22-000501MPI Agency For Health Care Administration vs. My Florida Case Management Services, Llc Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Tuesday, March 22, 2022.

Copies furnished to:

My Florida Case Management Services LLC Erin Ferber, Esquire

1470 NW 107`" Avenue, Suite M Nicholson Eastin

Sweetwater, FL 33172- 2735 Erin( a; NicholsonEastin. com

U. S. Mail) Electronic Mail)

Kelly Bennett, Chief MPI Bernard Hudson, Bureau Chief

Division of Health Quality Assurance Division of Health Quality Assurance

Medicaid Program Integrity Bureau of Health Facility Regulation

Kelly. Bennett( a ahca. niyflorida. com BHFR( a) ahca. myflorida. com

Electronic Mail) Electronic Mail)

Andrew Sheeran, Esquire Sonya Smith, Bureau Chief

Acting General Counsel Bureau of Financial Services

Office of the General Counsel Sonya. Sill ith( aAica. t florida. coni

Andrew. Sheeran( wahca. myflorida. com Electronic Mail)

Electronic Mail)

Shena L. Grantham, Esquire Katrina. Derico- Harris, MAR Unit Mgr.

MAL & MPI Chief Counsel Medicaid Accounts Receivables Unit

Office of the General Counsel Bureau of Financial Services

Shena. Grantham( a) ahca. myflorida. coin Katrina. Derico- Harris( a) ahca. myflorida. com

Electronic Mail) Electronic Mail)

Ryan Fitch, Chief Central Services Cheryl Travis, Bureau Chief

Division of Health Quality Assurance Bureau of Medicaid Fiscal Agent Operations

Bureau of Central Services Cheryl." I' ravis( a; ahca. inyflorida. com

CSMU- 86( a) ahca. myflorida. com Electronic Mail)

Electronic Mail)

Pamela Hull, Bureau Chief Erica Baker, Government Analyst 11

Medicaid Plan Management Operations Bureau of Plan Management Operations

Pamela. Hulkac ahca. inyflorida. coin Erica. Baker( ti,,, ahca. myflorida. com

Electronic Mail) Electronic Mail)

Susan Sapoznikoff

Medicaid Admin. Litigation Counsel

Office of the General Counsel

Susan. Sapoznikoff( cUahca. myflorida. com

Electronic Mail)

AHCA v. My MPI Florida Case Case No.: Management 2019- 0016728 services LLC

Final Order

Page 2 of 3

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has been

furnished to the above - named addressees by U. S. Mail or other designated method on this

day of - ^ — 2022.

Richar . oop, quire

Agency Clerk

State of Florida

Agency for Health Care Administration

2727 Mahan Drive, MS # 3

Tallahassee, Florida 32308- 5407

850) 412- 3689/ FAX ( 850) 921- 0158

AHCA v. My MPI Florida Case Case No.: Management 2019- 0016729 Final Order Page 3 of Services 3 LLC

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Petitioner, DOAH CASE NO.: 22- 050I MPI

MPI CASE NO.: 2019- 0016728

vs. PROVIDER ID.: 009572100

NPI NO.: 1982010880

MY FLORIDA CASE MANAGEMENT LICENSE NO.: N/ A

SERVICES, LLC.,

Respondent.

II

SETTLEMENT AGREEMENT

Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE

ADMINISTRATION, (" AHCA" or - Agency'), and Respondent, MY FLORIDA CASE

MANAGEMENT SERVICES, LLC., (`' Provider"), collectively " the Parties," by and through

the undersigned, hereby stipulate and agree as follows:

WHEREAS, pursuant to section 409. 902, Florida Statutes, the Agency has been

designated as the single state agency authorized to make payments for medical assistance and

related services under Title XIX of the Social Security Act, and is responsible for administering

the Florida Medicaid Program in accordance with state and federal law; and

WHEREAS, Provider is a Medicaid provider in the State of Florida, having been issued

Provider Number 0095721 and was a Medicaid provider during all times material hereto; and

WHEREAS, pursuant to section 409. 913, Florida Statutes, the Agency' s Bureau of

Medicaid Program Integrity (`' MPI") is empowered to audit for, inter alia, provider practices that

result in an unnecessary cost to the Medicaid program; and

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

Page 1 of 9

WHEREAS, the Agency conducted an audit of Medicaid claims submitted by or on behalf

of Provider for the period January 1, 2016, through December 31, 2017, (" the audit period"); and

WHEREAS, in its Final Audit Report (" FAR") dated January 6, 2022, ( attached without

exhibits as Exhibit A and incorporated by reference), the Agency notified Provider that a review

of claims for Medicaid reimbursement for dates of service during the audit period, performed by

MPI, indicated that certain claims, in whole or in part, were inappropriately paid by Medicaid; and

WHEREAS, AHCA sought repayment of the overpayment, in the amount of three hundred

seventy- four thousand nine hundred twenty- four dollars and zero cents ($ 374, 924. 00); and

