Tag Archives: medicaid

OIG Audit Finds Federal Database of Terminated Medicaid Providers Needs Improvement

LLA Headshot smBy Lenis L. Archer, J.D., M.P.H., The Health Law Firm

The Affordable Care Act (ACA) requires the Centers for Medicare and Medicaid Services (CMS) to establish a process for sharing information about terminated Medicaid providers. The federal database, called Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS), is designed to prevent terminated health care providers from billing another state’s program. However, an audit by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), released in March 2014, states the MCSIS is not working as intended.

The MCSIS is supposed to collect data from every state Medicaid program on providers that were terminated from Medicaid for cause. However, the report found that the HHS OIG is not receiving data from 17 states or the District of Columbia. It was also found that a majority of the data does not meet the ACA criteria.

To read the entire report from the HHS OIG, click here.

Specific Issues Within Database.

According to the OIG, only 27% of the 6,439 MCSIS records involve terminated Medicaid providers. The database is filled with providers who had not been terminated, but rather had died, retired, left the state or stopped working with Medicaid of their own accord. It is also reported that about one-third of the records are not related to for-cause provider terminations. A majority of the data comes from California, Pennsylvania, Illinois and New York. According to Reuters, more than half of the records submitted did not include a National Provider Identification number, which is critical to any state trying to identify a terminated provider.

Click here to read the entire article from Reuters.

Recommendations to Improve Database.

CMS is now exploring options to implement mandatory state reporting. The agency has begun requiring that states submit termination letters for each provider entered in the MCSIS, and that CMS employees review each letter to ensure the provider belongs in the system.

What This Mean for Medicaid Providers.

As CMS works to improve this database, those providers who have fallen through the cracks due to the reporting lag will now face repercussions for exclusion. Exclusion from Medicaid could mean exclusion from Medicare and other federal providers. It is important that health care providers know their status regarding exclusion, and contact an experience attorney to assist them in having their names removed from exclusion lists.

To read more on the devastating consequences of exclusion, click here for a previous blog.

Contact Attorney Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare or Medicaid Programs.

The attorneys of The Health Law Firm have experience in dealing with the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare or Medicaid  Programs, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

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 care provider, do you know your status regarding exclusion? Are you aware of the consequences of being excluded? Please leave any thoughtful comments below.

Sources:

Pell, M.B. “U.S Database for Tracking Medicaid Fraud Fall Short, Auditor Says.” Reuters. (March 27, 2014). From: http://www.reuters.com/article/2014/03/27/us-usa-medicaid-database-idUSBREA2Q08D20140327

Levinson, Daniel. “CMS’s Process for Sharing Information About Terminated Providers Needs Improvement.” Department of Health and Human Service Office of Inspector General. (March 2014). From: http://oig.hhs.gov/oei/reports/oei-06-12-00031.pdf

About the Author: Lenis L. Archer is as 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 © 1996-2014 The Health Law Firm. All rights reserved.

Duke University Health System Pays $1 Million to Settle Allegations of False Claims in Whistleblower Lawsuit

1 Indest-2008-1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On March 21, 2014, Duke University Health System in Raleigh, North Carolina, settled a whistleblower/qui tam lawsuit, according to the Department of Justice (DOJ). The lawsuit, filed in 2012, stated that the three-hospital academic medical center is alleged to have fraudulently inflated its Medicare bills by unbundling a number of cardiac services and billing for physician assistants’ (PAs) time illegally. Duke University Health System agreed to pay $1 million to resolve these allegations.

Click here to read the press release from the DOJ.

Duke University Health System Accused of Submitting False Claims to Federal Health Care Programs.

According to the complaint, the lawsuit was originally filed by a former health care bill coder and quality-control auditor for Duke’s revenue-cycle subsidiary, Duke Patient Revenue Management Organization. The former employee accused Duke University Health System of allegedly making false claims to Medicare, Medicaid and TRICARE by billing the government for services provided by PAs during coronary artery bypass surgeries when the PAs were acting as surgical assistants, which is not allowed. The whistleblower also alleged the medical center increased billing by unbundling claims when the unbundling was not appropriate. These unbundled claims were associated with cardiac and anesthesia services, according to the complaint.

To read the whistleblower’s complaint filed in December of 2012, click here.

According to the DOJ, the claims resolved by the settlement are allegations only, and there has been no determination of liability.

Whistleblowers Who Report Fraud and False Claims Against the Government Are Usually Employees.

