Strike Force Busts 89 People, Mostly Health Care Professionals, in Nationwide Crackdown on Medicare Fraud

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

In a nationwide takedown nearly 100 people, including doctors, nurses and other medical professionals, in eight cities were all allegedly charged in separate Medicare fraud schemes. These individual scams involved approximately $223 million in false billing, according to the Department of Justice (DOJ) and the Department of Health and Humans Services (DHHS). On May 14, 2013, more than 400 law enforcement officials with the Medicare Fraud Strike Force spread out between Miami, Detroit, Los Angeles, New York, New Orleans, Houston, Chicago and Tampa to make the arrests of these 89 people, according to the DOJ.

Click here to read the press release from the DOJ.

Medicare Schemes Could Not Have Happened Without the Help of Health Professionals.

According to an article in Reuters, one out of every four defendants in this crackdown was some type of health professional. Authorities say most of these allegedly complex scams could not have happened without the participation of a doctor signing off on a bogus service, or a nurse filling out false paperwork.

Click here to read the entire article from Reuters.

Florida Health Professionals Involved.

According to the DOJ, in Miami, a total of 25 people, including two nurses and a paramedic, were allegedly part of numerous Medicare scams, totaling about $44 million in false claims. In one case involving a home health agency, defendants allegedly bribed Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. The DOJ believes the lead defendant spent a majority of the money from the scam on luxury cars.

Phony Health Care Clinics Set Up.

In Tampa, nine individuals were charged in a variety of schemes, ranging from pharmacy fraud to health-care related money laundering. According to the DOJ, in one case four individuals allegedly established four health care clinics. The individuals allegedly used these clinics to steal more than $2.5 million from Medicare for surgical procedures that were never performed.

This Marks the Sixth Time the Medicare Fraud Strike Force Has Executed a Nationwide Crackdown.

This crackdown marks the sixth time the Medicare Fraud Strike Force has taken nationwide action against Medicare fraud. To date, the Medicare Fraud Strike Force is credited with making more than 1,500 arrests on charges related to $5 billion in allegedly false Medicare claims since 2007. According to the DOJ, it’s believed Medicare fraud costs the program between $60 billion and $90 billion each year.

Medicare operates under a pay-and-chase system, but according to the Washington Post, authorities are beginning to use new technology that flags suspicious claims before Medicare makes a payment. To read the entire Washington Post article, click here.

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.

Comments?

What do you think of these nationwide crackdowns on Medicare fraud? Do you think they work as a deterrent for others committing health care fraud? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Medicare Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing.” Department of Justice. (May 14, 2013). From: http://www.justice.gov/opa/pr/2013/May/13-crm-553.html

Kennedy, Kelli. “Doctors and Nurses Among Nearly 100 Charged in $223 Million Medicare Fraud Busts in 8 Cities.” Washington Post. (May 14, 2013). From: http://www.washingtonpost.com/politics/health_care/doctors-nurses-among-nearly-100-charged-in-223-million-medicare-fraud-busts-in-8-cities/2013/05/14/fbb0de3a-bcbc-11e2-b537-ab47f0325f7c_story.html

Morgan, David. “U.S. Charges 89 People in $223 Million Medicare Fraud Scheme.” Reuters. (May 14, 2013). From: http://www.reuters.com/article/2013/05/14/usa-healthcare-fraud-idUSL2N0DV3GZ20130514

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.

Two Separate Lawsuits Against Novartis Pharmaceuticals Corporation Allege Illegal Kickbacks and False Claims

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

Novartis Pharmaceuticals Corporation (NPC) is currently fielding two different lawsuits, filed just days apart from each other, by the U.S. Department of Justice (DOJ). The first lawsuit was filed on April 23, 2013, alleging the company gave illegal kickbacks to pharmacists. A second lawsuit was filed on April 26, 2013, alleging illegal kickbacks were paid by NPC to health care providers. According to the DOJ, the government’s complaint seeks damages and civil penalties under the False Claims Act, and under the common law for paying kickbacks to doctors to induce them to prescribe NPC products that were reimbursed by federal health care programs.

