Under Review: What You Need to Know About Clinical Privileges Hearings

The term “fair hearing” is used by different individuals and different organizations to refer to an administrative hearing or a private hearing in a hospital or professional association. There are a number of different types of proceedings that are often referred to as “fair hearings,” including clinical privileges (or peer review) hearings, which allow a physician who has had his or her clinical privileges revoked to be reviewed.

This type of hearing can also be referred to as:
• Privileges Hearing
• Fair Hearing
• Medical Review Hearing
• Credentials Hearing
• Medical Staff Hearing
• Disciplinary Hearing
• Credentials Committee Hearing or
• Ad Hoc Committee Hearing.

The physician that is subject to these hearings is not a Hospital employee, does not have a direct contract with the Hospital, is not a member of a group with an exclusive contract, but does have clinical privileges at the Hospital (based on proven clinical skills and competence to perform certain defined procedures in a hospital). When a hospital finds that a physician with clinical privileges is no longer competent (in the eyes of the hospital), a hearing will be conducted aimed at stripping the physician of his or her clinical privileges. This process (especially the litigation involved) can get ugly, and it is important for the physician in question to obtain the counsel of a health attorney who has experience in dealing with clinical privileges hearings.

Here is attorney George Indest’s basic rundown of clinical privileges hearings:

Indest’s Maxims for Hospital Peer Review Hearings

1. The peer review process is different in every hospital.
    a. Medical staff bylaws are different.
    b. Hearings are different (attorneys may not even be able to participate).
    c. The burden of proof may be placed on the physician.
    d. Investigation and appeals process may be different.
2. The hospital’s resources are virtually unlimited.
    a. Hospitals may use certain experienced companies as part of the process that have a tendency to favor the hospital.
    b. The hospital’s personnel and attorneys will do all of the work and provide all of the support for the medical staff and peer review committee.
    c. The hospital and medical staff will have unlimited access to hospital employees and documents.
3. You need legal representation from the time of the first rumor you hear that a complaint has been filed or a matter is being investigated.
    a. DO NOT “wait and see what happens.”
    b. DO NOT think that you will be an exception.
4. You must be represented by an experienced, knowledgeable health care attorney during the peer review process. The hospital will be.
5. The “nonconformist” or “trouble maker” will be forced into a hearing situation. The guy everyone likes won’t be.
6. If hospital administration (including nursing staff) is out to get you, you will be gotten.
    a. If the hospital administration identifies you as a “bad physician,” “troublemaker,” or “disruptive physician” you are in serious, serious trouble.
    b. Your prior cases may be reviewed and scrutinized retrospectively for problems that were “overlooked.”
    c. Every poor result or outcome will be analyzed.
    d. You will be written up for everything that happens, even for things for which others would not be written up. Incidents where you were just “joking around” will be written up as sexual harassment.
    e. Any patient complaints over insignificant matters that would have previously been handled in a routine way, will now be handled as significant events.
7. You will probably be offered an opportunity to resign prior to the commencement of the investigation . . .
8.  But you will foolishly turn down the opportunity to resign.
9. There are many options and alternatives available early in the process, but only an experienced health care attorney will know them. Options may include:
    a. Agreement not to admit, treat or perform certain procedures;
    b. Taking a leave of absence;
    c. Assessment by an independent organization (P.A.C.E., C.C.A.T.);
    d. Agreement to undertake additional training; or
    e. Resignation (prior to any proceedings being commenced).
10. A “fair hearing” is not fair.
     a. The resources are stacked in favor of the hospital and administration.
     b. Peer review proceedings are very expensive (for all parties).
     c. The burden may be and can be placed on you to prove you are currently clinically skilled and competent.
     d. There may be external motivations, other than quality (especially in cases of tenured professors, senior physicians and minorities). Certain motivations are economical in nature and can be identified by:
      i. Proceedings initiated by your competitors;
      ii. Complaints made by your competitors;
      iii. You allegedly bringing in too many cases (monopolizing the procedure rooms or operating rooms);
      iv. You bringing in the wrong cases (too many Medicare, etc.);
      v. One medical group controlling the whole department (in absence of an exclusive contract);
      vi. You being accused as an “overutilizer” (you use too many hospital resources);
      vii. You being accused as”cherry picking” the best cases (all non-indigent or non-Medicaid cases); or
      viii. You refusing to participate in managed care plans.
     e. If suspended pending investigation/hearing and the suspension goes over 30 days, then a report to the National Practitioner Data Bank (NPDB) is required (which means there will be a report to your state medical board or licensing authority).
     f. You may find the same individuals on:
      i. The Investigation Committee
      ii. The Peer Review/Hearing Committee
      iii. The Appeals Committee
      iv. The Board of Directors/Trustees (responsible for final recommendations)
     g. You may have a gag order and not be allowed to talk to witnesses or potential witnesses to help you prepare for your case.
11. It may not matter what the peer review or fair hearing committee recommends.
     a. The Board of Directors/Trustees can and will overrule the conclusions and recommendations of any peer review hearing (with the input of hospital administration and hospital attorneys).
     b. The peer review committee must make solid, unequivocal findings supported by evidence, as well as, strong, precise well-reasoned conclusions and recommendations. Make sure that you ask them to do this and that you (or your attorney) present to them a proposed recommendation or report.
12. Those who judge you are not your peers.
     a. They may be from all different specialities and some may not even by surgeons. (Try to have the hearing committee be appointed by your medical speciality association.)
13. The only rights you have are those in your medical staff bylaws (unless you are at a “public hospital” or in California)
14. The consequences to you of an adverse outcome will be lifelong and career-altering. Consequences include:
     a. National Practitioner Data Bank (NPDB) Reports, which are national, on file for 50 years, very difficult to get corrected or voided and also reported to your state medical board;
     b. State licensure action (in every state in which you have a license);
     c. Medical specialty associations will commence proceedings if they hear of an adverse outcome;
     d. You will unlikely ever get clinical privileges at another hospital;
     e. You may lose medical malpractice insurance coverage;
     f. You may be dropped from the panels of many HMOs, managed care plans and insurers;
     g. Contracts with employers and insurers may require you to report this (so that you can be terminated).
15. Once a peer review proceeding is commenced, it’s not just going to go away, and none of your friends on the Executive Committee or Board of Trustees is going to make it go away.
16. Once a peer review proceeding is commenced against you, you will be in the most important fight of your career and possibly your life.
17. You have no power, no control and no leverage. Get some:
     a. Assemble an experienced legal team;
     b. Begin preparing early and seriously;
     c. Get established, credible experts;
     d. Sue the hospital and certain individuals involved, if circumstances permit;
     e. Consider “political” or “public relations” avenues like letters to other physicians or patients, full page newspaper ads, getting your state or county medical society involved, or having a state legislator introduce a bill to require due process in all hospital adverse actions.
18. You are going to have to spend lots of money to properly defend yourself and you will not get it back if you win.
19. If you think you will be successful in suing in court to have an incorrect result overturned, you are probably wrong.
20. Court litigation can give you the leverage you need to obtain a favorable outcome on the peer review proceeding.

