Medicaid | The Health Law Firm Blog

Medicaid audits and regulation are a concern for health care professionals. Learn more about regulations and updates concerning Medicaid.

Accused of “Irregular Behavior” on Your USMLE Step Exams: What to Do

Many students, foreign medical graduates and those applying to receive a medical license in the United States find themselves accused of “irregular behavior” while taking the Step 1, Step 2 or Step 3 exams of the United States Medical Licensing Examinations (USMLE) administered by the National Board of Medical Examiners (NBME). Often the conduct turns out to be something that is not significant, was inadvertent, was not intended to provide any unfair advantage to the test-taker or is otherwise justifiable or explainable. Nevertheless, because of the extremely serious consequences a finding of “irregular behavior” may have, the applicant should act immediately upon being advised of a pending inquiry; he or she should take appropriate steps to attempt to defend himself or herself.

The USMLE defines “irregular behavior” as conduct that includes (but is not limited to) the following:

1. Seeking, providing, or obtaining unauthorized access to examination materials.

2. Providing false information, making false statements, or similar conduct in relation to application forms, scheduling permits, or related documents.

3. Taking an examination when the examinee is not really eligible for it (or attempting to do so).

4. Impersonating another test-taker or engaging a different person to take the examination for the actual applicant.

5. Obtaining, giving, or receiving assistance during the examination or attempting to do so (except for certain authorized acts).

6. Making notes in the secure areas of the test center, except for notes on the writing materials provided at the test center for this purpose.

7. Failing to comply with or follow any USMLE policy, procedure, or rule.

8. Failing to follow instructions of the test center staff.

9. Abuse or harassment (verbal or physical) of test center staff or any other disruptive or unprofessional behavior at the test center.

10. Being in possession of any unauthorized materials, including photographic equipment, or communication or recording devices, including electronic paging devices and cellular telephones, in the secure testing areas.

11. Changing or misrepresenting your examination scores to others.

12. The unauthorized reproduction of any examination materials or dissemination of them by any means, including via the Internet (this includes, for example memorizing them and repeating them, restructuring them, discussing the actual questions and answers, etc.). Note: all test questions and testing materials are copyrighted. You could be prosecuted or sued for violation of the NBME’s copyrights, and this has actually happened.

13. Communicating or attempting to communicate about specific test questions, answers, items, or cases with any other examinee, potential examinee, or preparation group at any time.

Some of the foregoing actions seem to be fairly common sense as far as what any person should know is prohibited. However, other forms of more innocuous behavior can result in accusations which fit within the above.

For example, we have been consulted by examinees accused of “irregular behavior” when they have done the following:

1. Wearing a wrist watch during the examination.

2. Taking a nationally advertised examination preparation course attended by hundreds of people when the preparation course allegedly had obtained unauthorized access to actual examination questions.

3. Using a cell phone, Blackberry or other communications device at the exam center.

4. Talking with another exam taker in a bathroom during the test.

5. Discussing test questions and the testing process on a blog.

6. Discussing the substance of test questions and cases with others.

7. Writing or marking something down prior to being instructed to do so.

8. Making a stray mark on an examination after being instructed at the exam center that you were not allowed to do so.

9. Failing to follow the orders of a proctor at an exam center.

10. Not being able to produce the correct form of identification (in this case, the monitor requested a photo driver’s license, when the applicant did not have one).

If you are accused of “irregular behavior” we advise you to immediately consult with an attorney who has actual experience in dealing with these matters. If the event is considered to be significant, you will be advised of this in writing and will be given an opportunity to explain it. Have your attorney help prepare this; don’t attempt to do it yourself.

If you are given the right to an appeal or a hearing in this matter, be sure to request this in writing by at least two different forms (e.g., via U.S. mail, via telefax, via Federal Express) that include proof of sending and proof of delivery. DO NOT RELY ON E-MAIL ALONE. Be sure that it is received at the NBME office (or the address specified in the letter you receive) within the time specified in the letter or the Bulletin setting forth the procedures you must follow. You have a number of procedural rights given to you in these matters. Exercise them in a timely and effective way.

Retain the services of an attorney who has experience working on NBME matters to represent you. Plan on attending any hearings (these are usually held at the NBME offices in Philadelphia, Pennsylvania), in person. All documents, statements, photographs, and other materials upon which you intend to rely should be clearly labeled, organized, indexed, copied and submitted ahead of time (similar to how it would be done in a court trial or hearing). Be sure that your attorney attends the hearing with you. Don’t retain the services of an attorney for this process if the attorney is not going to be available to represent you in person at the hearing in Philadelphia.