Click here to read the entire press release from the DOJ.

NPC Accused of Treating Health Care Professionals to Expensive Dinners, Product Discounts and Fishing Trips.

Both lawsuits allege NPC violated the Anti-Kickback Statute. In the April 23, 2013, complaint against NPC the lawsuit alleges the company gave kickbacks, in the form of rebates and discounts to pharmacies in exchange for the pharmacies’ cooperation in switching patients from competitors’ drugs to NPC products.

The April 26, 2013, lawsuit accuses NPC of paying doctors to speak about certain drugs at events that were allegedly social occasions. Many of the programs were allegedly held in circumstances in which it would be impossible to have a presentation. According to the DOJ, this included fishing trips off the Florida coast and meetings in Hooters restaurants. NPC is also accused of treating health care professionals to expensive dinners. The payments and dinners were apparently kickbacks to the doctors for writing prescriptions for NPC drugs.

Florida Doctors Involved.

The lawsuit alleges at least six Florida doctors of participating in the bogus conferences and taking thousands of dollars in kickbacks, according to the Tampa Bay Times. The doctors are not named or charged in the civil lawsuit.

To read the allegations listed in the lawsuit against Florida doctors, click here for the Tampa Bay Times article.

NPC Denies All Claims.

In a press release, NPC disputes all of the government’s allegations. The pharmaceutical company states that discounts and rebates by pharmaceutical companies are a customary and legal procedure, as recognized by the government. It also addresses the physician speaker programs by saying the programs are also acceptable practices designed to inform physicians about the uses of different types of medicines. Click here to read the entire press release from NPC.

The Law Against Using Bribes in Exchange for Selling a Drug or Service.

For years drug companies have paid doctors to speak about new drugs at educational conferences with other health care professionals. The practice is legal, but considered questionable.

Under the Anti-Kickback Statute, it’s a felony for health care professionals to accept bribes in exchange for recommending a drug or service covered by Medicare, Medicaid, TRICARE or the Department of Veterans Affairs health care program.

Whistleblowers Who Report Fraud and False Claims Against the Government Stand to Receive Large Rewards.

The original complaint against NPC was allegedly filed under the qui tam, or whistleblower, provisions of the False Claims Act by a former sales representative.

Individuals working in the health care industry, whether for hospitals, pharmacies, nursing homes, medical groups, home health agencies or others, often become aware of questionable activities. Often they are even asked to participate in it. In many cases the activity may amount to fraud on the government.

In a two-part blog series on whistleblower/qui tam lawsuits I explain types of false claims, the reward programs for coming forward with a false claim, who can file a whistleblower/qui tam lawsuit, and more. Click here to read the first part of this blog, and click here for the second part.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm represent plaintiffs, patients, health care professionals and health facilities in qui tam or whistleblower cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

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 these lawsuits? Please leave any thoughtful comments below.

Sources:

Masow, Julie. “Novartis Pharmaceuticals Corporation Disputes Allegations in Two US Government Lawsuits and Looks Forward to a Fair Discussion of the Facts.” Novartis Pharmaceuticals. (April 26, 2013). From: http://www.pharma.us.novartis.com/newsroom/pressreleases/137176.shtml

Davis, Brittany Alana. “Lawsuit: Pharmaceutical Company Gave Kickbacks to Florida Doctors.” Tampa Bay Times. (May 3, 2013). From: http://www.tampabay.com/news/courts/lawsuit-pharmaceutical-company-gave-kickbacks-to-florida-doctors/2119133

Department of Justice. “United States Files Complaint Against Novartis Pharmaceuticals Corp. for Allegedly Paying Kickbacks to Doctors in Exchange for Prescribing Its Drugs.” Department of Justice. (April 26, 2013). From: http://www.justice.gov/opa/pr/2013/April/13-civ-481.html

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.

