Dollars ($4,500.00) for a total amount due of Eighty-Five Thousand, Nine Hundred and Eighty-Six Dollars and Thirty-One cents ($85,986.31).

In Audit Number C.I. 07-5644-000/W/TBM, the Agency determined that the PETITIONER was overpaid in the amount of Twenty-Nine Thousand, Four Hundred and Thirty-Nine Dollars and Sixteen cents ($29,439.16) for services that in whole or in part were not covered by Medicaid. The Agency also imposed a fine of Sixty-Five Hundred Dollars ($6,500.00) for a total amount due of Thirty-Five Thousand, Nine Hundred and Thirty-Nine Dollars and Sixteen cents ($35,939.16).

Further, each FAR imposes corrective action measures on the Provider.

The FARs provided full disclosure and notice to the PETITIONER of procedures for requesting administrative hearings to contest the alleged overpayments and sanctions. The PETITIONER filed separate petitions with the Agency requesting formal administrative hearings on both FARs. On January 8, 2009, the Agency transmitted PETITIONER's formal hearing requests to the Division of Administrative Hearings ("DOAH" or "Division") and case numbers, reflected in the above case style, were assigned to the FARs. On May 6, 2009, the Agency and the PETITIONER filed an Agreed Status Report and Joint Motion to Consolidate Cases. An Order of Consolidation was entered on May 6, 2009.

On May 20, 2009, PETITIONER, through his qualified representative, withdrew the petitions for formal administrative hearing. The DOAH case was dismissed by the Administrative Law Judge on June 1, 2009, and jurisdiction of the case was relinquished by the Division to the Agency.

Page 2 of 7

FINDINGS OF FACTS

The PETITIONER received the FARs that gave notice of PETITIONER'S right to an administrative hearing regarding the alleged Medicaid overpayments. The PETITIONER filed petitions requesting administrative hearings on the FARs, and then caused the petitions and the administrative hearing to be DISMISSED. PETITIONER chose not to dispute the facts set forth in the FARs dated November 20, 2008. The facts alleged in the FARs are hereby deemed admitted by the PETITIONER, including:

1. In Audit Number C.I. 07-5643-000/W/TBM, the Agency determined that PETITIONER received overpayment in the amount of Eighty-One Thousand, Four Hundred and Eight-Six Dollars and Thirty-One Cents ($81,486.31) for services that in whole or in part were not covered by Medicaid, the audit also imposed sanctions in the amount of Forty-Five Hundred Dollars ($4,500.00), for a total amount owed to the Agency of Eighty-Five Thousand, Nine Hundred and Eighty-Six Dollars and Thirty-One cents ($85,986.31).

2. In Audit Number C.I. 07-5644-000/W/TBM, the Agency determined that PETITIONER received overpayment in the amount of Twenty-Nine Thousand, Four Hundred and Thirty-Nine Dollars and Sixteen cents ($29,439.16) for services that in whole or in part were not covered by Medicaid, the audit also imposed sanctions in the amount of Sixty-Five Hundred Dollars ($6,500.00) for a total amount owed to the Agency of Thirty-Five Thousand, Nine Hundred and Thirty-Nine Dollars and Sixteen cents ($35,939.16).

   
   

   Page 3 of 7

   
   

3. The total Medicaid overpayment owed by PETITIONER and due to the Agency for Audit Number C.I. 07-5643-000/W/TBM ($81,486.31), and, Audit Number C.I. 07- 5644-000/W/TBM ($29,439.16) is One Hundred, Ten Thousand, Nine Hundred, Twenty­ Five Dollars and Forty-Seven cents ($110,925.47). PETITIONER also owes the Agency cumulative sanctions in the amount of Eleven Thousand Dollars ($11,000.00) for the audits.

4. The total amount owed by PETITIONER and due to the Agency for Audit Number

   
   

   C.I. 07-5643-000/W/TBM, and, Audit Number C.I. 07-5644-000/W/TBM, consisting of total Medicaid overpayments ($110,925.47) and total Agency sanctions ($11,000.00), is One Hundred, Twenty-One Thousand, Nine Hundred and Twenty-Five Dollars and Forty-Seven cents ($121,925.47).

5. Each FAR imposes specific corrective action measures on the Provider and the provider must comply with such measures.

6. The Agency hereby adopts the facts set forth in the FARs, including

   
   

   1. The total amount of Medicaid overpayments and sanctions, One Hundred, Twenty-One Thousand, Nine Hundred and Twenty-Five Dollars and Forty­ Seven cents ($121,925.47}, is now due and payable from the Provider to AHCA.

   2. Statutory interest on the total Medicaid overpayment amount of One Hundred, Ten Thousand, Nine Hundred, Twenty-Five Dollars and Forty­ Seven cents ($110,925.47), is now due and payable, from Provider to AHCA, pursuant to Section 409.913, Florida Statutes.