WHEREAS, the Agency additionally applied a sanction in accordance with sections

409. 913( 15), ( 16), and ( 17), Florida Statutes, and Rule 59G- 9. 070, Florida Administrative Code,

specifically, assessing a sanction in the form of a fine against Provider in the amount of seventy-

four thousand nine hundred eighty- four dollars and eighty cents ($ 74, 984. 80) for violations of Rule

59G- 9. 070( 7)( e), Florida Administrative Code; and

WHEREAS, the Agency also sought to recover its costs in the amount of eight thousand

four hundred twenty- one dollars and twelve cents ($ 8, 421. 12) pursuant to section 409. 913( 23)( a),

Florida Statutes; and

WHEREAS, the total amount due was four hundred fifty- eight thousand three hundred

twenty- nine dollars and ninety- two cents ($ 458, 329. 92); and

WHEREAS, in response to the FAR Provider timely filed a Petition for a Formal

Administrative Hearing ( attached without exhibits as Exhibit B and incorporated by reference);

and

WHEREAS, the Parties now desire to resolve this matter without further administrative

proceedings;

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

Page 2 of 9

NOW THEREFORE, in consideration of the mutual promises and recitals herein, and for

other good and valuable consideration, the sufficiency of which is acknowledged by both the

Agency and the Provider, the Parties enter into this settlement agreement (" Agreement") intending

to be legally bound and agree as follows:

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

fine, and costs arising from the above - referenced audit.

a. Provider agrees to pay AHCA the sum of three hundred seventy- four thousand

nine hundred twenty- four dollar and zero cents ($ 374, 924. 00) (" total settlement amount due"),

which includes the overpayment in the amount of three hundred seventy- four thousand nine

hundred twenty- four dollar and zero cents ($ 374, 924. 00) and waivers of the sanction and costs.

b. No later than October 1, 2022, Provider shall make the first of two front - load

payments of thirty- five thousand dollars ($ 35, 000. 00). Any monies collected by the Agency' s

Bureau of Financial Services shall be used to offset the front - load payment. As of September 2,

2022, the Agency' s Bureau of Financial Services has collected five thousand three hundred

fourteen dollars and zero cents ($ 5, 314. 00). No interest applies to this front - load payment.

c. By no later than November 1, 2022, Provider shall make the second of two front -

load payments of thirty- five thousand dollars ($ 35, 000. 00).

d. Beginning December 1, 2022, and continuing on the 1st day of each subsequent

month, Provider agrees to submit twenty- two ( 22) monthly payments of twelve thousand dollars

and zero cents ($ 12, 000. 00) and one ( 1) final balloon payment of eighty- one thousand six hundred

forty dollars and seventeen cents ($ 81, 640. 17). The outstanding balance accrues at 10% interest

per year from the date of determination of the overpayment by the Agency. A copy of the

Amortization Schedule is attached hereto as Exhibit C and incorporated by reference.

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

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e. Should Provider' s enrollment with Medicaid be terminated, the total settlement

amount due shall be paid to the Agency no later than thirty ( 30) days after the date of teirnination.

f. Provider and AHCA agree that full payment of the total settlement amount due,

as set forth above, resolves and settles this case completely and releases the Parties from any

administrative or civil liabilities arising from the findings relating to the claims determined to have

been overpaid.

2. Provider agrees that this Agreement shall constitute the withdrawal of its Petition for

Formal Administrative Hearing.

3. Provider agrees that it shall not re - bill the Medicaid Program in any manner for claims

that were the subject of the review in this case and were determined to be not covered by Medicaid.

4. Payment shall be made to:

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid Accounts Receivable - Mail Stop # 14

2727 Mahan Drive, Bldg. 2, Suite 200

Tallahassee, Florida 32308

5. Payment shall clearly indicate that it is made pursuant to a settlement agreement and

shall reference the MPI Case Number and Provider Number.

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 remaining total settlement amount due under the terms of this Agreement from any

monies due and owing to Provider for any Medicaid claims.

7. The Parties reserve the right to enforce this Agreement under the laws of the State of

Florida, the Rules of the Medicaid Program, and all other applicable laws, rules, or regulations.

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

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8. Failure or delay by the Agency to enforce any specific provision of this Agreement

shall not be construed as, or act as, a waiver of the that provision and does not preclude the Agency

from enforcing that provision at any time.

9. This Agreement does not constitute an admission of wrongdoing or error by either

party.

10. The Parties acknowledge this Agreement neither waives, compromises, restricts, or

settles any past, present, or future violations of any criminal law by Provider, its officers or

employees, nor does it resolve any action, other than MPI case number 2019- 0016728, initiated

against Provider, its officers or employees, by any person or entity.

11. 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

the State of Florida. Venue for any action arising from this Agreement shall lie in Leon County,

Florida.

