09-000097MPI Agency For Health Care Administration vs. All Big Ten, Inc./Premier Health Care Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Wednesday, April 15, 2009.

r f ILl 0

MiCA

CLERK

STATE OF FLORIDA AGEHCY

DIVISION OF ADMINISTRATIVE HEARINGS ZOOq JUN 2 bPI I q

AGENCY FOR HEALTH CARE

ADMINISTRATION

Petitioner

vs CASE NO 09 0097MPI

PROVIDER NO 68583296

C I NO 07 5931 000

ALL BIG TEN INC PREMIER

HEAL TH CENTER

Respondent

FINAL ORDER

The Respondent having withdrawn its Petition for Formal Administrative Hearing there

remains no disputed issues of fact or law Therefore the Respondent owes the Agency

404 630 34 in Medicaid overpayments and an administrative fine of 3 500 00 The total

amount owed the Agency is 408 34 130 and shall bear annual interest of 10 from issuance of

this Final Order pursuant to Section 409 913 25 c Florida Statutes Based on the foregoing

this file is CLOSED

j

DONE and ORDERED on this the day of 2009 III

Tallahassee Florida

HOLLY BENSON SECRET

Agency for Health Care Administration

A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO

A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A

NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA AND A SECOND COpy

ALONG WITH FILING FEE AS PRESCRIBED BY LAW WITH THE DISTRICT COURT OF

APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS

HEADQUARTERS OR WHERE A PARTY RESIDES REVIEW PROCEEDINGS SHALL BE

CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES THE

NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE

ORDER TO BE REVIEWED

Copies furnished to

Daniel M Lake Esquire

Agency for Health Care

Administration

Interoffice Mail

William F Sutton Jr Esquire

Ruden McClosky Smith Schuster Russell

Post Office Box 4950

Orlando Florida 32802 4950

U S Mail

Daniel M Kilbride

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee Florida 32399 3060

Ken Yon Chief Medicaid Program Integrity

Lawrence E Stivers 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 f C c Ni 2009

c

Riclwd Shoop Esquire

Agency Clerk

State of Florida

Agency for Health Care Administration

2727 Mahan Drive Building 3

Tallahassee Florida 32308 5403

850 922 5873

1

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION

Petitioner

vs Case No 09 0097MPI

ALL BIG TEN INC PREMIER

HEALTH CARE

Respondent

ORDER RELINQUISHING JURISDICTION AND CLOSING FILE

This cause having come before the undersigned on

Respondent s Motion to Withdraw Petition for Formal Hearing

filed April 10 2009 and the undersigned being fully advised in

the premises it is therefore

ORDERED that

1 Respondents Motion to Withdraw Petition is GRANTED

2 The file of the Division of Administrative Hearings in

the above captioned matter is hereby closed and jurisdiction is

hereby relinquished to the Agency for Health Care

Administration

DONE AND ORDERED this 15th day of April 2009 in

Tallahassee Leon County Florida

O

DANIEL M KILBRIDE

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee Florida 32399 3060

850 488 9675

Fax Filing 850 921 6847

www doah state fl us

Filed with the Clerk of the

Division of Administrative Hearings

this 15th day of April 2009

COPIES FURNISHED

Daniel Lake Esquire

Agency for Health Care Administration

2727 Mahan Drive Suite 3431

Fort Knox Building III MS 3

Tallahassee Florida 32308

William F Sutton Jr Esquire

Ruden McClosky Smith Schuster

Russell P A

111 North Orange Avenue Suite 1750

Orlando Florida 32801

10 2009 15 32

RUden McClosky Ch8 4 10 2009 3 31 PM PAGE Apr 3 005 Fax Server

STATE OF FLORIDA

DIVISION OF ADMINlSTRA TIVB HBARlNGS

AGENCY FOR HEALTH CARE

ADMINISTRATION

Petitioner CASE NO 09 0097MPI

VI 685832596

07 5931 000

ALL BIG TEN INC PREMIER HEALTII

CARE

Respondents

RESPONDENTS MOTION TO WITHDRAW PETmON FOR FORMAL BEARING

COMES NOW Respondents ALL BIG TEN INC lPREMlER HEALTH CARE

hereinafter ndentBj by and through its UI1dersigned attomeys and mavts 10 withdraw its

petition for a fonual bearing in response to the decision of the Apcy for Health Care

