STATE OF FLORIDA
DIVISION' OF ADMINISTRATIVE HEARINGS
AGENCY FOR HEALTH CARE ADMINISTRATION,
FILED
AHCA
AGENCY CLERK
zooq OCT 12 A 11: 20
Petitioner,
vs. DOAH Case No. 09-0355MPI
RENDITION NO.: AHCA-09-QQ -5-MDO
HEARTLAND INTERNAL MEDICINE ASSOCIATES
Respondent.
!
HEARTLAND INTERNAL MEDICINE ASSOCIATES
Petitioner,
AGENCY FOR HEALTH CARE ADMINISTRATION,
Respondent.
I
FINAL ORDER
THE PARTIES resolved all disputed issues and executed a Stipulation and Agreement. The parties are directed to comply with the terms of the attached stipulation and agreement.
Based on the foregoing, this file is CLOSED.
DONE and ORDERED on this the 1i f- day of CJcfi>bA,y- , 2009, in Tallahassee, Florida.
Filed October 12, 2009 11:38 AM Division of Administrative Hearings.
DOAH Cases No. 09-0355MPI and 09-0359RU
AHCA v. HEARTLAND and HEARTLAND v. AHCA
Final Order
w-JL
H◊LLY BENSON, sbARY
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:
Debora E. Fridie, Esq.
Agency for Health Care Administration (Interoffice Mail)
William M. Furlow, III, Esquire
Metzger, Grossman, Furlow & Bayo, LLC 1408 North Piedmont Way
Tallahassee, Florida 32308 (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)
Kenneth Yon, Bureau Chief, MPI Agency for Health Care Administration (Interoffice Mail)
Peter H. Williams, Inspector General Agency for Health Care Administration (Interoffice Mail)
Finance and Accounting
Agency for Health Care Administration
Page 2 of3
DOAH Cases No. 09-0355MPI and 09-0359RU
AHCA v. HEARTLAND and HEARTLAND v. AHCA
Final Order
CERTIFICATE OF SERVICE
I 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 / y of
Richard Shoop, Esquire Agency Clerk
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308-5403
Page 3 of3
7 /i 7 /2009 1::.a PH Fl\OM: 863-J8f,-8t44 Heartland Int •·n;,l Med TO: 1- ;.o-:,ss-1953 PAGE: 002 OF 011
STATE OF FLORIDA
DIVISION PF ADMfN!STRATIVE 1-mARfNGS
AGENCY FOR HEALTH CARE
ADMINISTRATION.
Petitioner,
vs. OOAH Ca.'>e No. 09..035.SMPI
HEARTt.AND INTERNAL MEDICJNE
ASSOCIATES
Respondent.
/'
HEARTLAND INTERNAL Ml l)ICJNE ASSOCIATES
vs.
AGENCY FOR HEALTH CARE ADMINJSTRATlON,
DOAH Case No. 09-0359RU
Rci:ponctcnt.
-----------------'
STlPULATIQtl.1iNP AGREEMENT
The AOeNCY FOR HEALTH CARE ADMINISTRATION (nlk/a nnd hereinafter AHCA or the ·'Agency"). and HEARTLAND lN'l'ERNAL MEDICINE ASSOCIATES (n/k/a ar.d hercinufrer "HEARTLAND'' or "PROVIDER"), byund through the undersigned, hereby stipulate and agree to lhe following:
The purtlcs enler into this agreement for the purpo e of memorializing the resolution to this matter.
'/i17/20!}9 1:3•) PM FRC,11: 863<3Bfi-8i44 f"!cartland Internal Med TO: l -R ()-385·39!'.o PAGE: <)(I.J or 011
-' / l l
OOAI I Ca. ;:., No. 09-0355.MP.I und 0'.1;03:SORtJ
AllCA v. l·!EARTLAND and l·JCAJffl,AND v.AHC,\
Stipulation nnd /\grCcl!':<lnl
HEARTLAND is a Medicaid provider in the S1a1c of florido, operating unde PROVIDI!R Number 2663902-00.
