Health Facilities Law Blog

Appellate Court Reverses Nursing Board’s Revocation of License For Florida Nurse; “Due Process Rights Violated” Says Court of Appeal

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

On September 22, 2022, Florida’s First District Court of Appeal reversed a final administrative order from the Board of Nursing, saying that the state agencies engaged in “a game of bait and switch” when revoking a Florida nurse’s license. As a result, the discipline imposed on the nurse, revocation of her nursing license, is reversed. The appeals court said that the Florida Board of Nursing violated the nurse’s due process rights by imposing a penalty for violating patient confidentiality when she was only charged with having her license suspended in another state.

Details About the Case.

In 2018, the Florida Department of Health (DOH) filed a complaint and an amended complaint against the nurse. According to the DOH, she violated section 464.018(1)(b) by having her license to practice nursing in another state suspended. However, the Florida state nursing board issued a final order permanently revoking her Florida license, a punishment that was not within the regulatory guidelines that the Board of Nursing had previously adopted for the offense with which she was charged.

Also, the nurse had originally requested a formal hearing. She was allegedly informed she was not entitled to a formal hearing and was not notified she should appear when the Board of Nursing held the informal hearing on her case.

The nurse claimed the actions by the Florida DOH and the Florida Board of Nursing deprived her of her right to due process of law according to the U.S. Constitution’s Fifth Amendment, as applied to the states through the Fourteenth Amendment. The appellate court agreed.

State Agencies Not Communicating?

According to the court opinion, the Board and the DOH engaged in a “bait and switch game.” The state’s DOH allegedly failed to notify her of all the alleged violations that later led to the permanent revocation of her nursing license. The opinion of the appellate court stated: “More egregious than this, there was no mention in the amended complaint of an alleged violation of section 464.018(1)(h), [of Florida Statutes,] pertaining to her allegedly unprofessional conduct. In essence, the Board punished Appellant [the nurse] for this uncharged violation.”

Moreover, the appellate court said that the DOH applied the wrong disciplinary guideline for the uncharged violation. The applicable guideline only authorized a fine of up to $500 and probation as the maximum penalty. See Rule 64B9-8.006(3)(f)3, Florida Administrative Code (2012).

Based on these findings, the three-judge appellate panel reversed the revocation order, remanding it for further proceedings. Read the entire Florida court opinion on our website.

Click here to read our blog to learn more about state and DOH investigations that could help save your professional license.

Contact Health Law Attorneys Experienced in Board of Nursing Cases.

The Health Law Firm’s attorneys routinely represent nurses in Department of Health investigations, before the Board of Nursing, in appearances before the Board of Nursing in licensing matters, in formal and informal administrative hearings, and in appeals of Final Orders.

To contact The Health Law Firm please call (407) 331-6620 or toll free (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Dunn, Allison. “State Agencies Engaged in ‘Game of Bait-and-Switch’ When Revoking Nursing License, Florida Appeals Court Rules.” Daily Business Review. (September 22, 2022). Web.

Pazanowski, Mary Ann. “Florida Nurse Gets New Hearing in License Revocation Dispute.” Bloomberg Law. (September 21, 2022). Web.

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. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or toll-free (888) 331-6620.

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in health law practice. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

Centene Will Pay $19 Million Settlement to Washington State For Medicaid Fraud Allegations

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

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more.

To view the settlement agreement in full, click here.

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others. And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children. We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

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. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

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Florida Passes New Legislation That Allows Pharmacy Technicians to Administer Immunizations

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

On July 1, 2022, Florida passed HB 1209, allowing registered pharmacy technicians to administer immunizations to patients. The new law utilizes pharmacy technicians to seek certification to provide immunizations and become “Certified Registered Pharmacy Technicians.” These pharmacy technicians will then be allowed to administer all vaccines listed by the CDC in the Adult Immunization Schedule or recommended by the CDC for international travel. Additionally, it includes vaccines authorized by the FDA under an emergency use authorization or by the Florida Board of Pharmacy in response to a state of emergency declared by the Governor.

This is a big step in medicine, once again broadening the ability of health professionals to provide more efficient and less expensive health care. In the past, properly qualified pharmacists were allowed to administer vaccines, but even then, there was a shortage.

Certification Requirements.

To become certified by the Florida Board of Pharmacy, a registered pharmacy technician must complete six hours of approved immunization-related training. As a renewal condition, an additional two hours of approved continuing education must be completed each cycle, according to the Board of Pharmacy website. For more information, click here.