Major Medicare Offender Sentenced to Prison for Multi-Million Dollar Health Care Fraud Scheme

By Lance O. Leider, J.D., The Health Law Firm

The former owner of four mental health facilities in South Florida and North Carolina was sentenced to fourteen (14) years in federal prison on February 25, 2013. The former business owner pleaded guilty to defrauding Medicare out of tens of millions of dollars from 2004 through 2011, according to the Department of Justice (DOJ). He had previously been convicted of cocaine trafficking but decided to move to Medicare fraud supposedly because he thought it would be safer. In total the former mental health facility owner was indicted for defrauding the government of nearly $63 million. As part of his plea, he was ordered to repay $28 million.

Click here to read the press release from the DOJ.

Unnecessary Services, Illegal Kickbacks and Fake Mental Health Records.

The scheme, headed by the former business owner, involved three mental health clinics in Miami, Florida, and one in Hendersonville, North Carolina. All four facilities allegedly billed Medicare and Medicaid for services that were unnecessary or otherwise not provided. The clinics also paid bribes to local assisted living facilities (ALFs) in order to provide a steady stream of patients that were in no need of services. Employees of the clinic would then fabricate entire mental health records for the patients in order to bill the government programs. The former mental health facility owner and his employees allegedly thought that creating the medical records would aid them in avoiding detection by federal auditors, according to an article in the Miami Herald.

To read the Miami Herald article, click here.

Co-Conspirators Feeling the “Heat.”

Fifteen (15) of the former business owner’s co-conspirators have been charged for their alleged roles in the health care fraud scheme. Ten (10) defendants have already pleaded guilty, according to the DOJ.

This case was investigated by the Federal Bureau of Investigation (FBI), the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) and the Medicare Fraud Strike Force. These departments help make up the Health Care Fraud Prevention and Enforcement Action Team (HEAT) that works to stop Medicare fraud across the country.

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?

What do you think of the former business owner’s sentence? Do you think it is enough to deter other would-be criminals from scamming the government? Please leave any thoughtful comments below.

Sources:

Weaver, Jay. “Miami Businessman Who Stole Millions from Medicare Sentenced to 14 Year.” Miami Herald. (February 26, 2013). From: http://www.miamiherald.com/2013/02/26/3254507/miami-businessman-who-pleaded.html

Department of Justice. “Owner of Mental Health Facilities Sentenced to 168 Months in Prison in Connection with $63 Million Health Care Fraud Scheme.” Department of Justice. (February 25, 2013). From: http://www.justice.gov/opa/pr/2013/February/13-crm-234.html

About the Author: Lance O. Leider 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.

Occupational Therapists, Podiatrists, Psychologists and Optometrists Being Scrutinized in Medicare Audits

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

Our firm has recently seen an increase in the number of occupational therapists (OTs), speech therapists (STs), podiatrists, psychologists, optometrists and other licensed health professionals being scrutinized in Medicare audits and recovery actions. Often these result from claims submitted for evaluation or treatment entered in nursing homes or assisted living facilities (ALFs).

You Must Provide Complete and Detailed Documentation of Care Rendered.

In many cases, the provider may not have complete documentation of the care rendered because it has been placed in the patient’s record at the facility. Unfortunately, Medicare does not see this as an excuse to provide copies of all relevant medical records in support of claims during an audit. The provider must still obtain the records and forward them to the auditor. Failure to do so will result in a complete disallowance of claims for treatment or services.

Other Problems with Fort Comings in Documentations.

Other problems we have seen with forth comings in documentation that has resulted in claims denial include:

1. Failing to have a physician’s order, prescription or referral specifically requesting the services indicated,

2. Failing to have a legible signature from a doctor ordering such services, or the physician’s typed/printed name with the letters “M.D.” or “D.O.” after the name,

3. Lack of proof of medical necessity for the services rendered,

4. Illegible medical records or illegible medical records entries,

5. Failure to have a start time and stop time for services that are billed based on the amount of time spent with the patient,

6. Failure to have the signature (electronic or manual) of the individual health professional delivering the services on the health records documenting the delivery of those services.

Such deficiencies are easy for health professionals to avoid at the time of the delivery of services. Some of these may be corrected before the documents are produced in response to an audit request. However, after the documents have been provided as a response to an audit request, it may be too late to do anything about these document deficiencies.

Obtain Representation Early.