Indest’s Recommendations for the Subject of a Hospital Peer Review Hearing

1. You must ensure that your medical staff bylaws contain true “due process” rights for accused physicians.
2. You should attempt to have state legislation passed that requires all hospitals to afford physicians certain due process rights in peer review proceeding similar to what California has done.
3. The Medical Staff should never allow hospital administration (or the hospital parent corporation) to force them to adopt medical staff bylaws changes which eliminate or limit the hearing rights or due process rights of a physician who may be the subject of an adverse decision.
4. The peer review committee (fair hearing committee) should have its own independent legal advisor in all hearings. This must be someone other than from the law firm which represents the hospital.
5. You must treat the peer review process like you would a civil trial against you for medical malpractice.
6. If you are the subject of a peer review proceeding, immediately retain experienced, knowledgeable health care counsel to represent you.
7. Also, immediately retain a litigation attorney who has experience in this type of civil litigation. File suit immediately if the matter is not proceeding fairly and in accordance with medical staff bylaws and state laws.
8. If your hearing procedures/peer review procedures are not in your medical staff bylaws, make sure that both the medical staff bylaws and the hearing procedures state that the hearing procedures have the same force and effect as the medical staff bylaws.

If you are currently the subject of a peer review or clinical privileges hearing, call (407) 331-6620 or (850) 439-1001 to speak with one of our health law attorneys. You can also visit our website at www.TheHealthLawFirm.com.

What Does Proposed Liposuction Bill Mean For Florida Plastic Surgeons?

A new Florida bill aimed at making liposuction procedures safer is making its way through the Senate in Tallahassee. The bill was created as a result of the deaths of four South Florida mothers in their 30s during liposuction procedures, according to the Orlando Sentinel.

Present state rules say physician surgery offices must be inspected by the state Department of Health or accrediting organizations, unless the doctor performs procedures using only local sedatives that leave the patient awake. Cosmetic surgeons who perform liposuctions using local sedatives such as lidocaine do not have to have their offices inspected.

The bill says that any liposuction that removes more than 1 liter of fat can only be done in a regulated office. This would cover most liposuctions. It would force most liposuctions to be done in surgery offices inspected by the state, by doctors with life-support training, not in unregulated physician offices.

However, some doctors think that the legislation doesn’t go far enough. It does not ban liposuction in physician surgery offices, as some proposed. It does not force med-spas to be regulated, as Sobel proposed in bills that failed in the past. It does not force doctors to use an anesthetist for all liposuctions.

The bill has cleared the Senate Health Regulation Committee and now goes to the Senate Budget Committee, where it is expected to pass. A similar bill is pending in the state House and no opponents have come out against it so far.

The bill was filed by state Sen. Eleanor Sobel, D-Hollywood in reaction to four South Florida liposuction deaths since 2009.

Maria Shortall, 38, died when her bloodstream was blocked by fat sucked from her midsection and reinjected into her buttocks at an unregulated physician office. Kellee Lee-Howard, 32, died of drug interactions in the hours after a liposuction at the same office, and Rohie Kah-Orukotan, 37, died of an overdose of lidocaine given during liposuction at an unregulated medical spa. Another Miami woman was killed from a fat blockage after liposuction at a licensed surgery center.

Disciplinary action is pending against the doctor involved in the first two cases; the doctor in the third case has surrendered his medical license. No disciplinary action has been taken in the fourth case.