Unfortunately, many who are accused of “irregular behavior” do not realize the serious consequences that a confirmed finding of this can have. Although technically, it is not the same as “cheating” it can carry the same adverse stigma that “cheating” can have. It can prevent you from becoming licensed on time, delay your career, prevent you from obtaining desirable residencies and fellowships, prevent you from obtaining desirable employment, and have other consequences.

For additional information and documents related to “irregular behavior” and other legal matters visit our website at www.TheHealthLawFirm.com.

By The Health Law Firm|2024-03-14T10:00:26-04:00June 1, 2018|Categories: Health Care Industry, In the Know, Medicaid, NBME, The Health Law Firm Blog|Tags: ecfmg, irregular behavior, step 1, step 2, step 3, USMLE|Comments Off

Zone 4 Program Integrity Contractor (ZPIC) for Medicare and Medicaid Programs is Health Integrity, LCC

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

Health Integrity, LCC, was named the Zone 4 Program Integrity Contractor (ZPIC) for the Medicare and Medicaid programs. As the ZPIC for Zone 4, Health Integrity has been performing benefit integrity activities aimed to reduce fraud, waste and abuse in Medicare and Medicaid data matching programs.

A ZPIC is a business entity that contracts with Medicare and Medicaid and works with state Medicaid agencies, the Centers for Medicare and Medicaid Services (CMS), and law enforcement officials to identify improper billing and utilization patterns throughout Zone 4.

ZPIC Zone 4 includes Texas, Colorado, New Mexico, and Oklahoma.

What is a ZPIC?

ZPICs are private companies contracted by the CMS, used to conduct audits for Medicare and Medicaid overpayments. ZPICS also detect, investigate and gather evidence of suspected fraud and abuse to be turned over to the Office of Inspector General (OIG) for criminal or civil prosecution.. When you hear “ZPIC,” think “fraud.”

ZPIC audits are initiated by:

1. Whistleblower or qui tam lawsuits,
2. Probe audits,
3. Other audit agency findings,
4. Beneficiary/patient complaints,
5. Hotline complaints, or
6. Complaints and notices from other government programs.

How to Handle a ZPIC Audit.

When a physician, medical group or other health care provider receives a notice of an audit and site visit from a ZPIC, things happen fast with little opportunity to prepare. A ZPIC will routinely fax a letter to the practice shortly before the end of a business day the day before a site visit/audit to that practice. Auditors will request to inspect the premises, will photograph all rooms, equipment, furniture, and diplomas on walls. They will usually request copies of several patient records to review later. They will request copies of practice policies and procedures, treatment protocols, all staff licenses and certifications, drug formularies, medications prescribed, and medications used in the office. ZPIC auditors will inspect any medication/narcotic lockers or storage cabinets and will request drug/medication invoices and inventories. You will usually be contacted for follow-up information and documentation after the audit and will eventually be provided a report and, possibly, a demand for repayment of any detected overpayments.

For a checklist on what to do after you receive initial notification of a ZPIC audit, read our two-part blog. Click here for part one and click here for part two.

The Health Law Firm’s Success in a North Carolina Medicaid Action.

In October 2012, The Health Law Firm assisted a North Carolina Medicaid provider in reducing an overpayment demand made by the North Carolina Medicaid program by more than ninety-eight percent (98%). We were brought on to assist the provider in challenging an initial audit. We assembled and submitted documents to the auditor and assisted the client in presenting evidence at the hearing. The final result of the hearing reduced the Medicaid overpayment amount from $1.4 million to just $24,083. To read more on this successful Medicaid action, click here.

State Included in Zone 4.

ZPIC Zones are broken up by state. Health Integrity serves as the Zone 4 ZPIC. As indicated above Zone 4 includes Texas, Colorado, New Mexico, and Oklahoma.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Have you ever received notification of a ZPIC visit or audit? Please leave any thoughtful comments below.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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

Emergency Suspension Orders and Medicaid Fraud

In the recent case of Mendelsohn v. State of Florida Department of Health, Mendelsohn’s license to practice medicine was suspended under an Emergency Suspension Order (ESO).