      
      

      Page 4 of 7

      
      

   3. The Provider is required to comply with the corrective action measures detailed in the FARs.

CONCLUSIONS OF LAW

The Agency incorporates and adopts each and every relevant statement and conclusion of law set forth in the Final Audit Reports dated November 20, 2008. The admitted facts support the legal conclusion that the total overpayment and sanctions in the amount of One Hundred, Twenty-One Thousand, Nine Hundred and Twenty-Five Dollars and Forty-Seven cents ($121,925.47), are now due and owing from PETITIONER to the Agency. Under Section 409.913, Florida Statutes, interest accrues on the total Medicaid overpayment amount of One Hundred, Ten Thousand, Nine Hundred, Twenty-Five Dollars and Forty-Seven cents ($110,925.47) at 10% annually.

The corrective action measures imposed on Provider under the FARs must be satisfied by the Provider.

Based on the foregoing, it is:

ORDERED AND ADJUDGED that PETITIONER remit, forthwith, the sum of One Hundred, Twenty-One Thousand, Nine Hundred and Twenty-Five Dollars and Forty­ Seven cents ($121,925.47), together with statutory interest on the overpayment amount only, as set forth in Section 409.913, Florida Statutes. Interest at the statutory rate of 10% per annum shall accrue on the unpaid overpayment balance until paid in full.

Page 5 of 7

Provider must also satisfy the corrective action measures specified in each FAR. The PETITIONER's request for an administrative hearing is hereby DISMISSED.

DONE AND ORDERED this Cif-- day of aob , 2009, in Tallahassee,

Florida.

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:

Christopher A. Parrella, J.D., CHC, CPC The Health Law Offices of

Anthony C. Vitale, P.A.

2333 Brickell Avenue, Suite A-1 Miami, Florida 33129

David W. Nam, Assistant General Counsel Agency for Health Care Administration 2727 Mahan Drive

Tallahassee, Florida (Interoffice)

Kenneth Yon, Bureau Chief

Agency for Health Care Administration Medicaid Program Integrity

2727 Mahan Drive Tallahassee, Florida (Interoffice)

Page 6 of 7

Peter H. Williams, Inspector General Agency for Health Care Administration 2727 Mahan Drive

Tallahassee, Florida (Interoffice)

Finance & Accounting (Interoffice)

Page 7 of 7

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order was furnished by

U.S. or interoffice mail to the persons named below on this 1J'!;of e> 6e/ 2009.

RICHARD J. SHOOP, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, MS #3

Tallahassee, FL 32308

(850) 922-5873

Christopher A. Parrella, J.D., CHC, CPC The Health Law Offices of

Anthony C. Vitale, P.A.

2333 Brickell Avenue, Suite A-1 Miami, Florida 33129

David W. Nam, Assistant General Counsel Agency for Health Care Administration 2727 Mahan Drive

Tallahassee, Florida (Interoffice)

Kenneth Yon, Bureau Chief

Agency for Health Care Administration Medicaid Program Integrity

2727 Mahan Drive Tallahassee, Florida (Interoffice)

Peter H. Williams, Inspector General Agency for Health Care Administration 2727 Mahan Drive

Tallahassee, Florida (Interoffice)

Finance & Accounting (Interoffice)

Page 8 of 8

CHARLIE CRIST GOVERNOR

FLORIDA AGENCY FOR HEAl.lH CARE ADMINISTRATION

Better Health Care for all Floridians HOLLY BENSON SECRETARY

CERTIFIED MAIL No. 700103200004 8922 8000

November 20, 2008

Provider No: 265642601 Jesus J. Cid, M.D.

4726 W. Flagle:rStreet

Miami, Florida 33134

In Reply Refer to

FINAL AUDIT REPORT

C.I. No. 07-5643-000/W/TBM

Dear Provider:

The Agency for Health Care Administration (the Agency), Bureau of Medicaid Program Integrity, has completed a review of claims for Medicaid reimbursement for dates of service during the period January 1, 2004 through December 31, 2005. A preliminary audit report dated February 25, 2008 was sent to you indicating that we had determined you were overpaid $82,163.07.,... Based upon a review of all documentation submitted, we have determined that you were overpaid $81,486.31 for services that in · whole or in part are not covered by Medicaid. A fine of $4,500.00 has been applied. The total amount due is $85,986.31.

Be advised of the following:

1. Pursuant to Section 409.913(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 $500.00 for violation of Rule Section 59G-9.070(7)(e), F.A.C.

   • A fine of $500.00 for violation of Rule Section 59G-9.070(7)(c), F.A.C.

   • A fine of $1,000.00 for violation of Rule Section 59G-9,070(7)(t), F.A.C.

   • A fine of$2,500.00 for violation of Rule 59G-9.070(7)(h), F.A.C.

