Tag Archives: Department of Health and Human Services (DHHS)

The Affordable Care Act Offers the Government New Tools to Fight Healthcare Fraud

By Catherine T. Hollis, J.D., The Health Law Firm

In 2013, the government reported recovery of a record-breaking $10.7 billion in healthcare fraud in the past three years, according to the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ). The HHS credits the Affordable Care Act’s tough stance on fraud for improving the efforts to fight Medicare fraud.

The increase in fraud recovery is attributed in part to the Act’s proactive approach to preventing fraud. The Act contains several initiatives that address Medicare fraud, resulting in increased fraud-fighting tools available to the government. The joint effort between the HHS, the DOJ and the Health Care Fraud Prevention and Enforcement Action Team has been a primary driving force in seeking out fraud and securing recoveries. The HHS and DOJ’s website highlights some of the Act’s “powerful steps” toward fighting fraud, waste and abuse. Click here to read more from www.stopmedicarefraud.gov.

Tougher Punishment.

The Act increases federal sentencing guidelines for healthcare fraud by twenty percent (20%) to fifty percent (50%) for crimes that involve more than $1 million in losses. The Act also establishes penalties for obstructing a fraud investigation or an audit.

Stricter Screening for Enrollment and Revalidation.

According to the HHS, the new screening procedures include licensure checks and site visits for all providers and suppliers. In addition, the Act imposes higher scrutiny on providers and suppliers who may pose a higher risk of fraud or abuse. High risk providers and suppliers can be subject to unscheduled site visits and fingerprint-based criminal background checks.

The Center for Medicare & Medicaid Services (CMS) has started to revalidate the enrollment of all 1.5 million existing Medicare providers and suppliers, using the new screening requirements set forth by the Act. Thousands of enrollments have already been deactivated or revoked as the result of this effort. There is a blog on our website about the devastating and far reaching effects of being excluded from the Medicare program. Click here to read that blog.

New Detection Technology.

CMS is using the Fraud Prevention System to screen all fee-for-service Medicare claims. This system uses advanced predictive technology, similar to that used by credit card companies, to analyze claims prior to payment. It also scans for suspicious billing patterns. Claims identified by the Fraud Prevention System as suspect are reviewed by CMS for possible fraud.

Increased Resources.

The Act provides an additional $350 million over ten years (2011 through 2020) through the Health Care Fraud and Abuse Control Account.

These steps represent a more proactive approach to Medicare fraud. The government is focusing on preventing fraud before it happens, rather than paying fraudulent claims and seeking reimbursement after the fact. The tools contained in the Act, as implemented by CMS and HHS, further the goal of the Act to reduce fraud, waste and abuse in the Medicare system. To read a summary of the anti-fraud provisions in the Affordable Care Act, click here.

Anti-Fraud Provisions At Work.

On May 14, 2013, the HHS and DOJ announced the arrest of 89 people, including doctors, nurses and other medical professionals, in eight cities. These people are allegedly charged in separate Medicare fraud schemes. According to the DOJ, the scans involve approximately $223 million in false billing. Click here to read a blog on these arrests. To read more blogs on Medicare and Medicaid fraud, visit our website.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Do you think the Affordable Care Act will help cut down on healthcare fraud? Why or why not? Please leave any thoughtful comments below.

Sources:

Sjoerdsma, Donald. “The Affordable Care Act Bolstered, Didn’t Drive Medicare Anti-Fraud Efforts.” The Medicare Newsgroup. (March 22, 2013). From: http://medicarenewsgroup.com/context/understanding-medicare-blog/understanding-medicare-blog/2013/03/22/the-affordable-care-act-bolstered-didn-t-drive-medicare-anti-fraud-efforts

“The Affordable Care Act and Fighting Fraud.” U.S. Department of Health & Human Services and U.S. Department of Justice. From: http://www.stopmedicarefraud.gov/aboutfraud/aca-fraud/index.html

 

