Tag Archives: medicare audit

Centers for Medicare and Medicaid Services Puts Recovery Audit Contractor Program on Hold

4 Indest-2009-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On February 18, 2014, the Centers for Medicare and Medicaid Services (CMS) announced it is in the procurement process for the next round of Recovery Audit Program contracts. This means the program is, for the time being, on hold while CMS awards new contracts. According to CMS, it will select new vendors to continue the Recovery Audit Contractor (RAC) program, which is responsible for detecting improper Medicare payments. It is expected that this pause will also be used to refine and improve the RAC program. In the announcement it was not disclosed how long the program would be on hold.

Click here to read the announcement from CMS.

This news comes months after CMS revealed an enormous backlog of RAC appeals. The backup is so bad, providers are not able to submit new cases until the existing backlog clears, which could take two years or more.

Current Contracts Extended to Conclude Appeals.

According to Modern Healthcare, CMS extended its contracts with the four current vendors until December 31, 2015, for administrative and transition activities. These contracts were to end on February 7, 2014. The purpose of the extension is to allow the RACs to handle and wind down appeals. To read the entire article from Modern Healthcare, click here.

For providers this means a lull in additional documentation requests (ADRs), however it is important to remember RAC audits are not going away.

Dates to Remember.

Providers should note the important dates below:

- February 21, 2014, was the last day a Recovery Auditor could send a postpayment ADR;
- February 28, 2014, is the last day a Medicare Administrative Contractor (MAC) may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration; and
- June 1, 2014, is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment.

Backlog of RAC Appeals Worse Than Ever.

The RAC appeals process has become so overloaded that in December 2013, the U.S. Department of Health and Human Services’ (HHS) Office of Medicare Hearings and Appeals (OMHA) notified hospitals, doctors, nursing homes and other health care providers that the agency would be suspending acting on new requests for hearings. Health care providers were told they would not be able to submit any new appeals until the existing backlog clears, which could take two or more years. To read more on the backlog of RAC appeals, click here for my previous blog.

RAC Audits Will Be Back.

In the first three months of the fiscal year 2013, RACs recouped more than $2.2 billion from providers due to what the RACs deemed were overpayments. With money coming in, RAC audits are not going away. It has become common for state and federal regulators to enforce even the smallest violations, resulting in investigations, monetary fines and penalties. If found in violation, you will not only have to pay fines and face disciplinary action, you will also lose revenue because you will have to spend time dealing with the investigation, instead of practicing medicine. Whether you are trying to prevent Medicare and Medicaid audits, Zone Program Integrity Contractor (ZPIC) audits, or any other kind of healthcare audits, there are steps you can implement in your practice today that may save you down the line. Click here to read more on self audits.

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 about the RAC program being put on hold? What do you think CMS should do to improve the program? Please leave any thoughtful comments below.

Sources:

Kutscher, Beth. “CMS Recovery Audits on Hold as Contractors Wrestle Big Backlog.” Modern Healthcare. (February 20, 2014). From: http://www.modernhealthcare.com/article/20140220/NEWS/302209968/cms-recovery-audits-on-hold-as-contractors-deal-with-big-backlog

Centers for Medicare and Medicaid Services. “Recent Updates.” Centers for Medicare and Medicaid Services. (February 18, 2014). From: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.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 © 1996-2014 The Health Law Firm. All rights reserved.

Miami Medical Clinic Owner Pleads Guilty to $20 Million in Medicare Fraud

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

The owner of a Miami-based medical clinic pleaded guilty on January 8, 2014, for her involvement in several health care fraud schemes that allegedly cost the Medicare program around $20 million. The schemes allegedly involved fraudulent billing for home health care services and therapy prescriptions to patients that may not have required them, according to the Associated Press. The owner operated Merfi Corp., a medical clinic that employed physicians, physician assistants and other medical professionals authorized to dispense prescriptions for home health care services.

Click here to read the Associated Press article.