Doctors, nurses or staff employees working for hospitals, nursing homes, medical groups, home health agencies or others, often become aware of questionable activities. They are sometimes even asked to participate in it. In many cases the activity may amount to health care fraud.

It does not matter who you are. You may even be actively involved in the wrongdoing. This does not disqualify you from reporting the false claims activity or receiving a reward for doing so. In order to encourage employees with knowledge of fraudulent activity to come forward, the government will usually not seek to prosecute or punish that person in any way.

Normally the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Usually physicians, nurses or staff employees have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation that shows the fraud “disappears” or cannot be located once it is known that a company is under investigation.

Of course, the larger the amount of money the government has been defrauded the more likely it will be that the government will be interested in pursuing the case and the larger the reward the whistleblower will receive if there is a recovery.

To read more on whistleblower cases, read my previous blogs. Click here for part one, and click here for part two.

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

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. 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. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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 this settlement? Do you think whistleblower lawsuits are becoming more common? Please leave any thoughtful comments below.

Sources:

Carlson, Joe. “Duke Pays $1 Million to Settle Whistle-Blower Case.” Modern Healthcare. (March 25, 2014). From: http://bit.ly/1g3W7yw

Department of Justice. “Duke University Health System, Inc. Agrees to Pay $1 Million For Alleged False Claims Submitted to Federal Health Care Programs.” Department of Justice. (March 21, 2014). From: http://www.justice.gov/usao/nce/press/2014/2014-mar-21.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. 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 © 1996-2014 The Health Law Firm. All rights reserved.

AHCA Expert Not Allowed to “Use His Discretion” in Deciding Claims Were Improper in Medicaid Appeal Hearing

The forgoing case summary was prepared by and appeared in the DOAH case notes of the Administrative Law Section newsletter

FACTS: The Agency for Health Care Administration’s (“AHCA”) Office of Medicaid Program Integrity audited Dr. Rao, an authorized provider of Medicaid services, for claims between July 1, 2007, and June 30, 2009, and found him to be in violation of certain Medicaid provider policies. AHCA prepared a Final Audit Letter on June 1, 2011, notifying Dr. Rao that he had been overpaid by the Medicaid program by $110,712.09 for services provided during the audit period. Dr. Rao’s administrative hearing challenging AHCA’s overpayment determination was pending before DOAH. On August 17, 2012, Dr. Rao filed an unadopted rule challenge, alleging that AHCA’s overpayment determination was based on unadopted rules regarding the medical necessity of long-term monitored electroencephalograms (LTM EEGs).

OUTCOME: The ALJ found that AHCA’s peer review expert applied certain standards to the Medicaid claims he examined in conducting the Medicaid audit, but “exercised his discretion as to whether to apply them based on the specifics of each patient’s medical records.” The ALJ dismissed the unadopted rule challenge, explaining that “where application of agency policy is subject to the discretion of agency personnel, the policy is not a rule. . . . The medical standards at issue in this case are not self-executing and require the exercise of discretion in their application.” The ALJ noted that “the medical standards of practice must be applied on a case-by-case basis to determine whether the services provided were medically necessary, and provided both an appropriate level of care and standard of care ‘customarily furnished by the physician’s peers and to recognized health care standards” as required by section 409.9131(2)(d), Florida Statutes.

Source:

Radhakrishna K. Rao et al. v. AHCA, DOAH Case No. 12-2813RU (Final Order Aug. 20, 2013).

About the Author: The forgoing case summary was prepared by and appeared in the DOAH case notes of the Administrative Law Section newsletter, Vol. 35, No. 2 (Dec. 2013), a publication of the Administrative Law Section of The Florida Bar.

CMS Delays Stage 3 Meaningful Use for Medicare and Medicaid EHR Incentive Programs

MLS Blog Label 2By Michael L. Smith, R.R.T., J.D., Board Certified by The Florida Bar in Health Law, and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On December 6, 2013, the Centers for Medicare and Medicaid Services (CMS) announced a revised timeline for the implementation of Stage 3 meaningful use measures for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.

According to CMS, Stage 2 will be extended through 2016, and Stage 3 will begin in 2017 for those hospitals, physicians and other eligible providers that have completed at least two years of Stage 2 meaningful use. These changes affect two groups of eligible providers: providers who started Stage 1 in 2011, and who are currently scheduled to start Stage 3 in 2016, and those providers who started Stage 1 in 2012, and who are scheduled to start Stage 3 in 2016.

