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Ready or Not, It’s Irregular Behavior Season…

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

Every year at regular intervals, our firm receives calls from panicked medical students and residents about a recent letter they have received, alleging irregular behavior.

This letter may come from the National Board of Medical Examiners (NBME), the United States Medical Licensing Examination (USMLE), or the Educational Commission for Foreign Medical Graduates (ECFMG). No matter the organization, if you receive a letter alleging irregular behavior, it will typically say the following:

1. A bulletin or policy related to the exam stating that Irregular Behavior is not permitted.
2. The facts alleging irregular behavior in this case.
3. You have an opportunity to respond to the allegations, in person, with counsel.

Often there is a very short window of time to respond to such allegations. While this is important because it is urgent that you get your test results, it also gives a limited time to prepare to defend yourself.

What is Irregular Behavior?

Although irregular behavior is not the same thing as cheating, it is often thought of as the same by medical school officials and residency program directors. A notice of irregular behavior may hold up and delay your entry into a residency program, your graduation from medical school, and your job opportunities. Your examination scores will be held up while the matter is reviewed by a USMLE Committee on irregular behavior or until a hearing can be held.

What Should You Do?

Once you receive an irregular behavior letter, begin to compile documents to defend yourself. Write out your version of events in order to recall what happened. Collect character reference letters from professors and administrators that attest to your integrity.

Place the personal appearance date listed in your letter on your calendar. It is of utmost importance that you attend in person, preferably with representation. Hearings are usually held in Philadelphia, Pennsylvania, so plan accordingly.

Consequences of an Irregular Behavior Finding.

If a finding of irregular behavior is made against you, then this usually means that your best score is voided, and you must retake it. The USMLE Committee may require you to wait a year or more to retake the examination. This can prevent you from obtaining or entering a residency program or it may delay you from graduating. Furthermore, the notation that you were found to have committed irregular behavior will be placed on your Step exam transcript. This will be reported out when your test scores are reported.

As indicated above, many medical decision makers view this as similar to cheating. It may disqualify you for many jobs or residency programs that you would otherwise be considered for. If you are accused of irregular behavior, immediately consult with an attorney who has actual experience in dealing with this matter. You can find more information about irregular behavior by clicking here.

Comments?

Have you been accused of irregular behavior? How did you handle this allegation? Do you think a report of irregular behavior would hurt your professional career in any way? Please leave any thoughtful comments below.

Contact Experienced Health Law Attorneys.

The attorneys of The Health Law Firm provide legal representation to medical students, residents, interns and fellows in academic disputes, graduate medical education (GME) hearings, contract negotiations, license applications, board certification applications and hearings, credential hearings, and civil and administrative litigations.

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

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. http://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 © 1996-2015 The Health Law Firm. All rights reserved.

New MCAT Will Put the Social Skills of Potential Doctors to the Test

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

The 8,200 aspiring doctors expected to take the Medical College Admission Test (MCAT) this year will be seeing a different exam than their predecessors.

The doctor-patient dynamic is changing. So, to stay on top of this shift in the health care industry, the Association of American Medical Colleges (AAMC) announced in April 2015, the first major revision to the MCAT in 25 years. This test is the first high-stake exam encountered by physicians. The big difference physician hopefuls will notice is that the new test assesses social aptitude and not just hard science.

The New MCAT.

There are some old reliables on the MCAT that are here to stay. The exam will still test on biological sciences and physical sciences.

Here’s what has changed:

– Students will have more questions to answer, but more time to complete each question;

– The new MCAT adds a section covering introductory psychology, sociology and neuroscience;

– The MCAT has replaced its old section on “verbal reasoning” with a broader test of comprehension in the humanities and social sciences;

– The test has eliminated the essay;

– There is a new emphasis on research, including designing studies and analyzing their results;

– The scoring for the new test will be different; and

– Scores for each of the four sections of the MCAT will be reported separately, so medical schools can emphasize or de-emphasize some parts if they choose.

The AAMC created 900 free videos to help students prepare for the new test. To review those videos, click here.

What This Means for Test Takers?

According to a press release from the AAMC, the new MCAT test is part of a broader effort to improve the medical school admission process and to support the holistic review of applicants, which balances experiences, attributes and academic metrics. To read the press release from the AAMC, click here.

There has been a paradigm shift in medical education to acknowledge the competencies physicians need beyond medical knowledge. Doctors now need to possess a broad set of skills that will treat the whole patient. The new exam reflects these changes. It should be obvious that a good physician is well-rounded with many skills that stretch far beyond basic sciences. These proficiencies are now being tested and emphasized at an earlier age.