According to the ESO, Mendelsohn is licensed to practice medicine in Florida pursuant to the provisions of chapter 458, Florida Statutes. On December 9, 2010, he entered a plea of nolo contendere in federal court to a charge of conspiracy to commit fraud upon the United States in violation of 18 U.S.C. § 371. As a result of his conviction, the Florida Department of Health immediately suspended his medical license without a hearing pursuant to section 456.074(1), Florida Statutes (2010), which states:

(1) The department shall issue an emergency order suspending the license of any person licensed under chapter 458 . . . who pleads guilty to, is convicted or found guilty of, or who enters a plea of nolo contendere to, regardless of adjudication, to:

. . .

(b) A misdemeanor or felony under 18 U.S.C. s. 669, ss. 285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s. 1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the Medicaid program.

Mendelsohn argued that his federal conspiracy conviction was not related to the Medicaid program, so the Florida Department of Health could not issue an ESO without establishing that his actions posed an immediate danger to public safety.

Florida law requires that an order directing the immediate suspension of a practitioner’s license contain “every element necessary to its validity . . . on the face of the order.” In general, an ESO will not be upheld unless the order on its face sets out the specific facts and reasons for finding an immediate danger to the public health, safety, or welfare, as well as the Florida Department of Health’s reasons for concluding that the procedure used is fair under the circumstances.

However, Section 456.074(1), Florida Statues, however, requires DOH issue an emergency order suspending a medical license in certain circumstances without regard to specific proof that a petitioner is acting in a way that poses an immediate danger to public safety.

But Mendelsohn asserted that the Florida Department of Health incorrectly found that his conviction required an ESO under section 456.074(1)(b). Section 456.074(1)(b) requires the Florida Department of Health to issue an ESO when a practitioner has been convicted of a “felony under 18 U.S.C. s. 669, ss. 285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s. 1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the Medicaid program.”

Although Mendelsohn was convicted of a felony in violation of § 18 U.S.C. 371, he contended his conviction was not related to the Medicaid program, and thus, did not support the issuance of an ESO without further proof that he posed a threat to public safety.

The court ultimately agreed with Mendelsohn, deciding “the underlying facts do not qualify as one of those instances where the Florida Department of Health may issue an ESO without providing specific reasons why the suspension is necessary to prevent immediate harm to the public.”

Do not let the Florida Department of Health take away your license unless it is warranted. Contact a board certified health law attorney who is knowledgeable in handling these matters. For more information about Emergency Suspension Orders and other legal matters concerning healthcare providers visit www.TheHealthLawFirm.com.

George Indest is an attorney, board certified by the Florida Bar in Health Law, who represents health care professionals and providers, including pain management clinics and pain management physicians.

By The Health Law Firm|2024-03-14T10:00:27-04:00June 1, 2018|Categories: Department of Health, Health Care Industry, Medicaid, The Health Law Firm Blog|Tags: department of health, emergency suspension order, ESO, florida, fraud, medicaid|Comments Off

Tips for Responding to a Medicaid Audit

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

Should you find yourself, your facility or your health practice the subject of a Medicaid audit by your state Medicaid agency or audit contractor, there are a few things you should know.

The most important thing is that just because you are being audited, it does not mean that you or your business has done anything wrong. State and federal governments conduct audits for many different reasons. Typical reasons include: special audits of high-fraud geographic areas, auditing of particular billing codes, randomly selected provider auditing, and complaints of possible fraud.

Medicaid Audits in Florida.

The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG) and Bureau of Medicaid Program Integrity are the Florida agencies responsible for routine audits of Medicaid health care providers to ensure that the Medicaid Program was properly billed for services. Health care professionals receiving the greatest amounts of Medicaid payments are also the ones most likely to be audited. These include pediatricians, Ob/Gyns, family practice physicians and dentists. The Medicaid audit usually requests information in a questionnaire that the medical practice is required to complete, as well as a request for copies of medical records (including x-rays and other diagnostic studies) on the list of Medicaid patients selected for the audit.

If AHCA determines that Medicaid overpaid for services, it will use a complex mathematical extrapolation formula to determine the repayment amount. The amount of the repayment to the Medicaid Program can be considerably greater than (30 to 100 times as much as) the actual amount of overpayment disclosed by the sample of records audited. Additionally, fines and penalties can be added by the Medicaid Program. However, you can eliminate or reduce the amount of any such repayment by actions taken both before and during the Medicaid audit.

How to Know If You Are the Subject of an Audit.