   • A Corrective Action Plan in the form of an Acknowledgement Statement. (See attached.)

   • A Corrective Action Plan in the form of provider education. (See attached.)

   • A Corrective Action Plan in the form of a comprehensive quality assurance program (See attached)

•

EXHIBIT

2727 Mahan Drive, MS# 6

Tallahassee, Florida 32308

In addition to the above, be advised that in a separate case, Case No. 07-2136RU, Custom Mobility, Inc., vs. Agency for Health Care Administration, the Division of Administrative Hearings' law judge ruled that, while Cluster Sampling is a valid and accepted statistical methodology, the formula that the Agency uses should be published in an administrative rule. The Agency has appealed the judge's order. Since the ruling has been appealed, the application of the order is postponed and the Agency is continuing the audit process. In light of the above, you should continue to adhere to any instructions, communication, request for hearing, time deadlines, etc., referenced in the audit report. In regard to payment of the overpayment identified and sanctions imposed during the review, you may choose to pay the overpayment and comply with any sanctions imposed or you may request a hearing since the outcome of the appeal may affect the audit determinations. If you properly request a hearing, the Agency will work with you to place the audit in abeyance until the outcome of the appeal and any impact on this audit is known.

This review and the determination of overpayment were made in accordance with the provisions of Section 409.913, F.S. In determining the appropriateness of Medicaid payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, limitations and requirements found in the Medicaid provider handbooks and Section 409.913, F.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 Medicaid 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)

1. (004) Medicaid policy specifies how medical records must be maintained. A review of your medical records revealed that some services for which you billed and received payment were not documented. Medicaid requires documentation of the services and considers payments made for services not appropriately documented an overpayment.

   
   

2. (008) Medicaid policy defines the varying levels of care and expertise required for the evaluation and management procedure codes for office visits. The documentation you provided supports a lower level of office visit than the one for which you billed and received payment. This determination was made by a peer consultant in accordance with Sections 409.913 and 409.9131,

   F.S. The difference between the amount you were paid and the correct payment for the appropriate level of service is considered an overpayment.

   
   

3. (010) Medicaid policy requires that services performed be medically necessary for the diagnosis and treatment of an illness. You billed and received payments for services for which the medical records, when reviewed by a Medicaid physician consultant, indicated that the services provided did not meet the Medicaid criteria for medical necessity. The claims which were considered medically unnecessary were disallowed and the money you were paid for these procedures is considered an overpayment.

   
   

4. (026a) Medicaid policy addresses specific billing requirements and procedures. In some instances, you billed a procedure code as global and only the technical component was performed. The difference between the amount you were paid and the appropriate fee is considered an overpayment.

OVERPAYMENT CALCULATION

A random sample of 30 recipients respecting whom you submitted 278 claims was reviewed. For those claims in the sample, which have dates of service from January 1, 2004 through December 31, 2005, an overpayment of $5,887.35 or $21.17751799 per claim, was found. Since you were paid for a total (population) of 4,459 claims for that period, the point estimate of the total overpayment is 4,459 x

$21.17751799 = $94,430.55. 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:

F[t,

Where:

E -point estimate of overpayment - A,/

tB,]

B;

F = number of claims in the population = IV

A; = total overpayment in sample cluster B; = number of claims in sample cluster U = number of clusters in the population

i=l

N = number of clusters in the random sample

Y = mean overpayment per claim =

N A, IN B;

t = t value from the Distribution oft Table

All of the claims relating to 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 accepted for this purpose, we have calculated that the overpayment to you is $81,486.3 lwith 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 case 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

$85,986.31, which includes the 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 directed to Medicaid Accounts Receivable, (850) 488-5869.

To ensure proper credit, be certain you legibly record on your check your Medicaid provider number and the C.I. number listed on the first page of this audit report.

Please mail payment to:

Agency for Health Care Administration Medicaid Accounts Receivable

P.O. Box 13749

Tallahassee, Florida 32317-3749

If payment is not received, or arranged for, within 30 days ofreceipt 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 set forth by the Agency may result in termination from the Medicaid Program. Likewise, failure to comply with all sanctions applied or due 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. If a 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 hearirig is made, 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 see the attached Notice of Administrative Hearing and Mediation Rights.

Any questions you may have about this matter should be directed to: Tracy MacDonell, Investigator, Agency for Health Care Administration, Office of the Inspector General, Medicaid Program Integrity, 2727 Mahan Drive, Mail Stop #6, Tallahassee, Florida 32308-5403, telephone (850) 921-1802, facsimile

(850) 410-1972.

