cg een FILED STATE OF FLORIDA SEP 52 03 DIVISION OF ADMINISTRATIVE HEARINGS Baer GET WELL PHARMACY & MEDICAL SERVICES, INC. d/b/a/ GET WELL 4 ised : PHARMACY & MEDICAL SERVICES, oe Snl-Clesd = 5 & 2 Petitioner, DOAH CASE NO: 03-2147MPI v. JUDGE: Stuart M. Lerner provider no.: 021718200 AGENCY FOR HEALTH CARE audit no.: C.I. 00-1049-000-3 ADMINISTRATION, Rerdrhon Noi AHO ODA -D-M Respondent. / 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 attached settlement agreement. Based on the foregoing, this file is CLOSED. DONE and ORDERED on this the 99 aay of Ory ak , 2003, in Tallahassee, Florida. pM URT ILERK ee 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) William M. Furlow, Esquire Katz, Kutter, Alderman, Bryant & Yon, P.A. Post Office Box 1877 Tallahassee, Florida 32302-1877 (U.S. Mail) Stuart M. Lerner Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Tim Byrnes, Chief, Medicaid Program Integrity Kathryn Holland, Medicaid Program Integrity John Hoover, 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 “Reday a of Oras bs) 2003. aamnata! Ge) Lys »pCen, n @lealand ec Esquire Ope 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 GET WELL PHARMACY & MEDICAL SERVICES, INC. d/b/a/ GET WELL PHARMACY & MEDICAL SERVICES, Petitioner, DOAH CASE NO: 03-2147MPI vy. JUDGE: Stuart M. Lerner provider no.: 021718200 AGENCY FOR HEALTH CARE audit no.: C.I. 00-1049-000-3 ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and Get Well Pharmacy & Medical Services, Inc. d/b/a Get Well Pharmacy & Medical Services (“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 021718200 and was a provider during the audit period. 3. In its final agency audit report (final agency action) dated April 6, 2001, AHCA notified PROVIDER that review of Medicaid claims performed by Medicaid Program Integrity (MPI), Office of the Inspector General, indicated that certain claims, in whole or in part, were not covered by Medicaid. The Agency sought recoapment of this overpayment, in the amount of ra Get Well Pharmacy & Medical Services, Inc. d/b/a/ Get Well Pharmacy & Medical Services Settlement Agreement $662,812.98. PROVIDER then filed a petition for a formal administrative hearing and then withdrew it, pending review of additional documentation. The supplemental review resulted in an adjustment to the overpayment to $281,509.43, and then a further adjustment to $255,623.09. Despite adjustments, the parties were unable to settle the matter and the case was re-opened at DOAH and assigned DOAH case number 03-2147MPI. 4. During pre-trial evidence exchanges, the Agency evaluated additional documentation concerning the drug inventory issues. As a result, AHCA and the PROVIDER agree that the underlying facts of this matter show the integrity of the Medicaid program is best preserved by the resolution set forth below. 5. In order-to resolve this matter without further administrative proceedings, PROVIDER and the AHCA expressly agree as follows: (1) AHCA agrees to accept the payment set forth herein in settlement of the overpayment issues arising from the MPI review. (2) Within thirty days of receipt of the final order, PROVIDER agrees to make a lump sum payment of two hundred fifty thousand dollars ($250,000.00) in full and complete settlement of all claims in the proceedings before the Division of Administrative Hearings (DOAH Case No. 03-2147MPI). AHCA retains the right to perform a 6-month follow- up review. (3) 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.1. 00-1049- 000-3. Get Well Pharmacy & Medical Services, Inc. d/b/a/ Get Well Pharmacy & Medical Services 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 shall be in Leon County, Florida. 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 Get Well Pharmacy & Medical Services, Inc. d/b/a/ Get Well Pharmacy & Medical Services Settlement Agreement 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 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. 