ATTORl'JEYS ESTABLISHED 1912

FILED JAN 3 0 2014

111 W. Broadway• P.O. Box 117 •Bolivar, MO 65613 417-326-5261 or 800-743-5728 •fax 417-326-2845 • www.bolivarlaw.com

Offices in Bolivar and Springfield -- -- -------- ----------~~-~~--------~~=-~~~~~~~~~-~--~- -- - --~~-

Administrative Hearing Commission Attn: Clerk 301 West High Street PO Box 1557 Jefferson City MO 65102

Dear Clerk:

January 27, 2014

Re: Plantation Manor v. Department of Social Services, Missouri Medicaid Audit & Compliance Unit No.13-1828SP DHH No. 21403-001 DHH Client: Plantation Manor

Attached please find an original and two copies of a Motion for Stay for immediate filing in number 13-1828 SP.

Please return a file stamped copy to this office. A self-addressed ~d envelope is enclosed for your convenience. ~-

Thank you for your assistance in this matter. If you should have any questions, please do not hesitate to contact me.

TLM Enclosures cc: Plantation Manor

Matthew Laudano

Yours truly,

HEIDEMANN, P.C.

BEFORE THE ADMINISTRATIVE HEARING COMMISSION

ST ATE OF MISSOURI FI LEO PLANTATION MANOR,

Petitioner, vs.

JAN 3 0 2014

ADMINISTRATIVE HEARING­COMMJSSION

No. 13-1828 SP

DEPARTMENT OF SOCIAL SERVICES, MISSOURI MEDICAID AUDIT AND COMPLIANCE UNIT,

Respondent.

MOTION FOR STAY

COMES NOW, Petitioner, through counsel, and moves this Commission to stay or

suspend the action of the Missouri Medicaid Audit & Compliance Unit pending the

Commission's findings and determination in this cause.

In support of its Motion for Stay, Petitioner states as follows:

1. On September 18, 2013, Petitioner received correspondence from Missouri Medicaid

Audit and Compliance identifying billing enors, an appropriately redacted copy of which is

attached hereto and marked Exhibit A.

2. On October 18, 2013, Petitioner filed an Appeal in a Contested Case with this

Commission.

3. Discovery has been sent by both parties to obtain additional documentation and

information necessary to reach a disposition of this matter.

4. This matter is currently set for hearing on May 12, 2014.

5. On Friday, January 24, 2014, Petitioner received a phone call from Missouri

Residential Care Services, Inc. stating that their billing for personal care was being recouped as

payment for money owed.

6. Petitioner has fully complied with the rules and regulations governing an appeal of

the Missouri Medicaid Audit and Compliance Unit decision as set forth in the September 181h

correspondence.

7. Petitioner is a small facility of extremely limited means, and the recouping of their

billing for personal care will create a substantial financial burden on Petitioner and may cause

long lasting repercussions to the facility and its residents.

8. Petitioner requests this stay intending in good faith to reach a settlement of all issues

in this matter on or before the hearing on May 12, 2014.

9. Counsel for Petitioner has spoken to Counsel for Respondent and he is in agreement

with scheduling a telephone hearing to discuss this motion.

WHEREFORE, Petitioner prays this Commission enter its order staying any action by

Missouri Medicaid Audit and Compliance Unit in recouping money deemed owed in their

decision of September 18, 2013, until such time as this Commission has reached a decision in

this cause of action and for such other relief as the Commission deems just and proper.

DOUGLAS, HAUN & HEIDEMANN, P.C. 111 West Broadway, P.O. Box 117 Bolivar, Missouri 65613 Telephone: ( 417) 326-5261 Facsimile: (417) 326-2845 cheidemann@bolivarlaw.com

Craig R. eidemann ~ • Missouri Bar No. 42778 ~' Attorney for Petitioner

CERTIFICATE OF SERVICE

The undersigned certifies that a complete copy of the foregoing instrument was served to all attorneys of record, unrepresented parties and others on January 27, 2014 in the manner indicated, as follows:

Matthew J, Laudano Assistant Attorney General Supreme Court Building 207WHigh St PO Box 899 Jefferson City MO 65102

IEIBy enclosing same in an envelope addressed to the individual at the address as shown opposite, with first class postage fully prepaid, and by depositing said envelopes in a U.S. Post Office mailbox in Bolivar, Missouri, on the date of this Certificate listed above.

DBy personal service, hand delivered on the date of this Certificate listed above.

DBy leaving a copy at the attorney's office with a clerk, secretary or attorney employed by or associated with the attorney to be served on the date of this Certificate listed above.

DBy facsimile transmission on the date listed above to telephone number: at approximately .M.

DOUGLAS, HAUN & HEIDEMANN, P.C.

DHH No. 21403-001

'' . " · AI1···~Yi'i .. rr1· !)ppartrnen-r ol' ...... ..... i ..... :;...r t;... • ..t~·· "'_ lY -:;

~ SOCIAL SERVICES ~)ur PoteiJtial. Our Support.