An audit will usually begin with the provider receiving an initial audit request, usually by letter or fax. This request will serve to notify the recipient that it is the subject of an audit. The initial letter will not always identify the reason for the audit. What it will contain, however, is a list of names and dates of service for which the auditors want to see copies of medical records and other documentation.

This stage of the process is crucial because it is the best opportunity to control the process. Once the records are compiled and sent to the auditor, the process shifts and you are now going to have to dispute the auditor’s findings in order to avoid a finding of overpayment.

The biggest mistake that someone who is the subject of an audit can make is to hastily copy only a portion of the available records and send them off for review. The temptation is to think that since the records make sense to you, they will make sense to the auditor. Remember, the auditor has never worked in your office and has no idea how the records are compiled and organized. This is why it is so important to compile a thorough set of records that are presented in a clearly labeled and organized fashion that provides justification for every service or item billed.

Read the Audit Letter Carefully.

On top of the letter notifying you of the audit, AHCA will also supply you with a list of patients to be sampled. A standard sample will include a list of anywhere from 30 to 150 patient names, depending on the size of the practice. Regular audits routinely request 30 to 50 patient records. The audit letter will also include a questionnaire to be completed (Medicaid Provider Questionnaire) and a “Certification of Completeness of Records” form to complete and return with the copies of the patient records. (Please note: this will be used against you in the future if you attempt to add to or supplement the copies of the records you provided).

Compiling a Response to an Initial Audit Request.

The following are steps that you should take in order to compile and provide a set of records that will best serve to help you avoid any liability at the conclusion of the audit process:

1. Read the audit letter carefully and provide everything that it asks for. It’s always better to send too much documentation than too little.

2. If at all possible, compile the records yourself. If you can’t do this, have a compliance officer, experienced consultant or experienced health attorney compile the records and handle any follow-up requests.

3. Pay attention to the deadlines. If a deadline is approaching and the records are not going to be ready, contact the auditor and request an extension before it is due. Do this by telephone and follow up with a letter (not an e-mail). Send the letter before the deadline.

4. Send a cover letter with the requested documents and records explaining what is included and how it is organized as well as who to contact if the auditors have any questions.

5. Number every page of the records sent from the first page to the last page of documents.

6. Make a copy of everything you send exactly as it is sent. This way there are no valid questions later on whether a particular document was forwarded to the auditors.

7. Send the response package using some form of package tracking or delivery confirmation to arrive before the deadline.

Compiling all of the necessary documentation in a useful manner can be an arduous task. If you find that you cannot do it on your own, or that there are serious deficiencies in your record keeping, it is recommended that you reach out to an attorney with experience in Medicaid auditing to assist you in the process.

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 (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

Have you ever been the subject of a Medicaid audit? What was the process like? Please leave any thoughtful comments below.

Doctor or Nurse, Please, Please, Please: Talk to an Attorney Before You Talk to an Investigator

Despite mailing out hundreds of thousands of postcards and letters to physicians, nurses, dentists, pharmacists, and psychologists throughout Florida, we continue to receive calls from new clients and from potential clients, after they have already spoken to and made critical harmful admissions against their own interests to investigators. In Florida, you do not have any duty to cooperate with any investigator who is investigating you. This extends to Department of Health (DOH) investigators (who are sometimes titled “Medical Quality Assurance Investigators” or “Medical Malpractice Investigators“), Drug Enforcement Administration (DEA) special agents, police officers, sheriff’s deputies, or criminal investigators of any type.

Let me state this as succinctly and clearly as possible. If you are being investigated, you will not be better off making a statement. You will not be better off explaining your side of the story. The investigator is not your friend. The investigator is not on your side. All you are doing is falling for a trick and helping the government to make a case against you.

You have a right under the U.S. Constitution to not make any statement that may be used against you. This is so important that in criminal cases government investigators are required to advise you of this by reciting to you your Miranda rights.

However, in cases where you might have your medical license revoked or have your nursing license revoked or have your DEA number revoked or lose your Medicare provider status or your Medicaid provider status, the investigator is not required to advise you of your rights.

In a criminal case, there may be ways to have your statement thrown out. However, in a professional licensing case or other administrative case, it may be too late to avoid the damage. You may be the best witness the government has and you may be the only witness the government needs to prove ths case against you.

In the case where you could receive a $100 criminal fine, the investigators are required to read you your constitutional Miranda rights and to be sure that you understand them before you make a statement. However, in a case where you can lose your professional license, where you could lose your livelihood and ability to make a living, where you could lose everything you have worked so hard to obtain, they are not required to do this. You must protect yourself.