A health law attorney experienced in Medicare and Medicaid audits can save a provider tens of thousands of dollars in claims and overpayments being reimbursed to payers. Obtain representation at the earliest possible time.

Check Your Professional Liability Insurance Policy.

Many professional liability insurance policies will pay for the cost of legal representation in a Medicare or Medicaid audit. If your insurance company does not offer this benefit, you may purchase separate insurance coverage which does provide this benefit for only a small premium. Ask your insurance agent for information on this type of coverage. After you need it, it will be too late to purchase it. This mistake could put you out of business and negatively affect your professional license.

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.

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.

 

Lehigh University Student Sues Grad School for $1.3 Million for Bad Grade

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

While in school, we all received grades that we believed to be unfair or unwarranted. One graduate of Lehigh University in Pennsylvania, has taken her bad grade to court. She is suing the university over a “C+” grade. In the lawsuit, the student claims that if not for a zero she was given in participation for a fieldwork class in 2009, she would have gotten a “B.” That grade would have allegedly allowed the student to move on toward finishing her master’s in counseling and human services. The student claims the one bad grade prevented her from attaining her dream to become a licensed professional counselor. Now she is suing the university for $1.3 million, according to an article in The Morning Call.

Click here to read the entire article from The Morning Call.

Was the Grade Given for Unprofessional Behavior or in Retaliation of Student’s Activism?

According to an article in The Morning Call, the student claims she received the low grade because the teacher and the then-director of the degree program conspired to hold her back. The student allegedly claims they were unhappy she had complained after being forced to find a supplemental internship partway through the semester. The student also claims the teacher was biased against her (the student’s) activism for gay and lesbian rights.

Attorneys for the university argue the grade was given to the student in an effort to help her address the skills she needed to be a licensed professional counselor. It’s stated in the complaint that the student expressed unprofessional behavior during class, including outbursts of cursing and crying.

The student ended up graduating from Lehigh University with a master’s degree in human development. She now works as a drug and alcohol counselor, according to The Morning Call. The $1.3 million she is seeking represents the alleged difference in her earnings over her career if she was instead a state-certified counselor.

Can a Judge Change a Grade?

The judge in this case questions whether he has the legal authority to actually change a grade received by a student. He has looked at cases nationally and has been unable to find one in which a judge had done so. The student’s attorney believes the judge has a wide enough latitude to impose “equitable remedies,” according to The Morning Call.

From our experience with such matters, the courts are extremely reluctant to become involved in such academic matters. Absent convincing evidence of discrimination, it is doubtful the courts will decide in the student’s favor.

Legal Ramifications of this Case.

According to an article on Huffington Post, there have been a number of students who have sued their alma maters in grading conflicts. For example, two former Texas Southern University law students filed a lawsuit in 2012 against the university’s Thurgood Marshall School of Law because they received “Ds.” The bad grades led to their dismissal for not maintaining 2.0 GPAs and put a stop to their pursuit of becoming attorneys.

Click here to read more stories of students suing their schools.

Contact a Health Care Attorney that is Experienced in the Representation of Medical Students, Interns, Residents and Applicants.

The Health Law Firm and its attorneys represent medical school students in disputes with their medical schools, internship supervisors, and in dismissal hearings. We have represented residents, interns and fellows in various disputes regarding their academic and clinical performance, allegations of substance abuse, failure to complete integral parts training, alleged false or incomplete statements on applications, allegations of impairment (because of abuse or addiction to drugs or alcohol or because of mental or physical issues), because of discrimination due to race, sex, national origin, sexual orientation and on other matters.

To learn more about our experience in the representation of medical students, click here.

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 about this case? Do you think the judiciary should be injecting itself into the academic process? How do you think this lawsuit will end? Please leave any thoughtful comments below.