Plantation Manor 342 East Broadway Bolivar, MO 65613 Provider NP! #1780878090

Dear Plantation Manor:

JEREMIAH W. (JAY) NIXON, GOVERNOR • BRIAN KINKADE, INTERIM DIRECTOR

September 18, 2013

MISSOURI MEDICAID AUDIT & COMPLIANCE UNIT

P.O. Il!.1\.fi:Sflfl • -lt··fFEH~.(1:'1 (Tf\, \1(1 h:'Hl:!-ji,51)(>

W\.\·W.n~s.~·jO,!_;f)\' > :)73.751 ... B')'l

7012 3460 0000 4432 0075

Pursuant to the responsibility, as set forth in Title 42 of the Code of Federal Regulation (CFR) Parts 456.1 through 456.23, Missouri Medicaid Audit and Compliance ("MMAC"), Provider Review, has conducted a post-payment review of your MO HealthNet claims.

This review has identified billing errors in the amount of $9,179.90, as detailed in the enclosed documents:

• Attachment A - Outline of incorrect billing procedures (errors identified);

• Attachment B - A listing of MO HealthNet eligible participants for whom claims were submitted. The claims reviewed are identified. The information listed Includes the participant's name, I.D. number, date of service, date paid, amount paid, amount of the overpayment, and error/no error (indicated by an alpha character). All claims not identified as reviewed may be subject to future post-payment reviews.

The attachments, together with this letter, are your official notice of the claims incorrectly submitted and the total overpayment resulting from these errors. If you do not intend to appeal this decisionr a written plan of corrective action addressing how the identified billing errors will be corrected in the future (signed and dated by the enrolled provider) must be sent to MMAC within ten days of receipt of this notice; please send this information to my attention at the above address.

Because the amount due is in excess of $1000, you may, within ten days of receipt of this notice, submit a repayment plan for 40 percent of the overpayment amount to MMAC for approval.

In accordance with State Regulation 13 CSR 70-3.030 (6), no repayment plans will be considered for the first 60 percent of the overpayment amount. The first 60 percent is to be repaid within 45 days of receipt of this notice should you elect to make repayment directly to MMAC. You will be notified within ten days of MMAC's receipt of such a repayment plan whether it is rejected,

. accepted, or if a modified version could be acceptable.

If you wish to request that repayment of the $9,179.90 be accomplished through withholding from current reimbursement, as is generally preferred by MMAC, please notify

RELAY MlSSOURI

FOR HEARING AND SPEECH IMPAIRED

1-800-735-2466 VOICE • 1-800-735-2966 TEXT PHONE An /:,"qua/ Opportunity Nmployer, se.rvir..:es pnwided m1 a nondi.\·,·riminalo(V hosi.v. EXHIBIT A

Provider Name Page 2

this office in writing within ten days of receipt of this notice. Do not submit on-line adjustments for those clajms identified as errors. Doing this could cause adverse consequences such as duplicate recoupment or unnecessary claim voids. If an adjustment is needed by your organization, a representative from MMAC will contact you with specific instructions.

You will be promptly notified if such repayment through withholding is not acceptable to MMAC. If acceptable, MMAC will then determine the actual amounts to be withheld In order to recover the overpayment amount.

If the overpayment is not either repaid in full or an agreement reached whereby repayment will be made through withholding amounts from current reimbursement at the expiration of 45 days from receipt of this letter, MMAC will take immediate action to recover the overpayment amount. If a repayment plan has been agreed upon for 40 percent of the total overpayment, MMAC will only take action to recover 60 percent. Such recovery action may include withholding from your current MO HealthNet reimbursement, as authorized by State Regulation 13 CSR 70-3.030 (6).

This is a final decision regarding administration of the medical assistance program in Missouri. Missouri Statute, Section 208.156, RSMo (2000) provides for appeal of this decision.

If you were adversely affected· by this decision, you may appeal this decision to the Administrative Hearing Commission. To appeal, you must file a petition with the Administrative Hearing Commission within 30 days from the date of malling or delivery of this decision, whichever is earlfer; except that claims of less than $500 may be accumulated until such claims total that sum and, at which time, you have 90 days to file the petition. If any such petition is sent by registered mail or certified mail, the petition will be deemed filed on the date it is mailed. If any such petition Is sent by any method other than registered mail or certified mail, it will be deemed filed on the date it is received by the Commission. Appealing this decision can only be made to the Administrative Hearing Commission and not to MMAC or MHD.

Compliance with this decision does not absolve the provider, or any other person or entity, from any criminal penalty or civll liability that may arise from any action that may be brought by any federal agency, other state agency, or prosecutor. The Missouri Oepartment of Social Services, Missouri Medicaid Audit and Compliance Unit, has no authority to bind or restrict in any way the actions of other state agencies or offices, federal agencies or offices, or prosecutors.

If you have any questions concerning this review, please direct them to this office at (573) 751-3399.