According to the Florida Society of Plastic Surgeons, which backs the bill, it won’t be expensive for the state to regulate these offices. Additionally, the Florida Society of Plastic Surgeons hopes inspections will detect doctors who may be using local sedatives, such as lidocaine, for extensive liposuctions that should warrant stronger sedatives and more safety measures. Those measures include advanced life-saving training and having an assistant give anesthesia.

While no one has come out vehemently opposing the bill, if passed it will have some consequences for plastic surgeons who don’t update their practice to comply.

For more information about this and other health law topics, please visit www.TheHealthLawFirm.com.

National Practitioner Data Bank (NPDB) Update

On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (PPACA).  This legislation made many reforms to the American health care system and with it came many changes that will affect both health care providers and consumers alike.  One such change brought about by this legislation was the elimination of the independent Health Integrity and Protection Data Bank (HIPDB), and its merger with the National Practitioner Data Bank (NPDB).  This will not affect the purpose of the federal government’s clearing house for disciplinary and malpractice information, but will forever change how the information is disseminated.

 To understand the changes, one must first know the history of the NPDB.  The NPDB was established by Title IV of Public Law 99-660, of the Health Care Quality Improvement Act of 1986.  Its purpose was to improve the quality of health care by encouraging State licensing boards, hospitals and other health care entities, and professional societies to identify and discipline those who engage in unprofessional behavior.  The NPDB has been expanded and revised a number of times, but its greatest expansion came on January 28, 2010, when the U.S. Department of Health and Human Services issued a final rule implementing Section 1921 of the Social Security Act. 

Prior to this the NPDB dealt only with licensure and malpractice reports of physicians, dentists, and health care entities. This new regulation expanded the information collected and disseminated through the NPDB to include reports on all licensure actions taken against all health care practitioners.

Like the NPDB, the HIPDB was created to improve the quality of healthcare in America.  The HIPDB was formed under the Health Insurance Portability and Accounting Act of 1996 (HIPAA) and  specifically focused on combating fraud and abuse in health insurance and health care delivery, and promoting quality care.  The HIPDB collected reports made by federal and state licensing agencies, federal and state prosecutors, and federal and state government agencies that had excluded a practitioner, provider or supplier from their health plan.

The NPDB and the HIPDB were created to provide a resource for state licensing boards, hospitals, and other health care entities to assist them in their investigations of the qualifications of the healthcare practitioners they sought to license or hire.  These two data banks served this purpose independently of each other until the passing of PPACA on March 23, 2010.

Section 6403 of PPACA requires the Secretary of Health and Human Services (HHS) to maintain a national health care fraud and abuse data collection program for reporting certain adverse actions taken against health care providers, suppliers, and practitioners, and to submit information on the actions to the NPDB.  Section 6403 further requires the Secretary to establish a process to terminate the HIPDB and ensure that the information formerly collected in the HIPDB is transferred to the NPDB.

What does this mean to you?  Specifically, the NPDB has now become one large, all encompassing central data bank for all reports made against all health care professionals, whether the report deals with fraud, abuse, licensure actions, or malpractice.  The HIPDB has been eliminated as an independent data bank and in its place the Secretary of Health and Human Services has implemented a process in which all fraud and abuse reports will be collected and transferred to the NPDB.  Additionally, all information that was previously held in the HIPDB has been transferred to the NPDB.

For more information about the National Practitioner Data Bank and how it might impact you and your practice, visit www.TheHealthLawFirm.com.

Florida’s Strike Force Raids Pain Management Physicians

Florida is reported to have one of the worst prescription drug abuse problems in the country. Because of this issue, pain management physicians have been under increasing scrutiny and attack by federal and state agencies.  If you are a pain management physician or you work in a pain a management clinic, you need to be aware of the measures that state and federal agencies are taking against doctors who practice pain management and the owners of pain management clinics.

A news release sent out by the Florida Department of Health (DOH) this summer discusses “inspections” of physicians’ offices across the state, allegedly to ensure compliance with Florida’s new prescription drug law (House Bill 7095).  However, many of these may be more aptly termed as “raids.”  These raids, under the guise of being inspections, have resulted in a massive quantity of narcotics being seized from clinics and physicians’ offices by the Strike Force. It is claimed that no search warrants are necessary as the Strike Force states it is performing an “administrative inspection.” The pain management physicians targeted by these inspections are identified based on their purchasing, prescribing and dispensing levels.

Often these “inspections” will include Department of Health Investigators, Florida Department of Law Enforcement Special Agents, local police and law enforcement agents, and Drug Enforcement Administration (DEA) Special Agents.

•  Our primary concern and warning to the physician or owner is to not talk to any investigators or inspectors, but call your personal attorney immediately. Have the investigator or inspector talk to your attorney. All communications should be with and through your attorney.
• If you are requested to “voluntarily” relinquish (give up) your DEA registration or your medical license or other professional license, do not do this.  It will not help you and it will make every aspect of your case more difficult to defend.
• Do not make any statement (oral or written) or allow yourself to be interviewed.
• Obtain the complete names, addresses, titles and agencies for each agent there.  Obtain their business cards (which they should have).
• Do not volunteer up any documents, items or information.

To read more about inspections from the document released by the Florida Department of Health click here.