Sources:

Yates, Riley. “Judge decides quickly after request to dismiss Lehigh lawsuit over C+ grade.” The Morning Call. (February 13, 2013). From: http://articles.mcall.com/2013-02-13/news/mc-lehigh-university-student-sues-over-grade-0213-20130213_1_carr-and-nicholas-ladany-zero-in-classroom-participation-daughter-of-lehigh-finance

Kingkade, Tyler. “Megan Thode, Lehigh University Grad, Files $1.3 Million Lawsuit Over C+ Grade.” HuffingtonPost. (February 13, 2013). From: http://www.huffingtonpost.com/2013/02/13/megan-thode-lehigh-university-lawsuit_n_2671739.html?view=print&comm_ref=false

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. http://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.

Florida Pharmacy Owner Accused of Medicare Fraud

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

A family that owns a number of South Florida pharmacies is allegedly under investigation for Medicare fraud, according to a number of sources. On January 17, 2013, federal authorities raided one pharmacy location in Naples, Florida. Drug Enforcement Administration (DEA) agents removed boxes of documents and computers from the pharmacy, according to Naples News. The pharmacy owner and his mother are allegedly being investigated by the U.S. Office of Inspector General (OIG) of the Department of Health and Human Services (HHS).

Click here to read the entire Naples News article.

Pharmacy Owner and Mother Allegedly Submitted False Claims to Medicare, Medicaid and Tricare.

According to NBC2, a South Florida television station, the pharmacy owner and his mother were both allegedly part of a scheme that defrauded Medicare. The family allegedly submitted claims to Medicare Part D after beneficiaries had died. This information came from a letter sent to Medicare Part D providers from the Centers for Medicare and Medicaid Services (CMS) on October 17, 2012. The letter was obtained by NBC2. The scheme allegedly also involved submitting false claims to Medicaid and Tricare.

Click here to watch the NBC2 news story.

Investigation is Ongoing.

The pharmacy that was raided is part of a chain of stores owned by the same family. So far, only the pharmacy located on Rattlesnake-Hammock Road in Naples is being investigated. That location is reportedly still closed, but the other pharmacy locations are open.

Neither the DEA nor the OIG of the HHS has released a press release on this investigation.

As in all media reports, please remember that all persons are presumed to be innocent until proven guilty in a court of law.

Pharmacies Are Being Raided and Shutdown  All Over the State.

If  you have watched the news at all lately or have been reading our blog, you can tell there have been an increased number of raids on pharmacies, arrests of pharmacists and emergency suspension orders issued from the Department of Health (DOH).

Recently, the DEA served a Walgreens distribution center in Florida with an immediate suspension order (click here to read more on this story), and pulled the controlled substance licenses from two Central Florida CVS Pharmacies (to learn more, click here).

In my personal opinion, the recent raids and investigations at pharmacies are especially hard on the independent operators. If the large retail giants can’t survive, the small independent pharmacies stand little chance.

Talk with an Experienced Health Law Attorney About Medicare, Medicaid and Tricare 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.

What Do You Think?

As a pharmacy owner, pharmacy employee or health care facility owner, what do you think of the increased effort to find fraud? Do you think all facilities, not just pharmacies, are under the microscope? Please leave any thoughtful comments below.

Sources:

Freeman, Liz. “Sunshine Pharmacy in East Naples Remains Close, Day After Federal Raid.” Naples News. (January 19, 2013). From: http://www.naplesnews.com/news/2013/jan/19/sunshine-pharmacy-east-remains-closed-raid-federal/

Ritter, Rick. “Naples Pharmacy Busted for Medicare Fraud.” NBC2. (January 20, 2013). From: http://www.nbc-2.com/story/20627104/detectives-investigating-medicare-fraud-at-naples-pharmacy

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.

How Safe Is Your Hospital?

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

It’s been a long time since most of us have seen a report card, but hospitals all over the nation received their safety grades on November 28, 2012. Leapfrog, a national group that advocates for safer health care, determined the grades. According to the Orlando Sentinel, Florida hospitals ranked well. Overall, 39 percent (39%) of the 156 hospitals graded received A’s, earning the Sunshine State a tenth place ranking in the nation.

Click here to read the entire article from the Orlando Sentinel.

How Florida Hospitals Did.

Here is a list of the grades received by Florida hospitals:

A’s: 61 (This includes Orlando Regional Medical Center, Dr. P. Phillips Hospital,

Orlando Regional South Seminole Hospital and Health Central.)

