Mental Health Law Blog

Finding a Lawyer Who Accepts HPSO Insurance to Defend Healthcare Providers

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

Healthcare professionals such as pharmacists, licensed mental health counselors, advanced registered nurse practitioners (ARNPs), and massage therapists often struggle to find experienced lawyers in Florida who will accept their professional liability insurance after receiving complaints from the Department of Health (DOH). Specifically, in this blog, the insurance provider in question is Healthcare Providers Service Organization (HPSO) Insurance.

Advantages of Having HPSO Insurance.

The medical professionals HPSO Insurance covers can give a sigh of relief knowing they have excellent insurance coverage. HPSO Insurance provides professional liability coverage that protects them in the event of a lawsuit or negligence claim.

However, it’s not just the significant cases that HPSO covers. More often than not, healthcare professionals receive a notice of an investigation, a subpoena for a deposition in someone else’s case, a demand because of an allegation of sexual harassment or sexual impropriety, a complaint because of a breach of medical records confidentiality, or a Health Insurance Portability and Accountability Act (HIPAA) Privacy complaint, or some other administrative type of action. These situations can be incredibly stressful and time-consuming, but HPSO provides excellent coverage.

For example, if the individual receives a subpoena for a deposition, HPSO currently reimburses up to $10,000 in legal fees and expenses just for representation at the deposition. This means that the professional can focus on their work and not worry about the legal costs of a deposition. Additionally, the provider receives a notice of investigation or complaint from the DOH or Agency for Health Care Administration (AHCA). HPSO currently reimburses up to $25,000 in legal fees and expenses for their defense. The peace of mind that comes with knowing that they have this kind of coverage can be invaluable.

Finally, suppose a health professional is facing a complaint or investigation regarding a breach of medical confidentiality. In that case, HPSO reimburses up to $25,000 in legal fees and expenses for their legal representation in defense.

Whether you’re a nurse, physician, psychologist, or other healthcare professional, knowledgeable and skilled attorneys can assist you with legal issues.

Free Legal Advice: Get Insurance Right Away.

As a healthcare professional, it is essential to understand the importance of carrying insurance that covers any investigation, complaint, or administrative hearing that may be filed or opened against your license. Many healthcare professionals mistakenly believe their employer will cover them in such situations, but this is not always true.

Suppose you are still determining whether your employer will provide legal defense for any matters arising during employment. In that case, asking for a written statement confirming this is crucial. Without such a statement, you may find yourself without any legal support in the event of a complaint or investigation.

Unfortunately, in many cases, the employer terminates an employee and then files a complaint with the Department of Health (DOH). This can result in the DOH opening an investigation against the healthcare professional, leaving them vulnerable to potential legal action. In such cases, the employer is unlikely to pay for the healthcare professional’s legal defense costs, leaving the professional in a difficult position.

If you find yourself in this situation, you may be out of work, out of money, and facing an investigation and complaint that could result in your professional license and career termination. Taking proactive steps to protect yourself and your career is essential by investing in insurance that covers legal defense costs.

HPSO Insurance is both inexpensive and reliable. By purchasing this insurance, while you can afford it, you can rest assured that you will have the legal support you need in case of a complaint or investigation.

We Recommend That You Seek the Services of an Experienced Attorney in the Event of Any Notice of an Investigation.

If you work in the healthcare industry, you must be aware of the potential legal issues that could arise. One such issue is disciplinary action or licensure investigations. If you find yourself in this situation, seeking an experienced health law attorney is crucial. Don’t speak with investigators or provide documents or statements without seeking legal advice.

It’s important to remember that investigators and other professionals involved in the investigation are not on your side. They are looking for evidence against you, so don’t take any advice from them. Instead, rely on the guidance of a skilled attorney who can protect your rights and interests.

Another important consideration is insurance coverage. If you have good insurance, it can help cover the costs of legal expenses from the outset. However, not all insurance policies cover disciplinary complaints and licensure investigations. Be sure to check your policy carefully and ensure this type of coverage is included. If not, consider purchasing a separate policy that provides this coverage. It may cost extra, but it’s worth protecting yourself in case of a legal issue. It is worth it! Please do it!

Contact Experienced Health Law Attorneys Who Represent Healthcare Professionals and Providers.

Our firm specializes in providing legal representation to a wide range of healthcare professionals, including pharmacists, massage therapists, mental health counselors, registered nurses, and more. We offer a variety of services, such as representing clients before their professional board, handling DOH investigations, conducting administrative hearings, defending against malpractice claims, assisting with professional licensing matters, and addressing allegations related to HIPAA privacy violations and medical record breaches.