13. This Agreement constitutes the entire agreement between the Parties, including

anyone acting for, associated with, or employed by the Parties, concerning this matter, and

supersedes any prior discussions, agreements, or understandings. There are no promises,

representations, or agreements between the Parties other than as set forth herein. No modification

or waiver of any provision shall be valid unless a written amendment to this Agreement is

completed and executed by the Parties in the same manner as this Agreement was executed.

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

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

Page 5 of 9

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 Provider' s 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 or other proceedings to which it may be entitled by law, regulation,

or rules of the Agency regarding this matter and any and all issues raised. 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 Agreement in any forum now or in the future available to it, including the right to

any administrative proceeding, state or federal court action, or any appeal.

16. Provider does hereby discharge the Agency, and its employees, agents, attorneys and

representatives, from all claims, demands, actions, causes of action, suits, damages, losses, and

expenses, of any and every nature whatsoever, arising out of or in any way related to this matter

and the Agency' s actions, including, but not limited to, any claims that were or may be asserted in

any state or federal court or administrative forum, including any claims arising out of this

Agreement.

17. Each party to this Agreement understands its right to be represented by counsel in this

matter. Each party further acknowledges that this Agreement was read and understood by its

signatories prior to execution.

18. The Parties agree to bear their own attorney' s fees and costs.

19. This Agreement is and shall be deemed jointly drafted and written by the Parties and

shall not be construed or interpreted against the party originating or preparing it.

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

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20. 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.

21. This Agreement shall inure to the benefit of and be binding on the Parties' successors,

assigns, heirs, administrators, representatives, and trustees.

22. All times stated are of the essence.

23. This Agreement may be executed in one or more counterparts, with the same effect as

if all parties had signed the same document. All such counterparts together will constitute a single

agreement.

24. The Parties agree that if this Agreement has been signed with a digital signature or an

electronic signature by any signatory, such signature shall be legally valid and enforceable, and

have the same force and effect as a written signature, to the fullest extent permitted by Florida' s

Electronic Signature Act of 1996, Chapter 668, Florida Statutes.

25. In the event that any signature is delivered by facsimile transmission or by e- mail

delivery of a PDF version or similar format data file, such signature will create a valid and binding

obligation on the party executing the Agreement, or on whose behalf such signature is executed,

with the same force and effect as if such facsimile or data file signature page were an original.

26. This Agreement shall be in full force and effect upon execution by the last signatory

hereto.

THE REMAINDER OF THIS PAGE INTENTIONALLY BLANK

SIGNATURE PAGES FOLLOW

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

Page 7 of 9

MY FLORIDA CAS ANAGEMENT

SERVICES, LLC

Dated: - % Z 24

Ana T. Del Pino, wner

V

De vis Leon Quintana ner

Dated: q 124 2 2-

Erin Ferber, Esquire

Attorney for Respondent

THE REMAINDER OF THIS PAGE INTENTIONALLY BLANK

AHCA SIGNATURE PAGE FOLLOWS

AHCA v. My Florida Case Management Services LLC

MPI Case No.: 2019- 0016728

Settlement Agreement

Page 8 of 9

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

2727 Mahan Drive, Bldg. 3, Mail Stop # 3

Tallahas/ ee, YL 32308

Dated:

imneriy Vmoax

Deputy Secretary for HQA

Dated: 71, /, 4, :'

AndreW' Sheeran, Esquire

Acting General Counsel

Dated: t6 ' z 7

L. anttpin, Esquire

MPI hief Counsel

i Dated: SN AHCA

Susan Sapoz' 40 f quire

Medicaid Admin. i ' ation Counsel

v. My Florida Case Management Services LLC MPI

Case No.: 2019- 0016728 Settlement

Agreement Page

9 of 9

EXHIBIT A

RON DESANTIS

GOVERNOR

SIMONE MARSTILLER

SECRETARY

Federal Express Mail No.: 8138 8087 9165

January 6, 2022

Provider No.: 009572100

NPI No.: 1982010880

License No.: N/ A

MY FLORIDA CASE MANAGEMENT SERVICES, L. L. C.

1470 NW 107TH AVE STE M

SWEETWATER, FL 33172- 2735

In Reply Refer to

FINAL AUDIT REPORT

MPI Case No.: 2019- 0016728

Dear Provider:

The Agency for Health Care Administration ( Agency), Medicaid Program Integrity ( MPI), has

completed a review of claims for Medicaid reimbursement for dates of service during the period

January 1, 2016, through December 31, 2017. A preliminary audit report dated December 7,

2021, was sent to you indicating that we had determined you were overpaid $ 374, 924. 00. Based

upon a review of all documentation submitted, we have determined that you were overpaid

374, 924. 00 for services that in whole or in part are not covered by Medicaid. A fine of

74, 984. 80 has been applied. The cost assessed for this audit is $ 8, 421. 12. The total amount

due is $ 458, 329. 92.

Be advised of the following:

1) In accordance with Sections 409. 913( 15), ( 16) and ( 17), Florida Statutes ( 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 $ 74, 984. 80 for violation( s) of Rule 59G- 9. 070( 7)( e), F. A. C.