[n its Pinal Audit Report. C,1. Number 06-4468·000, (the ''Aa<lit Letter" or "FAR") dated Dc!cember 17, 2008, /,HCA notilicd HEARTLAND thnt review ofMe(liceld claims performed by Medicaid Program lnteg1·i1y (r.fPf} hidicated tlrnt, in its opinion. some
claims in whole or in part were not covered ()y M1:dicnld. The Agcncysought repayment oran ovcrptiymcnt in the nmoun ofThirty•Scven., 'fhousanrl Four Hundred Nineteen Dollars and Fifty-Nine cents ($37,419.59). AHCA also notified HF.J\lr11.,AND in the FAR that it is set-king s1mctions in t.hc forrn of a Two Thousand, i ive Hundred Dollars ($2,500.00) tbe and a Corrcet:Vt\ Acri<in Pinn in the form of o PROVIDER Acknowl dgcment Statement. Th
:,anctions were determined pursuiint to Rule 590-9_.070, P!2rida Admin..!filr.mjyef.;ode. ln
response, HEARTLAND pctitioued for u fomu1l d1ninistra.tlve hearing. 1-1 l ARTLAND's drnllenge to the Medicaid overpnyment determination w s referred to the Division of
Ad1 1ini!11rn1ivc Hearings ("DOAFJ'') for assigr.mcnt toun Admi11istrallvc Law Judge and
assigned DOA H Case Number 09-0355MPI. HEARTLAND also filed with DOA!-! an unpromulgatcd rule clrnltenge nnd therein chnllcnged the Medicaid policy of calculating some overpayments through cluster sumpling. Thm rule challc:1ge wus assigned to art Administrative
Law Judge and assigned DOAf-1 Case Numher 09-0J59R U. Slibr.equently, the Judge entered an
Order dated J:muary 2&, 2009, consolidating D(JAH Cu!:e Number 09-0355MPI and Case
Both parties stlpulnte and llgrce that HEARTLAND shall p,iy a Medicaid overpayment amour1t of Thirty Sevtn Ti1011sand, Four Hundred Nineteen Dollars nnd Fifty-Nir,e cents ($3 /,419. 9) and a sanction in the amounl of Two Thousand, f ive Hundred Dnllnrs
Page 2 of l(J
f)(JAH C1m.-.s No. 09-03!i;MJ)f :1od 09-03S9RU
MICA·,•. HEARTl.AND ;m.-1 I H:t\RTLA'ND v. Al ICA
ti;iuMion 11nd Agre nient
($2,500.00), for a total ovc:rpaymnnt amount ofThuty Nine Thousand, Nine Hundred, Nineteer. Dollars and Fifty-Nine cents ($39;919.59). ln addition, HEARTLAND 1igrees to complete a Correi:tivc Action Plan in the form ofa PROVIDER Ac.lmowledgement StateU1ent, which ls
i11corpornted uy reference into this Stipulation and ARreement.
In mdcr to resolvt! DOAH Case Number 0'9--0355MP! tmd Ca.qc
Number 09-0359RU without further adailnistr.i;rtiv procI:edings. AHCA and 1-lf::Af{TLAND
e.-.:µ1essly agree as follows;
(a} MICA will accept the overpayment seHorth herein as a complete resolution of the overpaymeflt issuesarisi!}S from the MP[ review cited in paragraph four (4) above.
·n1e adjusted Medicaid overpayment plus snncticm in the tornl amount cfThirty Nine Thous.ind, Nine Hundred. Nineteen Dollars and Fifty-Nine cent!i ($39,919.59) shnll be paid us follows:
Withb thirty (30) days of the issuance of the Order HEARTLAND shall pay the A e:-icy on initial puynrnnt of Nine Thousand, Eight Hundred, Seventy-Nine Dollars and Ninety ccn:s ($9,879.90).