We also handle DEA actions and other legal matters. Our team frequently defends physicians, dentists, nurse practitioners, and others against malpractice claims, civil lawsuits, administrative complaints, peer review actions, and audits by Medicare and Medicaid. If a healthcare professional has liability insurance that covers these types of claims, we will work to obtain coverage and seek reimbursement for legal fees. In some cases, we may accept an assignment of insurance policy proceeds to directly submit our bills to the insurance company.

We also defend health professionals and health facilities in general litigation matters and business litigation matters.

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: 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 Avenue, 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.

“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 © 2023 George F. Indest III. All rights reserved.

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

On June 15, 2023, a United States District Judge sentenced a Florida man to 15 years in prison for his role in an HIV prescription drug fraud scheme that amassed more than $230 million in two years. The defendant was initially indicted on June 17, 2022, and charged with six counts of conspiracy and money laundering. Unlike most of the fraud convictions we report on, this one was directed against the U.S. Food and Drug Administration (FDA) and involved adulterating and misbranding drugs. The defendant pled guilty to only two counts: conspiracy to defraud the United States and conspiracy to commit money laundering. Click here to view the press release from the U.S. Attorney’s Office, Southern District of Florida, to learn more about the arrest.

The Charges: Adulterated and Misbranded HIV Medications.

Prescription drug diversion is when prescription drugs are removed from regulated distribution channels and reintroduced into the wholesale market or otherwise illegally distributed. These drugs can be acquired through theft, fraud, or patients who were prescribed the medication and intentionally did not consume them.

In this case, U.S. vs. Lazaro Hernandez, the defendant would obtain prescribed drugs illegally, repackage them, falsify the documentation, and resell them to coconspirators through conspiracy wholesalers. To successfully divert the prescription medications, they got wholesale drug distributor licenses for LLC’s in Florida, New Jersey, Connecticut, and New York. These conspiracy wholesalers would purchase the diverted, adulterated, and misbranded drugs and documentation and sell them to pharmacies.

Adulteration occurs when any substance is added to or substituted, in part or in whole, or mixed with an approved drug. Misbranding of a drug occurs when someone places a label on it that is false or misleading in any way, as defined in Title 21 U.S. Code sections 351(d) and 352 (a)(1). In this case, the pharmacies billed health care benefit programs and dispensed adulterated and misbranded drugs to patients. The pharmacies paid $232,800,000 for the diverted drugs between April 2019 and at least October 2021.

The six counts that the defendant was initially charged with include conspiracy to introduce adulterated and misbranded drugs and to defraud the United States, conspiracy to traffic pre-retail medical products with false documentation, conspiracy to commit money laundering, and three counts of money laundering. The false documentation and money laundering charges were later dropped in the plea deal.

The Sentencing.

The government recommended a sentence of 188 to 235 months, which aligns with the defendant’s criminal history and total offense level (calculated in accordance with federal statutes and regulations), while the defense argued for a lesser amount of time due to the allegedly “secondary” role the defendant played in the fraud. The judge sentenced the defendant to 180 months. Also included in the sentence was a forfeiture of all proceeds from the scam and restitution in an amount that has yet to be determined.

This lower-than-recommended prison sentence came after the defendant spoke about his gambling addiction, which allegedly led him to participate in the fraud. Also, two of his 47 character references addressed the court in person. The judge was swayed to give him a lower sentence as a result. View the indictment in the case in full here.

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

The attorneys of The Health Law Firm provide legal representation to pharmacists, pharmacy facilities, physicians, nurse practitioners, CRNAs, dentists, psychologists, mental health professionals, nurses, and other health providers in Department of Health (DOH) investigations and hearings, Drug Enforcement Administration (DEA) investigations, audits and hearings, Food and Drug Administration (FDA) investigations and hearings, FBI investigations, Medicare/Medicaid investigations, audits and hearings, and many other actions involving defense of health professionals and providers.

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:

Minsky, David. “Fla. Man Sentenced To 15 Years In Prison Over HIV Drug Fraud.” Law360. (June 16, 2023). Web.

Becker, Zoey. “In fraud case targeting HIV meds, Florida man gets 15 years in prison.” FiercePharma. (June 21, 2023). 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 Avenue, Suite 1000, Altamonte Springs, FL 32714. Phone: (407) 331-6620; 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.