In comparison, for certification, registered pharmacists must have 20 hours of education to administer vaccines. Registered pharmacist interns (persons with five years of college) who are also under the supervision of a certified pharmacist must take the same 20-hour immunization course that the pharmacists take to become certified to administer immunizations.

While this new Florida law seems to adopt a substantial lessening in training requirements, remember the 20-hour course allows pharmacists to administer vaccines independently. The six-hour course is for pharmacy technicians to administer vaccines under the pharmacist’s supervision. The technician certification program or programs authorized will have to be approved by the Florida Board of Pharmacy in consultation with the Florida Board of Medicine and the Florida Board of Osteopathic Medicine.

Stay Informed and Prepared.

The Board of Pharmacy has the authority to adopt rules to add new vaccines as added by the Centers for Disease Control (CDC) and the Food and Drug Administration (FDA), but it often takes many months to do so. Pharmacies and the pharmacists, pharmacist interns, and pharmacy technicians who are responsible need to monitor these situations closely.

Pharmacies should print a copy of the CDC adult immunization schedule, the CDC’s recommended vaccines for international travel, and the FDA’s list of vaccines with emergency use authorizations and have this readily available for its staff to review. They should also update this list at least once a month. This will help the pharmacy staff keep on top if either of these federal agencies, the CDC or the FDA, changes its list of immunizations. As we’ve seen from the COVID-19 pandemic, keeping track of vaccine schedules and emergency use authorization changes can be very confusing.

Click here to read Florida HB 1209 – Administration of Vaccines, in full.

Consult With A Health Law Attorney Experienced in the Representation of Pharmacists and Pharmacies.

We routinely provide legal representation to pharmacists, pharmacies, and other health professionals who have received complaints against their licenses, notices of investigations, Medicare or Medicaid audits, Drug Enforcement Administration (DEA) audits, investigations, subpoenas, search warrants, and orders to show cause (OSC) or who are facing formal or informal administrative hearings.

The lawyers of The Health Law Firm are experienced in both formal and informal administrative hearings and in representing physicians, physician assistants, and other health professionals in investigations and at Board of Pharmacy hearings. Call our office now at (407) 331-6620 or toll-free at (888) 331-6620 and visit our website www.TheHealthLawFirm.com.

Sources:

Dix, Martin. “A Jump Forward For Fla. Pharmacy Technicians’ Vax Authority.” Law360. (August 19, 2022). Web.

Sexton, Christine. “Checking the pulse of Florida health care news and policy.” Florida Politics. (August 16, 2022). Web.

Dix, Martin. “Florida Legislation Authorizing Pharmacy Technicians to Administer Vaccines Contains Some Surprises.” Akerman. (July 28, 2022). Web.

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Florid Man Strikes Again: Government Asks for Life Sentence for Florida Man in $187M Medicare Fraud Case

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Hartley Brooks, Law Clerk, The Health Law Firm

On August 12, 2023, federal prosecutors recommended a life sentence for the Florida ex-CEO of a laboratory company who had been found guilty of fraudulently billing Medicare over one hundred million dollars. At the December 2022 trial of the Florida man, the jury convicted the Florida Man of all ten counts against him, including health care fraud, payment of kickbacks, and conspiracy to commit money laundering. He was ordered to pay $187 million in restitution.

I have to say it. They need to lock up that Florida man once and for all! I see his wanton actions all over Florida, reported time and time again. Now that Tim Dorsey is deceased (bless his Florida soul) we don’t have a character like Serge Storms to go around and assassinate (at least literarily) such evildoers as Florida man. Will this mean a big upsurge in crimes committed by Florida man?

Specifics of the Health Care Fraud Committed.

From 2016 to 2019, the ex-CEO operated with co-conspirators out of Palm Beach County to conduct a scheme that spanned the entire country. The Florida Man was the CEO of the laboratory company and the architect of the fraudulent scheme. The ex-CEO oversaw and approved every step of the Medicare fraud process.

The Florida Man recruited and bribed patient brokers, directed the use of deceptive marketing techniques, encouraged the use of telemedicine companies that gave approval without consideration, and took measures to conceal the fraud and make it seem legitimate.

The ex-CEO bribed patient brokers, telemedicine companies, and telemarketing companies to contact Medicare beneficiaries and pressure them into taking medically unnecessary genetic tests through his laboratory company.

I would find it hard to believe that such willful and wanton illegal acts occur in the great state of Florida, except that I get about ten phone calls a day from these people trying to hook me into their phony schemes. Well, after this conviction, maybe I’ll only be getting nine phone calls a day from them (unless they allow Florida man unlimited phone calls for such purposes from his prison cell; and since this is Florida, they may well do that!).

