STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS H.C. HEALTHCARE, INC., P ome] co eye = Petitioner, S Ss cy es vs. CASE NO. 06-4905MPI “ey RENDITION NO.: AHCA-08- 31 -s-mM = i w att AGENCY FOR HEALTH CARE mi = ADMINISTRATION, 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. w . DONE and ORDERED on this the ZZ day of borgast— , 2008; in Tallahassee, Florida. Lh vg, — Fn— HOLLY BENSON, 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: Daniel M. Lake, Esquire Agency for Health Care Administration (Interoffice Mail) William B. Watson, III, Esquire Watson & Watson Post Office Box 358686 Gainesville, Florida 32635-8686 (U.S. Mail) Barbara J. Staros © Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 D. Kenneth Yon, Chief, Medicaid Program Integrity, MS #6 Kiosha Jones, Medicaid Program Integrity, MS #6 Finance and Accounting, MS #14 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to yn the above named addressees by U.S. Mail on this the be day of Hfaguat. 2008. Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 \rays 1 ul 0 FLORIDA AGENCY FOR HEAITH CARE ADMINISTRATION: JEB BUSH CHRISTA CALAMAS GOVERNOR SECRETARY CERTIFIED MAIL No, 91 7108 2133 3932 6540 9998 October 31, 2006 Provider'No: 6601588-00 HC Healthcare Inc. 422 NE Lake Shore Terrace Lake City, FL 32055 In Reply Reler to FINAL AUDIT REPORT C.E. No.: 06-4287-000 Dear Provider: The Agency for Health Care Administration (the Agency), Burcau of Medicaid Program Integrity, has completed a review of claims for Medicaid reimbursement for dates of service during the period January 1, 2003 through December 31, 2004. A preliminary audit report dated July 10, 2006 was sent to you indicating that we had determined you were overpaid $106,040.36. Based upon a review of all documentation submitted, we have determined that you were overpaid $78,787.35 for services that in whole or in part are not covered by Medicaid. A fine of $1,500 has been applied. The total amount due is $80,287.35. : Be advised of the following: (1) Pursuant to Section 409.91 3(23)(a), Florida Statutes (F.S.), the Agency is entitled to recover all investigative, legal, and expert witness costs. (2) In accordance with Sections 409.913(15), (16), and (17), F.S., and Rule 59G-9.070, Florida Administrative Code (F'.A.C.), the Agency shall apply sanctions for violations of federal and state laws, including Medicaid policy. This letter shall serve as notice of the following sanction(s): ° A fine of $1,500 for violation(s) of Rule Section 59G-9.070, 7(c), F.A.C. ¢ A corrective action plan in the form of an acknowledgement statement is due within 30 days of receipt of this notice (please sce the attachment regarding the requirements for this sanction). This review and the determination of overpayment were made in accordance with the provisions of Section 409.913, FS. In determining the appropriateness of Medicaid payment pursuant to 2727 Mahan Drive, MS# 6 Tallahassee, Florida 32308 Visit AHCA online at http: /fahca.myflorida.com BPE Care in the Sunanine " www.FloridaCompareCare.gov (Page 2 of 6) HC Iealtheare Inc. C.1. No.: 06-4287-000 Page 2 Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, limitations and requirements found in the Medicaid provider handbooks and Scction 409.913, E.S. 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, billing bulletins, and the Mcdicaid provider agreement. Medicaid cannot pay for services that do not meet these guidelines. . : Below is a discussion of the particular guidelines related to the review of your claims, and an explanation of why these claims do not meet Medicaid requirements. ‘The audit work papers are attached, listing the claims that are affected by this determination. REVIEW DETERMINATION(S) Medicaid policy addresses the requirement for enrollment and participation in the Medicaid program. An individual provider must be enrolled as a member of the group practice(s) for which he/she performs services. You billed and received payment for services when the practitioner rendering the service was not identified as a member of your group. Payment made to you for services rendered by an individual who is not a member of your group is considered an overpayment, Medicaid policy specifies how medical records must be maintained. A review of your medical records revealed that some services for which you billed and reccived payment were not documented. Medicaid requires documentation of the services and considers payments made for services not appropriately documented an overpayment. OVERPAYMENT CALCULATION A random sample of 34 recipients respecting whom you submitted 100 claims was reviewed. For those claims in the sample, which have dates of service from January 1, 2003 through December 31, 2004 an overpayment of $2,972.32 or $29.7232 per claim, was found. Since you were paid for a total (population) of 3,635 claims for that period, the point estimate of the total overpayment ts 3,635 x $29.7232'= $108,043.83. There