If your office has been “inspected” and you need legal representation, you may call and speak to one of our health attorneys at (407) 331-6620 or (850) 439-1001.

More Information on IPN for Nurses

As health law attorneys, we are often contacted by nurses who decided to self-report, were set up by colleagues, involved in an off duty incident (DUI, narcotics possession), or drug tested at work and were directed to IPN as a result. These nurses now may face years of problems because they agreed to IPN in an attempt to save their license.

For those who have never heard of it, IPN stands for Intervention Project for Nurses. It is a program based in Florida aimed at providing an avenue for swift intervention/close monitoring and advocacy of nurses whose practice may be impaired due to the use, misuse, or abuse of alcohol or drugs, or a mental and/or physical condition. Other states have similar programs, like TPAPN (Texas Peer Assistance Program for Nurses)  in Texas or RAMP (Recovery and Monitoring Program) in New Jersey.

Let’s set things straight. IPN is not the easy way out if you are trying to save your license. Although IPN may have some benefits in rehabilitating a truly impaired nurse, for others, it only causes mounting problems. We hear so many horror stories about nurses who turned to IPN to save their licenses, only to never again be able to practice.

When you agree to IPN, you are agreeing to many, often unclear consequences. Nurses accepted into IPN must sign a five (5) year contract agreeing to monitoring, weekly counseling meetings, regular psychiatric visits, random urinalysis testing (with a mandatory call in every day of your life for the five year period), mandatory notification of all employers that you are in IPN and why, a strict prohibition on drinking any alcoholic beverage, or taking any medication (even over the counter medications) without the prior approval of IPN, possible loss of your privilege to administer narcotics, possible loss of your privilege to access any prescription medications, a possible requirement that you only work under the supervision of another registered nurse, and other possible requirements.

These stipulations are extremely expensive, especially if a nurse is not working (many currently or previously in IPN cannot find jobs). Drug testing, rehab and consults all must be paid for and can cost thousands of dollars. If you ever miss a drug test or a support group session or consultation ever comes back to IPN with less than perfect reviews of you, your contract may be extended or further consequences can be added (like license restrictions). Furthermore, not all IPN counselors and specialists should be viewed the same, and there are not any uniform evaluation requirements for the specialists. It is our experience that some are better than others, and some should be avoided at all costs! Just because you are 100% innocent of any charge against you and have a clean drug test, a specialist can still find fault leading to more problems for you.

Many nurses that have had major problems with IPN are nurses who have been prescribed medications. In IPN, it does NOT matter if you have a prescription. If you have a medical condition that requires treatment with a narcotic or other IPN banned medication (like Ritalin), you CANNOT take it. Shouldn’t nurses be able to be treated the same as anyone else? Additionally, you cannot have any alcohol, and IPN will test for alcohol use.

While the medication and alcohol restrictions are harsh, some nurses who have been subjected to IPN say that the worst thing is the negative stigma associated with nurses in IPN. You can get lucky with a contract that does not require random testing, without mandatory participation in weekly meetings. However, you will ALWAYS have to let your employer or potential employer know about IPN. It is our experience that this knowledge will prevent you from getting hired, most of the time, despite IPN’s claim that plenty of IPN nurses have jobs. Even if there are no restrictions on your license, you will still have a difficult time ever getting job, making your license (which you thought IPN could save) worthless.

When you are faced with any kind of allegation as a nurse, always remember that you have the right to an attorney during any questioning whether as part of an initial investigation, during a hearing, and while reviewing and considering a consent agreement. A drawback for many nurses faced with charges is the cost of an attorney. However, please consider that you are facing the possibility of a restricted license, a revoked license, and/or ending up with charges next to your name that may end your ability to ever practice as a nurse. Struggling to find work under IPN’s stipulations and with a restricted license is not easy, if at all possible. The cost of hiring an attorney who may be able to save your license and livelihood is well worth it when compared with the alternative of never being able to find work.

However, before you decide to hire legal representation, research health law expert attorneys in your area. A board certified health law attorney should be very familiar with cases involving IPN and should have experience going before the Board of Nursing. But do not make your attorney’s job difficult. Consult with a health law attorney before you make any decisions. After you sign an agreement with the Board of Nursing, an attorney’s options to assist you become limited. Even if you are 100% innocent, an attorney might not be able to get you out of IPN after you have already made a deal.

When the nurse may actually have committed the offense, there are a number of administrative and procedural measures which an experienced health care attorney may be able to use to avoid a suspension. This will also prevent the matter from becoming public until much later in the process.

For the innocent nurse, an experienced attorney familiar with Board of Nursing proceedings may be able to obtain additional drug testing, polygraph (lie detector) testing, scientific evidence, expert witnesses, evaluations by certified addictions professionals, character references, or other evidence which shows that the nurse is innocent of the charges.

We hope that this information will help nurses navigate IPN and Board of Nursing negotiations. Please, pass this information on to all nurses you know, so that unnecessary consequences can be prevented.

For more information, visit www.TheHealthLawFirm.com.

