STATE OF FLORIDA - LG DIVISION OF ADMINISTRATIVE HEARINGS anitea, ERK 11 AUG -8 A 409 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, CASE NO: 07-1404MPI Petitioner, JUDGE: CLAUDE B. ARRINGTON, C1. NO. 03-1233-000 2S vs. SANTOS T. DE LA PAZ, M.D., Respondent. / FINAL ORDER THIS CAUSE is before me for issuance of a Final Order. In a letter dated March 17, 2005, Santos T. De La Paz, M.D., (Respondent) was informed that the State of Florida, Agency for Health Care Administration (Agency) was seeking to recoup Medicaid overpayments in the amount of $200,575.62. Additionally, the Provider was notified that the Agency required the submission of a corrective action plan in the form of an acknowledgement statement, pursuant to Rule 59G-9.070, Florida Administrative Code. Pursuant to Section 409.913(6), F.S., the letter was sent Certified Mail, return receipt requested, to Respondent at the address last shown on the provider enrollment file. Respondent signed for the letter on March 21, 2005. A Petition for an Administrative Hearing was filed on April 19, 2005. On February 22, 2006, the Petition was forwarded to the Division of Administrative Hearings (“DOAH”) by the Agency and assigned to an Administrative Law Judge (“ALJ”). AHCA v, Santos T. De La Paz, M.D. DOAH Case No. 07-1404MPI Final Order On March 27, 2007, the Respondent’s Notice of Withdrawal of Petition for Formal Hearing was filed with DOAH. On May 25, 2007, the ALJ issued an Amended Order Closing File based on the Respondent’s Notice of Withdrawal of Petition for Formal Hearing. ORDER BASED on the foregoing, it is ORDERED and ADJUDGED that Respondent refund, forthwith, the sum of $200,575.62, together with statutory interest as set forth in §409.913(25)(c), Florida Statutes, and submit the corrective action plan in the form of an acknowledgement statement. Respondent shall make payment in full within 30 days of the rendition of this Final Order. DONE and ORDERED this /___ day of Augud , 2007, in Tallahassee, Leon County, Florida. IT se Cc. en, eee 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. AHCA v. Santos T. De La Paz, M.D. DOAH Case No. 07-1404MP] Final Order Copies furnished to: Claude B. Arrington Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Santos T. De La Paz, M.D. 2240 Coral Way South Miami, Florida 33145 Debora E. Fridie, Esquire Assistant General Counsel Agency for Health Care Administration _ 2727 Mahan Drive, MS#3 Tallahassee, Florida 32308 Tim Byrnes, Medicaid Program Integrity, MS #6 Fred Becknell, Medicaid Program Integrity, MS #6 Finance & Accounting, MS #14 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served on the above-named persons by U.S. Mail or interoffice mail as indicated on this oct day of Lhses , 2007. RICHARD SHOOP, AGENCY CLERK State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 (Page 5 of 7) 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 Agency Audit Report (FAAR); acknowledges a requirement to adhere to the specific state and federal Medicaid laws, 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 Agency within 30 days of the issuance ofthis FAAR. Please sign the enclosed statement and return it to: Carolyn Milligan 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 Agency Audit Report dated March 17, 2005 C.L 03-1233-000 : (Page 6 of 7) PROVIDER ACKNOWLEDGEMENT STATEMENT T , on behalf of Santos T, De La Paz, MD, (insert printed full nome here) a Medicaid provider operating under provider number 035713801, do hereby acknowledge the obligation of Santos T. De La Paz, MD to adhere to state and federal Medicaid laws, rules, provisions, handbooks, and policies, Additionally, Santos T. De La Paz, MD acknowledges that Medicaid policy requires: | 1. Medicaid policy defines the varying levels of care and expertise required for the evaluation and management procedure codes for office visits. Medicaid uses the Physician's Current Procedure Terminology (CPT) book, which contains complete descriptions of the standard codes. Medical records must state the necessity for and extent of services provided. The following requirements may vary according to the service rendered: history; physical assessment, chief complaint on each visit; diagnostic test and results, diagnosis; treatment plan, including prescriptions; medications, supplies, scheduling frequency for follow-up or other services; progress reports, 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. 2. The provider must retain all medical, fiscal, professional, and business records on all services provided to a Medicaid recipient, Records must be retained for a period of at least five years from the date of service. Medical records must state the necessity for and the extent of services provided, Record keeping requirements are outlined in the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up. 3, 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 generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational: * Reflect the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and Corrective action plan — Acknowledgement Statement Final Agency Audit Report daied March 17, 2005 GH. 03-1233-000 (Page 7 of 7) ¢ Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider. 4. The Florida Medicaid Provider General Handbook, Chapter 5 states: When presenting a claim for payment under the Medicaid Program, a provider has an affirmative duty to supervise the provision of, and be responsible for, good and services claimed to have been provided, to supervise and be responsible for Preparation and submission of the claim, and to present a claim that is true and accurate and that is for goods and services that: * Have actually been furnished to the recipient by the provider prior to submitting the claim; : * Are Medicaid-covered goods or services that are medially necessary; * Are ofa quality comparable to those furnished to the general public by the provider’s peers; * Have not been billed in whole or in part to a recipient or a recipient’s responsible party, except for such co-payments, coinsurance, or deductibles as are authorized by AHCA; * Are provided in accord with applicable provisions of all Medicaid rules, regulations, handbooks, and policies and in accordance with federal, state and local law; and * Are documented by records made at the time the goods or services were provided, demonstrating the medical necessity for the yoods or services rendered, * Medicaid goods or services are excessive or not medically necessary unless both the medical basis and the specific need for them are fully and properly documented in the recipient’s medical record, 5. The Physician Coverage and Limitations Handbook, Chapter 2, states: When a non-invasive radiological study is performed in an office setting, the physician billing the maximum fee must either directly or indirectly supervise the technical component of the study. The provider must directly perform the interpretation and results of the study. To be reimbursed the maximum fee for a radiology service, the physician must provide both the technical and professional components, The maximum fee includes the professional component and the technical component of the radiological service. Ifa group practice, members of the group must perform both the professional and technical cornponents of the service, By: Date: = (signature) (title) Corrective action plan ~ Acknowledgement Statement Final Agency Audit Report dated March 17, 2005 C.I. 03-1233-000

Docket for Case No: 07-001404MPI