STATE OF FLORIDA sey AGENCY FOR HEATH CARE ADMINISTRATION BOY =} 2 ne INDIAN RIVER MEMORIAL _ oR HOSPITAL, ae Petitioner, Te cle , vs. CASE NO. 02-058eMPI CI 01-1041-000 “ 5 AGENCY FOR HEALTH CARE Provider No. 010104400 .; ADMINISTRATION, és Respondent. ee, FINAL ORDER THE PARTIES resolved all disputed issues and executed a “settlement agreement”, which is incorporated by reference. The parties are directed to comply with the terms of the “settlement agreement”. Based on the foregoing, this proceeding is CLOSED. or DONE and ORDERED on this the day of Neve. AC, , 2002, in Tallahassee, Florida. “Pow Rhonda M. MedoWs, M.D. 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 PILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY BLONG 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: Indian River Memorial Hospital 1000 36° Street Vero Beach, Florida 32960-4810 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 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 named addressees by U.S. Mail or by Interoffice Mail on this the a day of Novem ee , 2002. } TT cL. . Chaglere Qu S30% “MLealand McCharen, Esquire 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 DIVISION OF ADMINISTRATIVE HEARI{SS u 7) py. PY 8 wa INDIAN RIVER MEMORIAL HOSPITAL, Petitioner, vs. Case No. 02-0588MPI Provider No. 010104400 CI No. 01-1041-000 AGENCY FOR HEALTH CARE ADMINISTRATION, RECEIVED Respondent. / GENERAL COUNSEL rd OCT 93 2002 SETTLEMENT AGREEMENT Agency for Health Care Administration Respondent, the State of Florida, Agency for Health Care Administration, and Petitioner, Indian River Memorial Hospital, 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 ” result of a KePRO review. 2. Ina final agency audit letter dated November 14, 2001, Petitioner was informed that the Agency sought - recoupment in the amount of $25,947.78. A copy of the recoupment letter is attached as Exhibit A to this agreement. The claims for which the Agency sought recoupment are set forth as Exhibit B of this agreement and are hereinafter referred to as the ““claims.'' 3. Petitioner challenged Respondent's action and requested a formal hearing regarding the claims. 4. Subsequently, the Respondent reviewed additional documentation. 5. To avoid the further time and expense of litigation, and for their mutual benefit, the parties are desirous of settling all the disputed matters with respect to the claims. 6. The Agency agrees to allow the Petitioner, Indian River Memorial Hospital, to pay the Agency the total sum of $8,776.45 within sixty (60) days of execution of the Settlement Agreement. 7. 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 he suspended until such time as the Agency receives payment of the balance in full. 8. Petitioner and Respondent agree that full payment as set forth above will resolve and settle this case an completely and release both parties, agents, successors, assigns, and their affiliates from all obligations and ~ liabilities arising form the findings in the audit referenced as: C.I. 01-1041-000. 9. Payments shall be made to: AGENCY FOR HEALTH CARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, FL 32317-3749 10. This settlement does not constitute an admission of wrongdoing or error by either party. However, the parties believe that this matter should be settled. 11. The Agency shall close the file in this case. 12. Each party shall bear its own attorney's fees and costs. 13. 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 améndment 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. Dated this day of of 2002. AGENCY FOR HEALTH CARE ADMINISTRATION Behe Lah b= phi fer ot Lil ba Derk CPi SHAN Aeting General Counsel Agency for Health Care Administration 2727 Mahan Drive Ft. Knox Buildyg 3 “Poe rida 32308 Bob Sharpe, Deputy Secretary Of Medicaid Agency for Health Care Administration 2727 Mahan Drive Ft. Knox Building 3 Tallahassee, Florida 32308 INDIAN RIVER MEMORIAL HOSPITAL River Memorial Hospital 1000736 Street vero Beach, FL 32960-4810 Ce: Mike Morton, Medicaid Program Integrity P.02705 r™ STATE OF FLORIDA ~IAHCA puna "A" AGENCY FOR HEALTH CARE ADMINISTRATION JE8 BUSH, GOVERNOR RHONDA M. mepows, MO, FAArP, SECRETARY : Poy CERTIFIED MAIL ~ RETURN RECEIPT REQUESTED 92 yy ; 7000 0600 0026 4157 415: 5. Date: November 14, 2001 Provider No. 0101044-00 Indian River Memorial Hospital Hospital Administrator 1000 36" Street Vero Beach, FL 32960-4810 RE: FINAL AGENCY AUDIT REPORT C.I. 01-1041-000 Dear Administrator: On July 19, 2001, your hospital was issued a Preliminary Audit Report that determined the hospital was reimbursed $25,947.78 for services not covered by Medicaid. This was based ona retrospective medical record review by the Keystone Peer Review Organization (KePRO), patient admission or a portion of the length of stay wherein it was determined that either the in 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 $25,947.78 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 4 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 contain 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. x le Visit AHCA Online at 2727 Mahan Drive « Mail Stop # www fohe, slate flus Tallahassec, FL 32308 07/22/2002 MON 09:48 (TX/RX NO 5542) [002 P.Q3/83 Indian River Memorial H ‘al 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 Genera! ’ 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 tight 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 0f $25,947.78. 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 323 17-3749 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, the fs Mike Morton, ; Program Administrator KB/mm Enclosures ce: Area Medicaid Office Medicaid Accounts Receivable x 2727 Mahan Drive » Mail Stap # _ Tallahassee, FL 432308 Visit AHCA Online at www fdhe. state. fl.us TOTAL P.23 0° 07/22/2002 MON 09:48 {(TX/RX NO 5542] @o03 Indian River Memorial Hospitat 7 d@4e4/ Prov. No. 0101044 00 KePRO Denials Rec.Org ID. | Rec Cur [DO 812573779/812573779:1BEARD (Kelley) [WENDY . WALA AA Md - 261611979 | 12/04/1995 EXHIBIT ey Ue "Be 07/10/2001 74237719648RIDGES 733398624, JENKINS... 09/06/1995 09/16/1995 812839187|812839187 JOHNSON aR 11/09/1995 [318641802] 348641805 ANCEY 08/25/1995 1720/1895 in 08/25/1995] 756140188) 756140188 PENUEL 11/08/1995 105671012/105671012jR 09/14/1995 11/13/1995 Total Due to Medicaia REBEKAH [594075123 RAWLIN BYRON [595205023 812701543/812701543 SWEARINGEN QUELLA [353444031 08/30/1995 06/04/2002 TUE 14:03 09/20/1995 (TX/RX NO 9894] [002

Docket for Case No: 02-000588MPI