~ir;r-erely, . _,/)

iz ClA,.l'1-'-/ '-0-UA-r'--"' Karen Burger Provider Review Analyst

Enclosure

The Missouri Medicaid Audit and Compliance Unit ("MMAC") is the unit within the Department of Social Services (''DSS"), the single state agency responsible for the administration of the Medicaid Title XIX Program in Missouri, charged with administering and managing Medicaid Title XIX audit and compliance initiatives and provider contracts under the Medicaid Title XIX Program. One of MMAC's responsibilities, as directed by the DSS, is to perform the functions and operations formerly under the MO HealthNet Division ("MHD"), Program Integrity Unit which includes monitoring the utilization of MHD services in the State in accordance with any and afl applicable f~deral and state laws and regufations.

EXHIBIT A

Attachment A Plantation Manor Page 1 ofS

ATTACHMENT A - Outline of Incorrect Billing Procedures

Plantation Manor

The following errors have been identified during a recent review of your post-paid claims. some of the errors have caused an incorrect payment due to billing or documentation errors. Each alpha character below correlates with the specified claims noted on Attachment B, and indicates the error, sites the program policy supporting the error, and will also indicate if it did or did not cause an overpayment.

A. Billed for full allocation of authorized units in a month with less than 31 days. Care Plan is in the format of units authorized per day.

According to 13 CSR 70-91.010 (l)(B) Obtaining Personal Care Services.

3. A new in-home assessment and personal care plan may be completed by the Department of Health and ·senior Services or its designee as needed to redetermine need for personal care services or to adjust the monthly ·amount of authorized units. In collaboration with the service recipient, the service agency may develop a new or revised set of personal care tasks, and weekly schedule of service delivery which shall be forwarded to the Department of Health and Senior Services or its designee. The service provider must always have, and provide services in accordance with, a current service plan. Only the Department of Health and Senior Services or its designee, not the service provider, may increase the maximum number of units for which the individual is eligible per month. Any service plan developed in accordance with paragraphs (1)(B)2. and 3. is a state approved service plan.

13 CSR 70-3.030 (3)(A) allows sanctions to be imposed by the MO HealthNet agency against a provider for any one of the following reasons:

2. Submitting false information for the purpose of obtaining greater compensation that to which the provider is entitled under applicable MO HealthNet program policies or rules, including, but not limited to .. billing for increased number of units from those actually ordered or performed or both.

* * * 7. Breaching of the terms of the MO Health Net provider agreement of any current written and published policies and procedures of the MO HealthNet program {Such policies and procedures are contained in provider manuals or bulletins which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, September 15, 2009.

EXHIBIT A

Attaclunent A Plantation Manor Page 2of5

This rule does not incorporate any subsequent amendments or additions.) or failing to comply with the terms of the provider

. certification oh the MO HealthNet claim form;·

(This error did result in an overpayment and is indicated on attachment 'B' with the alpha character 'A' written in the 'Error' column.)

B. Billed more units than participant is authorized.

According to section 13. LF, of the MO HealthNet Provider Manual on Personal Care, The authorization for services shows how many units of service are authorized and specifies the period of time covered by the authorization.

According to section 14.1, of the MO HealthNet Proyider Manual on Personal Care, Each state agency utilizes assessment and authorization processes unique to their program. All forms used to authorize personal care services show how many units of service are authorized and the period of time covered by the authorization.

2. Submitting false information for the purpose of obtaining greater compensation that to which the provider is entitled under applicable MO HealthNet program policies or rules, including, but not limited to .. billing for increased number of units from those actually ordered or performed or both.

* * * 7. Breaching of the terms of the MO Health Net provider agreement of any current written and published policies and procedures of the MO HealthNet program (Such policies and procedures are contained in provider manuals or bulletins which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, September 15, 2009. This rule does not incorporate any subsequent amendments or additions.) or failing to comply with the terms of the provider certification on the MO HealthNet claim form;

(This error did result in an overpayment and is indicated on attachment 'B' with the alpha character 'B' written in the 'Error' column.)

EXHIBIT A

Attachment A Plantation Manor Page 3 ofS

c. There is no entry for the date of service on at least one time sheet purportedly documenting services delivered during this billing period.

No date (Month/Year} recorded on the time sheet.

According to 13 CSR 70-91.010 (4)(A) 2 .. B., documentation of services delivered by the provider must include the date of service. Section 13.7.D(l)l. of the MO HealthNet Provider Manual on Personal Care, incorporated into regulation by reference at 13 CSR 70-3.030 (1), states documentatioh for services rendered must contain the date of service.

13 CSR 70-3.030 (3)(A) allows sanctions to be imposed by the MO HealthNet agency against a provider for any one of the following reasons:

4. Failing to make available and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants ... Services billed to the MO HealthNet agency that are not adequately documented in the patient's medical records or for which there is no record that services were performed shall be considered a violation of this section.