He also instructed co-conspirators to go to nursing homes, bingo halls, adult day care facilities, and poor communities in the Atlanta area to pressure Medicare beneficiaries into taking the genetic test.

A single genetic test billed to Medicare could earn the ex-CEO $9,000. In three years, the lab billed Medicare $463 million, of which $187 million was paid out. The Florida Man personally earned $21 million which he spent on luxury purchases, like a Ferrari.

Effects of the Fraud.

The Florida Man exposed Medicare to a fraud where it paid $187 million for medically unnecessary genetic tests; an exorbitant loss. The scheme also confused patients and confounded doctors.

One victim of the fraud was led to believe that the genetic test would tell her if her cancer would return. She took the test and, since it was negative for the mutated gene, she was wrongly led to believe her cancer would not return. Her cancer did return.

Another victim of the fraud tested positive for a gene mutation that they did not actually have. This made their primary care doctor re-bill the genetic test to Medicare to confirm the results. This test came back negative for the gene mutation. The lab’s test was faulty and gave an inaccurate result.

The federal prosecutors argued that the Florida Man preyed on cancer survivors, elderly patients, and people afraid of getting cancer to steal hundreds of millions of dollars from a social safety net.

Sentencing Recommendation.

The government recommended that the Florida Man’s sentencing be considered in decades, rather than months or years, due to the seriousness of the crime and the man’s unwillingness to accept responsibility or show remorse.

During the trial and in post-conviction pleadings, the ex-CEO continuously placed blame on his lawyers, his employees, and the lab directors. He claimed that the kickbacks and bribes were contracts reviewed and negotiated by lawyers and the genetic tests were appropriate and properly signed by physicians.

The government also recommended that the restitution be increased because, even though only $187 million was paid out by Medicare, the laboratory company billed Medicare $463 million. Prosecutors argued that the restitution should be calculated based on the intended loss of $463 million.

The federal prosecutors claimed that since this is one of the largest genetic testing scheme ever brought to trial, the sentencing must act as a deterrent. The prosecutors argued that a life sentence for the Florida Man would reflect the seriousness of the Medicare fraud and deter others from conducting similar healthcare fraud schemes.

Contact Health Law Attorneys Experienced Health Care Fraud and Anti-Kickback Statute Violations.

The attorneys of The Health Law Firm represent healthcare providers in cases of medical billing fraud, overbilling, Medicare audits, Integrity Contractor audits RAC audits, and False Claims Act cases throughout Florida and across the United States. Our attorneys 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.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

About the Authors: 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. Hartley Brooks is a law clerk with the health law firm. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

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HHS OIG Release of New “General Compliance Program Guidance” Provides Valuable Insight on Prevention of Health Care Fraud, Waste, and Abuse

By Michelle E. Missigman, J.D.

On November 6, 2023, the U.S. Department of Health and Human Services (HHS), Office of the Inspector General (OIG), released 91 pages of “General Compliance Program Guidance” (GCPG) on its website. This is the first compliance program guidance the OIG has released since 2008. The GCPG provides general compliance guidance, tools, and references for use by federal health care program providers.

This new guidance brings together many resources and links, making it a valuable and easy-to-read tool to keep on hand for any professional working within the healthcare industry.

The GCPG covers the following topics:

I. Introduction

The GCPG provides a thorough introduction to the OIG’s history and commitment to preventing health care fraud an abuse. It provides a roadmap for how the OIG intends to modernize and improve its publicly available resources. The OIG’s goal is to continue producing these resources, deliver information to the public in a user-friendly approach using modern technology, and produce informative and useful resources to help advance the health care industry’s compliance efforts in preventing fraud, waste, and abuse.

II. Health Care Fraud Enforcement

The GCPG provides a broad overview of federal healthcare fraud enforcement standards and laws, such as: the anti-kickback statute, physician self-referral law, false claims act, civil monetary penalties, exclusions from federal programs, criminal health care fraud statute, HIPAA privacy and security rules.

III. Seven Elements of a Successful Compliance Program

The largest section of the GCPG reinforces and provides a thorough explanation of the seven elements of an effective compliance program:

1. Written Policies and Procedures

2. Compliance Leadership and Oversight

3. Training and Education

4. Effective Lines of Communication with the Compliance Officer and Disclosure Programs

5. Enforcing Standards: Consequences and Incentives

6. Risk Assessment, Auditing, and Monitoring

7.Responding to Detected Offenses and Developing Corrective Action Initiatives

Much of the guidance in this section reflects the OIG’s prior guidance in monitoring Corporate Integrity Agreements (CIAs). Check out this article on CIAs.