This announcement does not change when providers must start Stage 2, nor does it affect the requirement for hospitals and critical access hospitals to upgrade to EHR technology to receive incentive payments. The Medicare and Medicaid EHR incentive programs are staged in three steps with increasing requirements for participation. Eligible providers who do not meet meaningful use requirements will still be penalized with reduced Medicare reimbursement starting January 1, 2015.

To read more from CMS, click here.

Reasons for the Timeline Change.

According to Modern Healthcare, CMS stated that the goal of the timeline change is two-fold. First, to allow CMS and the Office of National Coordinator (ONC) to focus on assisting providers to meet Stage 2 demands for patient engagement, interoperability and information exchange, as well as use data collected during the phase to inform policy decisions for Stage 3.

CMS expects that it will release a notice of proposed rulemaking for Stage 3 in the fall of 2014, and the corresponding ONC notice for proposed rulemaking for the 2017 Edition of the ONC Standards and Certification Criteria will also be released at that time. Click here to read the entire article from Modern Healthcare.

What this Means for You.

If you begin participation with your first year of Stage 1 for the Medicare EHR Incentive Program in 2014:

- You must begin your 90 days of Stage 1 of meaningful use no later than July 1, 2014 and submit attestation by October 1, 2014 in order to avoid the 2015 payment adjustment.

If you have completed one year of Stage 1 of meaningful use:

- You will demonstrate a second year of Stage 1 of meaningful use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid.
- You will demonstrate Stage 2 of meaningful use for two years (2015 and 2016).
- You will begin Stage 3 of meaningful use in 2017.

If you have completed two or more years of Stage 1 of meaningful use:

- You will still demonstrate Stage 2 of meaningful use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid.
- You will demonstrate Stage 2 of meaningful use for three years (2014, 2015 and 2016).
- You will begin Stage 3 of meaningful use in 2017.

Contact Experienced Health Law Attorneys.

The Health Law Firm routinely represents physicians and medical groups on EHR issues. It also represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the DEA, Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

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 revised timeline for the implementation of Stage 3 meaningful use? Will this affect you? If so, how? Please leave any thoughtful comments below.

Sources:

Conn, Joseph. “Meaningful-Use Deadline Pushed Back One Year.” Modern Healthcare. (December 6, 2013). From: http://bit.ly/1kkAtsC

Tagalicod, Robert and Reider, Jacob. “Progress on Adoption of Electronic Health Records.” Centers for Medicare and Medicaid Services. (December 13, 2013). From: http://www.cms.gov/eHealth/ListServ_Stage3Implementation.html

About the Authors: Michael L. Smith, R.R.T., J.D., is Board Certified by The Florida Bar in Health Law. He is an attorney with 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.

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.

Adventist Health System Settles Whistleblower Lawsuit

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On December 18, 2013, Adventist Health System/Sunbelt Inc., the parent company of Orlando-based Florida Hospital, settled a whistleblower lawsuit, according to court documents. The whistleblower lawsuit, filed in 2010, stated that seven Adventist hospitals in Florida overbilled the federal government between 1995 and 2009, allegedly resulting in tens of millions of dollars in false claims, according to an article in the Orlando Sentinel and other sources.

Click here to read the Order of Dismissal.

Previous reports from the Orlando Sentinel stated that the lawsuit could have damages of more than $100 million, but the details of the settlement are not yet available.

Alleged Details in the Case Against Adventist Health System.

The lawsuit claims that seven Adventist hospitals in Florida allegedly used improper coding to overbill Medicare, Medicaid and Tricare. In addition, the lawsuit alleges the hospitals also overbilled for a drug used in MRI scans and billed for computer analyses that were never performed.

The plaintiffs are a bill-coding and compliance officer, and a radiologist that were either employed or affiliated with Florida Hospital Orlando between 1995 and 2009. They allege the discrepancies occurred during those years.

To read the entire False Claims Act complaint filed, click here.

Hospitals that allegedly partook in the overbilling include: Florida Hospital Orlando, Florida Hospital Altamonte, Florida Hospital East Orlando, Florida Hospital Apopka, Florida Hospital Celebration Health, Florida Hospital Kissimmee and Winter Park Memorial Hospital.

This case was scheduled to go to trial in December 2013.

Click here to read more on this case from my previous blog.

Most Qui Tam Claims Filed by Employees.