“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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Licensed Professional Counselor Sentenced to Prison for $1.3 Million Medicaid Fraud Scheme

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

On March 13, 2022, a licensed professional counselor (LPC) was sentenced to nearly five years in prison for defrauding the Connecticut Medicaid Program of more than $1.3 million, announced the U.S. Attorney for the U.S. District of Connecticut. In addition to the prison time, he was sentenced to three (3) years of supervised probation upon release and ordered to pay restitution to Medicaid in the amount of $1,313,322.

A Wide-Ranging Fraud Scheme.

According to court documents, from 2014 to 2020, the defendant was a licensed professional counselor with offices in Hartford, Connecticut. Additionally, he owned two entities through which he managed group homes, including residences for women and children who were victims of domestic abuse.

According to prosecutors, he defrauded Medicaid from August 2018 through October 2020 by submitting claims for psychotherapy services never provided to patients. In addition, on a limited number of occasions, some of the services were rendered by unlicensed individuals who were not qualified or licensed to provide psychotherapy, the U.S. Attorney’s Office reported but were billed to Medicaid.

Taking Advantage of Tenants.

The former counselor required tenants of group homes to provide copies of their Medicaid member cards for themselves and their children as a condition of residency, said, prosecutors. Then he used the Medicaid numbers from the tenants to bill for bogus psychotherapy services. He used the numbers of approximately 65 tenants or their children to fraudulently bill Medicaid for roughly $543,117 in services that were never performed, court documents stated.

Scheming as a School Guidance Counselor.

The counselor did not stop there. In 2019, New Haven Public Schools hired him as a guidance counselor at the New Haven Adult and Continuing Education Center.

In February 2020, he apparently continued the same procedures when he accessed a database containing personal identifying information of current and former students, many of whom he did not have any professional relationship with and had never met. He used the Medicaid numbers of approximately 135 New Haven students to bill Medicaid and was paid approximately $593,383 from fraudulent claims.

The U.S. Attorney’s Office’s Civil Division stated that the Connecticut Department of Social Services, working in cooperation with law enforcement, suspended Medicaid payments to the defendant. They recovered $337,777.63 that he was scheduled to receive from Medicaid from billings that had been submitted. They also seized and forfeited $412,415.20 from the former counselor’s bank accounts. Additionally, the defendant paid restitution of $20,000, leaving a restitution obligation of $543,129.17.

The Connecticut Medicaid program initially suspended him as a Medicaid provider on April 28, 2020, and he was formally arrested on October 14, 2020. To learn more about the case, click here to read the press release from the U.S. Department of Justice (DOJ).

To read about a similar case involving a health care office manager convicted in a fraud case, click here.

Contact Health Law Attorneys Experienced in Medicare and Medicaid Investigations of Mental Health Counselors, Psychologists, Social Workers, and Family Therapists.

The attorneys of The Health Law Firm provide legal representation to mental health counselors, psychologists, psychiatrists, social workers, and family therapists in Medicaid and Medicare audits and investigations, Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) investigations, Department of Health (DOH) investigations, Department of Regulatory Agencies (DORA) investigations, Board Hearings, FBI investigations, and other types of investigations of health professionals and providers.

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:

Valinot, Nicole. “Hartford County Man Sentenced For Wide-Ranging $1.3M Medicaid Fraud Scheme.” Daily Voice. (March 13, 2022). Web.

Rhatigan, Chris. “CT Counselor Sentenced In $1.3 Million Medicaid Fraud Case: Feds.” (March 14, 2022). Web.

Pantini, Liz. “In The News: Counselor Pleads Guilty in Wide-Ranging Medicaid Fraud Scheme.” Yale School of Medicine. (January 25, 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 Avenue, Suite 1000, Altamonte Springs, FL 32714; Phone: (407) 331-6620; Toll-Free: (888) 331-6620.

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

Many healthcare professionals are unaware of the adverse long-term collateral effects of Medicare revocation or exclusion on their careers and future employment. However, if you are a physician, dentist, nurse, mental health counselor, psychologist, pharmacist, physician assistant, nurse practitioner, massage therapist, or other licensed health professional whose license is revoked or suspended, there may still be hope.
Lasting Consequences of Medicare Revocation.