IV. Compliance Program Adaptations for Small and Large Entities

Maintaining an effective compliance program can be burdensome for smaller entities that have limited resources. The OIG acknowledges this and provides guidance on how smaller entities can still implement a compliance program that meets the above seven elements of a compliance program.

For larger entities with more resources, the GCPG goes into detail about the compliance officer’s role within the organization. The compliance officer should have the authority to oversee and direct the organization’s compliance function and lead the compliance department. The organization’s board of directors and compliance office should meet periodically to evaluate the compliance department and determine whether it meets the needs of the organization.

V. Other Compliance Considerations

The GCPG considers other areas to assist entities in developing policies and procedures to reduce or eliminate potential fraud and abuse risks. Some other areas they have considered are: quality and patient safety, new entrants in the health care industry (e.g. technology companies, new investors, and non-traditional services in health care such as social services, food delivery, and care coordination services), financial incentives, and financial arrangements.

VI. Additional OIG Resources and Tools

Lastly, the CPCG lists links all of the resources available on the OIG website, including previous compliance program guidance, advisory opinions, special fraud alerts, safe harbor regulations, compliance toolkits, OIG reports and publications, corporate integrity agreements, self-disclosure information and access to OIG’s hotline. The OIG has even implemented a FAQ process to provide informal feedback to the health care community.

Contact Health Law Attorneys Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program and Assisting in Reinstatement Applications.

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 Program, 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 toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

About the Author: Michelle E. Missigman, is a health attorney practicing with The Health Law Firm. The firm has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Current Open Positions with The Health Law Firm. The Health Law Firm always seeks qualified individuals interested in health law. Its main office is in the Orlando, Florida, area. If you are a current member of The Florida Bar or a qualified professional who is interested, please forward a cover letter and resume to: [email protected] or fax them to (407) 331-3030.

Sources:

“Criteria for Implementing Section 1128(b)(7) Exclusion Authority.” U.S. Department of Health and Human Services Office of Inspector General. (2016). Web.

Dani Kass. “HHS Watchdog Lays Out New Grounds For Exclusion List.” Law360. (2016). Web.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.

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Ex-Navy Officer Sentenced to 2.5 Years in Prison For $2 Million Insurance Fraud

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Hartley Brooks, Law Clerk, The Health Law Firm

On October 18, 2023, an ex-Navy officer was sentenced to 30 months in prison after he pleaded guilty to conspiracy to commit wire fraud for his role in an insurance fraud scheme. The judge tacked on an extra three years of post-release supervision.

The case is U.S. v. Cote et al., case number 3:18-cr-01674, in the U.S. District Court for the Southern District of California.

The Fraudulent Scheme.

The former Naval officer admitted to conspiring with eight others to defraud the Traumatic Service Members Group Life Insurance Program. This insurance program provides short-term financial support for injured service members.

The former officer allegedly worked closely in the fraud scheme with his then-spouse, who was a Navy nurse, and a Navy doctor.

The scheme consisted of submitting fake or exaggerated injuries to the insurance company to enrich themselves. The ex-Navy officer submitted false claims to the program and encouraged numerous other Navy personnel to submit false claims.

The Navy personnel would submit their medical records to the former officer’s then-wife. As a Naval nurse, she would allegedly falsify the records and the Naval doctor would sign off on the documents. The ex-Navy officer received kickbacks under the guise of a “processing fee.”

The scheme defrauded the insurance program of $2,000,000, and the former Navy officer personally received $400,000, according to the reports on the case. He was sentenced to 30 months for conspiracy to commit wire fraud with three years of supervised release.

What is happening to the others involved in this scheme is not clear at this time. It is doubtful that they will have long, successful Navy careers.

Consult a Health Law Attorney Who Is Familiar with Army, Navy, and Air Force Health Care Professionals and Their Problems.