From our review of qui tam cases that have been unsealed by the government, it appears most of these are filed by physicians, nurses or hospital staff employees who have some knowledge of false billing or inappropriate coding taking place. Normally the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Usually physicians, nurses or staff employees have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation that shows the fraud “disappears” or cannot be located once it is known that a company is under investigation.

To learn more on whistleblower/qui tam cases, read our two-part blog. Click here for part one, and click here for part two.

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

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. 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. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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

Comments?

Individuals working in the health care industry 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. Has this ever happened to you? Please leave any thoughtful comments below.

Sources:

Aboraya, Abraham. “Adventist Health Whistleblower Lawsuit Settled.” Orlando Business Journal. (December 19, 2013). From: http://www.bizjournals.com/orlando/blog/2013/12/adventist-health-whistleblower-lawsuit.html

United States of America and State of Florida ex rel., Amanda Dittman and charlotte Elenberger, M.D. vs Adventist Health System/Sunbelt, Inc. Case No. 6:10-cv-1062-Orl-28GJK. Order of Dismissal. (December 18, 2013). From: http://assets.bizjournals.com/orlando/pdf/document.pdf

Jameson, Marni. “Whistleblower Lawsuit Alleges Florida Hospital Filed Millions in False Claims.” Orlando Sentinel. (August 8, 2012). From: http://articles.orlandosentinel.com/2012-08-08/health/os-whistleblower-lawsuit-florida-hospital-20120808_1_adventist-health-suit-claims-whistleblower-lawsuit

Amanda Dittman and Charlotte Elenberger, M.D. v. Adventist Health Systems/Sunbelt, Inc. No. 6:10-cv-01062-JA-GJK. False Claims Act Complaint. (July 15, 2010). From: http://www.thehealthlawfirm.com/uploads/whistleblower-lawsuit-adventist.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.

Florida Nursing Home Owner Arrested for Alleged $395,000 Medicaid Fraud Scheme

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A Miami-Dade nursing home owner was arrested for allegedly committing $395,000 worth of Medicaid fraud. The Florida Attorney General (AG) accused the nursing home owner of using the billing names of non-existent businesses to submit fraudulent invoices. The fake invoices were then allegedly paid with Medicaid funds. The nursing home owner was arrested on October 17, 2013, by the AG’s Medicaid Fraud Control Unit (MFCU) and the Miami-Dade Police Department.

To read the press release from the AG, click here.

Nursing Home Owner Allegedly Pocketed Medicaid Money.

According to the AG, the nursing home owner recorded forty-seven (47) fraudulent operating expense charges and submitted the cost report to the Agency for Health Care Administration (AHCA). The owner is accused of then writing checks to these phony businesses to “pay” the expense charges. The AG alleges that the nursing home owner was just paying himself. AHCA referred the case to the MFCU.

If convicted, the nursing home owner faces up to 90 years in prison and more than $1.9 million in fines.

MFCU and State and Federal Auditing Agencies.

The MFCU receives referrals from many other state and federal agencies. Often, matters that could be resolved as simple billing errors get escalated to criminal charges when Medicaid providers are interviewed and give evidence against themselves. Admitting to any misconduct, no matter how slight, may lead to far more serious criminal charges.

Click here for tips on how to respond to a Medicaid audit.

Take Fraud Charges Seriously.

In many cases those subject to Medicaid or Medicare fraud audits and investigations refuse to acknowledge the seriousness of the matter or they decide not to spend the money required for a top quality attorney to defend them.

If you are accused of Medicare or Medicaid fraud, realize that you are in the fight of your life. Your liberty, life and profession are at stake. Do not delude yourself. This is extremely serious. Be prepared to give up whatever you have if you can avoid a conviction.

Contact Health Law Attorneys Experienced in Handling Medicaid Audits, Investigations and other Legal Proceedings.

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Health Care Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), 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), 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. Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.

The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), 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.

Comments?

Have you heard of the MFCU? Would you know how to properly respond to a Medicaid audit? Please leave any thoughtful comments below.

Source:

Ray, Whitney. “Miami-Dade Nursing Home Owner Arrested for $395,000 in Medicaid Fraud.” My Florida Legal. (October 17, 2013). From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/F652FC98C9E1BA0C85257C0700530C42
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.

The American Academy of Family Physicians Releases Third List for Choosing Wisely Campaign

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

On September 24, 2013, the American Academy of Family Physicians (AAFP) released its third list of commonly prescribed tests and procedures that may not be necessary. This list is part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.

