24587 Malinowski Consulting (2)bt Carmel
ONE CIVIC SQUARE
CARMEL, INDIANA 46032-2584
ORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL - 1997
INDIANA Ht IAIL IAA GAtMPI
CERTIFICATE NO. 003120155 002 0
FEDERAL EXCISE TAX EXEMPT
35- 60000972
PURCHASE ORDER NUMBER
245$7
THIS NUMBER MUST APPEAR ON INVOICES, Al
VOUCHER, DELIVERY MEMO, PACKING SLIP;
SHIPPING LABELS AND ANY CORRESPONDENCE
RCHASE ORDER DATE
DATE REQUIRED I REQUISITION NO.
VENDOR NO.
DESCRIPTION
5/52014
ENDOR
— .Malinowski Consulting•;, ... -__M_ ..- Carmel Fire Department
SHIP 2 Cannel Civic Square
TO
755 West Cannel Drive, Ste ,300
Carmel, IN 46032
Cannel, IN 46032 .
(317) 571.2622
vrRMATION
BLANKET
CONTRACT
PAYMENT TERMS
FREIGHT
J
QUANTITY
UNITOF MEASURE
DESCRIPTION
UNIT PRICE
EXTENSION
Account 43.509\.'W)
1 Each Medicare Ambulance Cost Reporting
Send Invoice To:
Cannel Fire Department
2 Cannel Civic Square
Cannel, IN 46032-
PLEASE INVOICE IN DUPLICATE
$18,000.00
Sub Total:
$19,000.00
$19,000.00
DEPARTMENT
ACCOUNT
PROJECT
PROJECT ACCOUNT
AMOUNT
Cannel Fire Department
SHIPPING INSTRUCTIONS
• SHIP REPAID.
• C.O.D. SHIPMENTS CANNOT BE ACCEPTED.
• PURCHASE ORDER NUMBER MUST APPEAR ON ALL
SHIPPING LABELS.
• THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
24587
"nit-to Inrair net went.. •.fl
ORDERED BY
PAYMENT $19,000.00
• NP VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE PO.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
• I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
TyISAPPROP ATTIZ�•SUF •ENT PA OR THE ABOVE ORDER.
TITLE
CLERK - TREASURER' -
OFFICE f nPv
Malinowski Consulting
Fire Dept. - 2014
Appropriation #43-509.00; P.O. #24587
Contract Not To E.vcced $19,000.00
ADDITIONAL SERVICES AMENDMENT TO
AGREEMENT FOR PURCHASE OF GOODS AND SERVICES
THIS AMENDMENT TO THE GOODS AND SERVICES AGREEMENT ( "Agreement ") entered into by and
between the City of Carmel and Malinowski Consulting (the "Vendor"), as City Contract dated February 20, 2013 shall
amend the terms of the Agreement by adding the additional services to be provided by Vendor consistent with the
Scope of Work attached hereto and incorporated herein as Exhibit "A ". Furthermore, the terms of the Agreement
shall be amended to include the E- verify requirement as stated in Indiana Code § 22-5-1.7 et seq., which is attached
hereto and incorporated herein as Exhibit "B ". as well as the required E- verify Affidavit, attached hereto and
incorporated herein as Exhibit "C ". Also, pursuant to I.C. § 5 -22 -16.5, Vendor shall certify that in signing this
document, it does not engage in investment activities within the Country of Iran. The terms and conditions of the
Agreement shall not otherwise be affected by this Additional Services Amendment and shall remain in full force and
effect.
IN WITNESS WHEREOF, the parties hereto have made and executed this Amendment as follows:
CITY OF CARMEL, INDIANA
by and through its Board of Public
Works and Safety
By:
es Brainard, Presiding Officer
Date:
Mary A Burke, Member
Date: 1- /y
at 99/2a&,)
Lori S. Watson, Member
Date:
ATTEST:
Diana Cordray, !2?
Date:
( Wn.nN "14..n,Wa- aOmV- \MbAVtdeorti Pt
Malinowski Consulting
B
orized ignature
tit ✓G // it-6 j• /, in/o w j
Printed Name /�J
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Title
FID/TIN:k
Last Four of SSN if Sole Proprietor: r
Date: AOy / � 7u/fr./
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EXHIBIT "A"
ADMENDMENT TO EXISITING AGREEMENT
PREPARATION OF MEDICAID AMBULANCE COST REPORTS FOR 2013 & 2014
Section 1: Introduction
The purpose of this letter is to provide the City of Carmel with a formal proposal outlining how Malinowski
Consulting, Inc. can be of assistance in the area of providing technical expertise in the preparation of a
payment adjustment for eligible fee - for - service Medicaid ambulance services.