Doctor or Nurse, Please, Please, Please: Talk to an Attorney Before You Talk to an Investigator

Despite mailing out hundreds of thousands of postcards and letters to physicians, nurses, dentists, pharmacists, and psychologists  throughout Florida, we continue to receive calls from new clients and from potential clients, after they have already spoken to and made critical harmful admissions against their own interests to investigators.  In Florida, you do not have any duty to cooperate with any investigator who is investigating you.  This extends to Department of Health (DOH) investigators (who are sometimes titled “Medical Quality Assurance Investigators” or “Medical Malpractice Investigators“), Drug Enforcement Administration (DEA) special agents, police officers, sheriff’s deputies, or criminal investigators of any type.

Let me state this as succinctly and clearly as possible.  If you are being investigated, you will not be better off making a statement.  You will not be better off explaining your side of the story.  The investigator is not your friend.  The investigator is not on your side.  All you are doing is falling for a trick and helping the government to make a case against you.

You have a right under the U.S. Constitution to not make any statement that may be used against you.  This is so important that in criminal cases government investigators are required to advise you of this by reciting to you your Miranda rights.

However, in cases where you might have your medical license revoked or have your nursing license revoked or have your DEA number revoked or lose your Medicare provider status or your Medicaid provider status, the investigator is not required to advise you of your rights.

In a criminal case, there may be ways to have your statement thrown out.  However, in a professional licensing case or other administrative case, it may be too late to avoid the damage.  You may be the best witness the government has and you may be the only witness the government needs to prove ths case against you.

In the case where you could receive a $100 criminal fine, the investigators are required to read you your constitutional Miranda rights and to be sure that you understand them before you make a statement.  However, in a case where you can lose your professional license, where you could lose your livelihood and ability to make a living, where you could lose everything you have worked so hard to obtain, they are not required to do this.  You must protect yourself.

Many health professionals, when confronted by an investigator, who will usually call at a very inconvenient time (to catch you by surprise) and will usually flash a badge (to intimidate you), will refuse to acknowledge the seriousness of the matter and will fall for the bait to “tell their side of the story.”  This can be fatal to your defense and fatal to your license.

In the absence of a statement by the suspect (in this case, let’s assume this is YOU), the government may have a very difficult time of proving that you have committed any offense.  It may have other witnesses (who may not be around at the time of any hearing or trial).  It may have a lot of physical evidence or documents.  But it may be impossible for the government investigators to make any link between you and the evidence, unless you help the investigators do this.  You would be surprised at how many health professionals believe that they can just talk their way out of the situation;  in reality, they are just giving evidence that is used to make the case against them.

Any evidence at all, just admitting that you were there, admitting that the documents are yours, admitting that the patient was yours, admitting that you worked at the clinic, admitting that you wrote the prescription, admitting that the property is yours, admitting that you were on duty at the time, admitting that you have taken a drug, admitting that you signed the form, can be a crucial piece of evidence that could not otherwise be proven without your own testimony.

Remember, this is the investigators’ job and profession.  This is what they do full time, every day.  And they are very good at it.  They are 1,000 times better at getting you to admit the crucial elements of a disciplinary infraction than you are in “talking your way out of it.”  They will not be convinced by any excuses you make.  They do not have to be. They will not be the ones making the final decision against you.  Theirs is the job of putting together the case against you.  You will help them by talking to them, explaining why your decisions are correct, explaining why what you did is excusable, etc.  It will not work.  You will merely be giving them enough rope to hang you with.

Hint: If it is a Medicaid Fraud Control Unit (MFCU) special agent (investigator), you are probably under investigation for Medicaid fraud.

Hint: If it is an “auditor,” “surveyor” or “investigator” from an agency or company with “integrity” or “program integrity” in its name, they are probably investigating you for “lack of integrity,” i.e., false claims or fraud.

Hint: If it is a Drug Enforcement Administration (DEA) special agent (investigator) they are probably investigating you to prosecute you or to revoke your DEA registration for drug or prescribing violations.

Hint: If it is an Office of the Inspector General (OIG) special agent (investigator), you are probably under investigation for Medicare fraud or Medicare false claims.

Hint: If it is a Department of Health Quality Assurance Investigator or Medical Malpractice Investigator, they are probably only investigating possible disciplinary action against your license that could result in large administrative fines or revocation of your license.

Do not believe for a second that you are smarter than the investigator.  Do not believe for a second that you will convince the investigator (or anyone else) that there is a legal or medical justification for what you did or what they allege.  If it were as simple as that, then why would there be an investigation and why would you be the one being investigated?

Additionally, do not believe for a second that you can lie your way out of it, either.  Remember, if the government cannot prove the basic offense that it is investigating against you, it may be able to prove that you have committed perjury or lied to an investigator.  In the case of a federal official or a federal investigation, merely making a false statement (oral or written) to an investigator is a criminal act.  This is what Martha Stewart and many others have served time for in federal prisons.

These investigators are lied to all the time.  They are usually better at detecting lies than a polygraph expert is.  Furthermore, in most cases, you will be the very last person to be interviewed.  Therefore, they will already know just about everything that can be used against you.  If your statement contradicts in any way what others have told them, they will know you are the one who is lying.  However, knowing something or suspecting something does not mean it will be something that can be proven in court or in an administrative hearing.

It is much better to make no statement at all.  Blame it on your attorney.  Tell the investigator that your attorney will kill you if you were to talk to the investigator without your attorney being there ahead of time.  “Speak to my attorney.”  “My attorney can help you, I can’t.”