2) Pursuant to Section 409. 913( 23)( a), F. S., the Agency is entitled to recover all

investigative, legal, and expert witness costs.

2727 Mahan Drive • Mail Stop # 6 Facebook. Youtube. com/ com/ AHCAFlorida AHCAFlorida

Tallahassee, FL 32308 Twitter. com/ AHCA_ FL

AHCA. MyFlorida. com

My Florida Case Management Services, L. L. C.

Provider No.: 009572100

MPI Case No.: 2019- 0016728

Page 2

BACKGROUND

The Agency is designated as the single state agency authorized to make payments for medical

assistance and related services under Title X1X of the Social Security Act, otherwise known as

the Medicaid program. Pursuant to Section 409. 902, F. S., payments shall be made, subject to

any limitations or directions provided for in the General Appropriations Act, only for services

included in the program, shall be made only on behalf of eligible individuals, and shall be made

only to qualified providers in accordance with federal requirements for Title XIX of the Social

Security Act and the provisions of state law.

Reimbursement by the State for medical goods or services provided to persons eligible for

Medicaid assistance is available when the services are provided in accordance with applicable

Medicaid laws, regulations, and policies. Section 409. 913, F. S., authorizes the Agency to

operate a program to oversee the activities of Florida Medicaid recipients, and providers and

their representatives. MPI is the state Medicaid oversight program responsible for conducting

reviews, investigations, and/ or audits to determine possible fraud, abuse, overpayment, or

recipient neglect in the Medicaid program.

PURPOSE AND SCOPE

The purpose of this audit is to conduct a review of paid claims information and any Medicaid -

related records maintained during the aforementioned audit period that you submitted to MPI in

order to determine compliance with applicable Medicaid laws, regulations, and policy. The

review and the determination of overpayment were made in accordance with the provisions of

Section 409. 913, F. S.

As a Medicaid provider, you are obligated to comply fully with all state and federal laws, rules,

regulations, and statements of policy applicable to the Medicaid program, including the Medicaid

Provider Handbooks issued by the Agency and all applicable federal, state, and local laws

pertaining to licensure. Below is a discussion of the particular findings related to MPI' s 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.

FINDINGS

Page 2- 27 of the 2014 Community Behavioral Health Services Coverage and Limitations

handbook describes what types of community behavioral health providers can provide

psychosocial rehabilitation services. Pages 1- 4 through 1- 9 describe the minimum

qualifications of each type of provider. Persons who render psychosocial rehabilitation

services must, at a minimum, have received specific training, certification, and/ or hold a

human services related bachelor' s degree. A review of your records revealed that some

employees with non - human services bachelor' s degrees lacked required training or

certification in order to be eligible to render this service. ( Emp Elig - Employee Eligibility)

My Florida Case Management Services, L. L. C.

Provider No.: 009572100

MPI Case No.: 2019- 0016728

Page 3

The 2014 Florida Medicaid Community Behavioral Health Services Coverage and

Limitations Handbook, pages 2- 26 and 2- 27, describe who can receive community support

and rehabilitative services. Specifically, it states that psychosocial rehabilitation services are

appropriate for recipients who exhibit symptoms of sufficient severity to bring about

significant impairment in day to day personal, social, pre - vocational, and educational

functioning. Furthermore, page 2- 27 states that these services are intended to restore an

individual' s functioning so that independent living and successful life management can be

achieved. In addition, page 2- 1 of the handbook describes Rule 59G- 1. 010 ( 166), which

defines the conditions of medical necessity, and specifies that services should be

individualized, not be in excess of a recipient' s needs, and should reflect the level of service

for which no equally effective and less costly treatment is available. The 2012 Florida

Medicaid Provider General Handbook, page 5- 4, further specifies provider responsibilities,

and states that services must be of a quality comparable to those furnished by the provider' s

peers, and are documented by records that demonstrate the medical necessity for the services

rendered. A review of your records by a peer consultant in accordance with Sections 409. 913

and 409. 9131, F. S. revealed that the services provided were excessive, not appropriate to the

needs of the population served, and that the documentation did not support the medical

necessity of the services. ( NMN- No Medical Necessity/ Insuf Doc — Insufficient

Documentation)

The 2012 Florida Medicaid Provider General Handbook, pages 2- 62, states that Medicaid

payments for services that lack required documentation will be recouped. In addition, the

Community Behavioral Health Services Coverage and Limitations Handbook, page 2- 4,

states that providers must maintain documentation to support each service for which

Medicaid reimbursement is requested. A review of your records revealed that the

documentation for some services for which you billed and received payment was not

provided. Payments made to you for these services are considered an overpayment. ( No Doc

No Documentation)

OVERPAYMENT CALCULATION USING TWO - STAGE CLUSTER SAMPLING

The overpayment was calculated as follows:

In view of the average number of claims per recipient, two - stage cluster sampling was used. The

population of claims for which the overpayment was determined are those having dates of

service from January 1, 2016, through December 31, 2017. First, a random sample of recipients

for whom you submitted claims was taken. Then a random sample of claims from each of those

recipients was taken. Any overpayments for each of the claims in the latter sample were

determined. The overpayment in the sample was extended to the population of claims using

generally accepted statistical methods. The formula for the total overpayment in the population

is:

Point estimate of the population total overpayment is:

My Florida Case Management Services, L. L. C.