The attorneys of The Health Law Firm have represented federal physicians, nurses, dentists, and other health professionals in the Army, Navy, and Air Force, active duty and retired, as well as physicians, nurses, and other health professionals working for the Veterans Administration (VA) in the U.S. and around the world. They represent physicians and other health professionals with the Indian Health Service (IHS) and the Public Health Service (PHS). Representation has included disciplinary action, investigations, peer review investigations, clinical privileges actions, fair hearings, National Practitioner Data Bank (NPDB) actions, and appeals.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Correll, Diana Stancey. “Former Navy chief sentenced in $2 million insurance fraud scam.” Navy Times. (19 October 2023) https://www.navytimes.com/news/your-navy/2023/10/19/former-navy-chief-sentenced-in-2-million-insurance-fraud-scam/

Danney, Micah. “Ex-Navy Officer Gets 2.5 Years For $2.5M Insurance Fraud.” Law360. (18 October 2023) https://www.law360.com/health/articles/1734129?nl_pk=0cbd4c0b-c6c8-416a-9e67-b4affa63b102&utm_source=newsletter&utm_medium=email&utm_campaign=health&utm_content=2023-10-19&read_main=1&nlsidx=0&nlaidx=14&detected=1

Lehrfeld, Jonathan. “Former sailor pleads guilty in $2 million insurance fraud scam.” Navy Times. (1 November 2022) https://www.navytimes.com/news/your-navy/2023/10/19/former-navy-chief-sentenced-in-2-million-insurance-fraud-scam/

United States v. Toups No. 3:18-cr-01674 (S.D. Cal October 16, 2023)

About the Authors: 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. Hartley Brooks is a Law Clerk at The Health Law Firm. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2024 George F. Indest III, The Health Law Firm. All rights reserved. No part of this work may be reproduced in any form in any medium for any purpose without the written permission of the copyright holder. The copyright holder/creator reserves the right to have his name associated with every part of this work.

Steps to Take If You Receive an OIG Subpoena from the DOH

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

The U.S. Department of Health and Human Services (HHS) issues investigative subpoenas through the Office of the Inspector General (OIG). This agency investigates allegations of fraud, waste, and abuse against Medicare, Medicaid, and other federally funded healthcare programs. These subpoenas are very broad, usually requiring the production of thousands of pages of documents. Click here to see a sample of a subpoena duces tecum issued by the OIG.

Immediate Action to Take If the OIG Issues a Subpoena.

Immediately review the subpoena in detail to see what it requests and from whom. A subpoena may be issued to or served on the wrong person or organization. If so, have your attorney contact the issuer and attempt to resolve the matter. Document everything in writing. Whatever you do, do not ignore it.

A review of the requested documents will give you and your experienced healthcare attorney an idea of what type of case is being investigated by the OIG. That is one reason that it is important to immediately retain the services of a healthcare attorney experienced in responding to such subpoenas and dealing with the OIG’s Office and the U.S. Attorney’s Office.

Many Different Scenarios Can Lead to Investigations and Subpoenas.

If someone has filed a False Claims Act (FCA) complaint or lawsuit, also known as a whistleblower or qui tam suit, this may be why the OIG is investigating. Suspicion of violating Medicare and Medicaid participation rules, including the Conditions of Participation or the Conditions for Payment (Federal Regulations), can also lead to investigations and subpoenas. If you have committed violations of program requirements such that the government can seek Civil Monetary Penalties, this may give rise to such investigation. If you are suspected of Medicare fraud, including upcoding or billing for medically unnecessary supplies or services, this may lead to an investigation. A patient complaint about not receiving services or equipment billed to Medicare is a surefire way to investigate. Regardless, the matter is serious, so you should retain experienced health care counsel.

Follow These Helpful Steps to Ease the Process:

1. Immediately review the subpoena to ensure you know the expected delivery date of the requested documents. Be sure to respond in writing via a reliable courier or another method of tracking your sending of the documents and their receipt.

2. Immediately retain the services of an experienced healthcare attorney to start dealing with the OIG or the U.S. Attorney’s Office involved in the case.

3. Immediately start assembling the requested documents in the subpoena so they may be reviewed by your attorney before they are organized, labeled, numbered, and produced. This will take longer than you think.

4. Request an extension of time to respond, if needed, before the due date for the production of the documents. These are routinely given, especially for large document productions. Document the extension of time in writing.

5. Completely read the instructions given in the subpoena regarding how documents produced are to be organized, page-numbered, labeled, copied, and delivered. It is essential to produce them this way.

6. If documents are archived, in storage, require the reinstallation of old software to reproduce, or otherwise will take a long time to produce, you may request a “rolling production.” This is an agreement to produce the documents as you obtain them.

7. In reviewing the documents, attempt to determine precisely what the OIG and U.S. Attorney may be investigating. This will afford you time to begin preparation for your defense and will allow you to request a modification of what it is necessary to produce in many instances.

8. It is preferable for you not to personally communicate with OIG special agents, FBI agents, other investigators, or attorneys working for the OIG or U.S. Attorney’s Office. Anything you say to them, orally or in writing, can be used against you in the case. Also, any incorrect or false information you provide, orally or in writing, can result in a felony charge under 18 U.S.C. Sect. 1001. Have your attorney do all communication.

