Tag Archives: legal representation

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.

“Doctor of Death” Trial Could Ignite Stricter Oversight in the Healthcare Industry

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 paper, one Detroit-area oncologist appeared to be a wildly successful professional with impeccable medical credentials. According to his medical practice’s website, he went to medical school at Cornell Medical College, did an internal medicine residency at Maimonides Medical Center in Brooklyn, New York, and then completed a medical oncology fellowship at Memorial Sloan-Kettering Cancer Center, a very well-respected facility. The oncologist ran a professional practice of seven locations with a total of 60 employees.

However, on September 24, 2014, his reputation and accolades faded when he pleaded guilty to intentionally and wrongfully diagnosing healthy patients with cancer. He also admitted to giving these patients chemotherapy solely for the purpose of making a profit.

For healthcare professionals, this act is an obvious violation of the oath they took to serve their patients and to do no harm. But, if this oncologist is found guilty, you can be assured that oncologists, physicians, dentists, and all other healthcare professionals will be under a microscope to help ensure that something this egregious and dishonest does not happen again.

Allegations Against the Oncologist.

The details of the allegations, obtained from various employee whistleblowers, range from the mundane to the horrific. In the Federal Bureau of Investigation’s (FBI) complaint against the oncologist, there are dozens of examples of his wrongdoing described. The activities of which the doctor is accused include:

– Administration of unnecessary chemotherapy to patients in remission;
– Deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment;
– Administration of chemotherapy to end-of-life patients who would not benefit from the treatment;
– Deliberate misdiagnosis of patients without cancer to justify expensive testing;
– Fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments; and
– Distribution of controlled substances to patients without medical necessity.

There is also an issue of Medicare fraud. For the past six years, the doctor is accused of seeing a large number of patients per day. He would then bill every patient at the highest possible billing code, even though he allegedly only spent a few minutes with each patient. The amount of money related to the doctor’s Medicare fraud scheme is a staggering $35 million.

Click here to read the FBI’s complaint against the oncologist.

Charges.

The oncologist is facing a an abundance of legal issues. In all, the oncologist pleaded guilty in U.S. District Court to 13 counts of healthcare fraud, one count of conspiracy to pay or receive kickbacks and two counts of money laundering. He will be sentenced in February 2015 and faces up to 175 years in prison.

Other Healthcare Providers Could Pay for Oncologist’s Greed.

If the oncologist is found guilty, the aftereffects will surely be felt throughout the industry. For example, healthcare providers will need to more closely watch their Medicare billing. Any reimbursement submitted to Medicare will be under tight scrutiny. Keep in mind that Medicare pays close attention to the percentage of patients billed at each level. If a physician bills for every patient at the highest level, it’s going to send up a huge red flag. If you or your practice is being audited, click here for some tips on responding to a Medicare audit.

On top of the extensive healthcare fraud charges, the oncologist allegedly misled, endangered, and injured his patients. He betrayed the trust and privilege given to him as a physician by society, all in the name of greed. According to an article in The Washington Post, more than one patient died under the care of the oncologist. These families are now left to figure out whether their loved ones actually had cancer and died of chemotherapy complications, or whether they died of an actual cancerous ailment.

It’s crucial to remember that cutting corners to make a profit as a healthcare professional leads to great ramifications. Once a healthcare professional’s license and reputation are questioned, it is not an industry one can easily get back into.

Comments?

In your opinion, what is the worst offense this oncologist allegedly committed? Explain. Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced with Investigations of Health Professionals and Providers.

The attorneys of The Health Law Firm provide legal representation to physicians, nurses, nurse practitioners, CRNAs, dentists, pharmacists, psychologists and other health providers in accusations of disruptive behavior, Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations, Medicare investigations, Medicaid investigations and other types of investigations of health professionals and providers.

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:

Sullivan, Gail. “‘Death Doctor’ Who Profited from Unnecessary Chemotherapy for Fake Cancers Could Resume Practice in 5 Years.” The Washington Post. (October 1, 2014). From: http://www.washingtonpost.com/news/morning-mix/wp/2014/10/01/death-doctor-who-profited-from-unnecessary-chemotherapy-for-fake-cancers-could-resume-practice-in-three-years/

“Prominent Michigan Cancer Doctor Pleads Guilty: ‘I Knew That It Was Medically Unnecessary’.” The Inquisitr. (September 24, 2014). From: http://www.inquisitr.com/1485160/prominent-michigan-cancer-doctor-pleads-guilty-i-knew-that-it-was-medically-unnecessary/

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.

Kansas Cancer Treatment Center and Owner Pay $2.9 Million Settlement for Alleged False Claims Act Violations

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

A whistleblower or qui tam lawsuit against a cancer treatment facility in Kansas has been settled. On April 14, 2014, the Hope Cancer Institute and its owner agreed to pay $2.9 million to resolve allegations that they violated the False Claims Act by defrauding Medicare, Medicaid and the Federal Employee Health Benefits Program. According to the complaint, it is alleged that the cancer treatment facility submitted false claims for drugs and services that were not provided to beneficiaries.

Click here to read the entire whistleblower complaint filed in 2012.

The complaint identifies three former employees of Hope Cancer Institute as the plaintiffs or “relators” in this case.

Owner Allegedly Instructed Employees to Submit Inflated Claims and Altered Medical Records.

According to the Department of Justice (DOJ), between 2007 and 2011, the Hope Cancer Institute’s owner allegedly instructed employees to bill for a predetermined amount of cancer drugs at certain dosage levels. However patients were allegedly given lower dosages of these drugs. This resulted in the center submitting false claims to federal health care programs for drugs that were not actually provided to beneficiaries. The three plaintiffs also stated they watched the owner use a paper cutter and tape to alter medical records before faxing them to Medicare. The employees’ investigation allegedly turned up altered documents for 13 patients.