* * * 7. Breaching of the terms of the MO Health Net provider agreement of any current written and published policies and procedures of the MO HealthNet program (Such policies and procedures are contained in provider manuals or bulletins which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, September 15, 2009. This rule does not incorporat~ any subsequent amendments or additions.) or failing to comply with the terms of the provider certification on the MO HealthNet claim form;

(This error did result in an overpayment and is indicated on attachment 'B' with the alpha character 'C' written in the 'Error' column.}

EXHIBIT A

Attachment A Plantation Manor Page 4of5

Other Observations:

No participant (s) signature of proof of services rendered was provided for one or more dates of service in time period billed. Initials are not an acceptable form of signature.

There is no entry for the participant's signature on the time sheet documenting services delivered. The only signature on the time sheet has been identified as that of a faculty staff member.

According to section 13.7.0(1)6 of the provider manual: For each date of service: the signature of the participant, or the mark of the participant witnessed by at least one person1 or the signature of another responsible person present in the participant's home or licensed Residential Care Facility I or II at the time of service. A responsible person may include the personal care aide's supervisor, if the supervisor is present in the home at the time of service delivery. The personal care aide may only sign on behalf of the participant when the participant is unable to sign and there is no other responsible person present. The entire signature of the participant or witness to the mark or the responsible party must be present in the record for each date of service billed to MO HealthNet. Initials are not acceptable in lieu of the entire signature. The participant's DCN is not required on the time sheet.

According to 13 CSR 70-91.010 (4)(A)2. documentation of services delivered by the provider must include,

F. For each date of service: the signature of the recipient, or the mark of the recipient witnessed by at least one (1) person, or the signature of another responsible person present in the recipient's home or licensed Residential Care Facility I or II at the time of service. "Responsible person'' may incluoe the personal care aide's supervisor, if the supervisor is present in the home at the time of service delivery. The personal care aide may only sign on behalf of the recipient when the recipient is unable to sign and there is no other responsible person present.

13 CSR 70-3.030 (3)(A) allows sanctions to be imposed by the MO HealthNet agency against a provider for any one of the following reasons:

2. Submitting false information for the purpose of obtaining greater compensation that to which the provider is entitled under applicable MO HealthNet program policies or rules, including, but not limited to .. billing for increased number of units from those actually ordered or performed or both.

EXHIBIT A

Attachment A Plantation Manor Page 5of5

* * * 7. Breaching of the terms of the MO HealthNet provider agreement of any current written and published policies and procedures of the MO HealthNet program (Such policies and procedures are contained in provider manuals or bulletins which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, September 15, 2009. This rule does not incorporate any subsequent amendments or additions.) or failing to comply with the terms of the provider certification on the MO HealthNet claim form;

(This error did not result in an overpayment. This error is presented as educational with the purpose of preventing future reoccurrence. While not resulting in an overpayment for this review, it will be considered a finding in the future.)

The Code of State Regulations can be accessed at www.sos.mo.gov

MO HealthNet Manuals, Bulletins, sample forms, and the MO HealthNet Forms Request document are available via the Internet at the MO HealthNet Division's website: www.dss.state.mo.us/mhd.

EXHIBIT A

Attachment B PLANTATION MANOR Review Date January 1, 2012 to June 30, 2012.

ME. Proc Mod · Date of Service Units Net Error Overpaid DCN Claim ID Paid Date Name Last Name First Cd · Pro~edure . . . . . Cd . Cd 1 From To Pd · ' Payment Code Units $

63151541 . :~~~2037027618 .02;10;201~ __ .. ~?. :.Pe~sonal CareSerPer15 M.l~ ... ;T1019 :u~ .01/.~1/2.012 :01/30/201.2 ·' 62; $2.54.20.A . 2_ $ . 8.~0 63151541 :4912059024336 ,03/?~/2~1.? __ :is .. Pers~n~ICa~~-~erPerlSMin .... T~O~ ·u3 :02/.01/201? ... 02/28/2012: 62; .. $.254.20:..;. 6: $ 24.60 63151541 ;4912219025120 · 08/10/2012 .16 :Personal Care Ser Per 15 Min ;no19 U3 03/01/2012 03/30/2012 , 62 · $254.20 A 2: $ 8.20 5315154i :491ii3Cl018166 ·osii1/2012 - :lG :Pe~so~alC~re.SerPer15Min --· 'r:io19 'u3 '04/01/iou :04/'J.9/2012. 6Z. $254.io·:A,C . 62: $.254:20

63151541 :49l21580435~4 "'.O..~IO.Bf3_013 '.- :-... .>~ .'..P~rs~n.al 6ir~ ~~r P~r.1? M!n · .. ~.~ii9;~ . U3 ;os1.oi/20~2 :o51~y2012 " ... · (' .. $?~·~o:c : .. (s. _32.s_o