Sincerely,

-------::::>

'--=--)

Ms. Robi Olmstead AHCA Administrator

RO/tbm

Enclosure(s)

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), Florida Statutes. If you do not dispute the facts stated in the FAR, but believe there are additional reasons to 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 written request for an administr.ative hearing must conform to the requirements of either Rule 28-106.201(2) or Rule 28-106.301(2), Florida Administrative Code, and must be received by the Agency for Health Care Administration, Bureau of Medicaid Program Integrity by 5:00 P.M. no later than 21 days after you received the FAR. The address for filing the written request for an administrative hearing is:

AHCA Administrator, Richard Shoop, Esquire

Agency Clerk

Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3

Tallahassee, Florida 32308

The request must be legible, on 8 ½ by 11-inch white paper, and contain:

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;

1. An explanation of how your substantial interests will be affected by the action described in the FAR;

2. A statement of when and how you received the FAR;

3. For a request for formal hearing, a statement of all disputed issues of material fact;

4. F·or 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;

5. For a request for formal hearing, whether you request mediation, if it is available;

6. For a request for informal hearing, what bases support an adjustment to the amount owed to the Agency; and

7. A demand for relief.

   
   

   A formal hearing will be held if there are disputed issues of material 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 set 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 proceed without mediation. The mediation must be concluded within 60 days of having entered into the agreement, unless you and the Agency agree to 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. If a 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.

   
   

   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 for Health Care Administration (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 Office of Inspector General, Medicaid Program Integrity within 30 days of the issuance of this FAR. Please sign the enclosed statement and return it to:

   Gloria Derby

   Agency for Health Care Administration Office of Inspector General

   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.

   
   

   PROVIDER ACKNOWLEDGEMENT STATEMENT

   
   

   I ,on behalf of Jesus J. Cid, M.D.

   (insert printed full name here)

   
   

   a Medicaid provider operating under provider number 265642600, do hereby acknowledge the obligation of Jesus J. Cid, M.D., to adhere to state and federal Medicaid laws, rules, provisions, handbooks, and policies. Additionallyjesus J. Cid, acknowledges that Medicaid poli y requires:

   
   

   Medicaid policy states that, in order to qualify for reimbursement, medical records must be signed and dated at the time of the service. The policy states that the author of each (medical record) entry must be identified and must authenticate his or her entry by signature, written initials or computer entry. A review of your medical records revealed that some services, for which you billed and received payment, were not signature certified. These requirements are currently found in the Florida Medicaid Provider General Handbook, dated October 2003.

   
   

   The procedure codes listed in the Physician Coverage and Limitations Handbook are Health Care Common Procedure Coding System codes, Level 1 and Level 2. The codes are part of the standard code set described in the Physician's Current Procedure Terminology (CPT) book. The CPT code selected for billing must reflect the type, level, and description of the procedures performed. These guidelines are used in conjunction with the Physician Coverage and Limitation Handbook.

   
   

   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.

   
   

   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

• Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

By: Date: (signature)

(title)

Return completed acknowledgement statement to Office of Inspector General, Medicaid Program Integrity.

Comprehensive Quality Assurance and Provider Education

Corrective Action Plan · Jesus Cid, Provider Number 265642601

RE: Case #07-5643-000, Final Audit Report

PURPOSE:

The purpose of this Corrective Action Plan is to ensure that the provider of services (Jesus Cid, MID.) and their respective employees are knowledgeable of the Medicaid policies and procedures (as set forth in the Florida Medicaid General Handbook and Physician's Handbook) required for proper documentation of service provision and billing for payment of services rendered.

DESCRIPTION:

A Corrective Action Plan shall be a written document, submitted to the Agency, and will be an "acknowledgement statement", "provider education", "self audit", and a "comprehensive quality assurance program".

REQUIREMENTS:

Based upon the sanctions imposed which are governed by Chapter 59G-9.070, F.A.C., you are required to complete the attached acknowledgement statement, provider education and a comprehensive quality assurance Corrective Action Plan.

"Provider education" will be the successful completion of an educational course or courses that address the areas of non-compliance as determined by the Agency in the Agency action: In this case, for violation of 59G-9.070 (7)(f), Furnishing or ordering goods or services that are inappropriate, unnecessary or excessive, of an inferior quality, or that are harmful. Please see the Final Audit Report for specific findings.

A "comprehensive quality assurance program", which is required as a result of violation of 59G-

1. (7)(h), Submitting false or a pattern of erroneous medical claims, will monitor the efforts of the provider, entity, or person (herein known as "provider") in their internal efforts to comply with state and federal Medicaid laws, the laws that govern the provider's profession, and the Medicaid provider agreement. The program must contain at a minimum the following elements: identification of the physical location where the provider, entity, or person takes any action that may cause a claim to Medicaid to be submitted; contact information regarding the individual or individuals who are responsible for development, maintenance, implementation, and evaluation of the program; a separate process flow diagram that includes a step-by-step written description or flow chart indicating how the program will be developed, maintained, implemented, and evaluated; a complete description and relevant time frames of the process for internally maintaining the program, including a description of how technology, education, and staffing issues will be addressed; a complete description and relevant timeframes of the process for implementing the program; and a complete description of the process for monitoring, evaluating,

   
   

   
   

   and improving the program. The provider will identify one or more individuals who are the Medicaid policy compliance individuals for the provider, and must include the individuals involved with the areas of non-compliance, such as billing staff, who must successfully complete the required education. The Agency must approve quality assurance program. Please see the Final Audit Report for specific findings associated with this violation of Rule and this sanction.

