Petitioner: LAKE WALES MEDICAL CENTER
Respondent: AGENCY FOR HEALTH CARE ADMINISTRATION
Judges: DANIEL MANRY
Agency: Agency for Health Care Administration
Locations: Tallahassee, Florida
Filed: Jul. 22, 2002
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Monday, September 16, 2002.
Latest Update: Dec. 23, 2024
STATE OF FLORIDA act 1s C2
~" DIVISION OF ADMINISTRATIVE HEARINGS
LAKE WALES MEDICAL CENTER,
Petitioner,
v.
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION,
Respondent.
/
FINAL ORDER
THE PARTIES resolved all disputed issues and executed a Settlement
Agreement on Sopbwhe 27, 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.
DONE and ORDERED on this the aT day of S or , 2002,
in Tallahassee, Florida. -
Wel
fr Rhonda. 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:
Garnett Chisenhall, Esquire
Agency for Health Care
Administration
(Interoffice Mail)
W. David Watkins, Esquire
Watkins & Caleen, P.A.
1725 Mahan Drive, Suite 201
Tallahassee, FL 32317-5828
Daniel Manry
Administrative Law Judge
Division of Administrative Hearings
The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
Kelly Bennett, Assistant Bureau Chief, Medicaid Program Integrity
Debbie Lynn, Medicaid Program Integrity
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 1S day
of OGY, 2002.
_
Chante Tho rtessn
c*tealand 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
LAKE WALES MEDICAL CENTER,
Petitioner,
v. DOAH CASE NO.: 02-2905MPI
AHCA Provider NO.: 010166400
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION,
Respondent.
/
SETTLEMENT AGREEMENT
STATE OF FLORIDA, AGENCY FOR HEALTH CARE
ADMINISTRATION (“AHCA” or “the Agency”), and LAKE WALES MEDICAL
CENTER (“PROVIDER”), by and through the undersigned, hereby stipulate and
agree as follows:
1. PROVIDER is a Medicaid provider in the State of Florida.
2. In its Final Agency Audit Report issued on May 17, 2002 (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 $7,055.40.
3. In response to the Audit Letter, PROVIDER filed a petition for a
formal administrative hearing that was assigned Case No. 02-2905MPI.
4. Subsequent to the 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 $4,489.80. PROVIDER has agreed to pay
$4,489.80 as full and complete resolution of this matter.
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 agrees to pay to AHCA, within 30 days after
issuance of a Final Order, the sum of four thousand, four
hundred and eighty-nine dollars and eighty cents ($4,489.80) to
be made in one lump sum payment as full and complete
settlement of all claims in the proceedings before the Agency
and the Division of Administrative Hearings (Case No. 02-
2905MPI).
(c) 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.
(d) AHCA reserves the right to seek ‘enforcement of this
agreement by any legal means.
(e)
()
(g)
(h)
(i)
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. No. 01-1175-000.
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.
PROVIDER agrees that failure to make payment per the terms
of this agreement may result in the Agency pursuing all legal
means to enforce this agreement and may include a request for
attorney fees and all costs associated with the enforcement of
this agreement.
PROVIDER also agrees that failure to make payment per the
terms of this agreement may result in the Agency intercepting
its Medicaid payments until the balance due is repaid.
PROVIDER also agrees that failure to make payment per the
terms. of this agreement. may..result in sanctions, which may
include termination from the Medicaid program.
6. Payment shall be made payable to:
AGENCY FOR HEALTH CARE 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 Case Number, and shall reference the C.J. Number.
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. The parties agree to bear their own attorney’s fees and costs, if any,
except as expressly set forth in this agreement.
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 his signature alone binds
him to make the payment as set forth in this agreement. The parties further agree
that a facsimile or photocopy reproduction of this agreement with PROVIDER’S
signature alone shall be sufficient for the Agency to enforce the agreement and to
cancel the. hearing. in. this.. matter... Furthermore,.. PROVIDER agrees. that. upon.
receipt of the monies due and owing under this agreement, and upon PROVIDER’S
signature on the agreement, AHCA shall file a notice and motion. canceling the
hearing in this matter.
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. In the event PROVIDER breaches this Agreement, and enforcement
of this Agreement or recovery of damages for breach hereof is obtained by law or by
legal proceedings through an attorney at law, all costs of collection or enforcement,
including reasonable attorneys’ fees and costs, shall be paid by PROVIDER to
AHCA.
13. This Agreement constitutes the entire agreement between
PROVIDER and 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 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. law, 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 the Agency
should issue a Final Order which is consistent with the terms of this settlement, that
adopts this agreement and closes this matter.