Provider No.: 009572100

MPI Case No.: 2019- 0016728

Page 4

Where

N = the number of recipients in the population

Ni; = the number of claims for recipient i

y; = the mean overpayment for the ith recipient

n = the number of recipients in the first stage sample

The values of overpayment and number of claims for each recipient in the sample are shown on

the attachment entitled " Second Level Overpayment Calculation." From the above statistical

formula and related formulas, which are generally accepted for this purpose, we have calculated

that the overpayment to you is $ 380, 382. 85 with a ninety- five percent ( 95%) probability that it is

that amount or more. Because the statistical analysis identified an overpayment amount in

excess of the total amount paid to you for the universe of claims ($ 374, 924. 00), we are assessing

an overpayment of $ 374, 924. 00, the lesser of the two amounts.

PROVIDER RIGHTS

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 $ 458, 329. 92, which includes the overpayment amount as well as any fines applied and

assessed costs. 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) 412- 3901. To ensure proper credit, be certain that you

legibly record on your check your Medicaid provider number and the MPI Case No. listed on the

first page of this audit report. Please mail payment to:

Financial Services - MS # 14

Agency for Health Care Administration

2727 Mahan Drive Bldg. 2, Ste. 200

Tallahassee, FL 32308

Pursuant to Section 409. 913( 25)( d), F. S., the Agency may collect money owed by all means

allowable by law, including, but not limited to, exercising the option to collect money from cause

Medicare that is payable to the provider. The Final Audit Report constitutes a probable

My Florida Case Management Services, L. L. C.

Provider No.: 009572100

MPi Case No.: 2019- 0016729

Page 5

determination by the Agency that you were overpaid by the Medicaid program. This

correspondence is being sent to the address last shown on your provider enrollment file in

compliance with Section 409. 913( 6), F. S. Thus, pursuant to Section 409. 913( 27), F. S., if within

30 days following this notice you have not either repaid the alleged overpayment amount or

entered into a satisfactory repayment agreement with the Agency, your Medicaid

reimbursements will be withheld; they will continue to be withheld, even during the pendency of

an administrative hearing, until such time as the overpayment amount is satisfied. Pursuant to

Section 409. 913( 30), F. S., the Agency shall terminate your participation in the Medicaid

program if you fail to repay an overpayment or enter into a satisfactory repayment agreement

with the Agency, within 35 days after the date of a final order which is no longer subject to

further appeal. Pursuant to Sections 409. 913( 15)( q) and 409. 913( 25)( c), F. S., a provider that

does not adhere to the terms of a repayment agreement is subject to termination from the

Medicaid program. Finally, 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 Rule 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 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.

Section 409. 913( 12), F. S., provides exemptions from the provisions of Section 119. 07( 1), F. S.,

for the complaint and all information obtained pursuant to an investigation of a Medicaid

provider relating to an allegation of fraud, abuse, or neglect. The Agency has made the

determination that your violation( s) of Medicaid policy constitute fraud or abuse as referenced in

Section 409. 913, F. S. Thus, all information obtained pursuant to this review is confidential and

exempt from the provisions of Section 119. 07( 1), F. S., until the Agency takes final agency action

with respect to the provider and requires repayment of any overpayment or imposes an

administrative sanction by Final Order.

Any questions you may have about this matter should be directed to: Stephanie Gregic,

Government Operations Consultant III, Agency for Health Care Administration, Medicaid

Program Integrity, 2727 Mahan Drive, Mail Stop 46, Tallahassee, Florida 32308- 5403,

please email at Stephanie Gregie*, AHCA. myflorida. com.

Sincerely,

Jennifer Ellingsen, FCCM

AHCA Administrator

Medicaid Program Integrity

Agency for Health Care Administration

My Florida Case Management Services, L. L. C.

Provider No.: 009572100

MPT Case No.: 2019- 0016728

Page 6

JE/ sg/ j s

Enclosure( s)

Bureau of Financial Services

Electronic Mail)

Division of Health Quality Assurance

Bureau of Health Facility Regulation

Electronic Mail)

BHFR' a ahca. mN florida. com

Division of Health Quality Assurance

Bureau of Central Services

Electronic Mail)

CSMU- 86 U ahca. mN florida. com

Notice: Section 409. 913( 16), Florida Statutes ( F. S.), provides the authority for the Agency to impose the sanction of

termination for cause if a provider voluntarily relinquishes its Medicaid provider number or an associated license, or

allows the associated licensure to expire after receiving written notice that the Agency is conducting, or has conducted,

an audit, survey, inspection, or investigation and that a sanction of suspension or termination will or would be imposed

for noncompliance discovered as a result of the audit, survey, inspection, or investigation. This is notice that the

Agency is conducting an audit, survey, inspection, or investigation within the meaning of 409. 913( 16).