6315154.1 ;4~U15804352.4 :06/~~/~0~? ·-· . :~? .;P~~~~~l~ar~Se~Per151"'.Ji~ ... ,r1~~9 ;u3 :.05/p~/2012 _05/26/20~2; .. 4~; $1n.2~,c · 42: $ 172.20

63151?~~-· '.491~~~o-~~S?_4 _ :e_6/0,Y20.~3--.. . . ...-... ..1.6 ,,P~r.so.na.r_~~r~_?-~r.P.er~M~n ..... _!~019 .. 1:'3 .o~/~8(~g~~ .... ~?~3'?(~012, ~' ..... J~~-.20.A,c .. ··-~?_..$. .. 49:20

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22876596 [4912187094007 :07/06/2012 ;- ;16 ~PersonalCare5erPer15Min :T1019 ;U3 !06/01/2012 106/29/2012: 62; $254.20:A,C '. 52; $ 254.20

~~~~l_j;1~~~t.Jf~ ~~-~:~------- ~1:!~1:~~;;i~t-: ir[f~liSJ±--~•--!~t:~=_~::~I 04594372 14912130018168 !05/11/2012 : 1 '16 ·Personal Care Ser Per 15 Min T1019 lU3 :04101/2012 :04/29/2012 · 62: $254.20!A, c : 62: $ 254.20

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-~_23 72_~-~-- ... L~9121_870_~400~----~~? L~~B9~~ -------···-- ·-?·~·· Personal ~~~ .. ~.~-~-er 15 Min _;!.~.9..:1:~.i u~ ·- :06/0l/2012_;Q.~L~!.?.9-~~--6.?.J ..... }254.20!~~-c ........ : ........ ~~.:J! .. 254.2Q._ ~~?.6~.~~1 .. ·-~49120?I9.?.?..~~() . ;E.:Y~~20~~ ---~ .. -· ..... 13 ~Persona~S~!:s~~er 15 ~~~- ·-· .J~~~_19 1u3 IOl/01/7:_~12 .. ;.Q..Y.?_Q.(2012 : ___ -~-1.! .. _._,.$127.10~ ..... ,; ·-··-~~.:!Q_ 38065951 '4912069024338 ;03/09/2012 ;- ,13 ~PersonafCareSerPerlSMin !T10l9 ;u3 :02/01/2012 :02/28/2012; 31; $127.lO!A,C : 311$127.10

~:8-~~~~:;_1· ~~=~i2~~~§.4~3.f.(..i~-~(2.5/io12 _[~--=~~~ ~ -~ .. ]L~ . ~-~~=:13· · ~~~.i.~!r ~~~-s~~ P~r·i~~~~ ..• :·.~~_;noi9 ··}u3 ·_·!a~i~r2~i.~:-.j~3/os/26I~.: .... ... ~: ---$~~:.69 ;~-~-~-~:~~i~T~-~~:;~.,

~m:i:--~i!~:]i¥&~~~=-::~~:i~~::~i;~~:1~-~~-·~jiji~•;1~~-'.~_:-~i~;~~:2~~~1~~-g475232{) .... ~~~~~~58~~~~~.? .. :~6/.~.8.(~_o.~?. ..•. __ ·---·-·.---·· .... :.~~ .. :_Personal c~~.s~r ~er !:?~~---··;!1P1.~ .. i.~-- .. ~~?.lq_1(~~~2- _o5/~0f.2012-'-_J3.~'. _ ... ~~~~Q~A~ c. -·: __ _.!24~ .. $-.. ~o-~:'.'l:Q. 047.???~... '. ~.~~-~~?2~~~9}Q._.~Q?(O_~(~O~? - . . . . . .. . . ____ ;_!? l~:son~~~~~e S_er_~~r ~5 ~i~-- -··· iT!:_~~. _J,~~. _, 0.6(~1_!'.?:_Q~-~ --~~(~~/20.~_2 ~-- -·~~ _ .. $._~~~4~'.~.~.c ... :. .. ~2-~-~ 5Q~-~-?937~9E)4 ~49120~?g?7_622 .... . ~0.2[~Ef39~L .•.. ·--- .... }.~--~~~~.na~ C?~.~~.~~~-~~.~~~.. . :~~.019 ·--~~·---~~y911.29~2 ;~1J~.P!?.9P...... . 9~ : __ .. ~-~81_..3o.:.~ ... _. _ ., . _ ... 3; $ _1~--3~. ?.0_3_71~_64 .. -'-~~.~.-3.0.6~~2-~~-~~- _;~.3/09(20!_?_ .. _. __ .. ... _ ... :.1~ .. : P~rs<?~~~~~!~-~~!.-~~~ ~ !Vlin. . __ _!_3:_0~~·-··;_!.!3_ .. :.~2/~y~o~~ _ ~3!3_8/201~ ... ---~3, . .S.3.~~:~~. ~ . : . . ~-- .?. ... ?.6.90 .. 50~7.~~~4.. : ~~~~1-0.~98~1?.0 _.: 04/.13(20_12 --... .. -~~ .. ~~~?.~} c_a~e Ser. ~er 1~ ~!.~.... . :'.1~~.9 y~ . _,_0.3(01(?91? ;~3/~~!.~9~3...; . .. _. 93, . .~~~·30. ;f. .. . . -~ :. S. 12.30