Section 2: Background
The Cannel Fire Department provides City -wide ambulance services. A significant portion of those services
are provided to Medicaid participants. Recently the Federal Office of Medicaid Policy and Planning received
approval for a supplemental payment adjustment to in -state ambulance providers. The payment adjustment
is intended to reimburse providers the actual incurred costs of providing ambulance services to eligible
Medicaid beneficiaries.
Section 3: Objectives
The objectives are to:
• Provide all necessary documentation to State and Federal program administrators to clearly
document related eligible expenses.
• Make the process of preparing the Ambulance Cost Report as easy as possible on City employees who
can better service the Citizens.
• Describe the results of the Ambulance Cost Report to City officials and defend the results to State and
Federal program managers or auditors.
Section 4: Scope
To achieve the objectives of this service, Malinowski Consulting will cover all aspects of the Ambulance Cost
Report between the City of Carmel and the State of Indiana. This will include the following:
• Ambulance Cost Report Data Collection: Malinowski Consulting will perform all data
collection activities. City staff will provide direction as to where the information can be obtained.
• Ambulance Cost Report Presentation to City Officials: After the compilation of the
Ambulance Cost Report, Malinowski Consulting will meet with the appropriate City Officials (Mayor,
Fire Chief, etc.) to review the results of the analysis, focusing on the recoveries to the General Fund.
• Delivery and Negotiation with State Officials: All delivery, presentations and negotiations
with State agencies is included in this service.
• Audit Defense to Federal and State Auditors: In the event that State or Federal auditors have
questions regarding how the Ambulance Cost Report was prepared, Malinowski Consulting is ready to
stand completely behind the plan results.
Page 1 of 3
EXHIBIT "A"
ADMENDMENT TO EXISITING AGREEMENT
PREPARATION OF MEDICAID AMBULANCE COST REPORTS FOR 2013 & 2014
Section 5: Approach
The following approach to this assignment will include these steps:
• Schedule an on -site meeting with Fire Chief to collect ambulance specific data for the report.
• In cooperation with the Human Resource Department, determine wages and fringe benefits for the
Fire Department.
• Review City expenditure claims from the General and other Funds to ensure the utmost recoveries of
eligible supplies and other services and charges.
• Compile all data collected from various City departments into an electronic format that will generate
the appropriate report that meets State and Federal guidelines.
• Review the Ambulance Cost Report with the Fire Chief and Mayor to foster an understanding of the
submitted document.
• Deliver the Ambulance Cost Report to the responsible State agency contact guaranteeing receipt of all
required data.
• Monitor the approval and payment process by the State.
• Respond quickly to questions posed the Indiana Family and Social Services Administration, Indiana
State Board of Accounts and Federal program managers and auditors.
Section 6: Timing
The Ambulance Cost Reports will be prepared and submitted to Indiana FSSA by the Federal filing deadline
of May 31st, following each fiscal year end.
Section 7: Staffing
Malinowski Consulting will utilize the expertise of our Indiana based consulting staff.
• Charles Malinowski, President
• Barbara Malinowski, Operations Manager
• Daniel Vaughn, Consultant
• Bruno Afonso, Consultant
Section 8: Qualifications
The following are key qualifications that make Malinowski Consulting uniquely suited for this assignment:
• City of Carmel - Medicaid Ambulance Cost Reports, 2011 & 2012.
• 5 Indiana Counties - Medicaid Ambulance Cost Reports, 2011 & 2012.
• 22 Indiana Counties - Preparation of County -Wide Cost Allocation Plans for the years 2005
through 2013.
• 1 Indiana City — Preparation of City -Wide Cost Allocation Plan for 2012.
• 54 Indiana Counties - Preparation of Title N -D Monthly Expenditure Reimbursement claims for
the years 2004 through 2013.
Malinowski Consulting is an Indiana Corporation serving Indiana Counties since 2004 with a consulting
staff that is based exclusively within Indiana.
Page 2 of 3
EXHIBIT "A"
ADMENDMENT TO EXISITING AGREEMENT
PREPARATION OF MEDICAID AMBULANCE COST REPORTS FOR 2013 & 2014
Section 9: Fees and Expenses
Proposed Fees:
Our fee for this service shall be $9,500.00 for each reporting year / $19,000 in total and is contingent
upon the actual recovery of costs from the Federal Government.
• The City of Carmel and Malinowski Consulting, Inc. shall share equally in the recoveries up
$19,000.00. Any recoveries above $19,000.00 shall be l00% Carmel City's share.
• This fee is inclusive of all services performed and no additional expenses will be necessary.
• An invoice for the professional service fee will be submitted to the City only after the City has received
the actual reimbursement from the Federal Government.
Page 3 of 3