B’s: 38 (This includes Florida Hospital campuses in Orlando, Altamonte, Apopka, Celebration, east Orlando, Kissimmee and Winter Park.)

C’s: 49

D’s: 8

F’s: 0

To see the number of hospitals receiving each grade for patient safety by state, click here.

Grades Were Calculated by Safety Measures in Hospitals.

According to the Kaiser Health News article, Leapfrog calculated the grades based on 26 different measures of safety. The company used publicly-available data, including the number of blood line infections, falls in the hospital, bedsores and the consistency that hospitals follow recommended methods of care.

Physicians Believe Rating System is Pointless.

This grading system has physicians reportedly complaining. In the Kaiser Health News article doctors interviewed said that the grades are redundant and offer no benefit to hospitals since Medicare calculates and publishes most hospital-related issues.

Click here to read the Kaiser Health News article.

Leapfrog defends the ratings, saying the report cards provide a more transparent health care system for patients.

How to Fight Poor Online Reviews.

The Leapfrog grading system is just one of the many ways the performance of physicians, hospitals, nurses, dentists and all health providers is put on the chopping block. Other internet review websites like Vitals.com and Yelp.com allow patients to post virtually anything they want – good or bad. If you’ve personally received an unfavorable review that was possibly planted by a disgruntled patient, competitor or former employee you need to fight it. When the comment is posted, search engines like Google, Yahoo, Bing, AOL, or MSN may bring up the false statement every time someone searches for that health provider’s name. To learn legal strategies for health providers to fight bad online reviews, click here.

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?

As a health professional, do you think this grading system is redundant? Do you believe there is any merit to the grades hospitals received? Do you think patients benefit from the published grades? Please leave any thoughtful comments below.

Sources:

Jameson, Marni. “Did Your Hospital Make the Grade? Group Rates Quality of Care, More.” Orlando Sentinel. (November 28, 2012). From: http://www.orlandosentinel.com/news/local/breakingnews/os-leapfrog-hospital-grades-20121127,0,5928170.story

Rau, Jordan. “Hospitals Get New Grades on Safety.” Kaiser Health News. (November 28, 2012). From: http://capsules.kaiserhealthnews.org/index.php/2012/11/hospitals-get-new-grades-on-safety/

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.

Hospitals Allegedly Enforcing Questionable Practices to Increase Bottom Line

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

Doctors and hospitals around the country seem to be butting heads. In the past month, an article in The New York Times and a segment on the television “magazine” show 60 Minutes shed light on some questionable practices being enforced by hospitals on physicians working for them.

I previously wrote a blog on this structural shift in the practice of medicine. Click here to read that blog.

The effects of this trend are examined in these two news stories. Doctors and former employees from a number of hospitals around the country were interviewed and all seem to be dealing with the same issues. The biggest concerns addressed were: pressure to order unnecessary tests, admitting patients to fill hospital quotas and drive hospital profits, and the feeling of being controlled by hospital executives and administrators instead of practicing effective medicine.

Doctors Allegedly Pressured to Fill Emergency Room Beds to Increase Profits.

On December 2, 2012, 60 Minutes aired an investigative segment on one of the largest for-profit hospital chains in the country. Former employees and physicians alleged this hospital system thrived by buying urban-area hospitals and turning them into profit centers by filing empty beds from emergency rooms. A former emergency medicine doctor stated that the hospital in which he worked required an admission rate of twenty percent (20%) for patients seen in the ER and fifty percent (50%) for patients who were 65 years old and older (most of whom are Medicare patients) seen in the ER.

A former hospital system employee interviewed by 60 Minutes claimed he was in charge of auditing the hospital chain in question. He stated that he was convinced that doctors were under an extraordinary amount of pressure to fill hospital beds. He stated that he personally audited hospitals in Texas, Florida and Oklahoma, and concluded there were hundreds of thousands of dollars submitted to Medicare and Medicaid for hospital stays that did not meet standards for reimbursement, including medical necessity.