?.0~71~64 . -~~~2.13~018171. ,05/1.~~-~.~- :•. ... .. . . -·-··!~ .... ~.~rso.na~ ~ar~~~r!e: ~~ .. W[in.. . :.'..'.'-.Q:':_9_ .. -~~. ~~4£~1(20.12 :.0.4/~P~.3:3. ; 93c._. -~~.'.'-:~OA~ . . ~- ... ~?.: $. }81.30 5_D??.19_~4 .:.<1:9_12158043_5?~. ,_q6i~Y~~;-~ :• ·- .. :~~- .;.Pers9~~~.~!es.~~P.~rl;S~in .. _!~~.~~ . .. u~ .. ~5/01/~~.1~ :.~5}3~/201~ ...... ~~-. $~8~:.3~~·-c .. : . ~.3, ~· .3~~.30. 5037_1_~6.~ ,4~~~1~?.09~~11 .~7/06/20~2 ·- :-·- .1~ ,P_~so~al~reSer.~~r~5-~.i~ .... T101~ :u3 .Oo/.01/20~~ .~.6(29/201~. 93 $~8-~?0.A,C. .. ~3. $ 38130 48448345 · 4912037027623 02/10/2012 - - 16 Personal Care Ser Per 15 Min T1019 U3 01/01/2012 01/30/2012 62. $254.20 A 2 $ 820 48448345 '49,1.2069024340 :03/09/:2012 ·- ·- "16 PersonafCareSerPerlSMin no19·· -U3 02101.12012 '02;2a;2oi2 · s2' $254:20.A · i;' $ 24.60 48448345 491210208oisi .. 04/i3/2012 -- - 16 Personai Ca~e Ser Per 15 Min ··+1019 U3 "ci3/01/2012 "03/3612012 62 $i54.20°A,. i' .$ . 8:20 48448345 4912130018i72 ·as;ii;2012 · · .. 16 Personal c~re Ser Per 15 Min T10l9 U3 04/01/2012 ·04/06/2012 12 $49.20 'c · ·· 12 · $ 49.20

Page 1of2 EXHIBIT A

Attachment B PLANTATION MANOR Review Date January 1, 2012 to June 30, 2012

ME Proc Mod Date of Service Units Net Error Overpaid DCN Claim ID Paid Date Name Last Name First : Cd . P~~cedure ' . Cd Cd i From To . Pd Payment Code Units $

48448345 49~21300181~2 , 05(~1j201~ .• .• 16 Per~~~a! ~a~~ -~~.r Per 15 _Mi~ . '.~~~9 ... .U? _ . O~/f?.9./.~~12 _ 0~(.29/~01~ . . .. ?~. $2~~-~~. A, C 50. $ .~05.00 48448345 ,4.91215~0:i_3_53~. :06(0~/2012_ .• . .• . :16 _P~r~~n<ilSJ~eSerP~~~S_M!n .... }1~_19_ :u~ .. . ,05(~1/~~~~- _D~/30/2012. 6~. .$.~4.20_~!.c. .. §?: $ 2S4.2q ·18_4483~5 :49~~1~~0~~~14 .. o!/'?_6/?.012 .• -· --- .. 1_6 .~er~o~_alC_~reSerPe~l?.~i~. ·- .. :"!J:~19. Y3. ,06/~~l?.q1~. -~-6/2~/20_1~ .. - s~ ..... S.~13.~0_A.~..... 5.2 ... ~ 2_~3-~0 46.60147~ _4~12~3?~_?7624 .... o~(.~~/2~13 ;- . . . __ .. ?6. -~-~~?.~?!~'.~.s~_r ~er~~ Min ......• !3:~~~--.Y?.. ;~1/~Y?.~_12 .O.lf~~(20_1_2_ .... 3~ .. ·--~1~?.:.~~:A . . ........ ~: _$. _5.;o 4660~~7 ~ . ~4~12E~¥..~?.~~~ . ~ ?.?!~~!~~~2 __ __ .. ··-· -· .: ~~ f~=~-~n~-~~=~ ?.er ~e~ ~~ 'Yl.i~.. . ... }}.q~~- .. ;.~~- .. ~0_?/_0.1.f.f.01~ .. ?.~/.~~(2~-~2 .. ,, . ..:3.~: ·- }.!~?:~~ -~ ··- -· _. __ ~ .. $. .. ~2.39. 466~-1~7~ .. '.