A revocation or exclusion from Medicare is often a severe consequence of license discipline on a professional license and can devastate a provider’s career. The Centers for Medicare & Medicaid Services (CMS) can revoke a healthcare provider’s agreement to participate in Medicare. When this occurs, their Medicare billing privileges are terminated. Their legal authority to write prescriptions, referrals or orders for tests paid by Medicare also vanishes.

Additionally, the exclusion can last for many years. This can be a career-ending move for many healthcare providers especially physicians, as Medicare revocation is reported to the National Practitioner Databank (NPDB). In addition, it can potentially affect their opportunities to work in hospitals with other Medicare providers, or on health insurance panels.

For this reason, healthcare providers need to retain a health law attorney with experience in licensing issues who can help them navigate the complex legal system Medicare presents. A skilled attorney can review the facts of the case, develop a strategy for defending the provider’s license, recommend actions to avoid or mitigate the damages, and represent them in administrative hearings or proceedings in court. In some cases, an effective legal strategy may minimize the impact of discipline or even prevent Medicare revocation or exclusion. However, the best way to protect against license discipline and its consequences is to ensure that you are in compliance with Medicare standards, regulations and procedures.

To learn more, read one of my prior blogs here.

Contact Experienced Health Law Attorneys in Healthcare Licensing Issues.

If you have had a license suspended or revoked, or you are facing imminent action against your license, it is imperative that you contact an experienced healthcare attorney to assist in defending you. Remember, your license is your livelihood. It is not recommended that you should not attempt to pursue these matters without the assistance of an experienced health care attorney. The Health Law Firm routinely represents physicians, dentists, nurses, medical groups, clinics, and other healthcare providers in Medicare issues and in defense of actions in personal and facility licensing 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.

Sources:

Hollender, Allison and Wortley, Mackenzie. “Collateral Consequences of Medicare Revocations.” AHLA. (March 9, 2021). Web.

Simas, Steven. “Collateral Consequence of Healthcare License Discipline – Medicare Exclusion.” SIMAS & Associates. (October 3, 2017). 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 Avenue, 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 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.

“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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Attorneys Who Negotiated Multi-Million Dollar UnitedHealth Settlement Ask Court For $3.35 Million Fee Award

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

In October 2021, attorneys who had acted as the class counsel in litigation suing UnitedHealth Group over mental health reimbursement policies asked a New York federal court to approve a $3.35 million fee award. If approved, it would be an award of attorney’s fees in addition to the $10 million the insurer agreed to pay to settle their case.

According to the memorandum of law filed with the court, the mental health advocacy law firm argued that the results which they had achieved on behalf of the class of victims (who were all health insurance plan clients) easily justified the seemingly large requested fees and expenses.

We would agree with their argument. Too often disabled individuals, especially those suffering from mental disabilities, who need the help most, are victimized by large for-profit corporations. The attorneys and law firms who stand up for these individuals, especially those who are able to actually see the case through to completion, should be rewarded for their efforts.

Background.

The settlement reached in August 2021 resolved several consolidated lawsuits over UnitedHealth’s use of a “tiered” system to reimburse patients for out-of-pocket mental health treatment at lower rates than medical and surgical care were reimbursed. In addition to the $10 million private settlement agreement, UnitedHealth agreed to pay out $5.6 million to end claims from the New York State Attorney General and the U.S. Department of Labor. Read more about that here.

Payment of Full Legal Fees and Expenses.

The attorneys who are designated as “class counsel” in a class-action lawsuit are entitled to reasonable reimbursement of litigation expenses incurred in prosecuting a class action. In this case, after settling the case in chief, the class counsel negotiated a separate payment by United of up to $3.35 million for legal fees and expenses subject to court approval, according to the memorandum.

Additionally, the attorneys requested the court grant payment of $20,000 each for service (or incentive) awards for the three different class representatives. Incentive awards are designed to compensate the named plaintiffs for bearing the risks of bringing the suit, as well as for any time spent participating in the actual litigation of the case as an individual would have to do.

To be clear, the attorney’s fees will not be deducted from the $10 million settlement paid to the class members; they will be paid separately By UnitedHealth.

Is the Requested Amount Reasonable?

According to the memorandum filed with the court, the plaintiffs’ lawyers spent thousands of hours combing through data for over 110,000 class members and leading negotiations that included the federal and state agencies and the parties to the litigation. “Given the substantial risks plaintiffs faced in every phase of this case, the results achieved by class counsel are exceptional by any measure,” the memorandum argued.

To view the memorandum in full, click here to view it on our webpage.