Regardless of the changes, the same keys to succeeding as a physician applicant will apply: strong grades, competitive MCAT scores, well-rounded extracurricular activities, outstanding recommendation letters, and a promising interview.

Comments?

What are your thoughts on the new MCAT test? Do you think testing more than just basic science on the MCAT is a positive change or unnecessary? Please leave any thoughtful comments below.

Sources:

Diamond, Dan. “For the New Doctors We Need, The New MCAT Isn’t Enough.” Forbes. (April 22, 2015). From: http://www.forbes.com/sites/dandiamond/2015/04/22/we-need-a-new-type-of-doctor-but-will-the-new-mcat-be-enough/

Beck, Melinda. “Medical-College Entrance Exam Gets an Overhaul.” Wall Street Journal. (April 15, 2015). From: http://news.doximity.com/entries/1701511?user_id=2169203

Association of American Medical Colleges. “Future Physicians Take New Medical College Admission Test.” (April 20, 2015). From: https://www.aamc.org/newsroom/newsreleases/430138/20150420.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 © 1999-2015 The Health Law Firm. All rights reserved.

More Medicare Audits Now Than Ever Before

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

A Medicare audit, whether it is performed by a contractor of the Centers for Medicare & Medicaid Services (CMS), or by another organization, can be a daunting process. It is never “routine” and should never be taken lightly.

Because of the efforts to reduce expenditures on entitlement programs and the success that the government has had in recovering large sums of Medicare overpayments, we are seeing a tremendous increase in Medicare fraud initiatives, including but not limited to audits by Medicare Administrative Contractors (MACs), audits by Zone Program Integrity Contractors (ZPICs), Recovery Audit Contractors (RACs), the use of investigative subpoenas to obtain records, and related activities.

Medicare, Medicaid and TRICARE now routinely share audit results and information on repayments made by health providers. We had a client who conducted a self-audit and found an overpayment situation. The client made a voluntary disclosure and sent in a voluntary repayment of the amount it had overbilled Medicare. A few weeks later our client received an overpayment demand from the federal TRICARE program. The TRICARE demands were based on the same patients and the same claims for the co-pays and deductibles that had been paid back to Medicare.

Common Errors Found in Medicare Audits.

We often seem some common errors in Medicare audits. Most of the errors relate to improper or incomplete documentation. Such errors include:

1. Failure to obtain the physician’s signature on the order or plan.
2. Failure to have an order signed by a physician.
3. Tests, consults, prescriptions, therapy, or services ordered by a non-Medicare provider. 4. Failure to document the start time and stop time of each (time-based) procedure.
5. Failure to have complete, unique notes for each patient (use of “cloned” notes).
6. Failure to demonstrate if a client is progressing toward improvement or goal.
7. Lack of medical necessity for procedures performed.
8. Failure to have the care plan signed by the physician within 24 hours.

Locate and Review the Local Coverage Determinations (LCDs) for the Codes You Bill.

All Medicare providers should ensure that they are familiar with the local coverage determinations (LCDs) that are published by MACs for the CPT codes they routinely bill. These are available on the MAC website. Strict compliance with all such guidelines is required.

Make Sure to Obtain the Physician’s Signature Prior to Treatment.

Therapists and others providing services in response to a physician’s order or consult request must ensure that they obtain the proper physician’s signature before treating patients. Make this an ironclad rule in your practice or business. We have heard from some therapists that physicians often ignore their correspondence and documentation, or the physician sits on it for weeks at a time before signing it. If you refuse to touch the patient without the required doctor’s signature you cannot be faulted. The responsibility is on the physician who fails to sign a plan in a timely manner. If you are unable to do this, then just plan on providing the services for free. Guidance on documentation required for a therapist, as well as LCD, and therapy services required for Medicare can be found on the CMS website.

Checklist for Medicare Audits.

These are some of the actions we recommend you take and which we take in medicare blogrepresenting a physician or other health provider in responding to a Medicare audit.

1. All correspondence from Medicare, or the Medicare contractor, should be taken seriously. Avoid the temptation to consider the request from Medicare just another medical records request. Avoid the temptation to delegate this to an administrative employee.

2. Read the audit letter carefully and provide all the information requested. In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients, for which Medicare reimbursed you.

3. Include a copy of the complete record and not just those from the dates of service requested in the audit letter. Include any diagnostic tests and other documents from the chart that support the services provided. Many practices document the medications and immunizations given to the patient in a separate part of the chart and not in the progress notes; all documents, the complete record, should be provided to the auditor. Remember that even other physicians’ records obtained as history, including reports, consultations and records from other physicians or hospitals, should also be included. Consent forms, medical history questionnaires, histories, physicals, other physicians’ orders, all may be a crucial part of the record. If the patient was referred to you by a hospital order, nursing home discharge order or another order, obtains these to provide to the auditor.