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.
LAKE WALES MEDICAL CENTER
Petitioner/Provider
Dated: ? _ LY — ,2002
(signature)
By its: President
Dated: 7/#/oL , 2002
W. David Watkins, Esquire
Attorney for Petitioner
AGENCY-FOR HEALTH CARE
ADMINISTRATION
2727 Mahan Drive, Mail Stop #3
Tallahassee, FL 32308-5403
Inspector General
Valda Clark Christian
General Counsel
Sarreht ChrcocAl
Garnett Chisenhall
Assistant General Counsel
Dated: G/L? , 2002
Dated: thst vA , 2002
Dated: 9 / /€/ , 2002
= =
FLORA AGENCY FOR MEATH CARE ADM ISTRATICN <{23. SfOKe ¢
RHONDA M. MEDCWS, MO, FAAFP, SECAETARY
JEB BUSH, GOVERNOR
: pry —
May 17, 2002°
CERTIFIED MAIL ~ 7001 0320 0004 6781 6939
Provider No. 010166400 |
Ms. Phyllis Fitzwater
Director, Case Management ‘ R cE C F ; ;
Lake Wales Medical Center ?
410 South 11th Street I V Ep
Wales, FL, 33859
Lake Wales JUN 07 0000
MEDI
RE: FINAL AGENCY AUDIT REPORT Ie ROGRAM
CI. 01-1175-000
Dear Administrator.
Please refer to our provisional agency audit report dated August 15, 2001, wherein we made a
preliminary determination that you were overpaid $7,055.40, for services not covered by
Medicaid. This was based on retrospective medical record review by the Florida Medical
Quality Assurance, Inc. FMQAD, wherein it was determined that either the inpatient admission
or a portion of the length of stay was not medically necessary for Medicaid recipients. We have
received no response from you regarding this provisional agency audit letter. T erefore, the
agency has determined that you were overpaid $7,055.40 for claims that in whole or in part are
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 pursuarit 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. ; .
Pursuant to Florida Administrative Code 59G-4.150 (06/09/96) and Florida.Medicaid Hospital
Coverage and Limitations, January 1999, Appendix J, under Notice of Adverse Determination,
request for reconsideration of an initial adverse determination was to be made in writing to the
PRO within sixty calendar days after receipt of the denial notice. ‘Of the attached (see
Visit AHCA ontine ar
www fire. state flius
Exhibit |
2727 Mahau Drive * Mail Stop #6
Tallahassee, FL 32308
Lake Wales Medical Cevter
- Page 2
attachment) claim(s) reviewed, according to our records your hospital did not submit a timely
request for reconsideration by Florida Medical Quality Assurance, Inc. (FMQAI) on 0 claim(s),
Therefore, you waived your rights to an administrative hearing. If you have additional
documentation supporting a timely request for reconsideration, please submit within 21 days or
submit payment for these claims. Because of FMQAI’s termination of their Medicaid contract
with AHCA, adverse determinations that were dated for June thru September 1999 will be
granted hearing rights. For the remaining claim(s), you have the right to request a formal or
informal hearing pursuant to section 120.569, F.S. If a request for forma! 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 contain a concise
discussion of specific items in dispute. Additionally, you are hereby informed that if a 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 toa hearing.
It is important that a request for an informal hearing or a petition for a formal hearing be
sent only to the following address: .
Mr. Charles G. Ginn, Chief .
Medicaid Program Integrity **
Office of Inspector General
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. If a 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 the amount of the overpayment, please send your check in the amount shown
in the first paragraph of this letter. 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
Attention: Ms. Willie Bivens
P.O. Box 13749
Tallahassee, Florida 32317-3749
If payment is not received or arranged for, within 30 days of receipt of this letter, the Agency
may withhold Medicaid payments in accordance with the provisions of Chapter 409.913(26),
F.S. Questions regarding payment should be directed to Ms. Willie Bivens, Medicaid Accounts
Receivable, (850) 487-4298.