Many health professionals, when confronted by an investigator, who will usually call at a very inconvenient time (to catch you by surprise) and will usually flash a badge (to intimidate you), will refuse to acknowledge the seriousness of the matter and will fall for the bait to “tell their side of the story.” This can be fatal to your defense and fatal to your license.

In the absence of a statement by the suspect (in this case, let’s assume this is YOU), the government may have a very difficult time of proving that you have committed any offense. It may have other witnesses (who may not be around at the time of any hearing or trial). It may have a lot of physical evidence or documents. But it may be impossible for the government investigators to make any link between you and the evidence, unless you help the investigators do this. You would be surprised at how many health professionals believe that they can just talk their way out of the situation; in reality, they are just giving evidence that is used to make the case against them.

Any evidence at all, just admitting that you were there, admitting that the documents are yours, admitting that the patient was yours, admitting that you worked at the clinic, admitting that you wrote the prescription, admitting that the property is yours, admitting that you were on duty at the time, admitting that you have taken a drug, admitting that you signed the form, can be a crucial piece of evidence that could not otherwise be proven without your own testimony.

Remember, this is the investigators’ job and profession. This is what they do full time, every day. And they are very good at it. They are 1,000 times better at getting you to admit the crucial elements of a disciplinary infraction than you are in “talking your way out of it.” They will not be convinced by any excuses you make. They do not have to be. They will not be the ones making the final decision against you. Theirs is the job of putting together the case against you. You will help them by talking to them, explaining why your decisions are correct, explaining why what you did is excusable, etc. It will not work. You will merely be giving them enough rope to hang you with.

Hint: If it is a Medicaid Fraud Control Unit (MFCU) special agent (investigator), you are probably under investigation for Medicaid fraud.

Hint: If it is an “auditor,” “surveyor” or “investigator” from an agency or company with “integrity” or “program integrity” in its name, they are probably investigating you for “lack of integrity,” i.e., false claims or fraud.

Hint: If it is a Drug Enforcement Administration (DEA) special agent (investigator) they are probably investigating you to prosecute you or to revoke your DEA registration for drug or prescribing violations.

Hint: If it is an Office of the Inspector General (OIG) special agent (investigator), you are probably under investigation for Medicare fraud or Medicare false claims.

Hint: If it is a Department of Health Quality Assurance Investigator or Medical Malpractice Investigator, they are probably only investigating possible disciplinary action against your license that could result in large administrative fines or revocation of your license.

Do not believe for a second that you are smarter than the investigator. Do not believe for a second that you will convince the investigator (or anyone else) that there is a legal or medical justification for what you did or what they allege. If it were as simple as that, then why would there be an investigation and why would you be the one being investigated?

Additionally, do not believe for a second that you can lie your way out of it, either. Remember, if the government cannot prove the basic offense that it is investigating against you, it may be able to prove that you have committed perjury or lied to an investigator. In the case of a federal official or a federal investigation, merely making a false statement (oral or written) to an investigator is a criminal act. This is what Martha Stewart and many others have served time for in federal prisons.

These investigators are lied to all the time. They are usually better at detecting lies than a polygraph expert is. Furthermore, in most cases, you will be the very last person to be interviewed. Therefore, they will already know just about everything that can be used against you. If your statement contradicts in any way what others have told them, they will know you are the one who is lying. However, knowing something or suspecting something does not mean it will be something that can be proven in court or in an administrative hearing.

It is much better to make no statement at all. Blame it on your attorney. Tell the investigator that your attorney will kill you if you were to talk to the investigator without your attorney being there ahead of time. “Speak to my attorney.” “My attorney can help you, I can’t.”

All you have to do is state “I must talk to my lawyer before I say anything.” “I will have my lawyer contact you.” “I cannot say anything until I talk to my lawyer.” “I want a lawyer.”

If you are not the one being investigated, then there is no good reason why the investigator would want you to make a statement before you consulted with your attorney. What is the rush?

Then you must also avoid the old trick of the investigator telling you “If you don’t have anything to hide, why would you need a lawyer?” Please don’t fall for this trick, either. This is America. Smart people and rich people spend a lot of money on attorneys and other professionals to represent them and advise them. There is a good reason why they do this.

Far too often the health professional only calls us after he has given a statement. This is usually too late to avoid much of the damage that will have been be caused.

