STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS AGENCY FOR HEALTH CARE ADMINISTRATION Petitioner, vs CASE NO. 06-0377MPI C.I. NO. 00-0163-000 » KOMALA N. BHUSHAN, M.D., ee Respondent. FINAL ORDER Zea t= AVA MOU THE PARTIES resolved all disputed issues and executed a “Stipulation and Agreement”, which is incorporated by reference. The parties are directed to comply with the terms of the “Stipulation and Agreement”. Based on the foregoing, this proceeding is CLOSED. m it DONE and ORDERED on this the 5446 ~ Leon County, Florida. day of , 2006, in Tallahassee, Li ff nian Levine, Secretary Agency for Health Care Administration CASE NO. 06-0377MPI C.I. NO. 00-0163-000 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: Komala N. Bhushan, M.D. P.O. Box 316 Lecanto, Florida 34460 Debora Fridie, Esquire Attorney for Agency Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building 3, Mail Stop 3 Tallahassee, Florida 32308 The Honorable Ella Jane P. Davis Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Medicaid Program Integrity, MS #6 CASE NO. 06-0377MPI C.I. NO. 00-0163-000 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has been furnished to the above named addressees by U.S. Mail on this the 4B” day of xfer , 2006. FSS Agency Clerk . ve 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 HEARINGS ' ZUUb MAY -] A |}: Fo AGENCY FOR HEALTH CARE AGHINIra A ADMINISTRATION MINIS TRATIVE a HEARINGS Petitioner, CASE NO: 06-0377MPI 378206900 vs. 00-0163-000 KOMALA N. BHUSHAN, M.D. Respondent. / STIPULATION AND AGREEMENT The Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (a/k/a and hereinafter “AHCA” or “the Agency”), and the Respondent, KOMALA N. BHUSHAN, M.D., (a/k/a and hereinafter “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 3782069-00. RiGEny MAR 21 2096 | Page 1 of 9 Case No. 06-0377MPI C.I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement 3. In its Final Agency Audit Reports C.I. No 00-0163~-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 an overpayment in the amount of $147,739.20. In response, PROVIDER petitioned for an informal administrative hearing. The informal hearing officer entered an order transferring the case to the Division of Administrative Hearings after finding that there were disputed issues of material fact. After the provider requested an administrative hearing, AHCA reviewed documentation that was previously unavailable to them. Based upon that review, AHCA adjusted the overpayment to $142,954.83. PROVIDER has agreed to pay the overpayment plus some of AHCA'’s investigative costs in the amount of $1,000.00, for a total repayment amount of $143,954.83, 4. In order to resolve this matter without further administrative proceedings, PROVIDER and AHCA expressly agree as follows: (a) AHCA will accept the payment set forth herein as a complete resolution of the overpayment issues arising from the MPI review cited in paragraph 3 above. Page 2 of 9 Case No. 06-0377MPI C.1I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement (b) PROVIDER agrees to pay the adjusted overpayment amount of One Hundred Forty-Two Nine Hundred Fifty-Four and 83/100 Dollars ($142,954.83) plus One Thousand Dollars ($1,000.00) in costs to AHCA, for a total amount of One Hundred Forty-Three Nine Hundred Fifty-Four and 83/100 Dollars ($143,954.83), to be paid in twelve (12) equal installments of $12,655.92, each, which amounts include principal and statutory interest. By no later than March 31, 2006, PROVIDER agrees to make the first installment payment to AHCA of Twelve Thousand Six Hundred Fifty-Five and 92/100 Dollars ($12,655.92). PROVIDER shall pay each subsequent installment payment on the balance due within thirty (30) days of the due date of the previous payment until the overpayment amount is paid in full, by no dater than February 28, 2007. In the event that the»: PROVIDER pays the balance due early, there is no penalty for early payment. The outstanding balance of $143,954.83 will accrue interest at the rate as set forth in Section 409.913(25) (c), Florida Statutes, until the balance is paid in full. AHCA retains the right to perform a 6-month follow-up review. Page 3 of 9 Case No. 06-0377MPI C.I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement (c) (e) 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. Number 00-0163-000. 