Administration AHCA to seek Ieimb in the emount of S404 630 34 plus a fine of

3500 from Respondents based on AHeA Final Audit Report Cl No 07 S93 OOOIW RS

Final Audit R eportj and as growtds submits as follows

1 By tetter dmd December 2008j AHCA advised Respondents of its JiniHng q as

set forth in the Final Audit Report in which AHeA sought to teCt MIr the atnmm t of

S404 630 34 plus a 3500 pem1lty in Medi aid monies paid to Respondents

2 1n response to the Final Audit Report Respondents through counsel timely fitai

a Petition for Formal Hearing to contest the Final Audit Report thereby resulting in the rcfcrral

of tis matter to the Division of Adminiatrati tC Hearinp

3 SubaoqUCDt to AHCA seDding the Ymal Audit Report to Respondents 1he State of

Florida Agency for Persons for Disabilities APDj elegted to terminate its Medicaid Wavor

Apr 10 2009 15 32

Ruden McClosky Ch8 4 10 2009 3 31 PM PAGE 4 005 Fax Server

Sorvioes Agteement tho Agreementj with Respondents Without this Apment

Respondents are unable to blll and receive Medicaid payments iiom the State of Florida

4 As a IfiUlt of APD s decision to termiDate the Rl 1lpondent8 were

forced to cease operations II tbey could no longer receive payments for services nmdcred to

Florida Medicaid recipients

5 As a coosequmlce of ceasing operations Rcspondonts business entity was

administratively dissolwd by the State of Florida Division of CorporatiOlJl

6 PresontlYt Respondeots a n no lODger an active cmgoing business emity haYe no

fundI and have no ability to receive funds given APD s decision to tmmiD8te the Agrecm1Cl1t

With this in mind a continuation of any proceeding to contest AlICA s Final Audit Report is

both futJ le and ultimately a collective waste of time for all concerned

WHEREFORE given the matters set forth herein Respondents move for an Order

mmanding this matter back to AHCA for IIllY action that the qtI1Cy deems appropriate

Respectfully sqbmitted

By

William F Sutton Ir

Florida Bar No 701238

RUDEN MCCLOSKY S

SCHUSTER RUSSELL A

Hi N OnmgeAve Sui 1750

Or1ando Florida 32801

Telephone [phone]

Facsimile 401 244 8080

Attomeys for RuportdelJt8

All BIg T Inc lPremtu HeDllh C4re

Ruden Ch8 4 10 2009 Apr 10 2009 15 32

McClosky 3 31 PM PAGE 5 005 Fax Server

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true IIDCl correct copy hereof was furnished via U S Mail

this I am day of April 2009 to Daniel Lake Baq 1 AssJnw Genoral Coucsel Agency for Health

Care Administration 2727 Mihan Drive BuildinS MS 3 Tallehassee Florida 32308

RUDEN MCCLOSKY SMITIt

SCHUSTER ct RUSSELL P A

F Sutton Jr

Florida Bar No 701238

tj

CHARLIE CRIST Better flORIDA AGENCY Health FOR Care HEAlJ11 for CARE ADMINISTRATION HOllY BENS

GOVERNOR all Floridians SEC Y

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CERTIFIED MAIL No 70063450000389799217 t P C r l

V 7 Y

December 2 2008 CJr1

1 DO f 1PI

Provider No 685832596

All Big Ten Inc Premier Health Care

8051 North Tamiarni Trail

Box 35 SuiteF 6

Sarasota Florida 34243

In Reply Refer to

FINAL AUDIT REPORT C I No 07 5931 000fW RS

Dear Provider

The Agency for Health Care Administration Agency Office ofInspector General Bureau of