   
   

   TIMEFRAMES:

   
   

   Provider education: The provider will, within 30 days of the date of the Agency action, submit for approval the name of the course, contact information, and a brief description of the course intended to meet this requirement. In the event that the program is not approved, the provider will have 10 days to submit additional course information. Proof of successful completion of the provider education must be submitted to the Agency within 90 days of the date of the Agency action that brought rise to this requirement

   
   

   Comprehensive quality assurance program: A process flow diagram regarding the development of the program must be submitted to the Agency within 30 days from the date of the Agency action and must be updated every 30 days until the comprehensive quality assurance program is approved by the Agency. A process flow diagram regarding the maintenance, implementation, and evaluation of the program must be submitted to the Agency within 90 days from the date of the Agency action and must be updated every 30 days until the comprehensive quality assurance program is approved by the Agency. The evaluation process must contain processes for conducting internal compliance audits, which include reporting of the audit findings to specific individuals who have the authority to address the deficiencies, and must include continuous improvement processes. The plan must also include the frequency and duration of such evaluations. The Agency will review the process flow diagram and description of the development of the program and either approve the program or disapprove the program. If the Agency disapproves the program, specific reasons for the disapproval will be included, and the provider, entity, or individual shall have 30 days to submit an amended development plan.

   Upon approval by the Agency of the development process of the program, the provider, entity, or

   person shall have 45 days to implement the program. The provider shall provide written notice to the Agency indicating that the program has been implemented.

   
   

   The program must remain in effect for the time period specified in the Agency action and the provider must submit written progress reports to the Agency every 120 days, for the duration of the program.

   
   

   
   

   FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION

   Provider: 265642601 - JESUS J CID, MD

   Overpayment Calculation Using Cluster Sampling Dates Of Service: 1/1/2004 through 12/31/2005

   
   

   Number of recipients in population: Number of recipients in sample: Total payments in population:

   No. of claims in population:

   
   

   347

   Case ID:	07-5643-000
   Confidence level:	95%
   t value:	1.6991268

   30

   $196,639.08 4,459

   
   

   
   

   	Recip# 1	No. Claims 17	Total Dollars $742.68	Overpayment $374.14
   	2	12	$421.77	$170.39
   	3	13	$611.20	$288.93
   	4	9	$411.31	$130.13
   	5	21	$928.14	$375.76
   	6	1	$71.59	$0.00
   	7	12	$420.33	$192.41
   	8	1	$39.49	$0.00
   	9	8	$348.04	$137.27
   	10	7	$342.72	$156.56
   	11	13	$506.61	$224.92
   	12	8	$345.84	$172.56
   	13	12	$522.55	$289.77
   	14	9	$364.40	$158.22
   	15	11	$446.81	$122.62
   	16	47	$2,337.80	$1,635.85
   	17	7	$278.70	$161.41
   	18	6	$216.07	$81.47
   	19	16	$628.90	$338.33
   	20	11	$439.91	$256.62
   	21	2	$106.31	$31.01
   	22	7	$310.80	$135.07
   	23	7	$328.93	$129.03
   	24	3	$166.93	$71.47
   	25	2	$104.16	$0.00
   	26	2	$104.16	$0.00
   	27		$66.85	$0.00
   	28	3	$141.40	$92.71
   	29	6	$257.09	$115.18
   	30	4	$125.31	$45.52
   Totals:	30	278	$12,136.80	$5,887.35
   Using Overpayment per claim method
   Overpayment per sample claim:		$21.17751799
   Point estimate of the overpayment:		$94,430.55
   Variance of the overpayment:		$58,036,584.64
   Standard error of the overpayment:		$7,618.17
   Half confidence interval:		$12,944.24
   Overpayment at the 95 % Confidence level:		$81,486.31

   
   

   Overpayment run on 11/14/2008 Page 1 of 1

   
   

   
   

   CHARLIE CRIST GOVERNOR

   FLO · , · . · · ..

   Better Health Care for all Floridians HOLLY BENSON SECRETARY.

   
   

   
   

   CERTIFIED MAIL No. 7001 0320 0004 8922 8666

   
   

   November 20, 2008

   Provider No: 265642600 Jesus J. Cid, M.D.