The medical clinic owner faces up to 10 years in prison and is scheduled to be sentenced in March 2014.

Medicare Fraud Scheme Involved Kickbacks and Brides.

According to an article on Home Health Care News, through Merfi, the owner and her co-conspirators were allegedly given kickbacks and brides for providing fraudulent home health and therapy prescriptions and other medical documentation to owners and operators of other home health agencies and patient recruiters. The fraudulent documents were then used to bill Medicare.

To read the entire article from Home Health Care News, click here.

Case Investigated by Medicare Fraud Strike Task Force.

This case was investigated by the Medicare Fraud Strike Task Force. This task force has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion since the agency’s inception in March 2007. To learn more about the Medicare Fraud Strike Force’s anti-fraud efforts, click here to read a previous blog.

What You Need to Know about Medicare and Medicaid Audits.

I previously wrote a two-part blog on the increased number of Medicare and Medicaid audits being initiated against health professionals who treat home health care, assisted living facility (ALF) and skilled nursing facility (SNF) residents. This area of medical practice has been identified as one fraught with fraud and abuse. To learn more on the areas being targeted and how to respond to different types of audits click here for the first blog, and click here for the second.

Physicians, Nurse Practitioners and Physician Assistants Must Check Out Their Employers.

I have previously written blogs warning licensed health practitioners about illegal health care clinics. Often the individuals involved in fraudulent acts will use an unlicensed health clinic as a vehicle to process false claims. Licensed health professionals should jealously protect their Medicare and Medicaid provider numbers and make sure that they do not allow their name or numbers to be used in false billing activities. Check out any company or corporation that employs you to be sure it is properly licensed, as necessary. To read a previous blog I wrote on unlicensed health clinics, 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 healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

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

Comments?

Do you think similar schemes are fairly common? Do you think we will see more news stories like this with the increased anti-fraud efforts of the Medicare Fraud Strike Task Force? Please leave any thoughtful comments below.

Sources:

Associated Press. “South Florida Woman Guilty in $20M Medicare Fraud Scheme.” Miami Herald. (January 8, 2014.) From: http://www.miamiherald.com/2014/01/08/3858269/fla-woman-guilty-in-20m-medicare.html

Oliva, Jason. “Miami Clinic Owner Pleads Guilty to $20 Million Home Health Fraud.” Home Health Care News. (January 8, 2013). From: http://bit.ly/1h87Xv4

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.

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.

ZPICs Seek “Voluntary” Agreements from Physicians for Auto-Denial Edits for Home Health Services

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

According to the Centers for Medicare and Medicaid Services (CMS), the primary purpose of Zone Program Integrity Contractors (ZPICs) is to investigate instances of suspected fraud, waste, and abuse.  The specific actions employed by ZPICs to fulfil this mission include:

-  Investigating potential fraud and abuse for CMS administrative action or referral to law enforcement;
-  Conducting investigations in accordance with the priorities established by Center for Program Integrity’s (CPI) Fraud Prevention System;
-  Performing medical review, as appropriate;
-  Performing data analysis in coordination with CPI’s Fraud Prevention System;
-  Identifying the need for administrative actions such as payment suspensions and prepayment or auto-denial edits; and,
-  Referring cases to law enforcement for consideration and initiation of civil or criminal prosecution.

However, it appears that some of the ZPICs have been overly proactive in identifying the need for payments suspensions and are asking providers to voluntarily agree to payment suspensions for certain claims.

Click here to read more on ZPICs from CMS.

Physicians Being Targeted by ZPICs for Auto-Denial Edits.

Recently, physicians have been approached by ZPICs and asked to voluntarily agree to a payment edit on their National Provider Identifier (NPI) that would automatically deny any claim for payment for home health services that listed the physician as the ordering, attending, or referring physician.  A ZPIC requesting a specific physician to voluntarily cease ordering any home health services appears to go further than identifying the need for administrative action including a payment suspension.