is a 50 percent probability that the overpayment to you is that amount or more. We used the following statistical formula for cluster sampling to calculate the amount due the Agency: Where: N x E = point estimate of overpayment = aps A /> 5, | gel tel (Page 3 of 6) HC Healthcare Inc. C.1. No.: 06-4287-000 Page 3 u F = number of claims in the population = SB, il A, = total overpayment in sample cluster 8, = number of claims in sample cluster U = number of clusters in the population NV = number of clusters in the random sample N N Y = mean overpayment per claim = > A, /¥B, rel asd 1 =f value from the Distribution of ¢ Table All of the claims relating 1o a recipient represent a cluster. The values of overpayment and number of claims for each recipient in the sample are shown on the attachment entitled “Overpayment Calculation Using Cluster Sampling.” From this statistical formula, which is generally acceptcd for this purpose, we have calculated that the overpayment to you is $78,787.35 with a ninety-five percent (95%) probability that it is that amount or more. If you are currently involved in a bankruptcy, you should notify your attorney immediately and provide a copy of this letter for them. Please advise your attorney that we need the following information immediately: (1) the date of filing of the bankruptcy petition; (2) the casc number; (3) the court name and the division in which the petition was filed (e.g., Northern District of Florida, Tallahassee Division); and, (4) the name, address, and telephone number of your attorney, If you are not in bankruptcy and you concur with our findings, remit by certified check in the amount of $80,287.35, which includes thc overpayment amount as well as any fines imposed. The check must be payable to the Florida Agency for Health Care Administration. Questions regarding procedures for submitting payment should be dirccted to Medicaid Accounts Reccivable, (850) 488-5869. To ensure proper credit, be certain you legibly record on your check your Medicaid provider number and the C.J. number listed on the first page of this audit report. Picase mail payment to: Agency for Health Care Administration Medicaid Accounts Reccivable P.O. Box 13749 Tallahassee, Florida 32317-3749 If payment is not reccived, 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(27), F.S. Furthermore, pursuant to Sections 409.913(25) and 409.913(15), F.S., failure to pay in full, or enter into and abide by the terms of any repayment schedule sct forth by the Agency may result in termination from the Medicaid Program. Likewise, failure to comply with all sanctions applied or duc dates may result in additional sanctions being imposed. You have the right to request a formal or informal hearing pursuant to Section 120.569, F.S. Ifa request for a formal hearing is made, the petition must be made in compliance with Section 28- 106.201. F.A.C. and mediation may be available. If a request for an informal hearing is made, (Pages4 ot 6) IEC Healthcare Inc. : CL. No.: 06-4287-000 Page 4 the petition must be made in compliance with rule Section 28-106.301, F.A.C. Additionally, you are hereby informed that if a request for a hearing is made, 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 sce the attached Notice of Administrative Hearing and Mediation Rights. Any questions you may have about this matter should be directed to: Kiosha Jones, Investigator, Agency for Health Care Administration, Medicaid Program Integrity, 2727 Mahan Drive, Mail Stop #6, Tallahassee, Florida 32308-5403, telephone (850) 921-1802, facsimile (850) 410-1972. Sincercly, ose oe Beclet Fred Becknell AHCA Administrator FB/KJ/ni Enclosure(s) (Page 5 of 6) H1C Mealthcare Inc. C.I. No.: 06-4287-000 Page 5 NOTICE OF ADMINISTRATIVE HEARING AND MEDIATION RIGHTS You have the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If you disagree with the facts stated in the foregoing Final Audit Report (hereinafter FAR), you may request a formal administrative hearing pursuant to Section 120.57(1), Klorida Statutes. If you do not dispute the facts stated in the FAR, but believe there are additional reasons lo grant the relief you seek, you may request an informal administrative hearing pursuant to Section 120.57(2), Florida Statutes, Additionally, pursuant to Section 120.573, Florida Statutes, mediation may be available if you have chosen a formal administrative hearing, as discussed more fully below: The writien request for an administrative hearing must conform to the requirements of cither Rule 28-106.201(2) or Rule 28-106.301(2), Florida Administrative Code, and must be reccived by the Assistant Bureau Chief by 5:00 P.M. no later than 21 days afier you received the FAR. The address for filing the written request for an administrative hearing is: Assistant Bureau Chief Medicaid Program Integrity Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #6 Tallahassee, Florida 32308 ‘The request must be