08-006381MPI Agency For Health Care Administration vs. Mercy Hospital, Inc. Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Tuesday, May 19, 2009.

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STATE OF FLORIDA AGENCY AHCA CLERK

DIVISION OF ADMINISTRATIVE HEARINGS

ZOOq JUL 1 P 12 3lf

ST A TE OF FLORIDA AGENCY FOR HEALTH

CARE ADMINISTRATION

Petitioner

vs CASE NO 08 6381MPI

Audit No CI 09 8061 000

MERCY PROFESSIONAL PHARMACY Provider No 103854100

RENDITION NO AHCA 09 5 i2 S MDO

Respondent

FINAL ORDER

THE PARTIES resolved all disputed issues and executed a Settlement Agreement The

parties are directed to comply with the terms of the attached settlement agreement Based on the

foregoing this file is CLOSED

DONE and ORDERED on this the day of 1 2009 III

Tallahassee Florida

HOE

r t for Health Care Administration RETJf

Agency

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

L William Porter II Esquire

Agency for Health Care

Administration

Laserfiche

Lewis W Fishman Esquire

2 Datran Center

9130 S Dadeland Boulevard Suite 1121

Miami Florida 33156 7848

U S Mail

June C McKinney

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee Florida 32399 3060

Ken Yon Bureau Chief Medicaid Program Integrity

Diana Coumbe Medicaid Program Integrity

Finance and Accounting

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 on this the Bay of 2009

Richard Shoop Esquire

Agency Clerk

State of Florida

Agency for Health Care Administration

2727 Mahan Drive Building 3

Tallahassee Florida 32308 5403

850 922 5873

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION

Petitioner

vs Case No 08 6381MPI

MERCY PROFESSION L

PHARMACY

Respondent

SETTLEMENT AGREEMENT

STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION

AHCA or the Agency and Mercy Professional Pharmacy PROVIDER by and through

the undersigned hereby stipulate and agree as follows

1 The two parties enter into this agreement to memorialize the resolution to this

matter

2 PROVIDER is a Florida Medicaid provider provider number 103854100 and was

a provider during the audit period January 1 2005 to December 31 2005

3 In its Final Agency Audit Report constituting final agency action dated

November 17 2008 AHCA notified PROVIDER that review of Medicaid claims by Medicaid

Program Integrity MPI Office of the ARCA Inspector General indicated certain claims in

whole or in part had been inappropriately paid The Agency sought recoupment of this

overpayment in the amount of 37 574 54 In response PROVIDER filed a petition for formal

administrative hearing It was assigned DOAH Case No 08 6381MPI

I

Mercy Professional Pharmacy

Settlement Agreement

4 In order to resolve this matter without further administrative proceedings

PROVIDER and the AHCA agree as follows

1 AHCA agrees to accept the payment set forth herein in settlement of the

overpayment issues arising from the captioned audit

2 Within thirty days of entry of the final order PROVIDER agrees to make

a lump sum payment of thirty seven thousand five hundred seventy four

dollars and fifty four cents 37 574 54 in overpayment plus five

thousand dollars 5 000 in fines for a total of forty two thousand five

hundred seventy four dollars and fifty four cents 42 574 54 This fully

and completely settles all claims in these proceedings before the Division

of Administrative Hearings DOAH Case No 08 6381MPI

3 PROVIDER and AHCA agree that full payment as set forth above

resolves and settles this case completely It will release both parties from

any administrative or civil liabilities or claims arising from the findings in

audit C I 09 8061 000

4 PROVIDER agrees that it will not rebilJ the Medicaid Program in any

manner for claims that were determined not covered by Medicaid which

are the subject of the audit in this case

5 Payment shall be made to

AGENCY FOR HEALTHCARE ADMINISTRATION

Medicaid Accounts Receivable

Post Office Box 13749

tallahassee Florida 32317 3749

I

Mercy Professional Pharmacy

Settlement Agreement

6 PROVIDER agrees that failure to pay any monies due and owing under the terms

of this Agreement shall constitute PROVIDER S authorization for the Agency without further

notice to withhold the total remaining amount due under the teons of this agreement from any

monies due and owing to PROVIDER for any Medicaid claims

7 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

8 PROVIDER acknowledges their obligation to adhere to state and federal

Medicaid laws rules provisions handbooks and policies

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 and costs if any

I 1 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

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 Circuit Court Leon

County Florida

13 This Agreement constitutes the entire agreement between PROVIDER and

AReA 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 the AHeA 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