F. S. Accordingly, if you voluntarily terminate your Medicaid provider number, voluntarily relinquish an associated

license, or allow an associated license to expire following receipt of this notice but prior to the conclusion of this audit,

survey, inspection, or investigation, said action will result in the imposition of the sanction of tennination for cause

from the Medicaid program.

My Florida Case Management Services, L. L. C.

Provider No.: 009572100

MPi Case No.: 2019- 0016728

Page 7

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, 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:

Richard J. Shoop, Esquire

Agency Clerk

Agency for Health Care Administration 3

2727 Mahan Drive, Mail Stop #

Tallahassee, Florida 32308

Fax: ( 850) 921- 0158

Phone: ( 850) 412- 3630

E- File Website: htti):// a1) I) s. ahea. mN- florida. com/ Efile

Petitions for hearing filed pursuant to the administrative process of Chapter 120, Florida Statutes

may be filed with the Agency by U. S. mail or courier sent to the Agency Clerk at the address

listed above, by hand delivery at the address listed above, by facsimile transmission to ( 850)

921- 0158, or by electronic filing through the Agency' s website at

http:// ahps. ahca. m\\ florida. com/ Efile.

The request must be legible, on 8'/ 2 by 1 I - inch white paper, and contain:

1. 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;

2. An explanation of how your substantial interests will be affected by the action described

in the FAR;

3. A statement of when and how 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. For a request for formal hearing, whether 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. 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.

My Florida Case Management Services, L. L. C.

Provider No.: 009572100

MPI Case No.: 2019- 0016728

Page 8

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.

Final Audit Report Payment Stub

If you choose to make payment and do not wish to reg u est a hearin1-, please return this page

along with your check to:

Agency for Health Care Administration

Medicaid Accounts Receivable

2727 Mahan Drive, Mail Stop # 14

Tallahassee, Florida 32308

The check must be made payable to;

Florida Agency for Health Care Administration

Provider Name My Florida Case Management, L. L. C. I

Provider ID 009572100

MPI Case Number 2019- 0016728

Overpayment Amount 458, 329. 92

Check Number

Any questions you may have about this matter should be directed to: Stephanie Gregie,

telephone ( 850) 412- 4568, facsimile ( 850) 410- 1972. Email contact is

Stephanie. Gregie, al AHCA. mvflorida. com.

Payment for Medicaid Program Integrity Audit

EXHIBIT B

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA,

AGENCY FOR HEALTH CARE

ADMINISTRATION, MPI Case No.: 2019- 0016728

Provider No.: 009572100

Petitioner,

V.

MY FLORIDA CASE MANAGEMENT

SERVICES, LLC,

Respondent.

REQUEST FOR FORMAL ADMINISTRATIVE HEARING

Respondent, MY FLORIDA CASE MANAGEMENT SERVICES, LLC, (" MFCMS" or

Respondent"), by and through undersigned counsel, petitions the FLORIDA AGENCY FOR

HEALTH CARE ADMINISTRATION (" AHCA") for a Formal Administrative Hearing ( the

Request") pursuant to §§ 120. 569 and 120. 57, Florida Statutes, through which MFCMS may

challenge AHCA' s FINAL AUDIT REPORT ( hereinafter " FAR") dated January 6, 2022, MPI

Case No.: 2019- 0016728. MFCMS timely files this Request in accordance with Rule 28-

106. 201, Florida Administrative Code ( hereinafter " F. A. C."). as explained more fully below, and

in support of its Request states:

PARTIES

MFCMS is a Florida licensed Health Care Clinic, license number: 12044, that

provides targeted case management services, among other things. MFCMS' principal place of

business is located at 1470 NW 107t' Ave., Ste. M, Sweetwater, FL 33172- 2735. Its provider

number is 009572100. For the purposes of this Request, MFCMS' address and telephone

number are that of the undersigned counsel.

Filed with AHCA Agency Clerk 2/ 1/ 2022 8: 00: 00 AM

2. The agency affected by this Request is the Florida Agency for Health Care

Administration, Office of Inspector General, Bureau of Medicaid Program Integrity. Its address

is 2727 Mahan Drive, MS # 6, Tallahassee, Florida 32308.

SUBSTANTIAL INTERESTS

3. On January 6, 2022, AHCA released a FAR in which it alleged that Respondent

violated section 409. 913, Florida Statutes ( oversight of the integrity of the Medicaid program).

A copy of the FAR is attached as Exhibit 1.

4. MFCMS received the FAR by mail on January 11, 2022, and timely files this

Request within twenty- one ( 2 1 ) days, as required by Florida law.