The activities a ZPIC may use to fulfil its obligations to CMS are:

-  Request medical records and documentation;
-  Conduct interviews;
-  Conduct onsite visits;
-  Identify the need for a prepayment or auto-denial edits and refer these edits to the Medicare Administrative Contractors (MAC) for installation;
-  Withhold payments; and,
-  Refer cases to law enforcement.

The following functions are reserved for the MACs and not functions of the ZPICs.

-  Provider outreach and education;
-  Recouping monies lost to the Trust Fund (the ZPICs identify these         situations and refer them to the MACs for the recoupment);
-  Medical review not
-  Complaint screening; for benefit integrity purposes;
-  Claims appeals of ZPIC decisions;
-  Claim payment determination;
-  Claims pricing; and
-  Auditing provider cost reports.

While a ZPIC may refer a provider to the MAC for the imposition of an auto-denial edit, some ZPICs seem to have taken this process a step further and are attempting to have physicians voluntarily agree to the auto-denial edits.

Issues with Agreeing to an Auto-Denial Edit.

A physician who voluntarily agrees to an auto-denial edit could create significant problems for his or her patients and practice.  A physician agreeing to an auto-denial edit would need to cease ordering home health services and would need to refer the patients that need home health services to another physician.  Any physician that has been approached by a ZPIC seeking a voluntary auto-denial edit should consult competent legal counsel before agreeing to the auto-denial edit.

We have heard if ZPIC representatives allegedly intimidating or attempting to intimidate physicians who routinely order home health services for patients into agreeing to such auto-denial edits.

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?

Have you heard of these auto-denial edit requests from ZPICs? Please leave any thoughtful comments below.

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.

Copying and Pasting Clinical Notes in Electronic Health Records Could Be Considered Healthcare Fraud

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

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) is concerned about healthcare providers carelessly copying and pasting clinical notes in electronic health records (EHRs). According to an audit report released on December 10, 2013, copying and pasting in EHRs can lead to fraudulently duplicated clinical notes, which can be considered healthcare fraud. This practice is allegedly widespread across medicine, according to a Modern Healthcare article. Federal officials say there is a need to crackdown on this behavior.

Click here to read the entire audit report from the HHS OIG.

This is the first of two reports on fraud and vulnerabilities in EHR systems. The second report from the OIG will be on weaknesses in how the Centers for Medicare and Medicaid Services’ (CMS) payment contractors monitor for fraud in EHRs. This report is scheduled to be published soon.

Report Looks at Hospital Policies Regarding Copy-and-Paste Features.

The audit report studied 864 hospitals that had received subsidies for EHR systems as of March 2012. Out of those hospitals, only twenty-four percent (24%) had any policy regarding the improper use of copying-and-pasting in EHRs. The report concluded that too few hospitals actually have policies defining the proper use of copy and paste in EHRs.

According to Modern Healthcare, adoption of EHR systems has coincided with a rapid rise in higher-cost Medicare claims. This has led to officials looking into whether EHRs are enabling illegal upcoding. Officials say that EHR features such as copy and paste make it too easy to bill for work that wasn’t actually performed and help increase reimbursements, according to Modern Healthcare. Click here to read the entire article from Modern Healthcare.

In the report the HHS OIG recommends that the CMS strengthen its efforts to develop a comprehensive plan to address fraud vulnerabilities in EHRs. It was also suggested that CMS develop guidance on the use of the copy-paste feature in EHR technology.

Tips to Help Avoid Copy-and-Paste Errors.

Tools commonly available in EHRs that allow physicians to copy and paste patient information should be used with extreme care, according to an article on American Medical News. The article offers health care providers some guidelines to help avoid errors related to copying and pasting.

- Avoid copying and pasting of text from another person’s notes.

- Avoid repetitive copying and pasting of laboratory results and radiology reports.

- Note important results with proper context, and document any resulting actions. Avoid wholesale inclusion of information readily available elsewhere in the EHR because that creates clutter and may adversely affect note readability.

