STATE OF FLORIDA PILED AGENGY FOR HEALTH CARE ADMINISTRATION —agruiry ¢ ery AGENCY FOR HEALTH CARE - AME LS A a 93 ADMINISTRATION, Petitioner, vs. CASE NO. 07-1513MPI JUDGE: DANIEL MANRY ALINA GONZALEZ-MAYO, C.I. NO. 07-5328-000 3 RENDITION NO.: AHCA-07- OWS. = a Respondent. 2 : / i a FINAL ORDER Hh W «<= rm 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. DONE and ORDERED on this the _3/ day of Bttti , , 2007, in Tallahassee, Florida. fre Bie Cc. fa} M.D., 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 Lake, Esq. Agency for Health Care Administration (Interoffice Mail) Peter A. Lewis, Esq. Galdsmith, Grout & Lewis, P.A. 307 West Park Avenue Suite 200 Tallahassee, FL 32301 (U.S. Mail) The Honorable Daniel Manry Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) Tim Byrnes, Bureau Chief, Medicaid Program Integrity 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 S*day of _Vave—br~, 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 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No.: 07-1513MPI vs. Provider No.: 262730200 CL No.: 07-5328-000 ALINA GONZALEZ-MAYO, Respondent. / Z SETTLEMENT AGREEMENT ea STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “the Agency”), and ALINA GONZALEZ-MAYO (“PROVIDER”), by and through the undersigned, hereby stipulate and agree as follows: I. The parties enter into this agreement for the purpose of memorializing the resolution to this matter. 2. ALINA GONZALEZ-MAYO is a Medicaid provider in the State of Florida, provider number 262730200 and was a provider during the audit period. 3. In its Final Audit Report (FAR) dated February 20, 2007, AHCA notified ALINA GONZALEZ-MAYO, 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 six thousand two hundred ninety- five dollars and twenty-three cents ($6,295.23). A fine of five hundred dollars ($500.00) for violation of Rule Section 59G-9.070 (7) (c), Florida Administrative Code, and a corrective action Alina Gonzalez-Mayo Settlement Agreement plan in the form of an Acknowledgement Statement was also applied. In response to the FAR, the PROVIDER requested an administrative hearing on the alleged 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.1. No. 07-5328-000 was adjusted to one thousand two hundred forty-seven dollars and eighty-three cents ($1,247.83). A fine in the amount of five hundred dollars ($500) and costs in the amount of five hundred dollars ($500.00) are also assessed. The total amount due is two thousand two hundred forty-seven dollars and eighty-three cents ($2,247.83). 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. 07-5328-000. Within sixty (60) days of the date of execution of a Final Order adopting this Settlement Agreement, PROVIDER agrees to make one lump sum payment of two thousand two hundred forty-seven dollars and eighty-three cents ($2,247.83) to AHCA, in full and complete settlement of all matters pertaining to C.I. 07-5328-000. This amount is allocated as one thousand two hundred forty-seven dollars and eight-three cents ($1,247.83) for the Medicaid overpayment plus a sanction amount of five hundred dollars ($500.00) and a cost amount of five hundred dollars ($500.00). Alina Gonzalez-Mayo Settlement Agreement (3) PROVIDER and AHCA agree that full payment as set forth above and retum 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.J, 07-5328-000. (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 retum 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. il, 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. Alina Gonzalez-Mayo 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 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. Alina Gonzalez-Mayo 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. ALIN -MAYO Dated: alu \p? , 2007 BY: As waoke2 - NV (Print name) AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Bldg. 3, Mail Stop #3 Tallahassee, FL 32308-5403 Lada? hese Dated: /0 =3/ , 2007 Linda Keen Inspector General (Za Dated: tofee , 2007 th Dated: ‘1 / wWA . 2007 Craig Hs General Counsel Alina Gonzalez-Mayo Settlement Agreement Pian eth be, _ Dated: _j O [25- . 2007 Kim Kellt Chief Medicaid Counsel

Docket for Case No: 07-001513MPI