FILED STATE OF FLORIDA ANCA AGENCY FOR HEALTH CARE ADMINISTRATION AGERCY CLERK 2001 OCT -y > 2 Q9 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. CASE NO. 06-1550MPI JUDGE: Patricia M. Hart FRANCISCO JIMENEZ, D.D.S., C.l. NOS, 06-4351-000 & 06-4352-000 : RENDITION NO.: AHCA-07- Oln04 -s-mpo Respondent. ! FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. bday of Ct ___, 2007, in DONE and ORDERED on this the Andrew C. a Dee M.D., Secretary Agency for Health Care Administration Tallahassee, Florida. 80: y s- 120 L002 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: David W. Nam, Esq. Agency for Health Care Administration (Interoffice Mail) Francisco Jimenez, D.D.S Children’s Pediatric Dentist 600 South Dixie Highway Suite 207 Boca Raton, FL. 33432 (U.S, Mail) The Honorable Patricia M, Hart Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) Tim Byrnes, Bureau Chief, MP] Agency for Health Care Administration (Interoffice Mail) Linda Keen, Inspector General Agency for Health Care Administration (Interoffice Mail) Finance and Accounting Agency for Health Care Administration (Interoffice Mail) CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addressees by U.S. Mail and/or Interoffice Mail on this the P day of _§ <2 6er— , 2007, Richard Shoop, Esquire Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308-5403 Tel: (850) 922-5873 ° Fax: (850) 921-0158 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No. 06-1550MPI Vs. ; Provider No. 071247701 & 070668000 CI. No. 06-4351-000 & 06-4352-000 FRANCISCO JIMENEZ, D.D.S., Respondent. i } SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and FRANCISCO JIMENEZ, D.D.S, (“PROVIDER”), by and through the undersigned, hereby stipulate and agree as follows: 1, The parties enter into this agreement for the purpose of memorializing the resolution to these matters. 2. FRANCISCO JIMENEZ, D.D.S., is a Medicaid provider in the State of Florida; with provider numbers 071247701 & 070668000 and was a provider during the audit periods. 3. In Final Audit Reports (FARs) dated March 3, 2006 & March 29, 2006, AHCA notified FRANCISCO JIMENEZ, D.D.S., that review of PROVIDER’s Medicaid claims, performed by the Office of Medicaid Program Integrity (MPI), of the AHCA Inspector General, determined that certain claims, in whole or in part, were inappropriately paid by Medicaid, The FARs identified a Medicaid overpayment to the PROVIDER in the amount of twenty thousand seven hundred forty-two dollars ($20,742.00); thirteen thousand nine hundred seventeen dollars ($13,917.00) for C.l, No, 06-4351-000 and six thousand eight hundred twenty-five dollars Francisco Jimenez, D.D.S. Settlement Agreement (36,825.00) for C.l, No, 06-4352-000, In response to the FARs, the PROVIDER requested an administrative hearing on the alleged Medicaid overpayment, 4, The PROVIDER was assessed sanction amounts of five hundred dollars ($500.00) for C.I. No, 06-4351-000 and a fine of five hundred dollars ($500.00) for C.I. No, 06- 4352-000 for violations(s) of Rule Section 59G-9,070, Florida Administrative Code. Provider was assessed costs in the amount of one thousand dollars ($1,000.00) for C.I, No. 06-4351-000 and C.I. No, 06-4352-000, The total amount due from provider is twenty-two thousand, seven hundred forty-two dollars ($22,742.00). The PROVIDER must also submit corrective action plans in the form of a Provider Acknowledgement Statement for each provider number, 5, In order to resolve this matter without further administrative proceedings, the PROVIDER and AHCA expressly agree as follows: (1) AHCA agrees 1o accept the payment set forth herein and the executed Provider Acknowledgement Statements in settlement of the overpayment issues arising from C.I. 06-4351-000 & 06-4352-000. (2) Within thirty (30) days of the date of execution of the Final Order adopting this Settlement Agreement, PROVIDER agrees to make a payment in the amount of nine thousand and twenty nine dollars and fifty ‘five cents ($9,029.55). The PROVIDER will make two additional payments to AHCA, in the amount of seven thousand and twenty nine dollars and fifty five cents each, due sixty (60) days and at ninety (90) days after the date of execution of the Final Order. Said payments are in full and complete settlement of all matters pertaining to C.I. 06-4351-000 & 06-4352-000. The total amount to be repaid by provider is ($22,742.00) plus statutory interest for the Medicaid overpayment in this case. 2 .Francisco Jimenez, D,D.S. Settlement Agreement (3) PROVIDER and AHCA agree that full payment as set forth above and return of the executed Provider Acknowledgement Statements 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, 06-4351-000 & 06- 4352-000. (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 or return the signed Provider Acknowledgement Statements 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. 