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 And payment shall clearly indicate that it is per a stipulation and agreement and shall reference the C.I. Number and the Provider Number. Page 4 of 3 ‘ Case No. 06-0377MPI C.I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement 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. 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 and Agreement to AHCA; however a facsimile copy shall be sufficient to enable AHCA to cancel a hearing scheduled in this case. Page 5 of 9 Case No. 06-0377MPI * C.2I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement 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 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 Page 6 of 9 Case No. 06-0377MPI C.I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement parties have agreed to the terms contained within this agreement. 13. 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 Stipulation and Agreement, 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. 00-0163-000, 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 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 Page 7 of 9 D Case No. 06-0377MPI C.I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement 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. RESPONDENT KOMALA N. BHUSHAN, M.D. Ne— BY: L—— (Printed name and title) Date: 2 - | S_ , 200 Ob F Page 8 of 9 ! Case No. 06-0377MPI C.I. No. 00-0163-000 AHCA v. Komala Bhushan, M.D. Stipulation and Agreement AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308-5403 BY: fens. JAMES’“D. BOYD , Inspector General Date: Y- th , 2006 CHRISTA CALAMAS General Counsel Date: ten | 10 , 200 © ‘ a (Pipna 6 Fou < so aA DEBORA E. FRIDIE Assistant General Counsel Date: (Narca 2 5, 1 200 (0 Page 9 of 9 (Page 1 of 10) JE5 BUSH, GOVERNOR ALAN LEVINE, SECRETARY CERTIFIED MAIL — RETURN RECEIPT No. 7001 0360 0003 3823 0886 February 10, 2005 mB . . 7 te 3 Provider No: 3782069-p0 Sa Bam aa2 9 Komala N, Bhushan, MD Ce wh ~o rex) Nature Coast Pediatric Inc. : 222 a oe 512 N. Lecanto Hwy. 491 lak moOos Lacanto, FL 34460 wn cd a mo Jn Reply Refer to Ol- OSTT mer FINAL AGENCY AUDIT REPORT “ C.L No. 00-0163-000 Dear Provider: The Agency for Health Care Administration, Office of Medicaid Program Integrity has Completed a review of claims for Medicaid reimbursement for dates of service during the Period September 1, 2000, through September 30, 2002. A Provisional agency andit Teport dated ri Visit AHCA online at Wve fel C.state situs 2727 Mahan Drive © Mai} Stop 46 Tallahassee, FL 32308 (Page 2 of 40) Komala N. Bhushan, MD Page 2 attached, listing the claims that are affected by this determination, REVIEW DETERMINATIONS ST DETERMINATION(S) Medicaid policy Tequires services performed be medically necessary for the diagnosis and treatment of an iliness, You billed and received payments for services for which the medical Tecords, when reviewed by a Medicaid physician consultant, indicated that the services provided did not meet the Medicaid criteria for medical Recessity. The claims which Were considered medically unnecessary were disallowed and the money you were paid for these procedures is Considered an overpayment, OVERPAYMENT CALCULATION OVERPAYMENT CALCULATION {Page 3 of 10) Komala N. Bhushan, MD Page 3 If you are currently involved ina bankruptcy, you should notify your attorney immediately and Provide a copy of this letter for them. Please advise your attomey that we need the following Medicaid Accounts Receivable, (850) 488-5869, To ensure proper credit, be certain your Provider number and the audit number (C.I. 01-03 63-000) are shown on your check. Please mail payment to: Agency for Health Care Administratio; Medicaid Accounts