All you have to do is state “I must talk to my lawyer before I say anything.”  “I will have my lawyer contact you.”  “I cannot say anything until I talk to my lawyer.”  “I want a lawyer.”

If you are not the one being investigated, then there is no good reason why the investigator would want you to make a statement before you consulted with your attorney.  What is the rush?

Then you must also avoid the old trick of the investigator telling you “If you don’t have anything to hide, why would you need a lawyer?”  Please don’t fall for this trick, either.  This is America.  Smart people and rich people spend a lot of money on attorneys and other professionals to represent them and advise them.  There is a good reason why they do this.

Far too often the health professional only calls us after he has given a statement.  This is usually too late to avoid much of the damage that will have been be caused.

Everything above applies to oral statements or written statements.  Do not make either.  Contact a lawyer as soon as possible, preferably before making any statement, no matter how simple, defensive, self-serving or innocuous you may think it to be.

Think of this as an intelligence test.  Are you smart enough to follow this guidance and avoid this type of mistake?

For more information about investigations and other legal matters, visit www.TheHealthLawFirm.com.

Florida’s Pill Mills Still a Target

Last week, the DEA announced the results of enforcement efforts directed at Florida’s illegal prescription drug distributors.

According to the DEA, more than 100 individuals have been arrested in operations targeting pill mills in Florida, and the DEA, as well as Florida law enforcement, will continue to investigate and prosecute pain clinics, pharmacies and physicians who are contributing to Florida’s prescription drug trafficking epidemic.

Operation Pill Nation I, initiated in February 2011 in South Florida, has resulted in the arrest of 47 people, including 17 doctors and five clinic owners, and the seizure of more than $18.9 million in cash and assets. Furthermore, over 70 doctors, six pharmacy owners and five DEA Registered Controlled Substance Distributors have been stripped of their DEA registrations.

Operation Pill Nation II has resulted in enforcement actions against 22 individuals and one pharmacy allegedly involved in the illegal distribution of prescription drugs.

The DEA also announced the addition of a third Tactical Diversion Squad in Florida. Based in Orlando, this new group will be responsible for investigating prescription drug diversion in Central Florida.

According to the Orlando Sentinel, this new squad was created solely to investigate the illegal use and distribution of prescription drugs in the Orlando area. Currently, the Orlando squad is investigating doctors and pharmacies, their first case involves a Winter Park pharmacy.

Howell Branch Road’s The Medicine Shoppe is under investigation. It’s pharmacist is accused of  providing more than 15,000 oxycodone pills that were illegally distributed.

Coinciding with the DEA’s announcements, was the investigation of Tampa pill mills. DEA agents, and Florida state and local law enforcement executed six search warrants and served two immediate suspension orders to a doctor and a pharmacy in Tampa. Immediate suspension orders revoke authority to dispense or prescribe controlled substances.

Earlier this year, the DEA commissioned a pill mill hotline in Florida. This 24-hour pill mill tip line and e-mail address allow the public to provide information on suspicious pain clinics. Additionally, laws targeting pill mills were passed that makes it much more difficult to dispense narcotics at a clinic. However, the DEA’s raids will continue in order to eradicate Florida’s pill mill problem.

For more information on Florida pain clinics and the laws and legal matters that impact them, visit www.TheHealthLawFirm.com.

George Indest is an attorney, board certified by the Florida Bar in Health Law, who represents health care professionals and providers, including pain management clinics and pain management physicians.

Benchmark: DEA Conduct Resulted in Dismissed Charges

In light of the DEA‘s recent focus on Florida’s prescription drug trafficking problem, we wanted to discuss a former case in which the DEA‘s actions resulted in a favorable outcome for alleged drug dealers.

According to the Daily Journal, in 2004, U.S. District Judge Florence-Marie Cooper dismissed charges against three alleged methamphetamine dealers after an attorney to one of the defendants argued that the informant improperly relied on a “subinformant” to set up drug transactions in order for DEA agents to bust suspected dealers. According to the attorney, the informant used the intermediary to protect himself and the DEA from entrapment claims. Because of this, defense attorneys could not derive from the primary witness how the drug sale was arranged.

The attorney claimed that the subinformant contacted old friends and acquaintances in low-income areas and informed them of money to be made if they could find a large amount of methamphetamine for a prospective buyer. The informant posed as the buyer. By repeatedly calling these individuals to find a source for the methamphetamine transactions, the subinformant would turn the case over to the informant right before the transaction took place.

In this case, the DEA provided evidence only of the final interactions between the informant and the defendants. The attorney wanted to show that the entrapment actually occurred earlier, when the subinformant allegedly pressured the defendants to complete the methamphetamine deal.

In laying out the subinformant scheme in his discovery motion, the attorney cited phone records between the subinformant and the defendants in his case and in two other methamphetamine cases, U.S v. Parra, 03-CR- 121, and U.S. v. Corcuera, 03-CR-24. In the three cases, the subinformant had regular and frequent contact with the defendants, but the informant had very little or no contact with the defendants before the arrests.

Cooper agreed that the informant used an underling to keep the defense from analyzing the details of the drug deal. According to Cooper, using an intermediary to do the actual work assigned to the informant, allows the DEA to protect itself from inspection and from any charges of improper conduct.