- Review and update as appropriate any shared information found elsewhere in the electronic record (e.g., problems, allergies, medications) that is included in a note.

- Include previous history critical to longitudinal care in the outpatient setting, as long as it is always reviewed and updated. Copying and pasting other elements of the history, physical examination or formulations is risky, as errors in editing may jeopardize the credibility of the entire note.

Click here to read the entire article from American Medical News.

What This Means for Healthcare Providers Using EHRs.

The practice of copying and pasting previous information without checking can be considered careless and potentially dangerous to patients. It can be problematic when there are multiple teams taking care of one patient and using the chart to communicate. The right way is to make sure everything in the note you sign accurately reflects what happened on your shift.

In the report the HHS OIG stated that copy-and-paste features in EHRs will be under additional scrutiny. By knowing where the enforcement focus will be, providers can attempt to avoid copy-and-paste practices that are likely to lead to audits. Additionally, providers can beef up compliance efforts and policies.

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

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.

Don’t wait until it’s too late. If you are concerned of any possible violations and would like a consultation, contact a qualified health attorney familiar with medical billing and audits today. To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at http://www.TheHealthLawFirm.com.

Comments?

In your practice do you use an EHR system? Have you had any issues with copying and pasting clinical notes? Does your practice have a copy-and-paste policy? Please leave any thoughtful comments below.|

Sources:

Carlson, Joe. “Fed Eye Crackdown on Cut-and-Paste EHR Fraud.” Modern Healthcare. (December 10, 2013). From: http://www.modernhealthcare.com/article/20131210/NEWS/312109965/cut-and-paste-function-can-invite-ehr-fraud-officials-say

O’Reilly, Kevin. “EHRs: ‘Sloppy and Paste’ Endures Despite Patient Safety Risk.” American Medical News. (February 4, 2013). From: http://www.amednews.com/article/20130204/profession/130209993/2/

Levinson, Daniel R. “Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology.” Department of Health and Humans Services Office of Inspector General. (December 2013). From: http://www.modernhealthcare.com/assets/pdf/CH92135129.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. 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.

Miami “Rock Doc” Arrested on Medicare Fraud Charges

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

An osteopathic physician in Miami, Florida, dubbed the “Rock Doc,” was arrested on September 30, 2013. He is charged with twelve (12) counts of health care fraud, according to the Department of Justice (DOJ). The “Rock Doc” is accused of falsely billing the Medicare program for physical therapy procedures, such as massages and electrical stimulation, which were not necessary. If convicted the doctor faces up to ten (10) years in prison and a $250,000 fine.

Click here to read the press release from the DOJ.

In 2010, this osteopathic physician was the feature of a Wall Street Journal article called “Confidentiality Cloaks Medicare Abuse.” The article looked into the billing practices of the “Rock Doc” and many other doctors performing physical therapy and reaping the reimbursements from Medicare.

The physician’s nickname, “Rock Doc,” stems from his appearance of spiked, punk-styled hair, along with accessories of chains, bangles and leather bracelets.

Indictment Accuses Doctor of Spending Reimbursements on Himself.

According to the indictment, the “Rock Doc” is accused of falsely and fraudulently representing that his physical therapy treatments and services were medically necessary and had been provided to Medicare beneficiaries between December 2007 and August 2009. The indictment also alleges that he used the Medicare payments on himself or others.

To read the indictment against the osteopathic “Rock Doc” physician, click here.

Medicare regulations require that physical therapists billing under a physician must have completed an accredited physical-therapy education program. However, in the Wall Street Journal article, the “Rock Doc” said that he trained his “office girls” to do the work because hiring a physical therapist was too expensive.

Wall Street Journal Article Highlighted Physician’s High Medicare Reimbursements.

According to the Wall Street Journal article released in 2010, the “Rock Doc” admitted to receiving more than $2.6 million from Medicare between 2007 and 2009. His gross payments were allegedly more than 24 times the Medicare income of the average family doctor.