Health Benefits ABCs. “Summary of Anti-Fraud Provisions in the Affordable Care Act.” U.S. Administration on Aging, Department of Health and Human Services. From: http://www.smpresource.org/Content/NavigationMenu/ConsumerProtection/HealthCareReform/Anti-Fraud_Provisions_in_Health_Care_Reform.docx

“New Tools to Fight Fraud, Strengthen Federal and Private Health Programs, and Protect Consumer and Taxpayer Dollars.” U.S. Department of Health & Human Services. (March 15, 2011). From: http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html

About the Author: Catherine T. Hollis is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Is It Legal to Make Flu Shots Mandatory for Health Care Professionals?

00011_RT8By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The warnings have been loud and clear from the Centers for Disease Control and Prevention (CDC). This influenza season is off to an early and serious start. With that in mind, a number of states are requiring all health professionals in the state to receive the flu vaccination. Some of those opposed to getting vaccinated are being fired by hospitals and health facilities. Because of this, a controversy is arising between employee rights and patient safety, according to a number of news sources.

Click here to read more on this year’s flu season from the CDC.

Mandatory Flu Shots to Keep Patients Safe.

In December 2010, the Department of Health and Human Services (DHHS) announced a 10-year agenda to improve the nation’s health. It’s called Healthy People 2020. A part of this agenda calls for a ninety percent (90%) average vaccination rate of health professionals. Click here to read the press release on the Healthy People 2020 initiative from the DHHS.

According to an American Medical News article, there’s a push in the medical community to meet this goal as soon as possible. The CDC states that as of November 18, 2011, close to eighty-four percent (84%) of doctors in the U.S. had been immunized against influenza. The CDC is praising these doctors for this high number, hoping other health professionals and the public will follow suit.

The safety of patients is the chief reason for the mandate. In an ABC News article, one Indiana hospital said that it implemented the mandatory vaccine in September of 2012, to promote patient safety. Of the hospital’s 26,000 employees statewide, ninety-five percent (95%) have complied.

Health Care Professionals Are Fired If They Refuse to Get the Vaccine.

A large majority of employees at the Indiana hospital complied with the mandate; however, 1,300 employees did not. According to ABC News, eight employees, including at least three veteran nurses, were allegedly fired because they refused to get a flu vaccine.

The fired nurses are standing their ground, saying they should have the right to refuse the flu vaccine. One nurse had filed two medical exemption requests, a religious exemption request and two appeals. All were denied by the hospital. To read more on this story from ABC News, click here.

In October 2012, Rhode Island mandated immunizations for all health care workers who have patient contact. On December 6, 2012, a health care worker union filed a federal lawsuit against the Rhode Island Department of Health (DOH) to prevent it from implementing the regulations, according to a Fierce Healthcare article. Click here to read the entire Fierce Healthcare article.

Arguments Against the Flu Shot.

The attorney representing the Indiana nurses, who were fired, states that his clients had the right to refuse their flu shots. He argues Title VII of the Civil Rights Act of 1964 prohibits religious discrimination against employees. The attorney is suggesting religion is legally broad under the First Amendment, so it can include any strongly held belief. According to a Chicago Tribune article, in 2009 New York mandated flu shots for all health workers, during the H1N1 outbreak. Unions fought the issue in court, and the state has since relaxed the rule.

The Flu in Florida.

I’ve recently received calls from several local health care professionals working in different Florida hospitals, regarding refusing flu shots and other vaccinations. I’ve also read the news stories about Tampa General Hospital and Moffitt Cancer Center in Tampa requiring employees to receive the influenza vaccine. According to the news articles, the two Tampa health facilities require employees who refuse the flu shot to wear surgical masks.

However, the states and hospitals may not back down in this case. The issue may have to be decided by the courts. I promise to write more on this topic later.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals and Providers.

At the Health Law Firm we provide legal services for all health care providers and professionals. This includes physicians, nurses, dentists, psychologists, psychiatrists, mental health counselors, Durable Medical Equipment suppliers, medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other health care provider. We represent facilities, individuals, groups and institutions in contracts, sales, mergers and acquisitions.