5. MFCMS' substantial interests are affected by AHCA' s actions in that such action

could result in a substantial overpayment and imposition of costs and fees or possible termination

of MFCMS' participation in the Medicaid program, which would impair MFCMS' future ability

to provide services to its patients.

DISPUTED ISSUES OF MATERIAL FACT

6. MFCMS disputes the material facts alleged in the FAR and in the audit work

papers attached, listing the claims that are affected by the determination.

7. MFCMS disputes AHCA' s purported factual basis supporting its decision to

impose fines and costs totaling $ 74, 984. 80 pursuant to 409. 913( 15), ( 16), ( 17), and ( 23), Florida

Statutes, and Rule 59G- 9. 070, F. AC.

8. MFCMS disputes that some employees with non - human services bachelor' s

degrees lacked required training or certification in order to be eligible to render services.

2

Filed with AHCA Agency Clerk 2/ 1/ 2022 8: 00: 00 AM

9. MFCMS disputes that the services provided were excessive, not appropriate to the

needs of the population served, and that the documentation did not support the medical necessity

of the services.

10. MFCMS disputes that the documentation for some services for which MFCMS

billed and received payment was not provided.

H . MFCMS disputes that a valid statistical formula for sampling to calculate the

amount due the AHCA was used and that a true random sample was used as a basis for the

overpayment.

ULTIMATE FACTS ENTITLING MFCMS TO RELIEF

12. The ultimate facts alleged, which will be established at the hearing in this matter,

are that MFCMS' medical documentation is legible, detailed and comprehensive. The services

provided, and which are the subject of the FAR, were provided in accordance with Medicaid

policy, including all documentation requirements.

13. The ultimate facts alleged, which will be established at the hearing in this matter,

are that the employees of MFCMS with non - human services bachelor' s degrees had the required

training or certification in order to be eligible to render services at issue in accordance with

Medicaid policy.

14. The ultimate facts alleged, which will be established at the hearing in this matter,

are that the services provided and at issue were not excessive, were appropriate for the needs of

the population served, and the documentation did support the medical necessity of the services as

required by Medicaid policy.

3

Filed with AHCA Agency Clerk 2/ 1/ 2022 8: 00: 00 AM

15. The ultimate facts alleged, which will be established at the hearing in this matter,

are that MFCMS provided documentation requested by AHCA for all services for which

MFCMS billed and received payment.

16. The ultimate facts alleged, which will be established at the hearing in this matter,

are that AHCA' s interpretation of section 409. 913, Florida Statutes, and Medicaid program

procedure codes, descriptions, policies, limitations and requirements found in the Medicaid

provider handbooks is erroneous and misapplied.

17. The ultimate facts alleged, which will be established at the hearing in this matter,

are that MFCMS is a highly regarding provider of case management services under new

ownership and

STATUTES ENTITLING MFCMS TO RELIEF

18. The statutes and rules entitling MFCMS to relief include, but are not limited to,

chapters 120, 394, and 409, Florida Statutes, and Titles 28, 59 and 64 of the Florida

Administrative Code.

WHEREFORE, MFCMS, respectfully requests:

a. That this Request be referred to the Division of Administrative Hearings for

the scheduling of a formal hearing before an Administrative Law Judge;

b. That a formal administrative hearing be conducted pursuant to sections

120. 569 and 120. 57, Florida Statutes;

C. That the Administrative Law Judge enter a Recommended Order

determining that the allegations of the FAR against MFCMS are not legally or factually justified,

and that MFCMS did not violate section 409. 913, Florida Statutes, or the Medicaid program

4

Filed with AHCA Agency Clerk 2/ 1/ 2022 8: 00: 00 AM

procedure codes, descriptions, policies, limitations and requirements found in the Medicaid

provider handbooks;

d. That AHCA issue a Final Order adopting the Administrative Law Judge' s

Recommended Order in accordance with the relief requested herein;

e. That MFCMS be awarded attorneys' fees and costs in accordance with

sections 57. 1 l 1 and/ or 120. 595, Florida Statutes, or other appropriate authority; and

f. That MFCMS be granted such other relief as is deemed just and appropriate.

RESPECTFULLY SUBMITTED this 31 st day of January, 2022.

zi( o 5" IA.

Erin M. Ferber, P. A.

Florida Bar No. 68216

Email: Erin( a, NicholsonEastin. com

Rachel E. Broughton, Esq.