   4726 W. Flagler Street

   Miami, Florida 33134

   
   

   In Reply Refer to

   FINAL AUDIT REPORT

   C.1. No. 07-5644-000/W/TBM

   
   

   Dear Provider:

   
   

   The Agency for Health Care Administration (the Agency), Bureau of Medicaid Program Integrity, has completed a review of claims for.Medicaid reimbursement for dates of service during the period January 1, 2004 through December 31,·2005. A preliminary audit report dated February 25, 2008 was sent to you indicating that we had determined you were overpaid $32,739.Ql. Based upon a review of all documentation submitted, we have determined that you were overpaid $29,439.16 for services that in whole or in part are not covered by Medicaid. A fine of $6,500.00 has been applied. The total amount due is $35,939.16.

   
   

   Be advised of the following:

   
   

   1. Pursuant to Section 409.913(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 $2,500.00 for 4 violation(s) of Rule Section 59G-9.070(7)(e), F.A.C.

• A fine of $500.00 for violation of Rule Section 59G-9.070(7)(c), F.A.C.

• A fine of $1,000.00 for violation of Rule Section 59G-9,070(7)(f), F.A.C.

• A fine of $2,500.00 for violation of Rule 59G-9.070(7)(h), F.A.C.

• A Corrective Action Plan in the form of an Acknowledgement Statement. (See attached.)

• A Corrective Action Plan in the form of provider education. (See attached.)

  •

• A Corrective Action Plan in the form of a comprehensive quality assurance program (See attached.)

2727 Mahan Drive, MS# 6

Tallahassee, Florida 32308

Visit AHCA online at http://ahca. myflorida. com

• Jesus J. Cid, M.D.

Page2

In addition to the above1 be advised that in a separate case, Case No. 07-2136RU, Custom Mobility, Inc., vs. Agency for Health Care Administration, the Division of Administrative Hearings' law judge ruled that, while Cluster Sampling is a valid and accepted statistical methodology, the formula that the Agency uses should be published in an administrative rule. The Agency has appealed the judge's order. Since the ruling has been appealed, the application of the order is postponed and the Agency is continuing the

audit process. In light of the above, you should continue to adhere to any instructions, communication, request for hearing, time deadlines, etc., referenced in the audit report. In regard to payment of the overpayment identified and sanctions imposed during the review, you may choose to pay the overpayment and comply with any sanctions imposed or you may request a hearing since the outcome of the appeal may affect the audit determinations. If you properly request a hearing, the Agency will work with you to place the audit in abeyance until the outcome of the appeal and any impact on this audit is known.

This review and the determination of overpayment were made in accordance with the provisions of Section 409.913, F.S. In determining the appropriateness of Medicaid payment pursuant to Medicaid policy, the Medicaid program utilizes procedure codes, descriptions, policies, limitations and requirements found in the Medicaid provider handbooks and Section 409.913, F.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 Medicaid 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)

1. (004) Medicaid policy specifies how medical records must be maintained. A review of your medical records revealed that some services for which you billed and received payment were not documented. Medicaid requires documentation of the services and considers payments made for services not appropriately documented an overpayment. ·

   
   

2. (008) Medicaid policy defines the varying levels of care and expertise required for the evaluation and management procedure codes for office visits. The documentation you provided supports a lower level of office visit than the one for which you billed and received payment. This determination was made by a peer consultant in accordance with Sections. 409.913 and 409.9131,

   F.S. The difference between the amount you were paid and the correct payment for the appropriate level of service is considered an overpayment.

   
   

3. (010) Medicaid policy requires that services performed be medically necessary for the diagnosis and treatment of an illness. You billed and received payments for services for which the medical records, when reviewed by a Medicaid physician consultant, indicated that the services provided did not meet the Medicaid criteria for medical necessity. The claims which were considered medically unnecessary were disallowed and the money you were paid for these procedures is considered an overpayment.

   
   

4. (011) Medicaid policy requires that the provider retain all medical records on all services provided to a Medicaid recipient. The records must be accessible, legible and comprehensible. A review of your medical records revealed that some were illegible. Payment made to you for these services is considered an overpayment.

   
   

   ' Jesus J. Cid, M.D. 'Page 3

   
   

5. (003a) Medicaid policy states that, in order to qualify for reimbursement, medical records must be signed and dated at the time of the service. The policy states that the author of each (medical record) entry must be identified and must authenticate his or her entry by signature, written initials or computer entry. A review of your medical records revealed that some services, for which you billed and received payment, were not signature certified. Payment made to you for services not certified by a signature is considered an overpayment.

   
   

6. Medicaid policy addresses specific billing requirements and procedures. In some instances, you billed a procedure code as global and only the technical component was performed. The difference between the amount you were paid and the appropriate fee is considered an overpayment.