4. Make sure all the medical records are legible and legibly copied. If the record is not legible, have the illegible record transcribed and include the transcription along with the hand-written or illegible records. Make sure than any such transcriptions are clearly marked as a transcription with the current date it is actually transcribed. Label it accurately. Do not allow any room for there to be any confusion that the newly transcribed part was part of the original record.

5. If your practice involves taking or interpreting x-rays or other diagnostic studies, include these studies. They are part of the patient’s record. If the x-rays are digital, they can be submitted on a compact disc (CD).

For the complete checklist, click here.

Challenge Overpayment Demands from Medicare and Medicaid Audits.

Recently we have spoken with numerous physicians and other health care professionals, who have been placed on prepayment review after failing to challenge Medicare audit results. The problem is that these providers, once placed on prepayment review, have their payments held up for many months and are often forced out of business. Sometimes it appears that this may actually be the goal of the auditing contractor or agency.

Comments?

Have you or your practice ever been audited? What was the process like? Did you retain legal counsel to help with the process? Was having legal assistance worth it? Please leave any thoughtful comments below.

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

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. We also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals, occupation therapists (OTs), physical therapists (PTs), speech therapists (STs), rehabilitation therapists (RTs) and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid program.

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

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 © 1999-2015 The Health Law Firm. All rights reserved.

The Ins and Outs of Florida’s 2015 Legislative Session for Health Care Providers

10 Indest-2008-7George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in the Legal Specialty of Health Law

Committees are busy in Tallahassee as the 2015 Legislative Session is set to begin on March 3, 2015. For Florida physicians and other health care providers, now is the time to review the legislative bills that could affect you and your practice. There are many bills pending that could impact the future of medical practice and health care delivery in Florida.

On the table are some recognizable bills from last year, as well as a few new ones. To stay up to date on the 2015 Legislative Session as it relates to health care, check this blog regularly.

Bills Up for Consideration.

The two most profiled issues from the 2014 Legislative Session are back.

– House Bill (HB) 547 and the companion Senate bill (SB) 614 would give nurse practitioners the ability to prescribe controlled substances. It would also expand their scope of practice, which would exempt them from the requirement that certain medical acts be performed or supervised by a physician. To learn more on this bill, click here for our previous blog.

– HB 545 and the companion Senate bill SB 478 defines what is determined to be telemedicine or telehealth. These bills call for coverage in Medicaid programs. Lawmakers state an agreement has been made to require health care providers to be licensed in Florida to provide telemedicine in the state. House and Senate leaders have expressed confidence they will reach an agreement this year on telemedicine. Click here to learn more on telemedicine in Florida.

Each bill could dramatically change the landscape of the practice of Florida medicine.

Keep an Eye on These Additional Bills.

Other pending bills that could impact the delivery of health care in Florida, include:

– SB 516 addresses insurance coverage and reimbursement issues for emergency services;

– HB 279 would allow pharmacy interns to administer vaccinations to adults;

– HB 281 and SB 532 would allow licensed physician assistants under physician supervision to order controlled substances in the hospital setting; and

– HB 515 and SB 710 revise the scope of physical therapists and prohibit individuals with doctorates in physical therapy to present themselves as a doctor without informing the public of his or her actual profession as a physical therapist.

In Conclusion.

The 2015 Legislative Session is packed with bills that, if approved, will affect physicians, physician assistants, nurses, and other health care providers. As a health care provider, knowing the ins and outs of these bills can save you from the headache and possible fines that could come from non-compliance. We urge you to become involved with these issues. If you would like to know more, you can contact your local medical society. Again, we will stay on top of the progress of these bills, so check this blog regularly.

Contact Experienced Health Law Attorneys.

The Health Law Firm routinely represents physicians, pharmacists, pharmacies, optometrists, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, HIPAA complaints and violations, NPDB actions, 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 http://www.TheHealthLawFirm.com.

Sources:

Stone, Rick. “PAs, Nurse Practitioners Could Get Prescribing Authority.” Health News Florida. (February 11, 2015). From: http://health.wusf.usf.edu/post/pas-nurse-practitioners-could-get-prescribing-authority?utm_source=Health+News+Florida+eAlert+subscriber+list&utm_campaign=e231ee3f8a-Friday_February_13_20152_13_2015&utm_medium=email&utm_term=0_8d22eaa6f6-e231ee3f8a-249582973

Saunders, Jim. “Telemedicine Deal Likely in 2015, Legislators Say.” Orlando Sentinel. (February 3, 2014). From: http://www.orlandosentinel.com/news/politics/os-florida-telemedicine-deal-20150203-story.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 © 1999-2015 The Health Law Firm. All rights reserved.