Within thirty (JO) days afler the initial payme, t ofthe Nine Thou.send. Eight Hundred, SevenlyuNinc Dollars nnd Ninety cents (.$9;879.90). HEJ\RTLANO agrees to ma :c the first installment pay:neat to the Agency of Pive Thousand, One Hundred Fifty-Three Dollars and Sii.:ty.•five cents ($5,153.65). HEARTLAND shall pny each subsequent installment
pfilym nt on the baluncc due 'l.vithin days of the due date of the previous
7(17/2009 l:)e FM FROM: 8'.,J-)3 -$144 Heartland Internal Med TO: 1-850-3>}5-}953 !'AGE: 00 · c,; 011
DOAtl Ccscs No, 09-0SS:5Mlll 1md 09-03S9RU
/\HCA,-. lll trl'l,AND and HEI\RTLANO v. Al IC/\ S1ipuln1ion ;md A!:rccm:::11
payment until the overpnyrnen't an\ount ls pnid in full, by no later than seven
(7) months of the date of the i.1J.<inancc of the Fina! OrdeL
In the cventthaf HEARTLAND pays the balance due early, there is no penalty for early payment. The outstanding balance ofThirty-1',:ine Thoi:sand, Nine Hundred, Nineteen Dollars and Fifty-Nine cents ($39,919.59) will accTue intr.r:est at the rate as set tc,rth in Sectfon 409.913(25)(c), Florida Stntuter.. until l'he balance fa paid in full.
The A ency retains the righr to perform n six (6) mo:1th fof!ow up review.
(t1) Hl ARTLAND an<l /\HCA ugree that foll payment ns set fcl'th above will resolve und sett[e both DOAH Case Number 09-0355MPI 11:1d Cuse Numbel' 09,-0359R tJ completely and release all parties fron,all liabllitlcs arising from the lindings in the a:,dil referenced ns C;I; Nt11i1b r 06-4468-000.
HEARTLAND agrees that it will nm rcbill the Medicaid Program in ahy :nanner
fo1· claims lht\l were not covered by.Medicaid. which l!re the subject ofthc uu<lit in
HEARTL,\NDngn.:e:i-to fully cMperatc with any follow up reviews conducted
Payment shall he madt, to:
Medicaid Accounts Rccelvablc Post Offiet Box l3749 Tallulmssee, Florida 32317-3749
And payment :-:hall cle ady indicete that it is per a stip:tlation and agreement and shall reference
the C.I. Number 11.nd th<: Provider Number.
Pagc4 of'.G
1/11/iOO'l ·1: 38 Pl-I 1"1\011: 863-385-8144 n,-at't li't1,d !nt,,rn.,l Nii!ci 1'(,: 1-S50-.le5-39 ,:,
PAGE: 00'5 OF 011
:::, 11.1 :1- Ju J ··· 11;; ,;i : J.::,
...,,...
.,,·_,,..·,. r· ' , ro
asman 1•ur1ow & bO.l'O :>u,1r; j:;1::::.J
r:> r l 1
DOM I C.isl' No. 09-03S5MPl ond il?-03.SORU
1\1-ICA v. HEARTLAND 1md llliARTLAND v, AJIC,'\
81i1mla1ion uml Atre1>men:
HEARTLAND agrees lhat fui!ure to payany monies. due and owing·under the 1crms of this Agrecmcm shall c<mstiMe HEA.RTLANo·•s authorization for the A ency, without furthe-r 119ticr., to withhold the total remaining amount due under the terms of this i,gree1-:1cnt from a.:1y monies due and owing to HEARTLAND for any Medi aicl claims.
AHCA rr:snrves the right to enforce this Stipulation and Agree,mmt under the laws of the Srnte of florida, the Rules of the Medienid Program, and all other applicable rufos and regulations.
). E,-.:ccpr ns specifically provided 'in vnragraph four (4) above, the pnrtit:s agree to
bear thdt own allorncy's fees r1nd other costs, if any.
10. /\s a part of this Stipulation and Agreement, HEARTLAND a.gl'ees that AHCA mny impose a<lministrative sanctions pumlahtto Rule 59G-9.070. Florida Administralive Cede, us referenced in par.ngruph rour (4) atove.
I l. H1::ARTLA ND as its PROV!DER Acknowledgment Statemenl/Correctlvc Action
Plrln acknowledges that:
The Procc!dute Codes listed in the Physician Services Pee Schedule arc Hea!tl: Care Cominon Procedure Codi g System Codes, Level rand Level !J. The codc:s arc part ofthe s!andurd codes set described in the Physicians Current Procl,tllltC Terminology (CPT book). The CPT book givP-s (:ompltte dcscrip1ions of the stnn<lorrl corles. The CPT codr. set for billing must :eflect the type. level, on deseription of the procedure (s) performed. These guidelines are used in conjum.:lioll \llith the Physician Coverage Limitation
J !andbook. Tho docutnentation provided to the Agency revealed !httt
PROVIDER did not bill acwrding to the guidelines h1 certain instanct!S.