~~-~~~-~~?.?!74 .... '.9.?/.~~?.~~2 .... . ... ··-· _ ... '..~~ ·"·~er.:_o~~~ ~'..~.~e'.~~!: ~-~.!Vl~n .. :I~?..;.~- .. }J~ .. :.Q~/9.l/~~~-~.:~.~{~-3.~~~ ·-··--·?.! ... ·--~-~~?.·~~-~ .... , .... ~:.$ . ?.Q.5q__ 466~14:?_"'._ "~~13~~-~~E~~-~-~ __ . ~~:?.~9.~!~Q~~---- .. . . ·- . __ ... . ! ~~- _,P~~:~.~-~~~?.'..~ ~.:!-~'..~~ ~i!1 ...... . }~°..1.?. ... i ~~- .. ~~y~~t~_9_13_ . 93/30/~9_~~ __ . -· ... _ a:_._-~~.?.:~~·-· ___ ··- --~- ... -~~-L ... _:_ .. 4~5g1474.. _ -~~~-~?.~.~~02~-~~~ .. J~~;?./.~~~-- - _ ....... :- ..... '.~~-- ~~.=r.:_~~~l Car:~~-~-~-~!"-~- ~i~ ......... '.!101~- .!Y.~ ... ~03/~?.L2.9~~--:~3.l3.?.L~-1}: ___ -· .. ~~ ...... J~~'.~9.~~--- ..... ; ........ ~.J _ .;5.~Q-.~6~~~~74. _ . .:.~130~~-~~-~? .... }l_¥-~~!.~~~~ __ ; ___ .. ·- ··-. 1- .. ;~~-.Z~~nal.~~!.~ ~~.:!.~r 1.:?. .. M.!~ .... ·-- :no_~~-}:!.~ ..... l~Y9.~/2~~! --~'Y.:~/29_~3 . ..;_ _~3~----}254.2C~Y.\S ..... ! ···---~~!-~--~54.~~ ~§6('._14.! ~ ....... :'.~1-~~02.~.?.~?~ .... ~os/_ly~9p_ .Im .. .. -·. .. . .. ,---- .. }~. ~ ~~-r~?.~~-~-~:~. ?..::.~~~ .~?.~!~ .. -· :no19_~?- .. _,~4/011~~~~ . .E.~l~~L~P.~~- -~ ··-_ ?.~ ~ ...... §;3?.~~~ !~i .. ~S._: ____ l~.LLgz !O_ 4..~s.?1~~-~-- .... '.~~1?,9.~¥-59~~~~--- l?N_qY~E.~.. . ..... : ·---~~~ ... :~:::_~nal «?_r_:~e!..~.~:._;~!-1.!!:1 __ ~~~19 --~~?. __ )Es/011~~~~ .,~~~9l??!_2 ____ 631_ s2s4.20A ~--···· ~- --~~-~ _ _?54.?.9_

i!!~?~t:f~~~~it3!iii~~ ·~·· .::==~~1=~~3=~~~iig:~~~~J~~f:i~~'.~!:~;~i~~tit*i~ 2~5..~~~7.~. ·-···L~.~~39:370~62?_.)E,~j!_0/2012 ( . . .... - ..... _ ·--------- ·-?-~--;.Personal Ca~~1.~r!!!.~~---i:!_~019 _ll!.~.·-··/-~1/q1/~0~-~ .. l~.@9£~01~--J--~----$127.ml~.-·---L __ ;+L ... -~1_9.. ~-§~~-~-5?~ .. J-~~~~~~~-~~-3.'!.~ ... '.03/0~l3~.~3._J_____ _ __ .......... ---·· ·--f 16. ~!~:sol"!.~~~~ Per_;.? .. ~!~ ...... _J!l0~-~--~~01/2012 .. j3f28/2012 _; ___ 31j·· $127..:~~~.J ____ __?~j--~~Q.. .. -~ 6~9..~~2.§ .. . .:~?.}.~~2oso~~~-- _ :9~£~3/2~~2_ .f -·· ·--·-. _ .. __ ....... ~-~--;-~:.'..:?_nal c~~-~i:!".~=-"-~-Mi~--- Jno~~ .. _glo1z2.~~~-- i9.¥.~.3~.~-; -~_:1:.,_ $121 .10_!A __ ..... .L. ....... _1~_ t --~'.;9_ -~6~~~5?§_ ·--~~13002:_?.~Z.~ :OS/1y~o12 .... ··-- ··-----2.§_JPe:~I Ca::_ Ser Per~-~~----' T1019 iU3 . :o4/0l/2012_.~04G_6/20gj___ 30i $123.00iA, c .. i.-~Ql-~.-~?.?.'.QQ_ -~~?_98.?7_~---- ___ 49~~-~5-~~?~~- '06~?/~~}3_ ___ .. -···- ·-··-------·--·----~~rsonal Care S:_~~:_r ~~-~!~--.. --.l~9....~-1U3 __ )05/01/~~~2 105/30/2012 )_~;_ $127.10\A, c __ -i.-_.Ef..L!:?-2:.!9_ ~65?85_~. ___ _;_~912182~-~9~~- iO.? /0~3_~'!;_2 ---·· ... - ;16 1 Personal !=are Ser Per 15_~!~---·--·tT1019 JU3 _J06/01/~~13 .. ~/29/201~----_.:?]:_: --~.!P::!:.~JA, £__L_.2_:~.L..L.1Y._.10 _