The Choosing Wisely Campaign was initiated to give patients a catalog of procedures, tests and treatments that have been overused, misused or have been identified as ineffective. Since its launch in April 2012, more than fifty (50) medical specialty societies have created lists of procedures, tests and drug treatments that deserve to be questioned before a physician orders them or patients accept them.

The purpose is to help patients become more discriminating about what care they receive. Physicians and health care providers also need to use this information to review the latest research and use that information to help avoid any litigation.

I’ve previously written about the Choosing Wisely campaign. Click here for part one and here for part two.

AAFP’s Updated List of Commonly Prescribed Tests and Procedures That May Not be Necessary.

1. Do not prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable.

2. Do not perform voiding cystourethrogram routinely in first febrile urinary tract infection in children aged 2-24 months.

3. Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam. Evidence suggests that PSA-based screening leads to an overdiagnosis of prostate tumors.

4. Do not screen adolescents for scoliosis. Potential harms include unnecessary follow-up visits resulting from false-positive test results.

5. Do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications. Hormonal contraceptives are safe, effective, and well tolerated by most women.

Click here to read the AAFP’s previous recommendations.

Health Care Providers and Professionals’ Responsibility to Patients.

A doctor should have the knowledge, skill, training, and confidence to know when such tests and procedures are not warranted. Also, a health care professional or provider should not be swayed by increasing his/her personal bottom line. Specifically, physicians that work in a fee-for-service setting that rewards doctors for performing more procedures are at risk for ordering unnecessary tests or procedures. If a physician persists in ordering these tests solely for the means of increasing profits, he or she should be penalized. If not, the physician should be able to justify them.

Laws Protect Patients from Unnecessary Testing.

This situation may have the side effect of promoting additional litigation against doctors, healthcare clinics and hospitals that provide the unnecessary tests and procedures. Many states have laws that prohibit unnecessary tests and procedures and sanction those who provide them. For instance, Section 766.111, Florida Statutes, provides a private cause of action by a patient against a health provider who orders or furnishes such “unnecessary” diagnostic tests, but unlike other tort and medical malpractice statutes, it allows the prevailing party in such a case to recover attorney’s fees and costs. This law may by itself promote litigation in the face of the lists of tests produced by the specialty groups in the Choosing Wisely campaign.

Look for More Whistleblower/Qui Tam Cases.

As this list continues to grow, I believe that we will see more qui tam/whistleblower and false claims cases.

Qui tam cases have been brought under the federal False Claims Act for the recovery of Medicare payments from hospitals, physicians, nursing homes, diagnostic testing facilities, clinical laboratories, radiology facilities and many other types of healthcare providers. These cases allege that a false claim was submitted to the government. If the test or procedure was unnecessary, then it seems almost axiomatic that a claim for it is false. The plaintiff bringing such cases receives a percentage of the recovery, which often amounts to millions of dollars in successful cases.

Most states now have similar false claims act or qui tam laws providing similar causes of action and recoveries to individual plaintiffs in the case of state Medicaid payments as well.

Because medical necessity is a requirement for practically every Medicare and Medicaid service, as well as most services paid by private health insurers, the lists provided by the specialty may very well be exhibit one in future lawsuits.

We’ve recently written about a couple of whistleblower/qui tam cases stemming from unnecessary procedures. To read a blog on a group of Florida radiation oncology service providers accused of performing unnecessary and improperly supervised procedures, click here. To read a blog on Winter Park Urology’s settlement over allegations stemming from radiation therapy used to treat cancer patients, click here.

Contact Experienced Health Law Attorneys.

The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the Drug Enforcement Administration (DEA), Federal Bureau of Investigation (FBI), Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.
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 care professional or provider what do you think of the Choosing Wisely campaign? Please leave any thoughtful comments below.

Sources:

Hand, Larry. “AAFP Releases Third Choosing Wisely List.” Medscape. (September 25, 2013). From: http://www.medscape.com/viewarticle/811638

Carman, Diane. “Useless, Costly Medical Procedures Targeted by Choosing Wisely Campaign.” Health Policy Solutions. (October 15, 2013). From: http://www.healthpolicysolutions.org/2013/10/15/useless-costly-medical-procedures-targeted-by-choosing-wisely-campaign/

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.