legible, on 8 % by 11-inch white paper, and contain: 1. Your name, address, telephone number, any Agency identifying number on the FAR, 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 FAR; 3. A statement of when and how you received the FAR; 4. Vora request for formal hearing, a statement of all disputed issues of material fact; 5. Vora request for formal hearing, a concise statement of the ultimate facts alleged, as well as the rules and statutes which entitle you to relicf: 6. Kora request for formal hearing. whether you request mediation, if it is available; 7. Vor a request for informal hearing, what bases support an adjustment to the amount owed to the Agency: and 8. A demand for relief. A formal hearing will be held if there are disputed issues of materia! fact. Additionally, mediation may be available in conjunction with a formal hearing. Mediation is a way to use a neutral third party to assist the parties in a legal or administrative proceeding to reach a settlement of their case. If you and the Agency agree to mediation, it does not mean that you give up the right to a hearing. Rather, you and the Agency will try to settle your case first with mediation. If you request mediation, and the Agency agrees to it, you will be contacted by the Agency to sct up a time for the mediation and to enter into a mediation agreement. If a mediation agreement is not reached within 10 days following the request for mediation, the matter will procecd without mediation. The mediation must be concluded within 60 days of having entered into the agreement, unless you and the Agency agree 10 a different time period. The mediation agreement between you and the Agency will include provisions for selecting the mediator, the allocation of costs and fees associated with the mediation, and the confidentiality of discussions and documents involved in the mediation. Mediators charge hourly fees that must 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 reviewed pursuant to Chapter 120, Florida Statutes, and the action set forth in the FAR shall be conclusive and final. (Fage 6 of 6) FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Overpayment Calculation Using Cluster Sampling Provider: 660158800 - HC HEALTHCARE INC Number of recipients in population: 4,031 Case ID: 06-4287-000 Number of recipients in sample: 34 Confidence level: - 95% Total payments in population: $468,080.77 No. of claims in population: 3.635 t value: 1.6923602 Recip # No. Claims Totat Dollars Overpayment 1 4 $130.77 $0.00 2 13 $1,689.77 $648.73 3 1 $128.21 $0.00 4 1 $130.77 $0.00 S 2 $258.54 $0.00 6 14 $1,784.18 $127.77 7 4 $523.08 $130.77 8 2 $258.54 $127.77 9 2 $259.07 * $0.00 10 4 $130.77 $0.00 4 1 $134.30 $0.00 12 q $125.24 $126.21 13 5 $644.85 $0.00 14 1 _ $134.30 $0.00 15 § $642.38 $383.31 16 1 $128.21 $0.00 7 5 $653.85 $261.54 18 1 $128.21 $0.00 19 1 $128.21 $128.21 20 2 $261.54 $130.77 21 1 $128.21 $0.00 22 1 $126.21 $0.00 23 1 $128.21 $128.21 24 1 $130.77 $130.77 25 2 $258.54 $0.00 26 2 $258.98 $0.00 27 2 $258.54 $0.00 28 17 $2,202.70 $514.96 29 4 $128.21 $0.00 30 1 $128.21 $0.00 31 3 $395.84 $134.30 32 1 $131.30 $0.00 33 1 $134.30 $0.00 34 2 $255.54 $0.00 Totals: 34 100 $12,939.32 $2,972.32 Using Overpayment per claim method Overpayment per sampie claim: $29.72320000 Point estimate of ihe overpayment: $108,043.83 Variance of the overpayment: $298,853,613.15 Standard error of the overpayment: $417,287.38 Half confidence intervat: ; $29,256.48 Overpayment at the 95 % Confidence levet!| $78,787.35 Overpayment run on 10/26/2006 1/23/2006. Page 1 of 3 STATE OF FLORIDA ; AGENCY FOR HEALTH CARE ADMINISTRATION H.C. HEALTHCARE, INC., Petitioner, Case No.: 06-4905MPI vs. Provider No.: 660158800 C.I. No.: 06-4287-000 AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and H.C. HEALTHCARE, INC., (“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 this matter. 2. H.C. HEALTHCARE, INC. is a Medicaid provider in the State of Florida, provider number 660158800 and was a provider during the audit period. 3. In its Final Audit Report (FAR) dated October 31, 2006, AHCA notified H.C. HEALTHCARE, INC., 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 FAR identified a Medicaid overpayment to the PROVIDER in the amount of seventy-eight thousand seven hundred eighty-seven dollars and thirty-five cents ($78,787.35). A sanction fine of one thousand five hundred dollars ($1,500.00) for violation of Rule Section 59G-9.070 (7) (c), Florida Administrative Code, and a corrective action plan in the form of an Acknowledgement Statement H.C. Healthcare, Inc. Settlement Agreement was also applied. In response to the FAR, the PROVIDER requested an administrative hearing on the alieged Medicaid overpayment. 