Medicaid Program Integrity has completed a review of claims for Medicaid reimbursement for

dates of service during the period April 1 2006 through June 30 2006 A preliminary audit

report dated February 18 2008 was sent to you indicating that we had determined you were

overpaid 517 905 28 Based upon a review of all documentation submitted we have

determined that you were overpalcl 404 630 34 for services that in whole or in part are not

covered by Medicaid A fme of 3 500 has been applied The total amount due is 408 130 34

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

offederal and state laws including Medicaid policy This letter shall serve as notice

of the following sanction s

A fine of 3 500 for violation s of Rule Section 59G 9 070 7 c and 7 e

F A C

A corrective action plan in the form of a Provider Acknowledgement

Statement and is due within 30 calendar days of receipt of this notice please

see the attachment regarding the requirements for this sanction

2727 Mahan Drive MS 6 Visit AHCA online at

Tallahassee Florida 32308 http ahca myflorid a com

1 LJ o V l L I v u U I l I J u v L U

Page 2

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 DETERMINA TION S

1 Incorrect Illegible Insufficient and or Incomplete Documentation

Documentation provided did not meet guidelines set forth in the Developmental

Disabilities Waiver Services Coverage and Limitations Handbook These infractions are

considered overpayments and will be recouped by Medicaid An overpayment includes

any amount that is not authorized to be paid by the Medicaid program whether paid as

a result of inaccurate or improper cost reporting improper claims unacceptable

practices fraud abuse or mistake

Employee background checks FDLE FBI DCF clearance where required

experience education training and certification records and proof of drivers license for

those who transport recipients were requested All of these records were not included in

the documentation provided by the provider Claims submitted for services that were

performed by an employee whose records were either incomplete or not provided were

denied

M ll DIg lV 111 I rlt l1lil l nl lll l1 lll L l U

Page 3

Support Plans Plans of Care Individualized Implementation Plans lIP Annual Report

monthly summaries and contact logs were requested for each recipient Numerous

recipient files were missing the requested documentation Claims missing the required

supporting documentation were denied

Missing required type of service date and time of service detailed activities and

signatures on service logs lIP andlor monthly summaries These claims were denied

Numerous instances of falsified documentation were observed where the provider

Xeroxed a log entry and then changed the date s These claims were denied

The Developmental Disabilities Waiver Services Coverage and Limitations Handbook states the

following

Appendix C 8 Chapter 2 1 Required Training

The provider and its employees will ensure they receive the specific training required to

successfully serve each recipient

Appendix C I O Chapter 3 2 Screening Requirement

Each provider will maintain on file and make available upon request documentation that

include

A Level two background screening requirements

C All employees meet qualifications in this document and the Developmental Disabilities

Waiver Services Coverage and Limitations Handbook including copies oflicenses

certificates high school and college diplomas and certified college transcripts as required

Chapter 1 7 Service Authorization Form

A Department approved form sent to a waiver provider from the waiver support coordinator

authorizing the provision of specific services or supports to a recipient Without the service

authorization form the provider is not authorized to provide the service and cannot submit a

claim nor be reimbursed for the service Services provided without authorization may be subject

to recoupment of funds from the provider

Chapter 2 5 Service Authorization Requirements

In order for a recipient to receive a service it must be identified on a recipient s support plan

and cost plan also known as the plan of care and approved by the District Office before the

service may be provided Providers ofDD Waiver services are limited to the amount duration

and scope of the services described in the recipient s support plan and current approved cost

plan

Chapter 2 7 Documentation Requirements

Medicaid will only reimburse for waiver services at an approved rate that are specifically

identified in the approved plan of care by service type frequency and duration for which there is

sufficient documentation supporting the provision of a service to the recipient and