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

The claims made against the Hope Cancer Institute and its owner are allegations. There has been no determination of liability.

Most Qui Tam Claims Filed by Employees.

The plaintiffs in this case filed the lawsuit against their employer under the qui tam or whistleblower provision of the False Claims Act. This law encourages whistleblowers to file fraud claims on behalf of the government by giving them a share of whatever the government collects, usually 15 percent (15%) to twenty-five percent (25%). Under the law, the employees are also required to give the DOJ the evidence they have collected so the government can join the lawsuit.

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 staff employees who have some knowledge of false billing or inappropriate coding taking place. Typically the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Physicians, nurses or staff employees usually have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation showing fraud “disappears” or cannot be located once it is known that a company is under investigation.

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. “Government Settles False Claims Act Allegations Against Kansas Cancer Treatment Facility and Its Owner.” Department of Justice. (April 14, 2014). From: http://www.justice.gov/opa/pr/2014/April/14-civ-378.html

United States of America ex rel., Krisha Turner, Crystal Dercher and Amanda Reynolds v. Hope Cancer Institute, Inc. Case Number 2:12-cv-02122-EFM-JPO. Complaint. (March 1, 2012).

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.

Use Caution in USMLE Step Exam Preparation

CTH Blog LabelBy Catherine T. Hollis, 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 United States Medical Licensing Examination (USMLE) Bulletin of Information outlines several examples of conduct that is deemed to be irregular behavior.  On February 27, 2014, the USMLE posted an Announcement listing the types of alleged irregular behavior recently reviewed by the Committee for Individualized Review (CIR).  Some of the cases reviewed involved individuals who were accused of soliciting unauthorized access to examination materials or communicating about specific test items, cases, or answers with other examinees.  This particular type of irregular behavior seems to be increasingly alleged against individuals who have participated in online forum discussions requesting assistance with examination preparation.

Click here to read the entire February 27, 2014, USMLE Announcement.

Do Not Seek Specific Examination Materials or Attempt to Communicate With Other Examinees.

The USMLE is taking a hard line stance on enforcing its irregular behavior policies concerning soliciting test materials and communicating about specific test items.  We have recently seen a number of individuals accused of engaging in irregular behavior because of posts on forum websites that appear to be solicitations for specific examination materials or cases.  Some examples of these posts include:

–    Joining in requests from others for information on recent test questions after another individual’s post requesting Step 2 Clinical Skills  (CS) cases;
–    Requesting that others provide information about some of the cases at a specific test center;
–    Suggesting approaching examinees as they leave the exam center to ask about the exam; and
–    Requesting a list of CS cases for a specific test center.

Know the Rules.

All USMLE applicants are required to be familiar with the USMLE’s Bulletin of Information.  By signing a Step Exam application, an applicant is certifying that he or she has read and is familiar with all information contained in the Bulletin. You will still be held responsible for this whether you read it or not.

According to the Bulletin, irregular behavior includes any action that subverts or attempts to subvert the examination process.  As noted above, the Bulletin contains a non-exhaustive list of examples of conduct that is deemed to be irregular behavior.

Click here to read our previous blog about irregular behavior.

Irregular Behavior Has Serious Potential Consequences.

If an examinee is found to have engaged in irregular behavior, the CIR will impose sanctions.  These sanctions can include an annotation on an individual’s USMLE transcript, invalidation of scores, a report to the Federation of State Medical Boards, and even a bar from taking future USMLE examinations.

Appropriate Test Preparation.

Examinees can adequately prepare for the USMLE Step exams without the need to seek further assistance that might cross the line into irregular behavior.  On April 4, 2014, the USMLE posted an Announcement on its website with information about materials available from the USMLE, the National Board of Medical Examiners (NBME) and third parties. From the USMLE website, examinees can access free orientation and practice materials, including:

–    Informational materials on the overall USMLE program and content descriptions for each of the USMLE examinations;
–    Tutorials that illustrate the USMLE Step 1, Step 2 Clinical Knowledge (CK), Step 3 multiple-choice software and the Step 3 computer-based case simulation (CCS) Primum® software;
–    Sample multiple-choice test questions with answer keys for each Step exam;
–    Sample Step 3 CCS cases with feedback; and
–    Orientation materials for Step 2 CS.

Examinees may also, for a fee, take advantage of the self-assessment services offered by the NBME.  These services are designed to familiarize examinees with USMLE questions and provide feedback on the examinee’s areas of strength and weakness.

There are also a variety of commercial test preparation materials and courses that claim to prepare examinees for USMLE Step exams.  These courses are not affiliated with or sanctioned by the USMLE program, but may be helpful to you.

Click here to read the entire April 4, 2014, USMLE Announcement.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals.

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.

Comments?

Have you ever come across these online forums? Have you ever posted in these forums? Please leave any thoughtful comments below.

Sources:

“USMLE Takes Action Against Individuals Found to Have Engaged in Irregular Behavior.” USMLE. (February 27, 2014). From: http://www.usmle.org/announcements/?ContentId=130

“Use Caution in Selecting Review Courses.” USMLE. (April 4, 2014). From: http://www.usmle.org/announcements/?ContentId=67

“USMLE 2014 Bulletin of Information.” USMLE. (2013). From: http://www.usmle.org/pdfs/bulletin/2014bulletin.pdf

About the Authors:  Catherine T. Hollis is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://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. 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.

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.

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.
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