9. Remember, you do not have to produce any documents in your custody. Likewise, you do not have to create documents to produce.

10. Never alter, destroy, or create documents for which the subpoena is issued after you have received the subpoena. Consider all documents to be “frozen” in time. Also, immediately notify whoever is in charge of your document retention or document destruction program (if you have one) to ensure no further documents are destroyed or deleted.

11. If you do not have a document destruction program for obsolete documents as you read this, you need to create one (subject to number 10 immediately above). Make sure it addresses e-mails, electronically stored documents, and paper copies. Do not keep any documents for longer than you are required to keep them by law (including Federal Regulations).

12. Provide an explanation for any documents or categories of records that you should have but were destroyed by natural disasters, fires, etc. Include documentation (fire department, police report, insurance company appraisal, etc.) that shows this. Do not ever lie or exaggerate it.

For additional information, read one of our recent blogs on preparing for a healthcare audit request.

Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing 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 toll-free (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

By The Health Law Firm|2024-03-14T09:59:15-04:00January 1, 2024|Categories: Health Facilities Law Blog|Tags: Centers for Medicare and Medicaid (CMS) audit defense lawyer, Centers for Medicare and Medicaid (CMS) investigation legal representation attorney, False Claims Act (FCA) defense attorney, health care fraud defense attorney, healthcare fraud defense lawyer, Healthcare fraud legal representation, legal representation for fraud investigations, legal representation for health care professionals, legal representation for OIG notice of intent to exclude, medical overbilling defense lawyer, Medicare administrative hearing defense attorney, Medicare administrative law judge hearing legal representation, Medicare and Medicaid subpoena defense attorney, Office of Inspector General (OIG) Medicare audit lawyer, Office of Inspector General (OIG) Medicare exclusion attorney, Office of Inspector General (OIG) Medicare investigation attorney, qui tam defense attorney, reviews for The Health Law Firm, The Health Law Firm attorney reviews, whistleblower defense attorney|Comments Off

AHCA Exemptions From Employment Disqualification for Florida Health Professionals

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

Florida law requires that health professionals (including physicians, nurses, physical therapists, nurse practitioners, professional counselors, and social workers, among others) obtain a Level 2 background screening before working in a facility licensed by the Agency for Health Care Administration (AHCA). This includes third and fourth-year medical students, resident physicians, and nursing students. Often an arrest from years ago, sometimes decades ago, will be located during this screening. A letter stating that the individual is disqualified from employment or requiring an explanation may result. What do you do?

Level 2 Background Screens.

A level two background screening requires your fingerprints. It is done by checking the National Criminal Information System (NCIS) database maintained by the Federal Bureau of Investigation (FBI). The NCIS receives reports, arrests, investigations, and criminal actions from all U.S. law enforcement agencies and the military.

It is much broader than a Level 1 background screening and covers all states and U.S. jurisdictions.

Problems and Incomplete Reports.

Although agencies that report arrests and investigations are also supposed to report the outcomes to the NCIS, they often fail to do this. Therefore there may be incomplete information in the report that is received. An arrest may be entered, but the dismissal or other resolution of the case may be omitted. This will cause problems because you will have to explain what happened and produce court documents to prove it. For example, we had a nurse-client whose Level 2 background screening came back with an arrest for a drunk and disorderly charge, in New Orleans, at Mardi Gras when she was 18 years old, over 30 years prior. The courthouse had since been flooded during a hurricane, and all records were destroyed.

Another problem lies in military records. Reports from The Army Criminal Investigative Division (CID). Air Force Office of Special Investigations (OIS) and Navy Criminal Investigation Service (NCIS) are often received and entered into the system, even if the investigation concerned an administrative infraction, a minor infraction of regulations, or resulted in an Article 15 non-judicial punishment (NJP), an administrative proceeding which is not a criminal conviction. Civilian authorities often mistakenly interpret Article 15 non-judicial punishment (NJP) as a “conviction,” but U.S. Supreme Court cases specifically state that it is not.

Certain Criminal Offenses Will Disqualify Health Professionals from Employment.

Many criminal offenses may be returned on a Level 2 background screening which initially appears to disqualify the individual from being employed in an AHCA-licensed facility, especially where the patients will be elderly, disabled, or children. In this case, you will get a letter back from AHCA and/or your employer advising you that you are disqualified from employment, but you have thirty (30) days to provide documents to show what really happened, show the charges were dismissed, show that you have completed any sentence you received or show you have been fully rehabilitated.