Doctors interviewed for The New York Times article had similar stories. They stated in interviews that hospital administrators created quotas for how many patients should be admitted, because more admissions allegedly meant more money. Doctors who met or exceeded quotas were rewarded with increased compensation, while doctors who did not felt in danger of losing their jobs.

Click here to read the entire New York times article.

Consequences of Ordering Unnecessary Tests.

The New York Times article looked at a number of lawsuits filed by former employees who allege the hospitals they worked for compensated doctors for ordering more tests than necessary.

The Department of Justice (DOJ) recently settled with a hospital group in Joplin, Missouri. According to the DOJ press release, the hospital system had to pay more than $9.3 million for rewarding doctors partly based on how many tests they ordered. This is in direct violation of the Stark Law and the False Claims Act.

Click here to read the entire press release from the DOJ.

I recently wrote an article for Medical Economics on the legal ramifications of ordering unnecessary tests. To read that article, click here.

If you want to know more on the Stark Law, click here.

Doctors Feel Controlled By Hospital Executives.

Doctors also stated they felt controlled by hospital executives. This was due, in part, to a corporate wide computer software system that was customized to automatically order an extensive battery of tests, some unnecessary, as soon as a patient walked into the hospital. It’s also stated that the software would prompt a physician to reconsider when he or she decided to send an emergency room patient home.

Most doctors interviewed were upset that the program also generated reports that evaluated each doctor’s performance and productivity.

To watch the segment from 60 Minutes, click here.

Hospitals Say They are Embracing the New Model of Health Care.

The hospital system in question by 60 Minutes maintains that these allegations are not correct. The executive vice president said that as a whole admission rates haven’t changed in four years and are near or below industry averages. The hospital systems believe that by consolidating they are embracing the new model of health care and state patient care comes first.

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?

Do you think there are constant battles between doctors and hospitals? As a health professional, have you experienced the pressure to admit patients, order unnecessary tests or refer a patient inside your network? Please leave any thoughtful comments below.

Sources:

Creswell, Julie and Abelson, Reed. “A Hospital War Reflects a Bind of Doctors in the U.S.” The New York Times. (November 30, 2012). From: http://www.nytimes.com/2012/12/01/business/a-hospital-war-reflects-a-tightening-bind-for-doctors-nationwide.html?pagewanted=all

Kroft, Steve. “Hospitals: The Cost of Admission.” 60 Minutes. (December 2, 2012). From: http://www.cbsnews.com/video/watch/?id=50136261n

Department of Justice. “Missouri Hospital System Agrees to Pay $9.3 Million to Resolve False Claims Act and Stark Law Violations.” DOJ. (November 5, 2012). From: http://www.justice.gov/printf/PrintOut3.jsp

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 Pharmacy Owner Pleads Guilty to $23 Million Health Care Fraud Scheme

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

A co-owner and operator of three Miami-area pharmacies pleaded guilty on December 6, 2012, for his part in a $23 million health care fraud scheme. The pharmacy owner allegedly admitted in the Florida Southern Federal District Court to one count of conspiracy to commit health care fraud and one count of conspiracy to pay illegal health care kickbacks, according to a Department of Justice (DOJ) press release.

Click here to read the entire press release from the DOJ.

Pharmacy Owner Used Kickbacks and Referrals to Allegedly Scam Medicare and Medicaid.

According to court documents, the pharmacy owner allegedly admitted to paying illegal kickbacks to an unnamed number of co-conspirators in return for Medicare and Medicaid beneficiary information. That information was then used to submit fraudulent claims. A majority of the beneficiaries referred to the owner’s pharmacies reportedly resided at assisted living facilities (ALFs) in Miami.

The court documents state that the pharmacy owner also allegedly paid kickbacks to physicians in exchange for prescription referrals which were also billed to Medicare.

Unused and Partially Used Medicine Part of Scheme.

As part of the scheme, the pharmacy owner allegedly instructed drivers working for his pharmacies to pick up unused medications from ALFs around Miami. The medications were then allegedly placed back into pill bottles. Unused and partially used medications were billed back to Medicare and Medicaid, according to court documents.

Click here to read the court documents on this case.