Receivable... ° P.O. Box 13749 Tallahassee, Florida 32317-3 749 the petition must be received by the Agency within twenty-one (21) days of receipt of this letter, For more information regarding your hearing and mediation rights, please see the attached Notice of Administrative Hearing and Mediation Rights, Questions should be directed to: Jill Smith, Medical/Health Care Program Analyst, Agency Sincerely, oe tah. Ellen Williams AHCA Administrator EW/iS/itd Enclosure(s) Page 4 of 10) Komala N. Bhushan, MD Page 4 NOTICE OF ADMINISTRATIVE HEARING AND MEDIATION RIGHTS Strative hearing pursuant to Section 120.57(1), Florida Statutes. If you do not dispute the facts stated in the FAAR, but believe there are additional reasons to grant the relief you seek, you inay request an informal administrative hearing pursuant to Section 120.57(2), Florida Statutes, Additionally, pursuant to 7 : . 1 received by the Assistant Bureau Chief ‘by 5:00 P.M. no Iater than 21 days after you received the FAAR. The address for filing the written Tequest for an administrative hearing is: “"Tallatiassee, Florida 32308 The request must be legible, on 8 4 by 11-inch white paper, and contain: 1. Your name, address, telephone number, any Agency identifying number on the FAAR, if known, and name, address, and telephone number of your representative, if any: . 2. An explanation of how your substantial interests will be affected by the action described in the F. ; 3. A statement of when and low you received the FAAR; . 4. For ayequest for formal hearing, a statement of all disputed issues of material fact; 3. For a request for formal hearing, a concise statement of the ultimate facts alleged, as well as the rules and statutes which entitle you to relief: 6. For a request for formal hearing, whether you request mediation, if it is available; 7. 8 + Fora request for informal hearing, what basis support an adjustment to the amount owed be shared equally by you and the Agency, Ifa written request for an administrative hearing is not timely received you will have waived your right to have the intended action Teviewed pursuant to Chapter 120, Florida Statutes, and the action set forth in the FAAR shall be conclusive and final. (Page 5 of 10) OVERPAYMENT CALCULATION USING CLUSTER SAMPLING PROVIDER: . Komala nN. Bhushan mp c.r. NUMBER : 00-0163-000 CONFIDENCE LEVEL: 95 { VALUE: 1.699126 FILE NO.: 412 The file name is CLUS ( 11 ) NO. OF RECIPIENTS IN POPULATION: 2,547 NO. OF RECIPIENTS IN Sampne: . TOTAL PAYMENTS IN POPULATION: $915,281.46 NO. OF CLAIMS IN POPULATION. 24,497 RECIP. NO. CLAIMS § Toray, DOLLAR, § OVERPAYMENT 1 1 71.48.00. 23.11 2 2 115.16 15.22 3 2 117.39 37.81 4 2 |. 94.69 9 lag 5. 19 922,05 . . 254.85 6 1 71.48 0.00 7 a 232.71 - 114.65 8 14 479.88 150.48 a) 9 359.19 108.35 10 6 257.30 "83.14 11 12 559.62 ; 68.03 12 2 97.21 65.90 13 2 _ 79.12 37.81 14 6 173.10 50.17 15 2 92.84 . 30.22 16 6 304.17 ” 86.05 . 17 29 867.29 . 194.33 . 1a 29 1,112.92 203.45" 19: 35 1,375.82 371.02 20 21 925.36 276,84 ' 21 37. 1,303.91 305.56 22 20 378.74 90.66 23 2 55.68 0.00 24 40 1,195.96 . 143.36 25 29 758.44 97.44 26 5 213.22 ~ 419530 27 2s 773.44 134.53 28 9 305.62 0.00 29 12 406.75 42.00 30 1 48.27 16.96 TOTAL, 374 $13,748.78 . $3,021.17 USING OVERPAYMENT PER CLAIM METHOD THE OVERPAYMENT PER SAMPLE CLAIM Is : $7.99251318 THE POINT ESTIMATE OF THE OVERPAYMENT rs $195,792.60 THE VARIANCE OF THE OVERPAYMENT Ig $795,628,056.25 THE STANDARD ERROR OF THE OVERPAYMENT 7g $28,281.23 THE HALE CONFIDENCE INTERVAL Ig $48,053.40 (Page 6 of 10) THE OVERPAYMENT AT THE 95 % CONFIDENCE LEVEL Is $147,739.20 vss 02-09-2005 rage ¢ of 10} Corrective Action Plan — Acknowledgement Statement A “corrective action plan” is the process or Plan by which the provider will ensure future compliance with state and federal Medicaid laws, Tules, provisions, handbooks, acknowledges a requirement to adhere to the specific State and federal Medicaid Jaws, Tules, provisions, handbooks, and policies that are at issue in the FAAR; and, must be signed by the provider