We recommend that you obtain the services of an experienced health attorney in completing the forms and obtaining and producing the documents needed. You should contact an attorney at the earliest sign that this might occur. You will need certified copies of court documents and probation documents, as well as character reference letters.

The fact that you received prior screening when you applied for a license or before you began school is irrelevant to this process. You will have to follow the procedure, anyway. In the case of an actual guilty plea, a plea of nolo contendere (no contest), finding of adjudication withheld (deferred), or finding of guilty, you will have to request an exemption or a waiver from AHCA so that you may be cleared to be employed.

The Health Law Firm Attorneys have experience in Complying with AHCA Requirements and in Foiling Requests for Exemptions or Waivers.

The attorneys at The Health Law Firm have experience completing the petitions and providing the documents and explanations that AHCA requires in such matters.

Below is a copy of a decision letter from AHCA showing a successful result in such a case.

Exemptions for Employment Disqualification for Health Professionals

For more information, read our recent blog on Florida’s legislation on background checks for health professionals.

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, home health agencies, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and other healthcare providers. It also includes medical students, resident physicians, and fellows, as well as medical school professors and clinical staff. We represent health facilities, individuals, groups, and institutions in contracts, sales, mergers, and acquisitions. The lawyers of The Health Law Firm are experienced in complex litigation and both formal and informal administrative hearings. We also represent physicians accused of wrongdoing, patient complaints, and in Department of Health investigations.

To contact The Health Law Firm, please call (407) 331-6620 and visit our website at www.ThehealthLawFirm.com.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law 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 Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or toll-free (888) 331-6620.

New Study Faults Coding Structures For Increased Medical Billing Costs in U.S.

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

A study publicized in August 2022 revealed that the complex coding structures used in the United States drive up medical billing costs. This helps to make the U.S. one of the most expensive countries for health providers to get paid. According to the study, researchers used a micro-level accounting of billing and insurance-related (often abbreviated “BIR”) expenses in different national settings at six provider locations in five nations: Australia, Canada, Germany, the Netherlands, and Singapore. This most recent study supplements a prior study measuring such costs in the U.S.

The findings, published in Health Affairs Journal, revealed “BIR (billing and insurance-related) costs in the U.S. are generally much higher than the costs in other countries.” This means that all the extra costs of coding and billing, including the related expenses, are a significant factor in driving up health care cases in the U.S. Say what you want about doctors’ hating paperwork, but this study seems to validate that feeling.

The Findings of the Study.

The study confirmed what research has established that billing and insurance-related (BIR) costs in the U.S. are much higher than in other countries. For example, prices range from $6 in Canada to $215 in the U.S. for an inpatient surgical bill. In the U.S., that represented about 3.1 percent of the total professional revenue for the procedure. Providers also spent about 100 minutes processing the claim.

To compare, only Australia had similar billing and insurance-related costs to the U.S. Australia has a mix of publicly and privately funded payers and universal coverage. Billing and insurance-related costs were significantly less in Canada than in the other nations. The study said Germany, Singapore, and the Netherlands had equal billing and insurance-related costs.

A Common Trend: Complex Coding.

The U.S. has a coding process in which each payer has its forms and documentation requirements, creating a significant burden on providers to translate clinical documentation into billable codes for reimbursement.

Because of standardization in other countries, providers spend less time coding or do not need coders to translate documentation into billable codes. Additionally, “little physician time is spent entering billing-related information into the EHR [electronic health record] system, as charge codes are either generated automatically or entered manually by a lower-wage or nonclinical teammate,” the study stated. “As a consequence, these countries’ billing systems either require fewer labor resources or much less costly labor and physician time than the one in the U.S.”

Researchers also found that financial counseling could reduce overall billing and insurance-related costs in the U.S.

You can read the study in full and learn more by visiting Health Affairs, a leading peer-reviewed journal of health policy thought and research.

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

To contact The Health Law Firm, please call our office at (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.ThehealthLawFirm.com.

Sources:

LaPointe, Jacqueline. “Coding Drives Up Medical Billing Costs in the US.” Rev Cycle Intelligence. (August 3, 2022) Web.

Norris, Amanda. “REV CYCLE PROCESSES PUSH U.S. TO TOP OF LIST FOR HIGHEST MEDICAL BILLING COSTS.” Health Leaders Media. (August 10, 2022). Web.

