STATE OF FLORIDA Agee’ CLERK AGENCY FOR HEALTH CARE ADMINISTRATION a . mags SEP 30 ATE \b GREYNOLDS PARK MANOR, INC, PROVIDER NO. 020044100 Petitioner, AUDIT C1. NO. 05-2846-000 vs. CASE NO. 05-2456MPI AGENCY FOR HEALTH CARE RENDITION a -05- -S-| ADMINISTRATION, NO.: AHCA-05-O540) -S-MDO Respondent. ca [awe] / | wu FINAL ORDER U ri a Settlement THE PARTIES resolved all disputed issues and executed Agreement. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. raed DONE and ORDERED on this the 24 day of _26°/7&H-_, 2005, in Tallahassee, Florida. tie Cae Lee POM 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: Debora Fridie, Esquire Agency for Health Care Administration (Interoffice Mail) Martin E, Casper, M.P.H. Greynolds Park Manor, Inc. 17400 West Dixie Highway North Miami Beach, Florida 33160 (U.S. Mail) , Florence Snyder Rivas Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Tim Byrnes, Chief, Medicaid Program Integrity Vicki Remick, 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 2” day of Sspfeber , 2005. 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 GREYNOLDS PARK MANOR, INC. Petitioner, DOAH Case No. 05-2456MPI C.I. NO. 05-2846-000 vs. AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / STIPULATION AND AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and GREYNOLDS PARK MANOR, 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, operating under provider number 020044100. 3. In its Final Agency Audit Report C.I. No. 05-2846-000 (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 repayment of a Medicaid overpayment in the amount of $7,292.28. In response, Page 1 of 8 -Case No: 05-2456MPI C.I. No. 05-2846-000 Greynolds Park Manor, Inc. vs. AHCA * Stipulation and Agreement PROVIDER petitioned for a formal administrative hearing with the Division of Administrative Hearings, Case No. 05-2456MPI. After the PROVIDER requested a formal hearing, AHCA reviewed documentation that was previously unavailable to them. Based upon that review, AHCA adjusted the Medicaid overpayment to $3,766.77. 4. PROVIDER agreed to pay the adjusted Medicaid overpayment amount of $3,766.77 plus some of AHCA’s investigative costs, in the amount of $1,500.00, for a total repayment amount of $5,266.77. 5. In order to resolve this matter without further administrative proceedings, PROVIDER and AHCA expressly agree as follows: (a) AHCA will accept the total repayment amount set forth in paragraphs 3 and 4 above herein as settlement of the overpayment issues arising from the MPI review cited in paragraph 3 above. (b) Within thirty (30) days of issuance of the Final Order, PROVIDER agrees to make a single payment to AHCA of Five Thousand Two Hundred Sixty-Six and 77/100 Dollars ($5,266.77). O£ this amount, $3,766.77 is to reimburse the Medicaid program for overpayments, and $1,500.00 is to reimburse AHCA for Page 2 of 8 “Case No: 05-2456MPI C.I. No. 05-2846-000 Greynolds Park Manor, Inc. vs. AHCA ” Stipulation and Agreement (c) (d) (e) (f£) investigative costs. AHCA retains the right to perform a 6-month follow-up review. PROVIDER is responsible for ensuring timely delivery of the payment. 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. PROVIDER and AHCA agree that full payment as set forth above will resolve and settle this case completely and release all parties from all liabilities arising from the findings in the audit referenced as C.I. 04-2114-000. 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 to fully cooperate with any follow up reviews conducted by the Agency. Payment shall be made to: AGENCY FOR HEALTHCARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, Florida 32317-3749 Page 3 of 8 - Case No: 05-2456MPI C.I. No. 05-2846-000 Greynolds Park Manor, Inc. vs. AHCA * Stipulation and Agreement And payment shall clearly indicate that it is per a stipulation and agreement and shall reference the C.I. Number and the Provider Number . 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 Stipulation and Agreement under the laws of the State of Florida, the Rules of the Medicaid Program, and all other applicable rules and regulations. 8. Except as specifically set forth in paragraphs 3, 4, and 5(b) above with regard to AHCA’s investigative costs, the parties agree to bear their own attorney’s fees and other costs, if any. 9. 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 its signature alone binds PROVIDER to make the payment as set forth in this agreement. PROVIDER shall furnish the actual signed Stipulation Page 4 of 8 -Case No: 05-2456MPI C.I. No. 05-2846-000 Greynolds Park Manor, Inc. vs. AHCA * Stipulation and Agreement and Agreement to AHCA; however a facsimile copy shall be sufficient to enable AHCA to cancel a hearing scheduled in this case. 10. 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. 11. 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. 12. 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. This Stipulation and Agreement does not Page 5 of 8 - Case No: 05-2456MPI C.I. No. 05-2846-000 Greynolds Park Manor, Inc. vs. AHCA * Stipulation and Agreement constitute an admission of wrongdoing or error by either party with respect to this case or any other matter. However, the parties believe that this matter should be resolved because the parties have agreed to the terms contained within this agreement. 13, PROVIDER expressly waives in this matter its right to any hearing pursuant to §§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 stipulation and agreement and that adopts this agreement and closes this matter. 14. Provider does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter, C.I. No. 05-2846-000, and AHCA’s actions herein, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative Page 6 of 8 . Case No: 05-2456MPI /-C.r. No. 05-2846-000 Greynolds Park Manor, Inc. vs. AHCA Stipulation and Agreement forum, including any claims arising out of this agreement, by or on behalf of Provider. 15. This Stipulation and 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 Stipulation and 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 Stipulation and Agreement. 17. This Stipulation and 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 in this Stipulation and Agreement. 19. This Stipulation and Agreement shall be-in full force and effect upon execution by the respective parties in counterpart. Page 7 of 8 . Case No: 05-2456MPI -C.I. No. 05-2846-000 Greynolds Park Manor, Inc. vs. AHCA * Stipulation and Agreement PETITIONER GREYNOLDS PARK MANOR, INC. BY: MECC gs Dated: gle] 0S , 2005 MATIN E- CaSfeR Execmue Di REcTo, (Printed name and title) AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 BY: pated: 9-Z£ ,2005 Inspector General OC Wetter Cr larcor Dated: pptewcbey, 2005 CHRISTA CALAMAS General Counsel BY: E. FRIDIE Assistant General Counsel BY: Gia. © in sr Dated: _\ seoten ber 7 ,2005 DEBO Page 8 of 8

Docket for Case No: 05-002456MPI