The services we provide include reviewing and negotiating contracts, business transactions, professional license defense, representation in investigations, credential defense, representation in peer review and clinical privileges hearings, Medicare and Medicaid audits, commercial litigation, and administrative hearings.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of mandated flu shots for health care workers? Is receiving a flu shot mandatory at your job? As a health care professional, do you think it is important to receive a flu shot? Is there enough medical evidence to justify firing health care professionals for not receiving the flu shot? Please leave any thoughtful comments below.
Sources:

Lupkin, Sydney. “Nurses Fire for Refusing Flu Shot.” ABC News. (January 3, 2013). From: http://abcnews.go.com/Health/indiana-hospital-fires-nurses-refusing-flu-shot/story?id=18116967

Moyer, Christine. “More Physicians on Track to get Flu Shots.” American Medical News. (December 14, 2012). From: http://www.ama-assn.org/amednews/2012/12/10/hlsb1214.htm

Cheung-Larivee, Karen. “Health Unions Sue Over Mandated Flu Shots.” Fierce Healthcare. (December 10, 2012). From: http://www.fiercehealthcare.com/story/health-unions-sue-over-mandated-flu-shots/2012-12-10

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Ambulance Company in Tennessee Settles A $2 Million Overpayment Lawsuit

George F. Indest III, Board Certified by The Florida Bar in Health Law

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Dr. Thu Pham, O.D., Law Clerk, The Health Law Firm Attorney

A Tennessee ambulance company and the U.S. Department of Health and Human Services (DHHS) announced a settlement in a case over a post payment audit for more than two million dollars in May 2012. Back in March of 2010, the Nashville ambulance company sued the DHHS after being sent a $2.65 million overpayment demand, according to the Nashville Business Journal.

To see the Nashville Business Journal article on the lawsuit, click here.

Huge Fine Found Using Error Rate Extrapolation Formula.

According to the lawsuit, the ambulance company claimed that the fine was based on incorrect accounting by a Medicare Administrative Contractor (MAC) for the DHHS. The contractor reviewed “a small sample of claims and determined that many did not meet Medicare coverage criteria.”

The actual overpayment on those claims was $10,764, which was determined to be an error rate of fifty-one percent (51%). The error rate was then used to extrapolate and obtain the $2.65 million figure which was demanded from the ambulance company.

Ambulance Company Files Administrative Appeal.

Upon administrative appeal, the ambulance company said most of its claims were determined to be appropriate, yet the error rate was never recalculated and the company was still stuck with a large bill.

Disputes of payments included bills for transporting dialysis patients by ambulance. The DHHS said those trips were not valid because they were not emergencies. The ambulance company refuted this contending that the trips did not have to be emergencies because they were ordered by a doctor.

Click here to read the entire lawsuit.

What You Should Know About the Use of Statistical Sampling and Extrapolation Formulas.

In both state Medicaid audits and in Medicare audits, we have experienced increased reliance by the auditing agency on use of mathematical extrapolation formulas to estimate the amount that should be repaid. The formula used usually takes the overpayment that has actually been found and, based on several factors, multiplies it out to many times the actual overpayment amount, as is the example in this case. We have seen ratios of as high as 1 to 150 (or 150 times the actual disallowed claims amount) calculated.

Things you should know about this are as follows:

1.  Neither the Medicare program nor the state Medicaid programs should use an extrapolation formula, unless:

  a. There is a “high” error rate in the claims that have been submitted; or

  b. There have been prior educational efforts or prior audits of the provider, and the provider

has failed to correct the problems in claims submission previously found.

2.  The states each have different guidelines, rules or regulations on when they will apply the statistical formula. Some do not use it at all. Some use a higher percentage error rate to prompt use of the formula and some lower. For example, North Carolina uses one of the lowest percentage error rates we have encountered; an error rate of more than five percent (5%) will prompt its Medicaid agency to apply the statistical extrapolation to the recovery amount.