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 Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

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

Military physicians, Veterans Administration (VA) physicians, and former military and VA physicians often consult our firm concerning matters involving peer reviews of their care. In the military, whether Army, Navy, or Air Force, peer review for all physicians is governed by one general Department of Defense (DOD) Regulation. It is called the Defense Health Agency Procedures Manual (abbreviated DHA PM) 6025.13, which became effective October 1, 2019. VA physicians have different but somewhat similar regulations that apply to them.

We are often consulted by these physicians, who no longer even serve with those agencies after action has already been taken to report them to the National Practitioner Data Bank (NPDB) for allegedly substandard care. Such reports go into the NPDB for fifty (50) years and are reported to all state licensing boards and the Federation of State Medical Boards (FSMB).

They can haunt a physician’s career for life.

What to Do When Notified of a Claim, Investigation, Peer Review Action, or Quality Assurance Investigation (QAI)?

At your first notice that you are the subject of or named by a Federal Tort Claims Act (FTCA) claim or any inquiry or investigation related to your care, you should consult a healthcare attorney with experience in such matters. We are few and far between, but you can find us if you look for us.

You will have at least two opportunities for input into such matters, but you must take advantage of your earliest opportunity to influence the outcome.

1. You do need to obtain and review a copy of the medical record.

2. You do need to have an expert in your medical field review the case for you.

3. You can request an extension of time if needed.

What Are Questions I Should Ask of an Attorney with Whom I Consult?

These are the questions that I suggest you ask any attorney you consult with:

1. What is your experience in dealing with the military or VA medical system?

2. How many similar matters of this nature have you handled?

3. Are you familiar with National Practitioner Data Bank (NPDB) reports, challenges, and appeals?

4. How many such NPDB matters have you handled?

5. How many cases have you handled in which you assisted in making statements for input into such investigations or inquiries?

6. Are you familiar with the Memorandum of Understanding (MOU) between the DOD and the Department of Health and Human Services (DHHS) taking DOD NPDB reports out from under the regular NPDB procedures?

7. How many military or VA quality assurance investigations have you represented physicians?

8. How many VA and military peer review/clinical privileges hearings have you done?

9. How familiar are you with hospitals and health systems?

10. How familiar are you with the military medical system, the roles of the Surgeons General, and the Department of Defense Division of Health Affairs (DOD HA)?

11. How familiar are you with DOD PM 6025.13?

12. How familiar are you with: VHA Directive 1190 (Peer Review for Quality Managment), VHA Handbook 1050.01 (VHA National Patient Safety Improvement Handbook), VHA Handbook 1100.17 (National Practitioner Data Bank (NPDB) Reports), VHA Handbook 1100.19 (Credentialing and Privileging), VHA Directive 2008-077 (Quality Management (QM) and Patient Safety Activities . . . ), VHA Directive 1026 (VHA Enterprise Framework for Quality, Safety and Management), and VA Handbook 5120/14 (Employee/Management Relations)?

Don’t Wait until after the Decision to Report You Has Been Made.

Be sure to obtain experienced legal counsel to represent you in defending yourself against allegations of substandard care before the final decision has been made. Avail yourself all opportunities to provide your concise, objective, and well-reasoned medical rationale for your care at the earliest stage you can.

Click here to read a prior blog on how our firm can assist you in your legal matter.

For additional information on our representation of military physicians and where we represent them, click here.

For additional information on our representation of Veterans Administration (VA) physicians and where we represent them, click here.

Consult a Health Law Attorney Familiar with Army, Navy, and Air Force Health Care Professionals and Their Problems.

The attorneys of The Health Law Firm have represented physicians, nurses, dentists, and other health professionals in the Army, Navy, and Air Force, active duty and retired, as well as physicians, nurses, and other health professionals working for the Veterans Administration (VA), the Indian Health Service (IHS) and the Public Health Service (PHS), nationwide in the U.S. and around the world. Representation includes assisting in making significantly involved provider (SIP) statements, Defense Health Agency (DHA) investigation representation, DHA-PM 6025.13 legal representation, hospital clinical privileges hearings, medical staff fair hearings, medical staff peer reviews, disciplinary actions, investigations, National Practitioner Data Bank (NPDB) actions, and appeals. 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, and former military attorneys.

To contact The Health Law Firm, please call (407) 331-6620 or Toll-Free (888) 331-6620 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 or Toll-Free: (888) 331-6620.

Attorney Positions with The Health Law Firm. The Health Law Firm always seeks qualified attorneys interested in health law practice. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.

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Call (407) 331-6620 or Toll-free (888) 331-6620

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Under Medical Peer Review from the Military or the Veterans Administration? Get Experienced Legal Representation Now