“A law enforcement agency must not be allowed to shield itself from accountability by hiring someone outside of law enforcement who is free to violate citizens’ rights.” U.S. v. Alvarez, 02-CR-355.

With a subinformant, there is no requirement to monitor their actions. The DEA doesn’t tape, keep records or provide discovery for subinformants. The DEA has a history of failing to regulate its informants, including the nationwide Andrew Chambers scandal. An internal investigation launched by the DEA in 2000 revealed that Chambers repeatedly lied under oath over a 16-year period in which he earned almost $2 million to help bust drug felons.

However, even if informants were regulated it wouldn’t prevent subinformants from negotiating the transactions that entrap individuals.

These investigative measures by the DEA are also being used in operations directed at Florida pain clinics. In an effort to rid the state of pill mills, the DEA is using every tool to bust clinics, physicians and pharmacists that might be involved in a suspicious pain clinic.

For more information about legal matters concerning pain clinics, visit www.TheHealthLawFirm.com.

Nurses: Insuring Your Legal Protection

Though many nurses pursue a career in nursing hoping that they will never face disciplinary charges, any number of events not in a nurse’s control can lead to an investigation or administrative action. Nurses need to make sure they are covered if this ever occurs, with appropriate insurance.

The primary reason that a nurse should purchase a professional liability insurance policy is that this type of insurance usually includes coverage for legal defense of licensing and disciplinary action commenced against a nurse.

License defense coverage pays the legal fees and costs associated with defending a nurse when an investigation is initiated that may result in action against her nursing license or disciplinary action against the nurse. Coverage is usually available from the time the nurse receives written notice that an investigation by a state agency has been initiated. It will also cover formal complaints made against the nurse, informal hearings before the Board of Nursing, and formal administrative hearings before an administrative law judge.

Such investigations, complaints, and administrative action may be opened based on events including patient complaints, hotline calls, Code 15 reports, nursing home and home health agency surveys, abuse investigations by the Department of Children and Families (DCF), newspaper articles, copies of lawsuits, and many other sources. It is far more likely that a nurse will be involved in one of these types of actions than being sued for nursing negligence.

Professional liability policies, which provide coverage for licensure defense, will usually provide compensation to the nurse for her out-of-pocket expenses (travel, postage, etc.) that she herself incurs, as well as lost wages because of working time missed for hearings, depositions, etc. However, the maximum coverage available under such policies for licensure defense is usually limited. to between $10,000 and $15,000. This amount will usually be sufficient to provide for most of the legal fees and costs involved in defense of such a case.

Does Vicarious Liability Actually Absolve the Nurse From Liability?

The assumption that vicarious liability or the legal doctrine of respondeat superior protects a nurse against a medical negligence claim is a mistaken one. If the employer provides legal representation, the attorney representing the nurse will almost always be the same attorney representing and being paid by the hospital or employer.

In many circumstances, the nurse may conclude that her interests are contrary to those of the hospital or employer, which could result in the attorney hired by the hospital withdrawing from further representation of the nurse. Additionally, it may be necessary for the nurse to raise evidence showing that the injury was caused by another nurse or hospital employee, in order to defend herself. It is doubtful that an attorney representing the employer or hospital would raise this defense since it would prove liability against the employer hospital.

Many employers will not provide legal representation if the matter involves licensing or disciplinary action against the nurse. This could force the nurse to fund all the fees and costs associated with her defense. However, some larger corporations with good risk management programs will provide the nurse with legal representation for such matters.

If you are an agency nurse, a home health agency nurse, a nursing home nurse, an independent duty nurse, or you are not employed by a large hospital chain, then you should consider nursing liability insurance mandatory. It appears that complaints of negligence against nurses working in these positions are far more likely. This may be because of the high turnover of nurses in some types of healthcare facilities (such as nursing homes), or because the nurse is no longer employed at the facility when the investigation begins (for example, in the case of an agency nurse). Additionally, agency nurses may only work in facility for a short period of time making them less familiar with the facility’s policies and procedures, and not a part of the permanent team of nurses who may have established relationships with each other and are more likely to cover for each other.

As previously mentioned, a number of different proceedings may be covered by the licensure defense coverage provided in professional liability insurance. These proceedings may include an investigation by the Department of Health based on a patient complaint or Code 15 report; an abuse investigation (abuse of a child, abuse of a developmentally disabled or vulnerable person, or abuse of an elderly person) by the Department of Children and Families (DCF); allegations of nursing negligence or abuse being investigated by a state “surveyor” by the Agency for Health Care Administration (AHCA); an investigation into allegations of Medicaid over-billing or fraud; an investigation by the Agency for Health Care Administration or on the Attorney General’s State-wide Medicaid Task Force; and allegations of improper Medicare billing or fraud.

A nurse might be involved in a Medicaid fraud investigation, for example, in the case of an Advance Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA) or Certified Nurse Midwife (CNM) who has her own provider identification number and is allowed to bill as part of a group practice or independently. This might also occur, for example, in the case of a nurse working for a home health agency which receives its reimbursement for the nurse’s services from Medicare or Medicaid.

Cost of Professional Liability Coverage is Minimal

Nurses can purchase liability coverage rather inexpensively. For example, an excellent insurance policy providing coverage for nurses is available through the Nurses Service Organization (N.S.O.) for less than $100 per year. Professional liability coverage provided by this type of insurance represents a bargain at these rates.