OVERPAYMENT CALCULATION

A random sample of30 recipients respecting whom you submitted 293 claims was reviewed. For those claims in the sample, which have dates of service from January 1, 2004 through December 31, 2005, an overpayment of $6,077.02 or $20.74068259 per claim, was found. Since you were paid for a total (population) of 1,657 claims for that period, the point estimate of the total overpayment is 1,657 x

$20.74068259 = $34,367.31. 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:

E - point estimate of overpayment - F[t, A,/t,B,]

u

F = number of claims in the population = LB;

i=l

A; = total overpayment in sample cluster Bi = number of claims in sample cluster U = number of clusters in the population

N = number of clusters in the random sample

Y = mean overpayment per claim =

N Ai IN B;

t = t value from the Distribution of t Table

All of the claims relating to 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 accepted for this purpose, we have calculated that the overpayment to you is $29,439.16 with a ninety-five percent (95%) probability that it is that amount or more.

• Jesus J. Cid, M.D.

Page4

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 case number; (3) the court name and the division in which the petition was filed (e.g., Northern District of Florida, Tallahassee Division); and,

1. 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

   $35,939.16, which includes the 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 directed to Medicaid Accounts Receivable, (850) 488-5869. To ensure proper credit, be certain you legibly record on your check your Medicaid provider number and the C.I. number listed on the first page of this audit report.

   
   

   Please mail payment to:

   
   

   Agency for Health Care Administration Medicaid Accounts Receivable

   P.O. Box 13749

   Tallahassee, Florida 32317-3.749

   
   

   If payment is not received, or arranged for, within 30 days ofreceipt 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 set forth by the Agency may result in termination from the Medicaid Program. Likewise, failure to comply with all sanctions applied or due 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. If a 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, 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 (2 l) 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.

   
   

   Any questions you may have about this matter should be directed to: Tracy MacDonell, Investigator, Agency for Health Care Administration, Office of the Inspector General, Medicaid Program Integrity, 2727 Mahan Drive, Mail Stop #6, Tallahassee, Florida 32308-5403, telephone (850) 921-1802, facsimile

   (850) 410-1972.

   
   

   '2

   Sincerely,

   0

   .I

   Ms. Robi Olmstead AHCA Administrator

   
   

   RO/tbm

   
   

   Enclosure(s)

   .. )

   
   

   -e:,)(

   
   

   • Jesus J. Cid, M.D.

     '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), Florida Statutes. If you do not dispute the facts stated in the FAR, but believe there are additional reasons to 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 written request for an administrative hearing must conform to the requirements of either Rule 28-106.201(2) or Rule 28-106.301(2), Florida Administrative Code, and must be received by the Agency for Health Care Administration, Bureau of Medicaid Program Integrity by 5:00 P.M. no later than 21 days after you received the FAR. The address for filing the written request for an administrative hearing is:

     
     

     AHCA Administrator, Richard Shoop, Esquire

     Agency Clerk

     Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3

     Tallahassee, Florida 32308

     
     

     The request must be legible, on 8 ½ by I I-inch white paper, and contain:

     
     

     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;

     1. An explanation of how your substantial interests will be affected by the action described in the FAR;

     2. A statement of when and how you received the FAR;

• 3. For a request for formal hearing, a statement of all disputed issues of material fact;

1. 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;

2. For a request for formal hearing, whether you request mediation, ifit is available;

3. For a request for informal hearing, what bases support an adjustment to the amount owed ro the Agency; and

4. A demand for relief.

   
   

   A formal hearing will be held if there are disputed issues of material 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 set 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 proceed without mediation. The mediation must be concluded within 60 days of having entered into the agreement, unless you and the Agency agree to 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. If a 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.

   
   

   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 for Health Care Administration (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 1:J:ie 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 Office of Inspector General, Medicaid Program Integrity within 30 days of the issuance of this FAR. Please sign the enclosed statement and return it to:

   Gloria Derby

   Agency for Health Care Administration Office of Inspector General

   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.

   
   

   PROVIDER ACKNOWLEDGEMENT STATEMENT

   
   

   I ,on behalf of Jesus J. Cid, M.D.

   (insert printed full name here)

   
   

   a Medicaid provider operating under provider number 265642600, do hereby acknowledge the obligation of Jesus J. Cid, M.D., to adhere to state and federal Medicaid laws, rules, provisions, handbooks, and policies. Additionallyjesus J. Cid, acknowledges that Medicaid policy requires:

   
   

   Medicaid policy states that, in order to qualify for reimbursement, medical records must be signed and dated at the time of the service. The policy states that the author of each (medical record) entry must be identified and must authenticate his or her entry by signature, written initials or computer entry. A review of your medical records revealed that some services, for which you billed and received payment, were not signature certified. These requirements are currently found in the Florida Medicaid Provider General Handbook, dated October 2003.