All mg 1 U lnc I t remler tleaItn Lare l AK

Page 4

Chapter 2 11 Implementation Plan

Supported Living and Non Residential Support Services

A plan developed with direction from the recipient which includes information from the

recipient s current support plan and other pertinent sources Additionally The progress toward

achieving the goal s identified on the implementation plan shall be documented in daily

progress notes or monthly summaries

Chapter 2 14 Service Log

The service log shall include documentation that includes the recipient s name social security

number recipient s Medicaid ID number the description of the service activities supplies or

equ ipment provided and corresponding procedure code times and dates service was rendered

amount billed for each service provider s name and provider Medicaid II number

Chapter 2 49 Documentation Requirements

If the provider plans to transport the recipient in his private vehicle at the time of emollment

the provider must be able to show proof of valid 1 driver s license 2 car registration and 3

insurance Subsequent to emollment the provider is responsible for keeping this documentation

up to date

Chapter 2 55 Non Residential Support Services Documentation Requirements

Reimbursement and monitoring documentation to be maintained by the provider 4 Copy of

individual implementation plan and or behavior analysis services plan with supporting data is

warranted In addition to those requirements for an implementation plan found in the definition

the implementation plan for this service shall contain strategies to reduce the reliance on paid

supports to include the transfer of the support to a more cost effective service or unpaid

supports The strategies to reduce the reliance on paid supports should be measurable and

addressed in the monthly summary of progress and the annual report

Chapter 2 60 Personal Care Assistance

Personal care assistance in the family home should be provided only to assist the parent or

primary caregiver of children in meeting the personal care needs of the child Also Recipient s

living in foster or group homes are not eligible to receive this service except When a group

home resident is recovering from surgery does not require the care of a nurse and the group

home operator is unable to provide the personal care attention required to insure the recipient s

personal care needs are being met Once the recipient has recovered the service must be

discontinued

2 Incorrect unnecessary and inconsistent billing

The provider billed for units of service beyond those documented on the ervice logs

and or as stated in the recipient s plan of care and service authorization Additionally

the provider failed to follow service schedules as determined by the WSC and indicated

in the recipients Support Plan These claims were adjusted or denied

All BIg I U Inc I PremIer Health Care FAR

Page 5

The Medicaid Provider Reimbursement Handbook Non Institutional 081 states the following

Chapter 2 1 Service Authorization Requirements Home and Community Based Services

All home and community based services HCBS must be service authorized by the recipient s

case manager or support coordinator and be included in the recipient s plan of care Medicaid

may recoup reimbursement for services that were not service authorized or authorized in the

recipient plan of care

Additionally The Developmental Disabilities Waiver Services Coverage and Limitations

Handbook states the following

Chapter 2 7 Introduction General Service Documentation Requirements

DD waiver services are based on recipient needs that are documented in an approved plan of

care Medicaid will only reimburse for waiver services at an approved rate that are specifically

identified in the approved plan of care by service type frequency and duration and for which

there is sufficient documentation supporting the provision of a service to the recipient All

documentation must be dated and signed by the individual rendering the service

3 PCA SLC Companion IHSS and NRSS services provi Jed did not correlate with

recipient s support plan goals This documentation should address all recipient and

provider activities that were attempted accomplished or incomplete and any setbacks

experienced toward reaching the goals stated in the recipient s support plan The

provider billed PCA for services not included in the recipients Support Plan Activities

beyond those stated in the recipients Support Plan were performed resulting in an

excessive number of units of services being utilized and billed During completion of

activities Other was often checked on the recipient s log without clarification of

activities The provider independently completed housekeeping SLCIIHSS tasks

without the participation of the recipient This service is meant to teach the recipient

new skills to increase his independence and should not be completed without

participation from the recipient These claims were denied

The Developmental Disabilities Waiver Services Coverage and Limitations Handbook states the

following in

Chapter 2 7 Introduction General Service Documentation Requirements

DD waiver services are based on recipient needs that are documented in an approved plan of