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. Jul-25-2003 10:24am — From- KATZ KUTTER 8502240781 T-525 P.006/006 = F~348 Get Well Pharmacy & Medical Services, Inc. d/b/a/ Get Well Pharmacy & Medical Services Settlement Agreement 20. This Agreement shall-be in full force and effect upon execution by the respective parties in counterpart. GET WELL PHARMACY & MEDICAL SERVICES, INC. d/b/a/ GET WELL PHARMAGY & MEDICAL SERVICES om Dated: apache ? , 2003 hog With ITS: AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 Inspector General 7 “ . Dated: , / 2003 . Valda Clark Christian Generaf Counsel L. William Porter I Assistant General Counsel H:\USERSIPROFESSIONALSIBILLFIWILLOUGHBYISETTLEMENT AGREEMENT.DOC O56 03s x : : 5 eoL OL: 04 BSe¢5L (£543 Olt WOLL Coan STATE OF FLORIDA CA CsC«S LL GENCY FOR HEALTH CARE ADMINISTRATION Ot Hay 2} UEB BUSH, GOVERNOR - - RUBEN J. KING-SHAW, JR., SECRETARY ; , A elVISIOR | ; AOMIMIS TE April 6, 2001 HEARIN, CERTIFIED MAIL - RETURN RECEIPT NO. > 7000 0600 0023 5447 9436 Provider No. 0217182 00 Get Well Pharmacy & Medical Services, Inc. RE CE | V E D: Fort Lauderdale, Florida 33309 MAY 0 4 200) RE: FINAL AGENCY AUDIT REPORT MEDICAID PROGRAM " G.T. No. 00-1049-000-3/H/KNE __ANTEGRITY pear Ms. Willoughby: Pde BEES an on-site audit of your pharmacy was initiated on July 10, - 2000. The Florida Medicaid Program through the Agency for Health Care Administration has determined that you have been overbaid $662,812.98 in connection with claims submitted to Medicaid during the audit period(s) specified. This conclusion is supported by the audit results. . This review and the determinations were made in accordance with - the provisions of Chapter 409, Florida Statutes (F.S.), and Chapter 59G, Florida Administrative Code (F.A.C.). In applying for Medicaid reimbursement, providers are required to follow the applicable statutes, rules, Medicaid provider handbooks, statements of Medicaid policy, and, federal laws and regulations. Medicaid cannot properly pay for claims that do not meet Medicaid requirements. When a provider receives payment in violation of these provisions, those funds must be repaid. REVIEW DETERMINATIONS The audit included a statistical analysis of a random sampling, with the results applied to the random sample universe of claims submitted during the audit period. The audit period for this review was from August 16, 1999, through May 24, 2000. This review identified an overpayment of $20,656.15. The actual overpayment Visit AHCA Ontine ar 2727 Mahan Drive © Muil Stop #6 www fdhe.state flus Tallahassee, FL 32308 woe usr LUE, a 'S WOOL ULioy po434. 62523 Ob? WELL PreaKMAcY FA wg Jacqueline L. Willoughby, President Get Well Pharmacy & Medical Services, Inc. d/b/a Get Well Pharmacy & Medical Services Page 2 : he was calculated using a procedure that thas been proven valid and is deemed admissible in administrative and law courts as evidence of the overpayment. Attached are the overpayment calculations, a summary of documented discrepancies, and an itemized listing of iscrepancies noted in the review of the random sample. The audit also included a comparison of your lawful documented product acquisitions with your paid Medicaid claims. The audit - period for this review was from August 16, 1999, through May 24, 2000. The drug quantity billed to Medicaid, in many instances, exceeded the quantity available to dispense to Medicaid recipients? 0. This review identified an overpayment 9o 62,812 Attached are the overpayment calculations "5 mee Accordingly, we have determined at this time that you have been overpaid by the Medicaid program in the amount of $662,812.98. If you accept or concur with these findings, please send your check in the amount of $662,812.98, for the identified overpayment, made payable to the Florida Agency for Health Care - Administration, to: : ETERS STOLE ar 6 9 Agency for Health Care Administration Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida © 32317~3749 (Note: The check must be payable to the Florida Agency for Health Care Administration, not to any employee of the... agency.) To ensure proper exredit, be sure that your provider number is shown on your check. Questions» regarding payment should be directed to Ms. Willie Bivens at (850) 487-4298. . : You have the right to request a formal or informal hearing pursuant to section 120.569, F.S- Tf a petition for formal hearing is made, the petition must be made in compliance with rule section 28-106.201, F.A.c. Please note that rule section 28-106.201(2), F.A.C., 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. RECEIVED MAY’ 0 4 2001 MEDICAID PROGRAM INTEGRITY ee ee re ee eae Sor WELL CNAnmawY rH ta Jacqueline L. Willoughby, President Get Well Pharmacy & Medical Services, Inc. d/b/a Get Well Pharmacy & Medical Services Page 3 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 the Inspector General noe \ Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #.. 