4. Subsequent to issuance of the FAR, the PROVIDER requested and was granted an AHCA peer consultation to review disputed claims and submitted additional documentation regarding the overpayment. As a result of the peer consultation the Medicaid overpayment amount for C.I. No. 06-4287-000 was adjusted to forty-one thousand six hundred twenty dollars and ninety-eight cents ($41,620.98). A sanction fine in the amount of one thousand five hundred dollars ($1,500.00) and investigative costs in the amount of two thousand five hundred. dollars ($2,500.000) are also assessed. The total amount due is forty-five thousand six hundred twenty dollars and ninety-eight cents ($45,620.98). The PROVIDER must also submit a corrective action plan in the form of a Provider Acknowledgement Statement. 5. In order to resolve this matter without further administrative proceedings, the PROVIDER and AHCA expressly agree as follows: | (1) AHCA agrees to accept the payment set forth herein and the executed Provider Acknowledgement Statement in settlement of the overpayment issues arising from C.I. 06-4287-000. | (2) Within 6 months, at 10% interest, of the date of execution of a Final Order adopting this Settlement Agreement, PROVIDER agrees to make one lump sum payment of forty-five thousand six hundred twenty dollars and ninety-eight cents ($45,620.98) to AHCA, in full and complete settlement of all matters pertaining to C.I. 06-4287-000. This amount is allocated as forty-one thousand six hundred twenty dollars and ninety-eight cents (41,620.98) for the Medicaid overpayment plus a sanction amount of one H.C. Healthcare, Inc. Settlement Agreement thousand five hundred dollars ($1,500.00) and an investigative cost amount of two thousand five hundred dollars ($2,500.00). (3) PROVIDER and AHCA agree that full payment as set forth above and return of the Provider Acknowledgement Statement 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. 06-4287-000. (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 Statement 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. 3 Hc. Healthcare, Inc. Settlement Agreement 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 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 tules 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. H.C. Healthcare, Inc. 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. H.C LTHCARE, INC. Dated: f ry 1) ph , 2008 er Rhee t Keaen ASH Oco aie name) AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Bldg. 3, Mail Stop #3 Tallahassee, FL 32308-5403 4 KF — Dated: pes ze, , 2008 F.ie-i~ Inspector General Dated: Ausuat G , 2008 Craig . General Counsel Dated: GO //¥/_ 222 F, 2008 .L Assistant General Counsel everls Wrw Dated: [22 , 2008 im Kellum ; Chief Medicaid Counsel 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, 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, rules, provisions, handbooks, and policies that are at issue 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 and return it to: Kiosha Jones, Investigator Agency for Health Care Administration Medicaid Program Integrity 2727 Mahan Drive, Mail 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 Audit Report dated October 31, 2006 C.1. 06-4287-000 PROVIDER ACKNOWLEDGEMENT STATEMENT EAU SLEDGEMENT STATEMENT I , on behalf of HC Healthcare, Inc., (insert printed full name here) a Medicaid provider Operating under provider number 6601 588-00, do hereby acknowledge the obligation of HC Healthcare, Inc., to adhere to state and federal Medicaid laws, rules, provisions, handbooks, and policies. Additionally, HC Healthcare, Inc. acknowledges that Medicaid policy requires: 1) The Physicians Coverage and Limitations Handbook requires that if a physician provider employs or contracts with any health care practitioner (physician, physician assistant, or advanced registered nurse practitioner) who can enroll as a Medicaid provider and that health care practitioner is treating Medicaid recipients, he or she must enroll as a Medicaid provider. It also Tequires that two or more Medicaid providers whose practice is incorporated under the same tax identification number must enroll as a Medicaid provider group. In order to receive payment from Medicaid, each member of the group must also enroll as an individual treating provider within the group. 2) Medicaid policy requires that the provider must retain all medical, fiscal, professional, and business records on all services provided to a Medicaid recipient. The records must be accessible, legible and comprehensible. Records must be retained for a period of at least five years from the date of service, and must state the necessity for and the extent of services provided. These Tequirements are currently found in the Florida Medicaid Provider General Handbook, dated October 2003. Prior to this time, they were spelled out in the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up Reimbursement Handbook. By: Date: (signature) (title) « Return completed acknowledgement statement to Medicaid Program Integrity. Corrective action plan -- Acknowledgement Statement Final Audit Report dated October 3 1, 2006 C.1. 06-4287-000

Docket for Case No: 06-004905MPI