In 2009, Medicare administrators caught onto the doctor’s billing activity and began scrutinizing his bills. That increased oversight led him to sell his business.

According to the Miami Herald, the doctor was currently working at a hospital in Larkin County, Florida, when he was arrested.

To read the Miami Herald article, click here.

Fraud Charges Must Be Taken Seriously.

We have been consulted by many individuals, both before and after criminal convictions for fraud or related offenses. There are many times audit investigators must make a judgment on whether overcharges are simply an honest mistake or fraud. In many instances, we are convinced that the person is actually not guilty of fraud. However, 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. You need to sell everything you own, borrow everything you can and hire the absolute best criminal defense attorney available who has experience in defending such cases to represent you.

If you win and are acquitted, at least you still have a professional license and can start over. However, if you lose, you will most probably be in prison for years. You will lose your license. You will be excluded from Medicare. You will be a convicted felon. You will have nothing and will have no way of starting over successfully. Do not delude yourself. This is extremely serious. Be prepared to give up whatever you have if you can avoid a conviction.

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

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

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

Comments?

Do you think that being the subject of the Wall Street Journal article back in 2010, the “Rock Doc” basically alerted the government to his fraudulent billing practices? Please leave any thoughtful comments below.

Sources:

Weaver, Jay. “Miami Beach’s ‘Rock Doc’ Busted on Medicare Fraud Charges.” Miami Herald. (September 30, 2013). From: http://www.miamiherald.com/2013/09/30/3660611/miami-beachs-rock-doc-busted-on.html

Department of Justice. “Miami Physician Indicted in Medicare Fraud Scheme.” Department of Justice. (September 30, 2013). From: http://www.justice.gov/usao/fls/PressReleases/130930-01.html

United States of America vs. Christopher Gregory Wayne. Case Number 13-206912. Indictment. (September 30, 2013). From: http://www.thehealthlawfirm.com/uploads/RockDoc.Indictment.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.

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.

Oncologist Accused of Billing Medicare for Unnecessary Chemotherapy-Employee Whistleblowers Filed First Claim

4 Indest-2009-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A Michigan oncologist is accused of deliberately misdiagnosing patients with cancer so he could allegedly administer chemotherapy treatments and bill the government for those treatments, according to the Department of Justice (DOJ). For more than two years the oncologist allegedly billed Medicare for $35 million in fraudulent claims. The oncologist was charged on August 19, 2013, with one count of Medicare fraud, according to the DOJ.

On top of submitting false claims to Medicare, a criminal complaint alleges a number of other serious charges. These include hiring doctors who may not have been properly licensed to practice medicine, administering controlled substances to patients at dangerous levels, and delaying hospital care for a patient with serious injuries, among others.

The complaint is allegedly based on interviews with several nurse practitioners, medical assistants and another doctor who worked for the oncologist at Michigan Hematology Oncology Centers (MHO), according to the DOJ. These whistleblowers allegedly approached federal authorities with this information.

Click here to read the press release from the DOJ.

We are aware of similar stories regarding dermatologists misdiagnosing lesions as cancer. Some of these have been widely publicized in media reports, television news and magazine stories, such as “American Greed.”

Whistleblowers Come Forward with Serious Charges Against Oncologist.

The oncologist’s employees allege the doctor submitted fraudulent claims to Medicare for medically unnecessary services, including chemotherapy treatments, Positron Emission Tomograph (PET) scans, and a variety of cancer and hematology treatments for patients who did not need them. According to an article in Time, the complaint also alleges the oncologist administered unnecessary chemotherapy to patients in remission, deliberately misdiagnosed patients as having cancer to justify unnecessary cancer treatment, and administered chemotherapy to end-of-life patients who would not have benefitted from the treatment.