Mercy Professional Pharmacy

Settlement Agreement

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

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

1

Mercy Professional Pharmacy

Settlement Agreement

MERCY PROFESSIONAL PHARMACY

Dated H Q 2009

BY LQWI LJ 1 1S H 4 J

Print name

ITS 0 1 CIIA sc

AGENCY FOR HEALTH CARE

ADMINISTRATION

2727 Mahan Drive Mail Stop 3

Tallahassee FL 32308 5403

Dated 7 2009

petert

Inspector General

Dated 2 s 2009

JL

General Counsel

0

Dated II 2009

L bf r

Assistant General Counsel

JwcA Ji ll

CHARLIE CRIST FlORJDAAGCNcY FOR HEAtrH CARE ADMINISTlWION HOOo NS t I

GOVERNOR SECf tA I

CERTIFIED MAIL REtURN RECEIPT No 700 l 11 p J 17

25100001 44438050 1 11 llc li 3 S 9

l I11 A I ii I

November 17 2008 1 1 IJ S I j Ur

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Provider No 103854100 0 g m Pr 7

License No PH6824

Isabel Vasquez Pharmacy Manager

Mercy Professional Pharmacy

3661 S Miami Avenue Suite 110

Miami FL 33133

In Reply Refer to

FINAL AUDIT REPORT

c I No 09 8061 000 P DSC

Dear Ms Vasquez

The Agency for Health Care Administration Agency OCtlcc of Inspector General Bureau of

ledicaid Program Integrity has completed a rcyie of claims for Medicaid reimbursement for

dates of service during the period January 1 2005 through December 31 2005 A preliminary

audit report dated October 1 2008 was sent to you indicating that we had determined you were

overpaid 151 217 38 Based upon a review of all documentation submitted we have

determined that you were overpaid 37 574 54 for services that in whole or in part are not

covered by Medicaid A fine of 5 000 00 has been applied The total amount due is

42 574 54

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 vitness costs

2 In accordance with Sections 409 15 913 16 and 17 F S and Rule 590 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 5 000 00 for violation s of Rule Section 590 9 070 7 n F A C for failure

to demonstrate a sufficient quantity of goods available to support billings made to

Medicaid

2727 Mahan Drive MS 6 Visit AHCA online at

Tallahassee Florida 32308 http ahca myflorida com

E fr C 7 b

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Me rcl Professional Pharmacv

Page 2 of 4

This review and the determination of overpayment were made in accordance vith 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 follo v 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

enclosed listing the claims that are affected by this determination

REVIEW DETERMINA TION S

The audit included a comparison of your lawful documented product acquisitions with your paid

Medicaid claims Only product acquisitions from Florida licensed wholesalers were included in

the audit The audit period for this review was from January 1 2005 through December 31

2005 The drug quantity paid for by Medicaid for the drugs reviewed exceeded the quantity

available to dispense to Medicaid recipients This review identified an overpayment of

37 574 54 Enclosed for this review are the overpayment calculations which include the

summary sheet s the paid claims data and acquisition data

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 certitied check in the

amount of 42 574 54 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 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

Mercy Professional Pharmacy

Page 01 4

If payment is not received or arranged for within thirty 30 days of receipt of this letter

the Agency may withhold Medicaid payments in accordance with the provisions of Section

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 fomlal or informal hearing pursuant to Section 120 569 F S Ifa

request for a formal hearing is made the petition must be made in compliance with Section 28

106 201 F A C and mediation may be available If a request for an infonnal 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 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 Diana Coumbe Senior

Pharmacist Agency for Health Care Administration Office of Inspector General Medicaid

Program Integrity 2727 Mahan Drive Mail Stop 6 Tallahassee Florida 32308 5403

telephone [phone] facsimile 850 410 1972

Sincerely

L JiOiiJ

Ramona D Stewart RPh

AHCA Administrator

Office of Inspector General

Medicaid Program Integrity

RDS DSC

Enclosure s

cc Medicaid Accounts Receivable

Diana Coumbe

Lewis W Fisrunan Attorney and Counselors At Law Two Datran Center Suite 1121

9130 South Dadeland Boulevard Miami FL 33156

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Mercy Professional Pharmacy

Page 4 of 4

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 arc 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 confom1 to the requirements of

either Rule 28 I 06 20 I 2 or Rule 28 106 30 I 2 Florida Administrative Code and must be

received by the Case Management Manager 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

Case Management Manager

Office of Inspector General

Medicaid Program Integrity

Agency for Health Care Administration

2727 Mahan Drive Mail Stop 6

Tallahassee Florida 32308 5403

The request must be legible on 8 Ih by II inch white paper and contain

1 Y Ollr name address telephone number any Agency identifying number on the FAR if

kl1Ll I1 and name address and telephone number of your representative if any

An explanation of how YOllr substantial interests will be affected by the action described

in the FAR

3 A statement of when and hovv you received the FAR

4 For a request for formal hearing a statement of all disputed issues of material fact

5 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

6 l I request for fornlal hearing vhether you request mediation if it is available

7 For a request for informal hearing what bases support an adjustment to the amount owed

to the Agency and

8 A demand for relief

A formal hearing will be held if there are disputed issues of material fact Additionally

mediation may be available in conjunction with a formal hearing vlediation 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