Page 5of IO
DOA!l Ct$C$ Ne. 09-0355MPI 1111<! 09•0J59RU
MICA v. HH,'\R1'LAND nnd HHAHTLAND v. Al-!CA
Sti1>11l111ion nnd Agrecmem
Listed immediately below ure th violations uttdb 1tab!t to this review
determination.
The documentatfon PROV(l)E provided supports a lower level ot'offici: visit thnn the one PROVIDER billed and received payment. ·1nfs determination
was made by peen:onsultant in accordance with Sections 409.913 and 409.913 I, Florida Statutes. The difforencc between the amount PROVIDER paid and l he correct payment fol' the appropriate levd service is C,)nsidcrcd no overpayment.
Medicaid policy specifies how medical records must.be maintained. A :·eview of PROVIDER 's medical records revealed that son1e services for ,vhich PROVlDER billed and receiv11<l payment were not documented. Medicaid re(iuires documentation of the services and considerspnymenL'> for services net appropriately documented and. overpayment.
M,:dicald P,.')licy requires that services performed be rne<lkally necessary for the diagnosis and treatment of an illness. l>ROVIDER billed and received pityrnents :~or services for which the medical records, when reviewed by ii;
Medicaid physician consultant, iodicatcd that the services did not meet the medic-11 criteria for medical necessity. The claims which were considered medically u:.ni-..ces. ary were disuHowed and the money paid for rhe$e
procedures is considered an ov rpayment.
12. The iiignatorics to this Agree111ent, ac!bg in a represimtative capacity, represent tl:ot they urc duly authorized to enter into !his Agreement on behalf of the respective parties. Furthe1111ore, HE.t.o.RTLAND agrcrs thal its signature alone binds HEARTLAND to :nake the
7/17/20•)9 1: 38 f'H FROM: 8(o.l-J:S5-8144 Heartland lntern,il Mf:d TO: 1 ..,rnn--:l85-3<1!,1 PA(;F,, MB ur Oll
20o<:i-Ju1-n; (n, :<"l PM qer Grossmo.:-1 Furlc:w & Bayo P50385.3'153
DO/\l-1C:isc tJo. oi;i.QJSSMrf nn<l 09·0J.59ltV
Al!CA v. HHARTLAND tmd l-lE/\RTLAND v. AHC/\ Sti1,uh11i(ln and A!!mr.mr.nl
p/\ymcn1 ns set forth :n th is ilgrecmenl. HEARTLAND shall fomish the actual signed Stipulation nn<l Agrr:cmcm to Al-lCA; howr;ver a facsimile copy shnll be sufficient to oni1bk. /\HCA to
cane ; a hearing scheduled ln this case.
This Agreement shall be construed in ac,;ord.am:e with the provisions of th( laws orFlorida. Venue fo:- any action arising from this Agreement shall he in Leon Cour.ty, florida.
'.4. This Agreement constitutes the entire f!greemem between HEARTLAND nn<l AHCi'\. including anyone ncting for, ussooiated with or.employed by them, concerning all 11rntters arid supersedes any prior discussions, agteenicnts or undt!rstandings; there are ho promises. representations nr agreements bctWcen HEARTLAND and AHCA orhcr then as set forth lwrdn. No modification or waiver of My provi:,ion shall be valid unless a written c1mcndrnem io the Agreement is complce,-cd and propei'ly exf'..c11t1!c. by fhc parties.
This is un Agreement of settlement a11d co!Tlpromise. made ill !'Ctognition that the patties mny have differcn! or incorrect understandings, infomrnlion and coritcntions. as to for.ts and law. and with e11ch party compromising and settliilg any potential correctness or
incon-ectncss of its understandings, lnformntfort an_d contentions as to facts and law, S(> th.it no misundersw:-iding or misinformatim: shall be a ground for :-(::SCission hereof. This Stipulation and Ag1·ccmcnl. dot!ll net constitL1tc an admbsion of wrongdoing or error oy either rarty with re:sp1:ct
tc this case Ol' any other matter. However. the parties believe that this matter should lie resolved
ber:am;c: the panics have ugreed to the terms conraincd within this :igrcemenc.