Hawaii Hospital to Pay More Than $451,000 to Resolve Whistleblower/Qui Tam Allegation of Improper Claims

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Wahiawa General Hospital in Honolulu, Hawaii, agreed to pay $451,428 to settle two lawsuits alleging that the hospital improperly billed Medicare, Medicaid and Tricare. The settlement stemmed from a civil whistleblower/qui tam lawsuit. The lawsuit was filed by a doctor who allegedly worked at an outpatient clinic operated by Wahiawa General Hospital, according to the Department of Justice (DOJ). Wahiawa General Hospital signed the settlement agreement on August 29, 2013.

To read the press release from the DOJ, click here.

Whistleblower Receives Money in Settlement and Attorneys’ Fees Paid by Hospital.

According to the DOJ, the federal and state governments alleged that Wahiawa General Hospital wrongfully submitted claims to Medicare, Medicaid and Tricare from April 2008 through March 2011. The investigation was initiated after a doctor alleged the hospital submitted bills for services provided by resident doctors without the level of supervision required by law.

On top of the more than $451,000 settlement, Wahiawa General Hospital agreed to pay $75,000 in attorneys’ fees and costs to the attorneys who represented the doctor. The doctor will also receive more than $84,600 as part of the settlement, under the False Claims Act. To learn more on whistleblower/qui tam cases, read our two-part blog. Click here for part one, and click here for part two.

Most Qui Tams Filed by Doctors, Nurses and Employees.

From our review of whistleblower/qui tam cases that have been unsealed by the government, it appears most of these are filed by physicians, nurses or hospital staff employees who have some knowledge of false billing or inappropriate coding taking place. Normally the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Usually physicians, nurses or staff employees have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation that shows the fraud “disappears” or cannot be located once it is known that a company is under investigation.

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

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. 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. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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

Comments?

Individuals working in the health care industry 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. Has this ever happened to you? Please leave any thoughtful comments below.

Sources:

Associated Press. “Wahiawa General Hospital to Pay $450K Settlement.” Star Advertiser. (August 30, 2013). From: http://www.staradvertiser.com/news/breaking/221856781.html

Department of Justice. “Community Hospital Pays $451,428 to Resolve Allegation of Improper Claims.” Department of Justice. (August 30, 2013). From: http://www.justice.gov/usao/hi/news/1308wgh.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.

New York-Based MRI Company to Pay $3.57 Million Settlement to Resolve False Claims Act Allegations in Whistleblower/Qui Tam Case

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On August 27, 2013, the Department of Justice (DOJ) announced a settlement between the government and New York-based Imagimed LLC, its former owners and its former chief radiologist. This $3.57 million settlement resolves whistleblower/qui tam allegations of false reimbursement claims for radiology scans. The payment also settles accusations that the company violated the Stark Law and the Anti-Kickback Statute.

Click here to read the press release from the DOJ.

Imagimed owns and operates 15 magnetic resonance imaging (MRI) facilities under the name Open MRI.

MRI Company Accused of Not Following Proper Safety Precautions and Committing Health Care Fraud.

According to the DOJ, from July 2001 through April 2008, Imagimed, the company’s former owners and the former chief radiologist submitted claims to Medicare, Medicaid and TRICARE for MRI scans performed with a contrast dye without the direct supervision of a qualified doctor, as required by federal regulations.

The DOJ also alleges that from July 2005 to April 2008, Imagimed also had sham on-call arrangements with, and gave improper gifts to referring physicians, which is in violation of the Stark Law and the Anti-Kickback Statute.

Local Radiologist Blew Whistle and Receives a Cut of the Settlement.

According to the Associated Press, a local radiologist filed the lawsuit against Imagimed under the False Claims Act. The radiologist will receive $565,500 for coming forward. To read the Associated Press article, click here.

Whistleblowers stand to gain substantial amounts, sometimes as much as thirty percent (30%), of the amount the government recovers under the False Claims Act (31 U.S.C. Section 3730). Such awards encourage employees and contractors to come forward and report fraud. To learn more on whistleblower cases, read our two-part blog. Click here for part one, and click here for part two.

Most Qui Tams Filed by Doctors, Nurses and Employees.

From our review of qui tam cases that have been unsealed by the government, it appears most of these are filed by physicians, nurses or hospital staff employees who have some knowledge of false billing or inappropriate coding taking place. Normally the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Usually physicians, nurses or staff employees have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation that shows the fraud “disappears” or cannot be located once it is known that a company is under investigation.

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

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. 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. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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

Comments?