Florida Bar No. 1024986

Email: Racliel( wNicholsonEastin. coin

Nicholson & Eastin, LLP

707 N. E. 3` d Ave., Suite 301

Fort Lauderdale, FL 33304

Telephone: ( 954) 634- 4400

Facsimile: ( 954) 634- 4418

Attorneys for MFCMS

CERTIFICATE OF SERVICE

WE HEREBY CERTIFY that the foregoing Request has been electronically filed via:

s`

http_// apps. alica. niyflorida. com/ Etile this 31 day of January,

0 0 2054( fl—

Erin222. M. Ferber

5

Filed with AHCA Agency Clerk 2/ 1/ 2022 8: 00: 00 AM

EXHIBIT C

AGENCY FOR HEALTH CARE ADMINISTRATION

AMORTIZATION SCHEDULE

MY FLORIDA CASE MANAGEMENT SERVICES, L. L. C. / Provider # 009572100/ Case No. 2019- 0016728

LOAN DATA

Past Due Balance: 324, 924. 00 Table starts at date: 9/ 1/ 2022

Annual int rate: 10. 00% or payment number: 1

Term in years: 2

Payments per year: 12 MAR # 28406

First payment due: 9/ 1/ 2022

CALCULATED PAYMENT

Entered payment:

Calculated payment: 1$ 14, 993. 59

AMOUNT USED

Monthly Pmt Used: 14, 993. 59 $ 324, 924. 00

1st Pmt in Table: 1 Cumulative interest prior to payment 1: $ 0. 00

Table

Pmt Payment Beginning Ending Cumulative Payment Date

No. Due Date Balance Interest Principal Balance Interest Amount Paid

INT. 8/ 1/ 2022 374, 924. 00 0. 00 50, 000. 00 324, 924. 00 0. 00 50, 000. 00

1 9/ 1/ 2022 324, 924. 00 2, 707. 70 12, 285. 89 312, 638. 11 2, 707. 70 14, 993. 59

2 10/ 1/ 2022 312, 638. 11 2, 605. 32 12, 388. 27 300, 249. 84 5, 313. 02 14, 993. 59

3 11/ 1/ 2022 300, 249. 84 2, 502. 08 12, 491. 51 287, 758. 33 7, 815. 10 14, 993. 59

4 12/ 1/ 2022 287, 758. 33 2, 397. 99 12, 595. 60 275, 162. 73 10, 213. 09 14, 993. 59

5 1/ 1/ 2023 275, 162. 73 2, 293. 02 12, 700. 57 262, 462. 16 12, 506. 11 14, 993. 59

6 2/ 1/ 2023 262, 462. 16 2, 187. 18 12, 806. 41 249, 655. 75 14, 693. 29 14, 993. 59

7 3/ 1/ 2023 249, 655. 75 2, 080. 46 12, 913. 13 236, 742. 63 16, 773. 76 14, 993. 59

8 4/ 1/ 2023 236, 742. 63 1, 972. 86 13, 020. 73 223, 721. 89 18, 746. 61 14, 993. 59

9 5/ 1/ 2023 223, 721. 89 1, 864. 35 13, 129. 24 210, 592. 65 20, 610. 96 14, 993. 59

10 6/ 1/ 2023 210, 592. 65 1, 754. 94 13, 238. 65 197, 354. 00 22, 365. 90 14, 993. 59

11 7/ 1/ 2023 197, 354. 00 1, 644. 62 13, 348. 97 184, 005. 03 24, 010. 52 14, 993. 59

12 8/ 1/ 2023 184, 005. 03 1, 533. 38 13, 460. 21 170, 544. 81 25, 543. 89 14, 993. 59

13 9/ 1 / 2023 170, 544. 81 1, 421. 21 13, 572. 38 156, 972. 43 26, 965. 10 14, 993. 59

14 10/ 1/ 2023 156, 972. 43 1, 308. 10 13, 685. 49 143, 286. 94 28, 273. 20 14, 993. 59

15 11 / 1 / 2023 143, 286. 94 1, 194. 06 13, 799. 53 129, 487. 41 29, 467. 26 14, 993. 59

16 12/ 1/ 2023 129, 487. 41 1, 079. 06 13, 914. 53 115, 572. 88 30, 546. 32 14, 993. 59

17 1 / 1 / 2024 115, 572. 88 963. 11 14, 030. 48 101, 542. 40 31, 509. 43 14, 993. 59

18 2/ 1/ 2024 101, 542. 40 846. 19 14, 147. 40 87, 395. 00 32, 355. 62 14, 993. 59

19 3/ 1/ 2024 87, 395. 00 728. 29 14, 265. 30 73, 129. 70 33, 083. 91 14, 993. 59

20 4/ 1/ 2024 73, 129. 70 609. 41 14, 384. 18 58, 745. 52 33, 693. 32 14, 993. 59

21 5/ 1/ 2024 58, 745. 52 489. 55 14, 504. 04 44, 241. 48 34, 182. 87 14, 993. 59

22 6/ 1/ 2024 44, 241. 48 368. 68 14, 624. 91 29, 616. 57 34, 551. 55 14, 993. 59

23 7/ 1/ 2024 29, 616. 57 246. 80 14, 746. 79 14, 869. 78 34, 798. 35 14, 993. 59

24 8/ 1/ 2024 14, 869. 78 123. 91 14, 869. 78 0. 00 34, 922. 27 14, 993. 69

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