comprehended only principal mandatory covered services, viz., medical, inpatient hospital and prescribed drug services. Expanded, optional, and EPSDT service claim types were excluded as were claims for hospitalization in excess of 45 days. The enclosed reports list claims for services provided when the mother had been enrolled in your plan at the time of the birth and fee-for-service claims were also paid for that newborn during the first three months following birth. These fee-for-service claims are the responsibility of your plan and represent financial outlays for which your plan is Tesponsible. Visit AHCA Online at 2727 Mahan Drive » Mail Stop #6 wwwfdhe.stateflus Tallahassee, FL 32308 ape er oer rer ee cee TEE EY aT oe RT ITE FIT TE TT Teme = * 7 Neighborhood Health Plan, Inc. Newborn Project Page2 ' ' If your HMO did not receive claims from fee-for-service providers for the newborn during the three months following birth that does not in any way relieve you of your contractual financial responsibility for any such services furnished by such providers. : If any.of the fee-for-service claims for which we are indicating that you have responsibility were furnished by, “out-of-plan” providers, then appropriate documentation should be provided that meets the criteria for relieving the Plan of its responsibility for payment to the out-of-plan provider. For those recipients, please submit a copy of the “Statement of Understanding.” The subscriber should have a clear understanding that they were liable for services unauthorized outside the Plan’s provider network. For those recipients for whom claims were paid by both the Plan and Medicaid for fee-for- service, we will pursue repayment from the fee-for-service provider, based upon the documentation that you have submitted. At a minimum, the documentation must contain dates of setvice, provider name, amount paid, check number, and a copy of the canceled check or payment transaction. We must be able to demonstrate proof of payment to the fee-for-service provider that they did receive duplicate payments from the Agency and the Plan. If wedo not . receive the appropriate documentation, then it will be up to your Plan to recoup payment from the fee-for-service providers for any duplicate payments. ‘ : For those babies for whom you state that you did not receive capitation payments for the audit period, please submit documentation for our review that you fulfilled your contractual obligation in C.3. and'B:20 of the Medicaid Prepaid Health Plan Contract. Please note that failure to submit a newborn report does not relieve the provider of coverage liability. . The Agency has an obligation to hold HMOs accountable for the medical care of the newborns unless documentation is provided to relieve HMOs as cited in the contract: Ifyou have any questions about this matter, contact Ms. Vickie Divens, registered nursing consultant, Agency for Health Care Administration, Medicaid Program Integrity, Office of the Inspector General, 2727 Mahan Drive MS6, Tallahassee, Florida 32308-5403, telephone (850) 921-4949. Please send your check for $178,730.06 to this Agency. 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: Florida Agency for Health Care Administration Medicaid Accounts Receivable Attention: Ms. Willie Bivens P.O. Box 13749 Tallahassee, Florida 32317-3749 If payment is not received within twenty-one (21) days of the date of receipt of this letter, the Agency for Health Care Administration will withhold Medicaid payments in accordance with the provisions of section 409.913, Florida Statutes (F.S.), until the amount owed is fully recovered. sep ree gee Se RE ape cree ore z- ‘ “ay Neighborhood Health Plan, Inc. /Newborn Project Page 3 : Questions regarding payment should be directed to Ms. Willie Bivens, Medicaid accounts receivable, (850) 921-4396. ' . You have the right to request a formal or informal hearing pursuant to section 120.569, F.S. Ifa request for formal hearing is made, the petition must be made in compliance with rule section 28-106.201, Florida Administrative'Code (F.A.C.). Ifa request for an informal hearing is made, the petition must be made in compliance with rule section 28-106.301, F.A.C. Please note that rule section 28-106.201 (formal hearing) and 28-106.301 (informal hearing), F.A.C., specify that ’ the petition shall cqntain a concise discussion of specific items in dispute. Additionally, you are hereby informed that ifa request for a hearing is made, the petition must be received within twenty-one (21) days of receipt of this letter, and failure to timely request a hearing shall be deemed a waiver of your right to a hearing. ; It is important that a request for an informal hearing or a formal hearing be sent only to the following address: co Charles G. Ginn, Chief : . ' Medicaid Program Integrity Office of the Inspector General Florida Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #6 Tallahassee, Florida 32308-5403 Do not send requests or petitions 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. Ifa timely hearing request is not received, or if it is received and subsequently withdrawn by you, and repayment is not made by that time, an interest penalty of ten percent (10%) per year from the date of this final agency action shall be imposed in accordance with the provisions of section 409.913, F.S. , Sincerely, Robot, Pene Robert V. Peirce AHCA Administrator Medicaid Program Integrity RVP:vsd FAL.NBFFS Enclosures cc: Medicaid Accounts Receivable Medicaid Fraud Control Unit Medicaid Program Development Medicaid Program Integrity Administration © Medicaid Program Integrity Work Group Five Area 11 Medicaid Office ,

Docket for Case No: 02-000587MPI