Tag Archives: Medicaid provider

OIG Audit Finds Federal Database of Terminated Medicaid Providers Needs Improvement

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

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

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

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

Specific Issues Within Database.

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

Click here to read the entire article from Reuters.

Recommendations to Improve Database.

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

What This Means for Medicaid Providers.

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

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

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

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

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

Comments?

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

Sources:

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

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

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

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2014 The Health Law Firm. All rights reserved.

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

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

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

Source:

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

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

Florida Woman Arrested for $400,000 Medicaid Fraud Scheme

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

The owner of Homecare Unlimited, LLC, in Jacksonville, Florida, has allegedly been arrested for defrauding Medicaid out of more than $400,000, according to the Florida Office of the Attorney General (AG). The owner is charged with billing Florida’s Aged and Disabled Adult Waiver Program for services not rendered and billing for services to ineligible recipients. This Medicaid fraud scheme allegedly happened between January 2008 and June 2011.

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

Business Owner Accused of Fraud and Grand Theft.

The Florida Times-Union states that some of the people the business owner claimed to have provided services for were in jail at the time she supposedly rendered the services. The AG’s Medicaid Fraud Control Unit (MFCU) has charged the owner with two counts of Medicaid provider fraud and one count of grand theft.

The business owner is also accused of falsifying her application to become a Medicaid provider by hiding previous felony convictions and using a phony social security number, according to The Florida Times-Union.

Click here to read The Florida Times-Union article.

Defrauding Medicaid Comes with Hefty Consequences.

The business owner now faces up to 90 years in prison and a $30,000 fine. She is already serving time in prison for prescription drug trafficking charges.

What is the MFCU?

The MFCU is a division of the Florida Office of the AG. It is in charge of investigating and prosecuting health care providers suspected of defrauding the state’s Medicaid program. When the unit opens a case against a provider, the first step is usually the issuance of an investigative subpoena, requesting specific patient records. It is important to remember that the MFCU would not be involved unless criminal fraud was suspected. This is not a routine audit.

Click here to read a previous blog on ways to properly respond to a MFCU subpoena. Remember that the MFCU does not issue a subpoena without reason. If you are contacted by the MFCU, your first step should be to call an attorney experienced in Medicaid fraud.

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, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

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


Comments?

Would you know how to respond to a subpoena from the MFCU? Tell us below.

Sources:

Meale, Jenn. “Attorney General Bondi Announces the Arrest of Duval County Resident for $400,000 in Medicaid Fraud.” My Florida Legal. (February 14, 2013). Press Release From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/36E3A9F88A5AC81785257B12006F3A8D

Treen, Dana. “Jacksonville Woman Charged with Medicaid Fraud in $400,000 Scam.” The Florida Times -Union. (February 14, 2013). From: http://jacksonville.com/news/crime/2013-02-14/story/law-disorder-woman-faces-charges-400000-medicaid-scam

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.