care Medicaid will only reimburse for waiver services at an approved rate that are specifically

identified in the approved plan of care by service type frequency and duration and for which

there is sufficient documentation supporting the provision of a service to the recipient All

documentation must be dated and signed by the individual rendering the service

Chapter 2 9 Daily Progress Note

Daily on days service was rendered notes of the recipient s progress towards achieving his

support plan goals for the periods being billed or the summary describing the treatment or

training provided to the recipient or tasks accomplished

All Big 10 Inc I Premier Health Care FAR

Page 6

Chapter 2 14 Service Log

The service log shall include documentation that includes the recipient s name social security

number recipient s Medicaid ID number the description of the service activities supplies and

dates service was rendered amount billed for each service provider s name and provider

Medicaid ID number

Chapter 2 27 Companion Services

This service must be provided in direct relation to achievement of the recipient s goals per his

support plan and

Chapter 2 29 Special Considerations

Companion services are provided in accordance with an outcome on the recipient s support plan

and are not merely a diversion

Chapter 2 54 Non Residential Support Services Limitations

Non residential support services are limited to the amount duration and scope of the services

described in the recipient s support plan and current approved cost plan

Chapter 2 57 Personal Care Assistance

Personal care assistance is a service that assists a recipient with eating meal preparation

bathing dressing personal hygiene and other self care activities of daily living The service also

includes activities essential to the health safety and welfare of the recipient and when no one

else is available to perform them Personal care assistance may not be used solely for

supervision Personal care assistance is limited to the amount duration and scope of the services

described in the recipient s support plan and current plan of care

Furthermore the Medicaid Provider General Handbook states the following

Chapter 2 44 Record Keeping Requirement

Medicaid requires that the provider retain all medical fiscal professional and business records

on all services provided to a Medicaid recipient In order to qualify as a basis for reimbursement

the records must be signed and dated at the time of service or otherwise attested to as

appropriate to the media

Chapter 2 45 Record Retention

Records must be retained for a period of at least five years from the initial date of service

Chapter 2 45 Right to Review Records

Authorized state and federal agencies and their authorized representatives may audit or examine

a provider s or facility s records This examination includes all records that the agency fmds

necessary to determine whether Medicaid payment amounts were or are due This requirement

applies to the provider s records and records for which the provider is the custodian

Chapter 2 46 Incomplete Records

Providers who are not in compliance with the Medicaid documentation and record retention

policies described in this chapter may be subject to administrative sanctions and recoupment o

All Big 10 lnc PremIer Health Care r AK

Pag 7

Medicaid payments Medicaid payments for services that lack required documentation or

appropriate signatures will be recouped

OVERPAYMENT CALCULATION

A random sample of 30 recipients respecting whom you submitted 1 381 claims was reviewed

For those claims in the sample which have dates of service from Apri11 2006 through June

30 2006 an overpayment of 89 727 80 or 64 97306300 per claim was found Since you were

paid for a total population of 7 687 claims for that period the point estimate of the total

overpayment is 7 687 x 64 97306300 499 447 94 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

U U

E t N A II YB 2

N N 1 B

Where

E point estimate of overpayment F A B

t t

u

F number of claims in the population L Bi

i

Ai total overpayment in sample cluster

B 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 Bj

tAil t

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 attaclunent 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

404 630 34 with 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

Alll Slg 1 U lnc I l remler li ealtn Lare l AK

Page 8

If you are not in bankruptcy and you concur with our findings remit by certified check in the

amount of 408 130 34 which inc1udesthe 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 calendar days of receipt 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 15 913 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 21 days ofreceipt 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 Ms Robin Satchell

Investigator 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

Ms Robi Olmstead

ARCA Administrator

Office of Inspector General

Medicaid Program Integrity

RO RS kj

Enc1osure s FAR worksheets staff spreadsheet

cc William F Sutton Jr c o Ruden McCloskey PA