Open for Registration: Telemedicine Association Begins Telemedicine Accreditation

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

The American Telemedicine Association (ATA) recently announced that it was accepting a limited number of applications for its telemedicine provider accreditation program. According to the ATA the purpose of the accreditation is to recognize organizations that provide top-notch online health care services. The ATA calls the service its “Accreditation Program for Online Patient Consultations.”

Details on ATA’s Accreditation Program.

Eligibility to register and apply for accreditation is aimed at any United States based organization that provides real-time interactive doctor-patient interactions via live online video services. Currently the ATA is not certifying so-called “store-and-forward” providers. However, this may be a possibility in the future as this technology becomes more widely used.

The ATA’s standards for the accreditation program are modeled after those found in state and federal laws and regulations, industry best practices, and input from the community. The primary focus is on robust policies and procedures, appropriate areas of practice (i.e. online treatment is appropriate for the illness), and patient health and safety.

Telemedicine Laws Different in Every State.

As with any health care good or service, the rules and regulations differ widely from state to state and with federal payors like Medicare. It is important to check your state medical board’s rules and opinions on telemedicine to avoid disciplinary action for inadvertently violating the medical practice act or some other applicable regulation.

Also note some states that permit telemedicine still require the physician to be licensed in the state in which the patient resides. Before engaging in telemedicine services, you should also look at the regulations in the states in which your patients are located to see if you need to have a license. Being accredited, while certainly a step in the right direction, will not necessarily exempt you from compliance with the law.

There has been a recent push to expand the scope of telemedicine services that are payable by Medicare. If these efforts are successful, there will undoubtedly be a spike in the number of providers offering remote services. Additionally, many private insurers have been piloting programs to see if the purported savings offered by telemedicine actually reduce the cost of claims.

Comments?

What do you think about the ATA’s accreditation program? Where do you think telemedicine will be in five years? Please leave any thoughtful comments below.

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

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

The services we provide include reviewing and negotiating contracts, business transactions, professional license defense, representation in investigations, credential defense, representation in peer review and clinical privileges hearings, Medicare and Medicaid audits, commercial litigation, and administrative hearings. To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at http://www.TheHealthLawFirm.com.

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. http://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 © 1996-2015 The Health Law Firm. All rights reserved.

Physician Argues Definition of “Peer” at Formal Administrative Hearing

peer reviewFACTS: The Agency for Health Care Administration (“AHCA”) is responsible for administering Florida’s Medicaid program and conducting investigations and audits of paid claims to ascertain if Medicaid providers have been overpaid. With regard to investigations of physicians, section 409.9131, Florida Statutes, provides that AHCA must have a “peer” evaluate Medicaid claims before the initiation of formal proceedings by AHCA to recover overpayments. Section 409.9131(2)(c) defines a “peer” as “a Florida licensed physician who is, to the maximum extent possible, of the same specialty or subspecialty, licensed under the same chapter, and in active practice.” Section “109.9131(2)(a) deems a physician to be in “active practice” if he or she has “regularly provided medical care and treatment to patients within the past two years.”

Alfred Murciano, M.D., treats patients who are hospitalized in Level III neonatal intensive care units and pediatric intensive care units in Miami-Dade, Broward, and Palm Beach County hospitals. His practice is limited to pediatric infectious disease. He has been certified by the American Board of Pediatrics in two areas: General Pediatrics and Pediatric Infectious Diseases. AHCA initiated a review of Medicaid claims submitted by Dr. Murciano between September 1, 2008, and August 31, 2010, and referred those claims to Richard Keith O’Hern, M.D., for peer review. Dr. O’Hern practiced medicine for 37 years, and was engaged in a private general pediatric practice until he retired in December of 2012. During the course of his career, he was certified by the American Board of Pediatrics in General Pediatrics, completed a one-year infectious disease fellowship at the The University of Florida, and treated approximately 16,000 babies with infectious disease issues. However, he was never board certified in pediatric infectious diseases, and at the time he reviewed Dr. Murciano’s Medicaid claims, Dr. O’Hern would have been ineligible for board certification in pediatric infectious diseases. In addition, Dr. O’Hern would have been unable to treat Dr. Murciano’s hospitalized patients in Level III NICUs and PICUs.

After Dr. O’Hern’s review, AHCA issued a Final Agency Audit Report alleging Dr Murciano had been overpaid by $l,051.992.99, and that he was required to reimburse AHCA for the overpayment. In addition, AHCA stated it was seeking to impose a fine of $210,398.60.