The pharmacy owner and his co-conspirators allegedly submitted more than $23 million in false and fraudulent claims to Medicare and Florida Medicaid programs.

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?

What do you think of this case? Is the Miami area just a hotbed for Medicare and Medicaid schemes? Please leave any thoughtful comment below.

Sources:

United States of America v. Jose Carlos Morales. Case Number 12-23374, Preliminary Injunction and Supporting Memorandum of Law. (September 14, 2012). From: http://www.thehealthlawfirm.com/uploads/USA%20v%20Morales.pdf

Department of Justice. “Pharmacy Owner Pleads Guilty in Miami for Role in $23 Million Health Care Fraud Scheme.” Department of Justice . (December 6, 2012). From: http://www.justice.gov/opa/pr/2012/December/12-crm-1461.html

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.

Industry Trend: Hospital Systems Merging and Acquiring Private Practices All Over the Country

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

There’s a structural shift that is sweeping the health care system – hospitals are acquiring private physician practices. It is happening all over the U.S., including right here in Central Florida. On December 31, 2012, Orlando Health – a nonprofit, multi-hospital system that owns Orlando Regional Medical Center and eight other hospitals – will allegedly merge with Physician Associates – Central Florida’s largest medical practice, according to the Orlando Sentinel. The alleged price tag on this sale is $50 million, with each of the group’s 95 physicians receiving about $500,000 a piece.

Critics Believe the Merger will Hurt Patients.

Orlando Health maintains the goal of the merger is to move toward a new payment model and reduce health care costs, but critics interviewed in the Orlando Sentinel article disagree.

The trend around the country is that after a merger patients will see a facility fee tacked onto a doctor’s fee, even if patients go to the same doctor’s office. Critics also believe providers will feel obligated, or will be required, to only refer patients to the hospital that employs them. Another fear is job loss, as hospitals take over office management.

To read the article from the Orlando Sentinel, click here.

An Investigation into Acquisitions.

In August 2012, the Wall Street Journal took a closer look at what happens after an acquisition of a private practice by a hospital system.

The article stated as physicians are absorbed into hospital systems, they can get paid for services at the hospital systems’ rates, which are typically higher than what insurers pay to independent doctors. Some services that physicians previously performed at their facilities may start to be billed as hospital outpatient procedures, this can double or triple the cost.

Medicare pays more for certain services if they are performed at hospital facilities. According to the Wall Street Journal, if a hospital system transforms a private clinic to become an outpatient facility or moves services onto a hospital site, the hospital’s Medicare reimbursement rates will increase.

To read the entire Wall Street Journal article, click here.

Physician Associates Writes Letter to Patients.

On November 15, 2012, the Physician Associates Chairman of the Board of Directors posted a letter to patients on the practice’s website. The letter assures patients nothing about the service they receive will change. The letter says the sale is about patients receiving the best possible care in a new, fast-paced health care environment. In response to the sale price, the chairman said a large component of the purchase price reflects the sale of all of the Physician Associates’ assets to Orlando Health, along with an agreement to provide future employment.

Click here to read the entire letter.

Contact Health Law Attorneys Experienced in Business Transactions and Contracts.
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 the merger between Physician Associates and Orlando Health? Who do you think it will benefit more, the patients or the doctors? Please leave any thoughtful comments below.

Sources:

Jameson, Marni. “$50M sale of Physician Associates Signals Major Shift in Orlando Health Care.” Orlando Sentinel. (November 13, 2012). From: http://articles.orlandosentinel.com/2012-11-13/news/os-physician-associates-orlando-health-20121109_1_orlando-health-health-care-physicians

Wilde Matthews, Anna. “Same Doctor Visit, Double the Cost.” Wall Street Journal. (August 27, 2012). From: http://online.wsj.com/article/SB10000872396390443713704577601113671007448.html

Walker, M.D., Erik. “Letter to Our Patients Regarding Potential Orlando Health Merger.” Physician Associates. (November 15, 2012). From: http://www.paof.com/news/2012/11/letter-our-patients-regarding-potential-orlando-health-merger

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. http://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.