622.000: ee Tallahassee, Florida 32308-5403 Do not send requests or petitions to any other address. Ifa hearing request is not received within 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 21-day period. Any questions that you may have regarding this matter should be directed to: Ms. Kathryn N. Holland, Senior Pharmacist, Agency for Health Care Administration, Medicaid Program Integrity, . Office of the Inspector General, 2727 Mahan Drive, Mail Stop #6, Tallahassee, Florida 32308-5403, telephone number (850), 922~. Sincerely, b psth— D. Kenneth Yon Program Administrator Medicaid Program Integrity DKY/knh Attachment (s) cc: Medicaid Program Integrity Administrative Section Medicaid Accounts Receivable, Attn: Willie Bivens Heritage Information Systems, Inc. Medicaid Program Development Area Medicaid Office RECEIVED MAY 0 4 200) MEDICAID PROGRAM INTEGRITY Q:\P-getwellpharmacy , ‘ | esr ua e.uu, OL Ut Buys. 6 s4oza ctl Well Fr ; os . 694 HARMAGY PAGE 25 Provider Name: Get Well Pharmacy and Medical Provider Number: 021718200 Dates of Service: 8/16/99 - 5/24/00 Investigator; Heritage Information Systems, Inc. Prorated Invoice Analysis Results (Calevlation of Overcharges: 8/16/99 - 5/24/00) Purchases | Shoriage | Cost/Unit 2.021 [1,380 1,073) 18 33.00 75.0o| 3.050] "3.07A| dB Te] _—_—892] “1687 NS 0 eS ee ee a a Total Overcharge 3 16,228.63 ele n ay i} Sia ho) 255] Basra] 60) 1.70 FFimestntgsrGM |__| Tom mm] TT] Viracept 250 MG 2,100] 3.030] _“6o.31%] 2.520) 1,747] 53 $709.53 TOTAL|S 662,812.98 () Because the pharmacy wulization reparts showed 3 total units billed Ggure that was tess than the mumber of units billed to Medicaid alone, 100% of purcbases were. attributed to Medicaid claims. . . we : . , : , . fy CORR ENE ET Eyre oe RECEIVED MAY 0 4 2001 MEDICAID PROGRAM INTEGRITY O3/ 03/4001 OLeU4 BI44L (23235 I=) é hl WELL PHARMACY PAGE 39. . Page: J FLORIDA MEDICAID 12/0472000; 14:20:12 _ Series: 99 - 44 | Pharmacy Andit - Fina} Report Farm RPT . Audit Date: 07/10/2000 Audit Time Period: 08/16/1999 - 05/24/2000 Pharmacy: Get Well Pharmacy Address: 2962 North West 60th Street Avditors: Mack Tripodi - | Fort Lauderdale, FL 333090000 Ron Skinner, CPA - . . Billy Thornas, R.Ph Provider #: 021718200FL ; Maria Concepcion $e L Description of Claim Samples & Overall Findings: #of Claims § Paid to Phey A. Total Utilization During Audit Time Period: 2,529 1,981,246,.87 B. Total Judgmental Sample: -- 2 ~~: - cee Wa vs C. Discrepant Claims in Judgmental Sample: * oo D, Documented Sanctions in Judgmental Sample: ; E. Total Random Sample: ” 250 0... 192,074.42 F. Discrepant Claims in Random Sample: * 45 18,156.28 G, Documented Sanctions in Random Sample: 43 11,582.59 H. Random Sample Average Sanction Amount ("G" divided by "E"): : _ 46.21036 1. Random Sample Universe ("A" minus "B"): 2,329 ee J. Extrapolated Overcharges ("H” multiplied by "I"): 107,623.92 K. Total Calculated Overpayment ("D" plus ‘J"): L. Tota) Recommended Recoveries: : (Includes 95% Ont-Sided Lower Confidence Limit of Extrapolated Random Sample Plus Judgmental Findings, any, from ling "D") = * 20,656.15 Il, Summary of Actual Discrepancies Documented —_(6e# Section IV for claimelevel derail) Code Discrepancy Description Original hard-copy preseription cannot be found on file during the audit. CF UR The number of refills billed and pals 10 the pharmacy exceeds the number authorized by prescriber, Refills are dispensed without documented authorization from the prescriber. Quantity paid exceeds the quantity authorized by the prescriber. DS , The days svpply value submitmed by the pharmacy is not consistent with the quantity and directions. A pharmacy submits a claim for a medication that is different fom the medication dispensed to the patient, or ordered by the prescriber. NPNA _ The hard-copy prescription contains no patient name. me DEAcen The hoed-copy. prescription does not contain a DEA number (if tequired), WPB The patient identified on a hard-copy prescription is not the patient identified on the paid ¢laim. WMD The claim for the prescription contains an incorrect prescriber license number. MISC “Assessed when an issue has been cited that is not listed above. Follow up research may be Tequired, * Some discrepancies may not call for monetary sanctions, These are noicd to the pharmacy for educational purposcs only. Since some claims have multiple discrepancies, individual claims may be Usted twice, thereforg may excecd sanctions listed in section I. RECEIVED “may 04 2001 MEDICAID PROGRAM INTEGAITY # Discrepaocies 1 TST re eee vacuy ee aoe) bhi WELL PHARMACY PAGE a7 oe FLORIDA MEDICAID 12/04/2000: 11:20:13 Series: 99 - 44 Pharmacy Audit - Fina! Report Form RPT3 Provider #; 021718200FL Pharmacy: Get Well Pharmacy | m 7 a Til. Comments / Notes: RECEIVED MY 0.4 200) MEDICAID PROGRAM. INTEGRITY

Docket for Case No: 03-002147MPI