Individuals working in the health care industry 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. Has this ever happened to you? Please leave any thoughtful comments below.

Sources:

Department of Justice. “MRI Diagnostic Testing Company, Imagimed LLC, and Its Former Owners and Chief Radiologist to Pay $3.57 Million to Resolve False Claims Allegations.” Department of Justice. (August 27, 2013). From: http://www.justice.gov/opa/pr/2013/August/13-civ-958.html

Associated Press. “Federal Authorities Settle MRI Case for $3.75M.” The Wall Street Journal. (August 29, 2013). From: http://online.wsj.com/article/APcf5d7d677786468bb9d446b6c3082e5d.html?KEYWORDS=medicare

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.

CMS Fights Medicare Fraud With Ban on New Home Health Agencies and Ambulance Suppliers in Three Cities

LOL Blog Label 2

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

The Centers for Medicare and Medicaid Services (CMS) announced it will temporarily ban new home health providers and ambulance suppliers from enrolling in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) in three fraud “hot spots.” According to CMS, the six-month moratorium begins July 30, 2013. It applies to newly enrolling home health agencies (HHAs) in Miami, Florida, and Chicago, Illinois. It also applies to newly enrolling ambulance suppliers in Houston, Texas. Existing providers and suppliers can continue to deliver and bill for services. The goal of the ban is to fight healthcare fraud.

Click here to read the press release from CMS.

Authority to impose a moratorium was included in the Patient Protection and Affordable Care Act (PPACA). According to a summary of the anti-fraud provisions in the Affordable Care Act, the Act allows CMS to prohibit new providers from joining the program where necessary to prevent or fight fraud, waste or abuse in certain geographic areas or for certain categories of services. This is the first time CMS is exercising its authority.

Why Moratorium Was Imposed in These Areas.

According to CMS, the decision to impose the moratorium was based on a number of factors, including a disproportional number of providers and suppliers relative to beneficiaries, a quick increase in enrollment applications from providers and suppliers, and extremely high utilization in these areas.

Miami Area a Hot Bed for Healthcare Fraud and Abuse.

The Miami area has stood out as one of the nation’s hubs of Medicare fraud, according to CMS. For example, in May 2013, a Miami patient recruiter for an HHA was sentenced to 37 months in prison for participating in a $20 million Medicare fraud scheme. Click here to read a previous blog. In that same month, workers from a Miami-area HHA were accused of bribing Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. To read more, click here.

According to the Miami Herald, with a large number of elderly Medicare beneficiaries living in Miami, it’s not a surprise that healthcare fraud is so prevalent. South Florida allegedly accounts for one-third (1/3) of all healthcare fraud prosecutions in the nation. Click here to read the entire Miami Herald article.

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

In 2011 and 2012, the government reported recovery of $14.9 billion in healthcare fraud judgments, settlements and administrative impositions, according to CMS. In addition, CMS has revoked 14,663 providers and suppliers’ ability to bill the Medicare Program since 2011. The Affordable Care Act seeks to improve anti-fraud and abuse measures by focusing on prevention rather than the traditional “pay-and-chase” model of catching crooks after they have committed fraud. Click here to read a blog on the Affordable Care Act’s other fraud fighting tools.

What This Means for Health Care Professionals and Providers.

By knowing the government is beefing up measures to fight healthcare fraud, providers can attempt to avoid practices that are likely to lead to Zone Program Integrity Contractor (ZPIC) or Recovery Audit Contractor (RAC) audits. Additionally, a provider can be prepared for potential audits by increasing its documentation and compliance efforts.

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 CMS’ decision to invoke the moratorium? Do you think this should have been done sooner? Please leave any thoughtful comments below.

Sources:

Centers for Medicare and Medicaid Services. “CMS Imposes First Affordable Care Act Enrollment Moratoria to Combat Fraud.” CMS.gov. (July 26, 2013). From: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-26.html

Chang, Daniel. “Feds Ban New Home Healthcare Agencies in Miami to Fight Medicare Fraud.” Miami Herald. (July 26, 2013). From: http://www.miamiherald.com/2013/07/26/3524612/feds-ban-new-home-healthcare-agencies.html

Beasley, Deena. “U.S. Bans New Home Health, Ambulance Providers in Three Regions.” Miami Herald. (July 26, 2013). From: http://www.reuters.com/article/2013/07/26/us-medicare-moratoria-idUSBRE96P14P20130726

About the Authors: 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.

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.