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 any other healthcare provider. 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 or Toll-Free (888) 331-6620 and visit our website at www.ThehealthLawFirm.com

Sources:

Stone, Rachel. “Attys Who Struck $10M UnitedHealth Deal Seek $3M Payday.” Law360. (October 28, 2021). Web.

Stone, Rachel. “UnitedHealth Strikes Deal To End Mental Health Policy Suits.” Law360. (August 12, 2021). 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.

Psychiatric Practice Pays $310,000 in FCA Settlement for Employing Physician on OIG Exclusion List

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

On February 23, 2022, a psychiatric practice and its owner agreed to pay $310,874 to resolve allegations they improperly hired and employed a physician who was excluded from federal healthcare programs. The physician who was hired was on the OIG’s exclusion list, the “List of Excluded Individuals and Entities” (LEIE). As a result, the government took the position that claims for services the physician provided filed against government programs were illegal pursuant to the false Claims Act (FCA). Details were disclosed in a Press Release by the U.S. Attorney for the District of Connecticut.

Geriatric & Adult Psychiatry, LLC (GAP), along with the owner, entered into a civil settlement agreement to resolve their liability under the federal and state False Claims Acts, the U.S. Department of Justice (DOJ) said in a press release.

Past Conviction Overlooked.

In 2006, the physician had been convicted in the Southern District of Florida of conspiracy to commit healthcare fraud. Because of his conviction, the Office of the Inspector General (OIG) excluded him from all federal healthcare programs. Such an exclusion includes Medicare, Medicaid, Tricare, Veterans Administration (V.A.), and Indian Health Service (I.H.S.) programs.

When the OIG excludes an individual or entity from federal health care programs, no payments may be made for items or services furnished by that excluded individual. Additionally, the law prohibits any person or organization that receives such funds from employing or contracting with a person on the LEIE, in any way. To avoid potential liability, it advised that health care providers check the List of Excluded Individuals/Entities (LEIE) on the OIG website: http://oig.hhs.gov/exclusions.

In addition, the OIG has issued a Special Advisory Bulletin to providers who might employ or contract with an excluded individual or entity to provide guidance. To review this OIG Bulletin, click here.

For more helpful information, click here.

Despite this, to medical group hired the former physician as the clinical director in 2016 where he served in that position until 2021. During that time, both the practice and its owner billed and sought reimbursements from Medicare, Medicaid, TRICARE, and the Railroad Retirement Medicare Program. Additionally, GAP’s reimbursements were used to pay the physician’s salary and benefits.

Payment Prohibition & Civil Monetary Penalties (CMPs).

Health care providers receiving funds from federal health care programs must check to see if potential employees and contractors are excluded by searching the LEIE to ensure that person is not listed. Providers have mistakenly assumed that exclusion does not apply to an individual or entity that provides services that extend beyond direct patient care; this is wrong. Payment prohibition extends to anyone who chooses to employ or contract with an excluded individual or entity in any capacity. Providers who violate this prohibition are required to pay back all federal health care program funds inappropriately received and may also be subject to civil monetary penalties (CMPs) and action under the False Claims Act (FCA).

Furthermore, payment of an excluded individual’s salary, benefits, or expenses, directly linked to federal health care program funds is expressly prohibited. Click here to read my prior blog and learn more about this.

Little Known Fact: You Must Actively Apply to Get Taken Off the LEIE.

A little-known fact, often overlooked, is that a person or entity on the LEIE must actually apply to be removed from it, no matter how short the period of exclusion. Thus if a person is excluded and placed on the LEIE for only two years, they must apply to the OIG after that period of time, completing its detailed, notarized application, and be removed from the list. Removal is not automatic.

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 (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Yankowski, Peter. “Officials: Hamden psychiatric practice to pay $310,000 settlement over employee who lost medical license.” Stamford Advocate. (February 23, 2022). Web.

Health Law Weekly. “Psychiatric Practice, Owner Pay $310K for Employing “Excluded” Individual.”American Health Law Association (AHLA). (February 25, 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 Avenue, Suite 1000, Altamonte Springs, FL 32714; Phone: (407) 331-6620; Toll-Free: (888) 331-6620.