or its President, director, or owner. The acknowledgement statement is due to the Agancy within 30 days of the issuance of this FAAR. Please sipn the enclosed statement and return it to: Jill Smith, Medical/Health Care Program Analyst Agency for Health Care Administration Medicaid Program Integrity 2727 Mahan Drive, Mail Stop # 6 Tallahassee, FI, 32308-5403 Phone (850) 921-1802 Facsimile (850) 410-1972 Failure to comply with the requirements set forth above may result in the imposition of additional sanctions, which may include monetary fines, suspension, or termination from the Medicaid Program, Corrective action plan — Acknowledgement Statement Final Agency Audit Report dated February 10, 2005 C.L. 00-0163-000 {rage 4 of 10) PROVIDER ACKNOWLEDGEMENT STATEMENT NL DGEMENT STATEMENT ou behalf of Komala N. Bhushan, MD, (insert printed fall mame here) , 8 Medicaid provider operating under provider number 3782069-00, do hereby acknowledge the obligation of Komala N. Bhushan, MD, to adhere to State and federal Medicaid laws, rules, Provisions, handbooks, and policies. Additionally, Komala N. Bhushan, MD, acknowledges that Medicaid policy requires: 2) scheduling frequency for follow-up or other Services; progress Teports, treatment rendered; the author of each (medical record) entry must be identified and must authenticate his or her entry by signature, written initials or computer entry; dates of service; and referrals to other services. To be reimbursed for a ‘Child Health Check-Up, the Provider must be enralled in Medicaid with a Child Health Check-Up Category of service, The Screening Toust meet al! the Tequirements contained-in the Florida Medicaid Child Health Check-Up Coverage and Limitations Handbook,- To be reimbursed by Medicaid, the provider must assess and document in the child's medical record all the required components of a Child Health Check- objective testing, when required; laboratory tests including blood lead testing, when required; appropriate immunizations: health education, anticipatory gnidance; diagnosis and treatment; referral and follow-up, as appropriate. Corrective action plan ~ Acknowledgement Statement Final Agency Audit Report dated February 10, 2005 C.L 00-0163-000 age y of 1u) — : o 5, a : og 4 a E BE ay om B: B kn a B 3 o e 2, = E [=r o B | a an a a g & 3 4) . The Physician Services Coverage and Limitations Handbook, Chapter 2, states: Medicaid reimburses for services that are determined to be medically necessary and do not duplicate another provider's service. In addition, the services must meet the following criteria: * Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; * Be individualized specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient’s needs; , “© Be consistent with Benerally accepted professional medical standards as determined by the Medicaid Program, and not experimental or investigational; © Reflect the Jevel of services that can be safely furnished, and for which no » equally effective and more conservative or less costly treatment is available statewide; and © Be firmished in a manner not Primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider, 3) The Physician Coverage and Limitations Handbook, Chapter 2, states that a type service, Ophthalmological services are performed by an ophthalmologist in the diagnosis and medical or surgical treatment ofa reported vision problem. : . Optometric services are medically necessary services that provide for examination, diagnosis, treatment and matlagement of ocular and adnexal pathology, Visual examinations to determine the need for eyeglasses are also covered. Optometric services must be furnished by or under the direct supervision of a Medicaid-enrolled optometrist, Corrective action plan ~ Acknowledgement Statement Final Agency Audit Report dated February 10, 2005 C.F. 00-0163-000 age 1D of 70) By: . Date: (signature) (title) Corrective action plan — Acknowledgement Statement Final Agency Audit Report dated February 10, 2005 C.f, 00-0163-000 .

Docket for Case No: 06-000377MPI