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. Francisco Jimenez, D,D.S. Settlement Agreement 12, . This Agreement shal! 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 . 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 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. Francisco Jimenez, D,.D.S. Settlement Agreement - 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. 20. .. This Agreement shall be in full force and effect upon execution by the respective parties in counterpart. Francisco Jimenez, D.D.S. Settlement Agreement Dated: "4 | €/ > + , 2007 (Print name) AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Bldg. 3, Mail Stop #3 Tallahassee, FL 32308-5403 ‘\ Cc Ahenda) 7 Leen Dated: fo-f , 2007 Linda Keen ; . Inspector General i ' Dated: 2 , 2007 ‘aig H? Simi General yi ; sf Uv Dated: 4 I David W. Nam Assistant General Counsel Reef tary Dated: im Kellum ; Chief Medicaid Counsel , 2007 , 2007 Corrective Action Plan — Acknowledgement Statement A “corrective action plan” is the process or plan by which the provider will ensure firture compliance with state and federal Medicaid laws, rules, provisions, handbooks, _and policies. For purposes of this matter, the sanction of a corrective action plan shall take the form of an “acknowledgement statement”, which is a written document submitted to the Agency within 30 days of the date of the Agency action that brought rise to this requirement, An acknowledgement statement; identifies the areas of non- compliance as determined by the Agency in this Final Audit Report (FAR); acknowledges a requirement to adhere to the specific state and federal Medicaid laws, tules, provisions, handbooks, and policies that are at issuc in the FAR; and, must be signed by the provider or its president, director, or owner, - The acknowledgement statement is due to Medicaid Program Integrity within 30 days of the issuance of this FAR, Please sign the enclosed statement aud return it to: Terri Dean, Medical/Health Care Progratn Analyst Agency for Health Care Administration Medicaid Program Integrity . 2727 Mahan Drive, Mal) Stop #6 Tallahassee, FL 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 March 29, 2006 C.1. 06-4351-000 PROVIDER ACKNOWLEDGEMENT STATEMENT 1_FRAMCIKCS —_ “N1+41.€ yon behalf of FRANCISCO JIMENEZ, (insert printed full name here) a Medicaid provider operating under provider number0712477-01, do hereby acknowledge the obligation of Francisco Jimenez, to adhere to state and federal Medicaid laws, rules, provisions, handbooks, and policies. Additionally, Francisco Jimenez acknowledges that Medicaid policy requires: Administration Fee Reimbursement: “Medicaid does not reimburse for behavior management iff « Billed routinely every time the recipient visits the office, or * Billed with either sedation or analgesia on the same date of service," Exam and Treaiment Plan: "Reimbursement for the orthodontic exam and treatment plan, procedure code D8900, includes models, photographs, radiographs, and the diagnosis and treatment plan. These services are not reimbursed separately," we S/°Y/9A By: - (title) Return completed acknowledgement statement to Medicaid Program Integrity. Cottectlve action plan -- Acknowledgement Statement Final Agency Audit Report dated March 29, 2006 C.L, 06-435 1-000 (Wape 6 of 6). Se einer naa : . wo oe 7 Return: completed acknowledgement statement to Medicaid Program Integrity. Corrective action plin -- Acknowledgement Statement Final Agency Audit Report dated March 29. 2006 C.J. 06-4352-000 (Page 5 of &) . LA omréctive action pain” is 5 the proces or plan by vibich the provider will ensure . future compliance with state and federal Medicaid laws, rules, provisions, handbooks, cand policies, : For purposes of this matter, the sanction ofa corrective action plan shall Failure log mply with the reqiuirements set forth above. may, result | in the} imposition ; a ‘of additional sanctions, which may include monetary fi ines, suspension, or termination : from the Medionid program, : Corrective action plan -- Acknowledgement Statement Final Agency Audit Report dated March 29, 2006 C.I. 06-4352-000

Docket for Case No: 06-001550MPI