Focusing on Protecting the Nurse’s Individual Interests

Perhaps most importantly, the nurse should have an attorney focusing on her interests only in defending her against any type of negligence or licensing complaint. A nurse with her own professional liability insurance coverage will be able to hire a separate, independent attorney, and often the insurer will allow her to pick her own attorney.

Important Considerations When Purchasing Liability Protection

When deciding on which professional liability insurance to purchase, the nurse should inquire as to the extent of coverage for licensing in disciplinary defense coverage. Some professional liability insurers have a “broad form” of coverage which may provide legal defense for the nurse in almost any type of administrative action. This might include, for example, defense of a discrimination complaint filed against the nurse with the Florida Commission on Human Relations (FCHR) or the U.S. Equal Employment Opportunity Commission and for Medicare and Medicaid complaints. Other companies limit coverage to only actions that may result in disciplinary action against the nurse’s license. The nurse should always attempt to get the broadest coverage available for disciplinary defense and licensure defense coverage.

Additionally, the nurse should inquire as to whether or not she will be allowed to select her own attorney. Many insurance companies have contracts with certain law firms to provide legal services on their cases for a reduced fee. The insurance company may require you to use one of its own contracted attorneys, or even one of its in-house attorneys which it employs directly. Given the limited number of attorneys with experience at handling nursing law issues and trying malpractice cases, the nurse should attempt to obtain coverage through a company which allows her to choose her own attorney.

The most important reason to purchase professional liability insurance is for the licensure defense coverage. A nurse does not want to risk losing her nursing license because she was unsuccessful at defending an investigation against her license or did not have the resources to do so. Since there are far more complaints filed each year against nurses’ licenses than here are nursing malpractice lawsuits, it is far more likely that a working nurse will need legal defense of a licensure complaint investigation.

For more information about the legal needs of nurses visit www.TheHealthLawFirm.com.

South Florida Painkiller Network Newest Target in String of Florida Pill Mill Raids

Another South Florida pill mill was busted by federal agents this month, adding to Florida’s increasingly negative reputation as one of the worst drug trafficking states.

According to the Miami Herald, 24 people were indicted on charges of defrauding Medicare while distributing oxycodone and oxymorphone across Miami-Dade and Broward counties. These healthcare providers were involved in a distribution network allegedly worth $40 million.

Five pain management clinics in Miami, Hialeah and Plantation served as fronts for the fraud. A physician wrote prescriptions for oxycodone and oxymorphone to beneficiaries of Medicare and other prescription-drug insurance plans at these five clinics. Allegedly, these beneficiary patients were involved in the clinics’ scheme. The patients would then fill the prescriptions at certain pharmacies throughout Miami that were also involved in the network. When the prescriptions were filled, the pharmacy owners would bill Medicare, knowing that the drugs were unnecessary for the patients.

This bust follows a string of other DEA, DOH, and FDLE raids in Florida, including one in August. According to the Miami Herald, August’s Operation Oxy Alley involved pill mills being targeted as organized-crime for the first time. The country’s four largest pain clinics (located in Palm Beach and Broward Counties) were targeted, resulting in the arrest of 32 individuals, including 13 doctors.

Operation Pill Nation, the predecessor to Operation Oxy Alley, targeted pain management clinics in Palm Beach, Broward and Miami-Dade Counties. An effort to crackdown on Florida pill mills and drug trafficking perpetuated by medical clinics and doctors, Operation Pill Nation and similar investigations have resulted in the shutting down of clinics throughout South Florida according to the Palm Beach Post.

South Florida is not the only region where pill mills are running rampant. The entire state of Florida has been pegged by the DEA as one of the worst in terms of drug trafficking and about 85 percent of all oxycodone sold comes from Florida. Pain management clinics, pharmacies, pharmacists and doctors in Jacksonville, Melbourne, Mount Dora, Orlando, Miami, Fort Lauderdale, Delray Beach, West Palm Beach have been busted by Florida and federal agencies (DEA, DOH, FDLE) for unlawfully dispensing powerful narcotics, like oxycodone, to any patient that came in the door. In one instance, buyers of highly addictive oxycodone and Xanax, came all the way from Ohio, Kentucky, and Tennessee to get their fix at a Jacksonville pill mill.

The DEA and other federal and state agencies carry out relentless investigations in order to bust these clinics and doctors. Acting as patients, they may bribe a receptionist in order to immediately see a doctor, and then present unrelated symptoms in order to get a narcotics prescription. Drug companies also become involved in targeting pill mills, as they report any clinic or physician who orders narcotics in large quanities (like this Florida doctor who prescribed over 250,000 oxycodone pills in eight months).

Although the crackdown on pill mills and drug trafficking in Florida has eliminated many illegitimate practices, there have been serious consequences for any patient with real pain. Physicians are wary of writing any painkiller prescription, even for a patient whose pain warrants a stronger prescription.

If you are a pharmacist or physician dealing with pain management in Florida, be aware of the recent raids and learn more about what you can do to prevent the DEA, DOH, FDLE or local police from knocking on your door. Visit our website at www.TheHealthLawFirm.com or read this article on the DEA‘s involvement in the healthcare field for more information.