Supreme Court Rules FCA Case Liability Requires Defendants’ Subjective Belief

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

On June 1, 2023, the Supreme Court handed down an opinion on the knowledge standard required in False Claims Act (FCA) cases in a precedential decision that leaves the whistleblower plaintiffs bar reeling. In a unanimous ruling, the high court said liability of defendants in FCA cases would be based on their own belief in the falsity of their claims, rather than an “objectively reasonable” interpretation of the law or regulation. This appears to set the age-old maxim of “ignorance of the law is no excuse” on its head. Now, apparently, a defendant can argue that he, she or it was ignorant of the law and win.

The case before the Supreme Court was consolidated from two lower court decisions in the cases United States ex rel. Schutte v. SuperValu Inc. and United States ex rel. Proctor v. Safeway.

When Subjective Belief is Relevant in FCA Cases.

In the cases which the Supreme Court decided, the whistleblowers accused SuperValu and Safeway of violating the FCA by overcharging Medicare, Medicaid, and the Federal Employee Health Benefits Program for prescription drugs.

According to the rules of these programs, pharmacies cannot charge the government more than the “usual and customary” price for a drug, which is the cash price charged to the general public. The plaintiffs claimed that the pharmacies overbilled the government when they started offering discounted prices to consumers under a price-match program to compete with other pharmacies. They also offered a membership discount program but did not adjust their “usual and customary” prices, continuing to charge the government more than they should have.

The Lower Court’s Ruling.

The Seventh Circuit Court of Appeals ruled in April 2022, that the pharmacies had submitted false claims by not reporting their discounted prices, which were the “usual and customary” prices. The appeals court also stated that the retailers had made reasonable interpretations of ambiguous laws without being warned against it by authoritative guidance. The circuit court referred to the Safeco standard from the Supreme Court’s 2007 Safeco Insurance Co. of America v. Burr case in its decision.

Click here to learn more about the Seventh Circuit Court of Appeal’s ruling.

The Supreme Court’s Ruling.

The Seventh Circuit’s perspective was rejected by the Supreme Court, which instead focused on the defendant’s intentions when submitting false claims. Justice Clarence Thomas, writing for a unanimous court stated, “What matters for an FCA case is whether the defendant knew the claim was false. Thus, if [the defendants] correctly interpreted the relevant phrase and believed their claims were false, they could have known their claims were false.” Read the opinion in full here.

Under this rationale, a defendant could successfully make the argument, “I didn’t know the claim was false and I never bothered to do anything to make sure of that fact.” Even objectively unreasonable claims, such as charging a million dollars for a drug which only cost one dollar, could be successfully defended.

Contact Health Law Attorneys Experienced in Handling Health Care Fraud Investigations and other Legal Proceedings.

The Health Law Firm represents healthcare providers in Medicare and Medicaid audits, and in RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid.

The Health Law Firm’s attorneys routinely represent physicians, dentists, pharmacists, psychotherapists, medical groups, clinics, pharmacies, assisted living facilities (ALFs), home health 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 toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Elberg, Jacob. “Supreme Court maintains focus on defendant’s subjective beliefs in False Claims Act cases.” SCOTUS Blog. (June 1, 2023). Web.

Wilson, Daniel. “Justices Say FCA Liability Hinges On Defendants’ Beliefs.” Law360. (June 1, 2023). Web.

Gaivin, Kathleen. “False Claims Act ruling by High Court a ‘clear win’ for government, expert says.” McKnights Senior Living. (June 2, 2023). 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 Avenue, Suite 1000, Altamonte Springs, Florida 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Florida Attorney Says AHCA Must Put Medicaid Final Orders Online

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

Florida’s Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against AHCA, trying to force AHCA into compliance with state public records laws.

Attorney Nancy Wright says the AHCA orders fall under a state law that requires all proceedings determined by a state agency to be placed into a centralized electronic database accessible to the public. This would allow citizens and healthcare providers more accessible access to those decisions and transparency when understanding Medicaid policies and decisions made by AHCA.

Access to Medicaid Final Orders.

The plaintiff’s attorney argued before a three-judge panel of the court of appeal that she should not be required to pay hundreds of dollars to gain access to Medicaid final orders to prepare for clients’ Medicaid hearings when the law requires the agency to publish these. The attorney further argued that this fee was an unfair and unjustified barrier to justice. She should be given free access to these orders to provide her clients the best possible representation.

More Details of the Case.

The Florida Health Justice Project and the National Health Law Program filed the lawsuit against AHCA on behalf of Wright in December 2020 in the First District Court of Appeal of Florida.
“[Medicaid law’s] notorious complexity and rapid regulatory changes put even lawyers on edge,” she said in a statement when she filed her suit. “AHCA’s unwillingness to make their [sic] final orders accessible means that I cannot fully advise my clients on how and why decisions on services are being made. This lack of transparency makes a complicated system almost impossible to navigate for the many unrepresented enrollees.”