Two Parties Settle.

On May 25, 2012, the United State District Court announced the ambulance company and the DHHS had settled and compromised. The lawsuit was dismissed against the DHHS without prejudice for a period of ninety (90) days.

Click here to see the order of dismissal.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Sources:

Nashville Business Journal. “Ambulance Company Sues Over $2.65M Bill.” Nashville Business Journal Online. (March 15, 2012). From: http://www.bizjournals.com/nashville/stories/2010/03/15/daily2.html

First Call Ambulance Service, Inc., v. Department of Health and Human Services, Case Number 3:10-0247, Order of Dismissal, May 25, 2012 available at: http://www.thehealthlawfirm.com/uploads/First%20Call_Dismissal.pdf

First Call Ambulance Service, Inc., v. Department of Health and Human Services, Case Number 3:10-cv-0247, First Call Ambulance Service, Inc., Sues Department of Health and Human Services Over $2.65 Million, March 20, 2010 available at: http://www.thehealthlawfirm.com/uploads/First%20Call%20Case.pdf

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

South Florida Man Admits to a $42 Million Medicare Fraud Scheme

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The owner and operator of a Miami home health care agency pleaded guilty for his part in a $42 million home health Medicare fraud scheme, according to the Department of Justice (DOJ), the FBI and the Department of Health and Human Services (DHHS). The 43 year-old man pleaded guilty before a U.S. district court judge to one count of conspiracy to commit health care fraud on August 2, 2012.

To see the entire press release from the Department of Justice (DOJ), click here.

First Part of the Fraud Operation Involved Kickbacks and Bribes.

The Miami man was the owner of a Florida home health agency that claimed to provide home health care and physical therapy services to eligible Medicare recipients.

In the first part of the scheme, he allegedly would pay kickbacks and bribes to recruiters. In return, the recruiters would provide patients to the home health care agency. His patients, who received Medicare, were used to bill Medicare for $42 million in unnecessary home health care and therapy services, the government alleged.

The plea documents show that patients’ files were falsified to make it appear that these Medicare recipients qualified for the services when many actually did not.

Second Part of the Fraud Operation Included Paying off Doctors.

The second part of this operation involved the owner of the home health agency and his accomplices allegedly paying off doctors. In this exchange, the doctors would allegedly provide the schemers home health and therapy prescriptions, and medical certifications.

The Opertation Busted by the Medicare Fraud Strike Force.

In the end, the crimes resulted in $42 million in false and fraudulent Medicare claims that were filed between January 2006 and November 2009, according to the government. Medicare paid approximately $27 million on those false claims, according to plea documents.

As part of his plea agreement, the home health agency owner has agreed to forfeit two residential properties and cash proceeds of the fraud over to the government.

This case was investigated as part of the Medicare Fraud Strike Force. The Strike Force is a joint effort of the Department of Justice (DOJ) and the Department of Health and Human Services (DHHS) designed to combat fraud through the use of Medicare data analysis techniques.

To learn more on the Medicare Fraud Strike Force, click here.

Contact Health Law Attorneys Experienced in Handling Medicare Audits.

Medicare fraud is a serious crime and is vigorously investigated by the FBI, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS). Often other state and federal agencies, including the U.S. Postal Service (USPS), state Medicaid Fraud Control Units (MFCUs) and other law enforcement agencies participate. Don’t wait until it’s too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Department of Justice, Office of Public Affairs. “Miami Home Health Care Agency Owner Pleads Guilty in $42 Million Medicare Fraud Scheme.” Department of Justice. Press Release. (August 2, 2012). From: http://www.justice.gov/opa/pr/2012/August/12-crm-965.html

CBS Miami “Health Care Agency Owner Pleads Guilty In $42M Medicare Scheme.” Miami CBS 4 Local. (August 2, 2012). From: http://miami.cbslocal.com/2012/08/02/health-care-agency-owner-pleads-guilty-in-42m-medicare-scheme/

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.