.~.o..s.-~ ~~ z~ . _ .'.~-~-~-~~~?._02152 ~-J02z~£f3..~12 . ____ --·--·---.. .J~~..i~-~~?.!.~~~:. .. ~::. ~~-is Mi~----~:!.~~~----~~? ____ 101t~11~~13. .. ;01/3!?£~~-~ 4 ... __ -~L--$127 .10 jA _ ----L- --~~- t_ 4.10 . 3.§.§_1§2.7.~-- .. ~4912069024?,~.~·-··· !03/09/20~?+·· __ --·- -~--·· -· j.?:.~-;~~;~9-~~!.~~:~~~_!:.f_er1s Min ____ ..jT3:_9~ .. 1u3 -~93!.~..!Gg-~_f~?J.?Bl~P.~?. L ....... -~~---J;_~7.1~_!.'. __ .. _ .. ) ....... - _3-.j ... t_.1-?-39._ 26616279 ;4912102080154 104/13/2012 , i16 !Personal Care Ser Per 15 Min (T1019 iU3 :03/01/2012 i03/26/2012 ! 271 $110.70:A i lj $ 4.10

-~!1-~.~-~i.~~;~~~1q~:~37_~zi~=foV1iJJi~~ .... ·.~~=--~· :--=+16~_7Personal Care·se·r Pe~~~~in --=~19 jU3 -!01io~3]i_~~0/2oi2 ~--=~2)·---·$25~~= ! --~j~=:!~~~ ~-?.~?~_°.?~ _ .. ;.~~~~9024~~- .... ;.Q3/0~/~9.:1:~ _i __ ·-·· ...... :--· ·- .. ~;~ . ,.~~?..~~-~.:~-~r:.~~ 15 ~- __ ... j:~~~-~--- .t~~ .... . \~yo1(~~~.? .. ~oy2afl~~~-i. -· ·-- 62 L. ..... }254.20:~ .. ·-- J. ··-· .. ~~-~-- -~~~!? .. S_?~2.9.g_6.9. . . .}~~-~-~~20801?~-- j~~l~f~~3 ___ .. -·-··- ·-··--·· ... _ +~-~-- -~~~~~~~!.1 .. ~~~"=-~e!..~=~-15 Mi.!:1_ ___ _; !~.1::9-... j.~.? ___ )9.Y.?}!.~~12-. ;~Y~~!~~~---i------~.9l. __ . $205.~91~---~---··}.;J .... --~:.~o .. . _3_~?~5.~.?.~ .. ..i.~~~3E?2.~76~- . ...!~?f}~(±~~~- • ____ .... ·-+~~- -~ ~~~-~-~-a~~~.i:..~-~-::.-~~~~~~-- ____ [!~~~_:i ___ .L~~- _ -~~(Sl_y2g_l}. :~~~¥.-~E~- ;_. __ 12 :. __ . _ .J.49.2EL_ ··---+- ..... ..l-~ . . .... : ..... . §~7~?9§.~ ..... :.~~~~9.??.e~?~~?- ... @3.1-~.Q(~0_.:13_ . ----··-··-·.;.~ .. ;~~~on~ Car~~~r:.~_e;_~.~..!.~- ···-··-··;!~£~--- f-~~ ..... i9.Y15~~1.?:. j0~~91201~ .. ! ...... ~J...- ... J.??:~_c!.!P.-........... J. ·-· .---~~ $ ... 1l:~9---~4???9.5~. ··-·· l~9-~0~9.~~?.~~: .. i~_9~~q1~···. . . . _ =·· -··--·~;~jP..~.~~~~~.!~~~-:_~~~~!? _Ty!~i:_ ....... i!.~~~~- .. l~~ .. +~~lf?¥?.9~?. ~~~{?_S/2~~.2-... ~ ....... ~~-1---··· ... ~~22~~;~-- , . j __ ....... ?.! $ .. ...1.?.~ 34725963 '4912102080156 :04/13/2012 '- - :is iPersonalcareserPerlSMin !Tl019 jU3 103/01/2012 ·03/30/2012 · 31: $127.lO!A ; 1; $ 4.10

3472sss3· · · . ~~~~?.i~9.~j~i?.~ .. -i~/~11_20~~-: I .. ·- .'•:: ... · -~·;xs_: .·:·~~-~~~~~'-~~~~~~-p~~ J.~:-~E-.:~::·~-=~.!9~ .. ·:r u~·--·· ;~1ifZi:~13· i~~2~~l~ii.: ~-.:~-~ji :· -· ... siv:-iot.\·. ·c: ·· · t· · --·3~··s · 127:10· • I ' ! i • o ; : : ! $16,236.00 · : ! $9,179,90

Page 2 of 2 EXHIBIT A