The criminal complaint also alleges, according to Time, that the oncologist distributed controlled substances to patients without medical necessity and employed foreign doctors who might have been unlicensed to practice medicine in the U.S.

According to Time, the complaint also cited one case in which the oncologist’s patient fell and hit his head at the oncologist’s office, and was told he needed chemotherapy before he could be taken to the hospital. The patient allegedly later died from the head injury.

Click here to read the entire Time article.

Oncologist Faces Prison Time and Fine.

According to Detroit News, the oncologist could face up to 10 years in prison and a $250,000 criminal fine if convicted. The oncologist has entered a not guilty plea in this case. At this point, these accusations are just that, allegations. A check of the oncologist’s license status from the Michigan Department of Health (DOH) shows that his license is active.

To read the Detroit News article, click here.

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.

To learn more on whistleblower 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:

Department of Justice. “Oakland County Doctor and Owner of Michigan Hemotology and Oncology Centers Charged in $35 Million Medicare Fraud Scheme.” Department of Justice. (August 6, 2013). From: http://www.justice.gov/opa/pr/2013/August/13-crm-885.html

Pickert, Kate. “Medicare Fraud Horror: Cancer Doctor Indicted for Billing Unnecessary Chemo.” Time U.S. (August 15, 2013). From: http://nation.time.com/2013/08/15/medicare-fraud-horror-cancer-doctor-indicted-for-billing-unnecessary-chemo/

Hunter, George. “Michigan Cancer Doctor Formally Charged in Medicare Fraud Scheme.” Detroit News. (August 19, 2013). From: http://bit.ly/14T8A2A

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.

Cardiologists Face Higher Scrutiny by CMS

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

As the U.S. population ages and heart disease continues to be a leading cause of health issues, cardiologists and cardiology practices are finding themselves billing Medicare for more and more visits and procedures.

Along with that increase in reimbursement from Medicare comes an increase in scrutiny.  According to the Centers for Medicare and Medicaid Services (CMS), more than sixteen percent (16%) of total Medicare spending in 2010, was for cardiovascular care.

Some experts predict that this number will increase as cardiologists continue to adopt state-of-the-art technology and procedural techniques when treating their patients.

All of this means that whistleblowers, Recovery Audit Contractor (RAC) auditors, Zone Program Integrity Contractor (ZPIC) auditors, and CMS’s data mining services are going to be more incentivized to come after cardiovascular reimbursements.

To read more on the high scrutiny cardiologists face, click here to read an article on Modern Healthcare.

The Audits Are Coming.

Cardiology physicians and practices need to understand that just because they are doing things the “right way” does not mean that they will not be the subject of an audit. Auditing can be triggered by any number of things ranging from disgruntled employees, competing practices, dissatisfied patients, random audits, above average billing for certain codes, etc. None of these triggers means that a practice is doing anything wrong, but it will have to face an audit nonetheless.

Being prepared before an audit happens can be the most effective defense.  Review some of these prior articles and blogs we have written for tips in establishing audit protocols and handling audits in general:

Self Audit Now to Save Your Practice Later
Responding to a Medicare Audit – Practice Tips
Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 1
Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 2

The Best Defense for an Audit is to be Prepared Before an Audit Happens.

So long as CMS employs a “pay and chase” method of reimbursement, audits will be a permanent part of the healthcare landscape.  Every medical practice should consult with an attorney experienced in handling Medicare, Medicaid and other third party audits in order to develop effective policies and procedures.  By preparing for an audit prior to its occurrence a practice is in the best position to avoid any kind of sanction or overpayment demand.

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

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

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

Comments?

Do you think cardiologist and cardiology practices are under a higher amount of scrutiny? Please leave any thoughtful comments below.

Sources:

Carlson, Joe. “Cardiologists Enmeshed in High-Scrutiny Climate.” Modern Healthcare. (July 8, 2013). From: http://www.modernhealthcare.com/article/20130708/BLOG/307089995/cardiologists-enmeshed-in-high-scrutiny-climate

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.