   
   

   The procedure codes listed in the Physician Coverage and Limitations Handbook are Health Care Common Procedure Coding System codes, Level I and Level 2. The codes are part of the standard code set described in the Physician's Current Procedure Terminology (CPT) book. The CPT code selected for billing must reflect the type, level, and description of the procedures performed. These guidelines are used in conjunction with the Physician Coverage and Limitation Handbook.

   
   

   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.

   
   

   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

   • Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

By: Date: -----------

(signature)

(title)

Return completed acknowledgement statement to Office of Inspector General, Medicaid Program Integrity.

Comprehensive Quality Assurance and Provider Education Corrective Action Plan

Jesus Cid, Provider Number 265642600 RE: Case #07-5644-000, Final Audit Report

PURPOSE:

The purpose of this Corrective Action Plan is to ensure that the provider of services (Jesus Cid, MID.) and their respective employees are knowledgeable of the Medicaid policies and procedures (as set forth in the Florida Medicaid Physician's Handbook) required for proper documentation of service provision and billing for payment of services rendered.

DESCRIPTION:

A Corrective Action Plan shall be a written document, submitted to the Agency, and shall either be an "acknowledgement statement", "provider education", "self audit", or a "comprehensive quality assurance program".

REQUIREMENTS:

Based upon the sanctions imposed which are governed by Chapter 59G-9.070, F.A.C., you are required to complete both provider education and a comprehensive quality assurance Corrective Action Plan.

"Provider education" will be the successful completion of an educational course or courses that address the areas of non-compliance as determined by the Agency in the Agency action: In this case, for violation of 59G-9.070 (7)(f), Furnishing or ordering goods or services that are inappropriate, unnecessary or excessive, of an inferior quality, or that are harmful. Please see the Final Audit Report for specific findings.

A "comprehensive quality assurance program" which is required as a result of violation of 59G-

9.070 (7)(h), Submitting false or a pattern of erroneous medical claims, will monitor the efforts of the provider, entity, or person (herein known as "provider") in their internal efforts to comply with state and federal Medicaid laws, the laws that govern the provider's profession, and the Medicaid provider agreement. The program must contain at a minimum the following elements: identification of the physical location where the provider, entity, or person takes any action that may cause a claim to Medicaid to be submitted; contact information regarding the individual or individuals who are responsible for development, maintenance, implementation, and evaluation of the program; a separate process flow diagram that includes a step-by-step written description or flow chart indicating how the program will be developed, maintained, implemented, and evaluated; a complete description and relevant time frames of the process for internally maintaining the program, including a description of how technology, education, and staffing issues will be addressed; a complete description and relevant timeframes of the process for implementing the program; and a complete description of the process for monitoring, evaluating, and improving the program. The provider will identify one or more individuals who are the

Medicaid policy compliance individuals for the provider, and must include the individuals involved with the areas of non-compliance, such as billing staff, who must successfully complete the required education. The Agency must approve quality assurance program. Please see the Final Audit Report for specific findings associated with this violation of Rule and this sanction.

TIMEFRAMES:

Provider education: The provider will, within 30 days of the date of the Agency action, submit for approval the name of the course, contact information, and a brief description of the course intended to meet this requirement. In the event that the program is not approved, the provider will have 10 days to submit additional course information. Proof of successful completion of the provider education must be submitted to the Agency within 90 days of the date of the Agency action that brought rise to this requirement

Comprehensive quality assurance program: A process flow diagram regarding the development of the program must be submitted to the Agency within 30 days from the date of the Agency action and must be updated every 30 days until the comprehensive quality assurance program is approved by the Agency. A process flow diagram regarding the maintenance,

implementation, and evaluation of the program must be submitted to the Agency within 90 days

from the date of the Agency action and must be updated every 30 days until the comprehensive quality assurance program is approved by the Agency. The evaluation process must contain processes for conducting internal compliance audits, which include reporting of the audit findings to specific individuals who have the authority to address the deficiencies, and must include continuous improvement process_es. The plan must also include the frequency and duration of such evaluations. The Agency will review the process flow diagram and description of the development of the program and either approve the program or disapprove the program. If the Agency disapproves the program, specific reasons for the disapproval will be included, and the provider, entity, or individual shall have 30 days to submit an amended development plan.

Upon approval by the Agency of the development process of the program, the provider, entity, or person shall have 45 days to implement the program. The provider shall provide written notice to the Agency indicating that the program has been implemented.

The program must remain in effect for the time period specified in the Agency action and the provider must submit written progress reports to the Agency every 120 days, for the duration of the program.

FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION

Provider: 265642600 - JESUS J CID

Overpayment Calculation Using Cluster Sampling Dates Of Service: 1/1/2004 through 12/31/2005

Number of recipients in population: Number of recipients in sample: Total payments in population:

No. of claims in population:

146

30

$75,640.31 1,657

Overpayment run on 11/18/2008 Page 1 of 1

Docket for Case No: 09-000099MPI

Orders for Case No: 09-000099MPI