OUTCOME: Dr. Murciano argued at the formal administrative hearing that Dr O’Hern was not a “peer” as that term is defined in section 409.9131(20)(c). The ALJ agreed and issued a Recommended Order on May 22, 2014, recommending that AHCA’s case be dismissed because it failed to satisfy a condition precedent to initiating formal proceedings. While recognizing that AHCA is not required to retain a reviewing physician with the exact credentials as the physician under review, the ALJ concluded Dr. O’Hern was not of the same specialty as Dr. Murciano.

On July 31, 2014, AHCA rendered a Partial Final Order rejecting the ALJ’s conclusion that Dr. O’Hern was not a “peer.” In the course of ruling that it has substantive jurisdiction over such conclusions and that its interpretation of section 409.9131(2)(c), Florida Statutes, is entitled to deference, AHCA stated that it interprets the statute “to mean that the peer must practice in the same area as Respondent, hold the same professional license as Respondent, and be in active practice like Respondent.” AHCA concluded that “Dr. O’Hern is indeed a ‘peer’ of Respondent under the Agency’s interpretation of Section 409.9131(2)(c), Florida Statutes, because he too has a Florida medical license, is a pediatrician and had an active practice at the time he reviewed Respondent’s records. That Dr. O’Hern did not hold the same certification as Respondent, or have a professional practice identical to Respondent in no way means he is not a ‘peer’ of Respondent.” AHCA’s rejection of the ALJ’s conclusion of law regarding Dr. O’Hern’s “peer” status caused AHCA to remand the case back to the ALJ to make the factual findings on the claimed overpayments that were not made in the Recommended Order because of the ALJ’s conclusion that Dr. O’Hern did not qualify as a “peer.”

On August 18, 2014, the ALJ issued an Order respectfully declining AHCA’s remand. AHCA then filed a Petition for writ of Mandamus in the First District Court of Appeal, asking the court to direct the ALA to accept the remand and to enter findings of fact and conclusions of law with regard to each overpayment claim. The court assigned case number 1D14-3836 to AHCA’s Petition, and the case is pending.
Source:

AHCA v. Alfred Murciano, M.D., DOAH Case No. 13-0795MPI (Recommended Order May 22, 2014), AHCA Rendition No. 14-687-FOF-MDO (Partial Final Order July 31, 2014)
About the Author: The forgoing case summary was prepared by and appeared in the DOAH case notes of the Administrative Law Section newsletter, Vol. 36, No. 2 (Dec. 2014), a publication of the Administrative Law Section of The Florida Bar.

A New Year Means New Audits and Site Visits for Assisted Living Facilities – Protect Yourself Now

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

For Assisted Living Facilities (ALFs) in Florida, it’s time to do a little brushing up on your compliance material.

Beginning in January 2015, the Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), Bureau of Medicaid Program Integrity (MPI), will conduct site visits to determine compliance with the Florida Medicaid Provider General Handbook and the Assistive Care Services Coverage and Limitations Handbook. This is just one of several initiatives aimed at ALFs to curtail fraud, waste, and abuse in the Florida Medicaid program.

Be Prepared.

The goal of a site visit is to determine if providers are rendering and documenting required services; to determine if assistive care services are being rendered by qualified and properly trained staff; to identify quality of care/environmental issues; and, to document and report ALF providers’ deficiencies to any managed care organizations with which the ALF is contracted.

According to the Florida Assisted Living Association (FALA), the majority of MPI sanctions concerning these fines are associated with the failure to have the following completed forms on file for each resident:

1. AHCA Form 1823 – The Health Assessment
2. AHCA Form 035 – The Certification of Medical Necessity
3. AHCA Form 036 – Medicaid Service Plan

Knowing is Half the Battle.

This announcement shows that the government will continue rigorous and thorough enforcement efforts this year. ALFs should consider this a fair warning to get supporting documentation in order. If you’re worried your ALF may not be in compliance, we suggest getting a compliance assessment. If your ALF is being audited we always suggest contacting an experienced health law attorney immediately. For general tips on how to respond to a Medicaid audit, click here for a previous blog.

Comments?

Did you know about these anti-fraud initiatives? Do you feel like your ALF is prepared for a site visit? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced in Representing Assisted Living Facilities.

The Health Law Firm and its attorneys represent assisted living facilities (ALFs) and ALF employees in a number of different matters including incorporation, preparing contracts, defending the facility against malpractice claims, licensing and regulatory matters, administrative hearings, and routine legal advice.

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

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 © 1999-2015 The Health Law Firm. All rights reserved.