View the press release from The Florida Health Justice Project.

However, the trial court sided with AHCA and granted summary judgment to the agency.

The Appeal.

The Elder Law Section of the Florida Bar expressed their support for Wright and submitted an amicus brief on appeal. They highlighted that the Florida Department of Children and Families regulates Medicaid eligibility proceedings with the same law that provides authority to AHCA. Furthermore, the Department publishes its final orders in an electronic database, making them readily available to the public.

However, accessing these same orders on Medicaid coverage requires a public records request which can be costly and time-consuming. In its brief, the Elder Law Section argued that this disparity is unfair as it burdens those attempting to access said records. The brief further suggested that upholding the trial court’s summary judgment would only perpetuate this inequality of access to public records.

To learn more, read the complaint in full here.

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

Physicians, therapists, counselors, and other health professionals who accept Medicaid are routinely audited by the Medicaid Program to detect overpayments or fraudulent claims. Medicaid fraud is a severe crime and is vigorously investigated by the state Medicaid Fraud Control Unit (MFCU), the Agency for Healthcare Administration (AHCA), Program Integrity Contractors (PICs), the FBI, and the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS). Other state and federal agencies may also participate, including the U.S. Postal Service (USPS) and other law enforcement agencies. 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 law 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, mental health counselors, therapists, home healthcare 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 toll-free at (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 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.

By The Health Law Firm|2024-03-14T09:59:30-04:00May 16, 2023|Categories: Mental Health Law Blog|Tags: Agency for Health Care Administration defense attorney, AHCA preliminary audit report defense attorney, behavioral therapist defense attorney, Bureau of Medicaid Program Integrity defense attorney, defense attorney, defense lawyer, Florida health law attorney, Florida Medicaid attorney, Florida Medicaid lawyer, health care fraud defense attorney, health care fraud defense representation, health care law firm, health law attorney, health law lawyer, legal representation for health professional license, legal representation for Medicaid overpayment demand, legal representation for overbilling, Medicaid audit administrative hearing defense attorney, Medicaid audit administrative hearing legal representation, Medicaid audit appeal attorney, Medicaid audit attorney, Medicaid audit defense lawyer, Medicaid audit legal representation, Medicaid overpayment demand defense attorney, Medicaid overpayment demand lawyer, medical license defense attorney, mental health counselor defense attorney, Office of Inspector General defense attorney, overbilling defense attorney, physician defense attorney, professional counselor defense attorney, psychotherapist defense attorney, representation for Medicaid program audit, The Health Law Firm review|Comments Off

From the archives: CMS Using Medicare Termination to Squash Doctors Involved in Overprescribing Opioids

Previously published on February 11, 2022
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Recently it has come to our attention that there may be a nationwide effort by the Centers for Medicare and Medicaid Services (CMS) Medicare Administrative Contractors (MACs) to squelch physicians who prescribe opioids and other narcotic medications. We have seen letters sent out by CMS MACs to physicians notifying them that their Medicare program billing privileges have been terminated because CMS has identified them as a provider who is overprescribing.

Nationwide Effort to Run “Pill Mills” Out of Business.

We are well aware of efforts by the various law enforcement authorities at the state and federal level to prosecute and put out of business physicians identified as “pill mills” and the pharmacies that fill their prescriptions. These include surprise audits and inspections, followed by administrative actions or criminal prosecutions, by the Drug Enforcement Administration (DEA), the state Attorney General’s Office, the Department of Health, statewide task forces, and local sheriff’s offices and police departments.

However, this new heavy-handed tactic hits physicians in the pocketbook. It takes advantage of an arcanely-complex system of administrative appeals that is heavily weighted in favor of the government.

If You Receive a Letter from CMS Regarding Termination of Your Medicare Billing Privileges, Act Immediately.

Do not hesitate or wait if you receive a letter notifying you that CMS is terminating your billing privileges. You must get an experienced health care attorney to represent you right away and appeal the decision through a “request for reconsideration.” You must also ask that the termination not go into effect while the appeal is pending and provide reasons why it should not. Often you only have a few days to do this.

In Truth, There May Be No Oversprescribing.

