Tag Archives: Medicaid defense lawyer

CMS in the Hot Seat for Lax Oversight of Medicaid Managed Care Organizations

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

For years, each state has kept an eye on its own Medicaid managed care plans, while the Centers for Medicare and Medicaid Services (CMS) is required to monitor how well each individual state is doing. However, a recent Government Accountability Office (GAO) report claims CMS is sleeping on the job. The report, released on June 20, 2014, stresses the need for more federal oversight of these plans.

With the implementation of the Affordable Care Act (ACA), the Medicaid program is expected to expand significantly. Most of the new beneficiaries enrolled in managed care are covered almost entirely by federal funds. The need for federal oversight in this area is of growing importance to ensure accountability of taxpayers’ dollars.

To read the entire report from the GAO, click here.

Report Findings: MCOs Need to be Watched by the Feds.

The persistent theme of the GAO report is that CMS and the Department of Health and Human Services (HHS) have done little to control the integrity of managed care organizations (MCOs). Federal programs have delegated managed care supervision to each individual state, but fail to provide needed guidelines and resources. CMS has not updated its MCO program guidance since 2000.

The report found neither state nor federal programs are well positioned to identify improper payments made to MCOs. Further, these programs are unable to ensure that MCOs are taking appropriate actions to identify, prevent or discourage improper payments.

For example, the report looked at state program integrity (PI) units and Medicaid Fraud Control Units (MFCU) from seven states. These anti-fraud groups admitted to primarily focusing their efforts on Medicaid fee-for-service claims. Meanwhile, claims made to MCOs have flown under their radar.

GAO Recommendations.

The GAO recommends that CMS:

– Require states to conduct audits of payments to and by MCOs;

– Update its managed care guidance program integrity practices and effective handling of MCO recoveries; and

– Provide states with additional support in overseeing MCO program integrity.

The GAO also suggests that CMS increase its oversight, especially as states expand their Medicaid programs. The GAO report recommends CMS take a bigger role in holding states accountable to ensure adequate program integrity efforts in the Medicaid managed care program. If CMS does not step up to the plate, the report predicts a growing number of federal Medicaid dollars will become vulnerable to improper payments.

The Future of MCOs.

If this report is taken seriously, be assured that audits of MCOs will become more frequent and extensive. If CMS ramps up their efforts, claims could be reviewed in detail by Medicaid integrity contractors. Now is the time to verify you are in compliance and receiving proper payments; before CMS turns the magnifying glass on you or your facility .

Comments?

What do you think of the GAO’s assessment of MCOs? Do you think CMS needs to step up and provide more oversight? Please leave any thoughtful comments below.

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

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Health Care Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), the FBI, and the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS). Other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies often participate. Don’t wait until it’s too late. If you are concerned about possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today. Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.

The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions. To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Mullaney, Tim. “Federal Government Needs to Boost Medicaid Managed Care Oversight, GAO Says.” McKnight’s Long-Term Care & Assisted Living. (June 20, 2014). From: http://www.mcknights.com/federal-government-needs-to-boost-medicaid-managed-care-oversight-gao-says/article/356779/

Adamopoulos, Helen. “GAI Calls on CMS to Increase Medicaid Managed Care Oversight.” Becker’s Hospital Review. (June 20, 2014). From: http://www.beckershospitalreview.com/finance/gao-calls-on-cms-to-increase-medicaid-managed-care-oversight.html

Bergal, Jenni. “Advocates Urge More Government Oversight of Medicaid Managed Care.” Kaiser Health News. (July 5, 2013). From: http://www.kaiserhealthnews.org/stories/2013/july/05/medicaid-managed-care-states-quality.aspx?referrer=search

About the Author: Lenis L. Archer is as attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

 

Speech Therapist Arrested for Billing Medicaid $500,000 for Work at Florida Day Care Centers While Living in Illinois

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

A speech therapist was arrested on March 29, 2013, for allegedly billing Medicaid more than $500,000 for services that she did not provide, according to the Florida Office of the Attorney General (AG). The speech therapist now faces charges of Medicaid fraud and grand larceny.

Click here to read the press release from the AG.

Billed Medicaid for Services Provided in Florida, While Living in Illinois.

According to an article in The Palm Beach Post, authorities began investigating the speech therapist when they received a tip that she was overbilling for services provided. During the investigation it was found that while the speech therapist reported to Medicaid she lived in Florida, she has been allegedly living in Illinois for the past eight years. The speech therapist allegedly employed two unlicensed speech therapists to work for her in two Florida day care centers. From January 2008 until February 2013, the speech therapist billed Medicaid for services she allegedly did not administer.

To read the entire article from The Palm Beach Post, click here.

Speech Therapist Faces Restitution and Prison Time.

The Florida AG’s Medicaid Fraud Control Unit (MFCU) and the West Palm Beach Police Department made the arrest. If convicted, the speech therapist faces up to $20,000 in fines, 60 years in prison and restitution.

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

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

Faced with an Medicaid Audit? Contact Health Law Attorneys Experienced in Handling Medicaid Audits.

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Healthcare Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), the FBI, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS). Often other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies participate. Don’t wait until it’s too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today. Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.
The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

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

Comments?

How did the speech therapist get away with this for so long? What are your thoughts on this story? Please leave any thoughtful comments below.

Sources:

Seltzer, Alexandra. “Authorities: Woman billed Medicaid $500,000 for working at West Palm Beach day care centers while in Illinois.” The Palm Beach Post. (March 28, 2013). From: http://www.palmbeachpost.com/news/news/crime-law/authorities-she-billed-medicaid-500k-for-working-a/nW6ht/

Meale, Jenn. “Medicaid Fraud Control Unit Arrests Speech Therapist for $500,000 of Medicaid Fraud.” Florida Office of the Attorney General. (March 29, 2013). From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/AE5D612364AD29C285257B3D004BE6B5

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.