Lake Wales Medical C ‘er a
' Page 3
Any questions you may have about this matter should be directed to: Debbie Lynn, Human
Services Program Specialist, Agency for Health Care Administration, Medicaid Program
Integrity, 2727 Mahan Drive, MS #6, Tallahassee, Florida 32308, telephone (850) 488-8194,
Sincerely,
(ir fos
Mike Morton
AHCA Administrator
MVM:djl
Enclosures
ce: Medicaid Program Development
Area Medicaid Office
Willie Bivens
Medicaid Accounts Receivables
LAKE WALES MEDICAL CENTER
FMOA! Hospital Denials
Provider No. 0101664 00__
DENIAL
ADMIT DISCHARGE BEGIN DENIAL DENIAL OVERPAYMENT
RECIPIENT NO LAST NAME FIRST NAME DATE DATE DATE END DATE DAYS
ADVERSE DETERMINATION - (June - September 1999} LENGTH OF STAY/ADMISSION DENIAL
8106307115 Bousman David 12/01/1997 12/09/1997 12/07/1997 12/09/1997 2 $1,282.80
7630102453 Ganzalez Ciara ~ 01/13/1998 01/15/1998 01/13/1998 01/15/1998 2 $1,282.80
7545160444 Jacobs Thessalonina 03/01/1998 03/07/1998 03/06/1998 03/07/1998 1 $641.40
8113477977 Otiver Dorothy 03/05/1998 03/10/1998 02/08/1998 03/10/1998 2 $1,282.80
2116491134 Velez Eduardo 06/08/1998 06/11/1998 06/08/1998 06/11/1998 3 $1,924.20
RECONSIDERATION DETERMINATION
7349698208 Spradiey Linda 04/07/1998 04/09/1998 04/08/1998 04/09/1998 1 $641.40
ae
$7,055.40
FLORIDA AGENCY FOR HEALTH CARE ADMINGTRATION
JE8 BUSH, GOVERNOR FHONOA M, MEOOWS, MD, FAAFP, SECRETARY
PLEASE INCLUDE THIS REMITTAN CE FORM WITH YOUR PAYMENT
Date: May 17, 2002
C.I.No.: 01-1175-000
Provider No. 010166400
Name of Entity: Lake Wales Medical Center
Address: 410 South 11th Street
Lake Wales, FL, 33859
Payment Due to the Agency for Health Care Administration:
Managed Care Fine
Notice of Intent- MC&HQ
Final Order - MC&HQ $7,055.40 Medicaid Overpayment
Administrative Complaint - MC&HQ Medicaid Fine
Other Investigative Cost
eee
SEND PAYMENT TO:
Agency for Health Care Administration
Medicaid Accounts Receivable
Attention: Willie Bivens
P. O. Box 13749
Tallahassee, Florida 32317-3749
Amount Enclosed:
Attomey: NA
Preparer: MPI, djl
Investigator: Debbie Lynn,
Human Services Program Specialist
Visit AHCA online at
2727 Mahan Drive + Mail Stop #6
www. fdhestateflius
Tallahassee, FL 32308
CERTIFIED MAIL RECEIPT
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} PS Form 3800, Janvary 2001 tee tte us * +: See Revetse fot tnstitetions
SENDER: COMPLETE THis SECTION
*® Compiete items 1, 2, and 3, Also complete
item 4 if Restricted Delivery is desired.
™ Print your name and address on the reverse
se “Sat we can return the card to you,
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Or uni the front if Space permils,
1. Articte Addressed to: D -
Phyllis Fitzwater C
Director, Case Mahagement
Lake Wales Medical Center
410 South 11" Street
Lake Wales, FL 33859
0. Is delivery address Gifterent trom item 17 CJ Yes
W YES, enter delivery address below: ONo
3. Service Type
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4. Resticted Oelivery? (Extra Fee) OD Yes
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Domestic Return Receipt
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3 Form 3811, August 2001
Docket for Case No: 02-002905MPI
Issue Date |
Proceedings |
Oct. 15, 2002 |
Final Order filed.
|
Sep. 16, 2002 |
Order Closing File issued. CASE CLOSED.
|
Sep. 10, 2002 |
Joint Motion to Relinquish Jurisdiction (filed by Respondent via facsimile).
|
Aug. 09, 2002 |
Amended Notice of Hearing issued. (hearing set for September 23 and 24, 2002; 9:30 a.m.; Tallahassee, FL, amended as to Date and Location).
|
Aug. 07, 2002 |
Notice of Hearing issued (hearing set for October 17, 2002; 9:30 a.m.; Bartow, FL).
|
Jul. 29, 2002 |
Joint Response to Initial Order (filed via facsimile).
|
Jul. 23, 2002 |
Notice of Service of Interrogatories & Request for Production of Documents (filed by Respondent via facsimile).
|
Jul. 22, 2002 |
Final Agency Audit Report filed.
|
Jul. 22, 2002 |
Petition for Formal Administrative Hearing filed.
|
Jul. 22, 2002 |
Notice (of Agency referral) filed.
|
Jul. 22, 2002 |
Initial Order issued.
|