In one recent case, we represented a physician who received such a letter stating she was terminated from Medicare. She was not a pain management physician, and she had over 2,000 patients. She only prescribed a handful (literally, less than ten) of these patients opioids, but the medical necessity was present and well-documented. However, because Medicare was aware of the prescriptions, it terminated her because it was paying for them.

Consequences of a Medicare Privileges Termination.

There are many, many seriously adverse consequences of a termination of Medicare privileges. Often we refer to this as a “death sentence.” It could be the death of your medical practice and possibly your medical career.

Consequences include:

1.    A waiting period of ten (10) years before you can even reapply.

2.    Placement on the OIG’s List of Excluded Individuals and Entities (LEIE).

3.    Having to notify hospitals and other health facilities where you are on the staff so that your medical staff privileges can be terminated.

4.    Being terminated from your state’s Medicaid Program.

5.    Being placed on the exclusion list for all federal contracts and contractors.

6.    Being terminated from the provider panels of all health insurers.

7.    Being excluded from any job or any position, including contractor or subcontractor for any organization that receives and government funding.

8.    Possible loss of medical license or non-renewal of medical license because of #1, #2 and #4 above (in most states).

Act Fast; Don’t Delay!

Act fast if you receive such a letter. Do not delay. Retain the services of a health lawyer experienced in Medicare appeals and federal administrative hearings.

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

The lawyers of The Health Law Firm routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicare and Medicaid investigations, audits and recovery actions. They also represent them in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge. Attorneys of The Health Law Firm represent health providers in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.

Call now at (407) 331-6620 or Toll-Free (888) 331-6620 or visit our website 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 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.

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By The Health Law Firm|2024-03-14T09:59:31-04:00May 8, 2023|Categories: Mental Health Law Blog|1 Comment

Humana Agrees To Pay $11.2 Million Settlement to End Nurses’ Overtime Suit

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

On September 27, 2021, Humana agreed to pay $11.2 million to end claims that the health insurance company denied a group of nurses overtime pay by misclassifying them as exempt employees. A Wisconsin federal judge approved the deal with Humana, and a group of more than 200 nurses reached, securing a $36,000 average payment for each nurse involved in the suit.

A Violation of the Fair Labor Standards Act (FLSA).

This dispute stems from a class-action lawsuit filed in 2017 alleging that Humana misclassified its clinical nurse advisers as exempt employees and denied them overtime compensation, violating the Fair Labor Standards Act. Many professionals and supervisors or managerial employees are considered to be exempt from overtime laws.

In the suit, the company faced allegations from nurses who claimed they were never paid for overtime even though they were required to work more than 40 hours per week to meet Humana’s production goals and expectations.

The Settlement.

The settlement agreement will allocate almost $3 million to cover attorney fees and costs. Additionally, the 221 nurses that are part of the settling class will get nearly $8 million based on the number of full-time weeks the nurses worked. According to the motion, the average payment per nurse for unpaid overtime and liquidated damages will be over $36,000.

The case is O’Leary v. Humana Insurance Co., et al., case number 17-cv-1774, in the U.S. District Court for the Eastern District of Wisconsin. Click here to view the court’s brief in full.

To read about another case dealing with alleged pay discrimination in the healthcare field, click here to read one of my prior blogs.

Contact Health Law Attorneys Experienced in Representing Nurses and Other Healthcare Professionals.

The Health Law Firm’s attorneys routinely provide legal representation to nurses, pharmacists, pharmacy technicians, dentists, dental assistants, physicians, physician assistants, mental health counselors, and other health providers. We also provide legal representation for employers in EEOC complaints, workplace discrimination complaints, and suits involving harassment or discrimination complaints. We also provide legal representation in Department of Health, Board of Medicine, Board of Nursing investigations and complaints, DORA investigations and complaints. We provide litigation services in state and federal courts and state and federal administrative hearings. We provide legal representation across the U.S., not just in Colorado, Florida, Louisiana, Virginia, and Washington, D.C.

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:

Spezzemonte, Irene. “Humana To Pay $11.2M To End Nurses’ Misclassification Suit.” Law360. (September 27, 2021). Web.

Webster, Katherine. “Court OKs $11.2M Overtime Settlement Between Humana, Nurses.” Top Class Actions. (September 30, 2021). 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 Toll-Free: (888) 331-6620.

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From the archives: CMS Using Medicare Termination to Squash Doctors Involved in Overprescribing Opioids

Humana Agrees To Pay $11.2 Million Settlement to End Nurses’ Overtime Suit