J ff.:it\ RTLAND expressly waives in this oumer its right 10 any hearing pursu2111 to
Sections 120569 or l20..S 7, Florida S.tatQt the making of findings or foct ano conclusions of
law hy DOAl·I a11d the Agency. an<l all further and other pro.;ecdinr s r:, whtch it may be entitled
Puge7of lO
?/17/2009 l: ·-; PM F, R : 1M: ;)63-385· $144 !fo;,r:tland Internal Hed 1'1,: 1-850-385-3953 PA<:lE: /JO') Or" 011
2:00S-Ju1-lc O,:'.f'3 PM Ger Grossman rurlow & 8ayo 850385:195;3
DOAH Cuscs Nu. 09-0:15;,MP[ ond M-03S9Rll
AIICA v HEARTLAND and llilARTLAND 11, Af·!CA
S1ipula:ion and Agreement
by law 01· rules of tht, Agency r-i!garding this procc1,diog n11d any and nll issues ra.ised herein. HEARTLAND fi.Jrther agrees that the Agency should issue a Flnal Order which is consif:tcnt with the tenns ofthi:; Stipulation nnd Agreement, rind which adopts this.agreement and doses rhis mutter as to DOAH Case Number 09-0JS5MPI and Case Number 09-0359RU.
HEARTLAND does hereby discharge the Sra:c ofFlorida, Agency for Health Care Administnu[on. and its agents. representative . and attorncysofand from .ill claim!!, dc111un:.ls. actious, canses ofacUon, suits, damages, losses and expenses, of any and every nature wiiatscever, arising out ofor in any way related to DOAH Case Number 09-0355MPf, C.I. No. ()(>.,ftl68-·000: .ind DOAH Case Number 09·0359RU an:! AHCA 's aetlons herein, including, but not limited to, uny claims that were or mny be i:sserlcd in any federal or suite court or administrative forwn, including ;my claims arising o-t,t of lhis awecmenr, by or on behalf of tmAR'l1.,AND.
I&. This Stipulation and Agreeme1it fs and shal: be decmedjointly dl'aftcd and written
b_y all panit1s to it and shal I not construed or int7rprctccl against the party originating or
To the extent that any provision of this S!ipulatlon and Agreemenl is prohibited by law, ror any reason. such pr wision shall be effective to the extent r:ot so prohibited, and such prohibiLion shall not nffect ouy other provision of this Stipuiation znd Agreement
This Stipulation and Agreement s!mll inure lo the benefit of and be binding on
..:;ich party's successors, assigns, heirs. administrators. representatives.and tnistces.
All times stated herein are oftbe essem;e in this Stipulation und Agreeme:.t.
This Stipulation nnd Agreement shall be in full force nnd effect upon cxe.cution by
the respective parties in co1.1nterpart.
DOMi Cnm No. O'J-OJSSl'-Wt and il4.0359RU
Al ICA v. r!HA!ffl,ANI) mul HF.A:lTLAND 11, AHCA
St\;m1a;l,,n ;met J\.creem n,
HEARTLAND INTERNAL MEDICINE
ASSOCJATES
BY: .. ,:::,·. _- ' .,:.,,,:\::0----
\.
Dale:
,_7 (/4 y ,2009
WILLIAM M. FURLOW, ESQUIRE ME'rZGER, GROSSMAN, FURLOW & BAYO, Ll.C
BY,-()
WILL
Attorney for HEAR'l'LAND INTERNAL
MEDICINE ASSOCJATES
Date, - j_,.. .;•:.;;;.:..200;;.;;...9
Pugc 9ufl0
1:.:1:
00.>\M Ca c:i No. 99.03'.iSMPl and 09-0359R1J
:\HCA v. HF.ARTLM..fD and HF./\RTLAND v. i\llCA
Stlp11l111\on i1nd A1:n:cr;1cr.1
t\GENCY FOR HEALTH CARE
ADMIN!STRATION
2727 Mahan Drive, Mail Stop #3
_K
Tallahassee, FL 32308 5403
BY:
PETER II. \VlUJAMS
Inspector General
UY:
Date:
BY:
Gcmeral Counsel
•--4-?r-/2_2_9
E.
[f.
Dl 80RA flUL)m.
Assistant General Counsel
,!QQ?_
23 ,2009
Page IO ofl()
| Issue Date | Document | Summary |
|---|---|---|
| Oct. 12, 2009 | Agency Final Order |