Everything above applies to oral statements or written statements. Do not make either. Contact a lawyer as soon as possible, preferably before making any statement, no matter how simple, defensive, self-serving or innocuous you may think it to be.

Think of this as an intelligence test. Are you smart enough to follow this guidance and avoid this type of mistake?

For more information about investigations and other legal matters, visit www.TheHealthLawFirm.com.

By The Health Law Firm|2024-03-14T10:00:27-04:00June 1, 2018|Categories: Department of Health, Health Care Industry, Medicaid, Medicare, Nurses, The Health Law Firm Blog|Tags: attorney, dea, dentist, doh, fdle, investigation, investigators, license, nurse, physician, psychologist|Comments Off

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

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

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

Click here to read the press release from the AG.

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

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

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

Speech Therapist Faces Restitution and Prison Time.

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

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

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

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

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

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

Comments?

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

Sources:

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

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

By The Health Law Firm|2024-03-14T10:00:47-04:00June 1, 2018|Categories: Medicaid, Medicaid audit, The Health Law Firm Blog|Tags: defense attorney, defense lawyer, false claims act, FCA, Florida defense attorney, Florida defense lawyer, Florida Office of the Attorney General (AG), legal defense, legal representation, medicaid, medicaid audit, Medicaid defense attorney, Medicaid defense lawyer, Medicaid fraud, Medicaid Fraud Control Unit (MFCU), Medicaid fraud defense attorney, Medicaid fraud defense lawyer, Medicaid overbilling, Medicaid scheme, Medicaid therapist provider, speech therapist|Comments Off

Halifax Whistleblower Claims Hospital Overbilled Medicare

The U.S. Department of Justice has joined a whistleblower suit filed against Halifax Hospital by the hospital’s director of physician services, according to the Daytona Beach News-Journal.

The U.S. Department of Justice filed its part of the lawsuit on Friday. It claims that Halifax Health defrauded the federal government by submitting thousands of false claims for Medicare and Medicaid payments worth millions of dollars. By filing, the U.S. Department of Justice hopes to recover millions of dollars in Medicare and Medicaid payments that it says were made in error to Halifax.

Elin Baklid-Kunz filed a lawsuit against Halifax in 2009. As a whistleblower, he could be awarded a percentage of whatever the government recovers. Generally, whistleblowers can be awarded 25 percent to 30 percent of the recovery. He claims Halifax overbilled Medicare by inappropriately admitting patients and had financial arrangements with some of its doctors that violated a federal anti-kickback law.

The federal Stark Law prohibits Medicare and Medicaid payments for hospital services that are prescribed by doctors who have profit-sharing agreements with the hospital. The law was made to ensure that referrals are made for medical reasons only, without financial motives.

However, according to the lawsuit, Halifax had agreements with its doctors that gave them a financial incentive to generate hospital revenues.

The Justice Department’s lawsuit focuses on doctors’ contracts, claiming that Halifax administrators “could not have reasonably concluded” the agreements to pay bonuses to doctors did not violate the Stark Law. Neurosurgeons at Halifax received generous incentive compensation that boosted their based salaries by hundreds of thousands of dollars. These neurosurgeons referred patients to Halifax and, between 2004 and 2010, Halifax charged Medicare more than $35 million for neurological services, the suit states. Each neurosurgeon individually generated over $2 million in profits for Halifax Hospital in 2009, according to the suit. The Justice Department claims a similar pattern existed with the hospital’s seven oncologists.

For more information on similar legal matters, visit www.TheHealthLawFirm.com.

By The Health Law Firm|2024-03-14T10:00:27-04:00June 1, 2018|Categories: Health Care Industry, In the News, Medicaid, Medicare, The Health Law Firm Blog|Tags: daytona beach, florida, halifax, hospitals, medicaid, medicare, stark law, whistleblower|Comments Off

Medicaid Fraud Control Unit Arrests Three Florida Women for Allegedly Bilking Medicaid Out of $27,000

By Lance Leider, J.D., The Health Law Firm

Three Central Florida women were arrested by the Attorney General’s (AG) Medicaid Fraud Control Unit (MFCU) on July 18, 2013, for allegedly defrauding Medicaid out of $27,000. According to the AG, the owner and two managers of Destiny TCM Corporation are accused of billing Medicaid for services never rendered and also bribing people in order to obtain their Medicaid recipient numbers.

To read the press release from the AG’s office, click here.

Violated Medicaid Fraud Kickback Statute.

An article in the Orlando Sentinel states that the Destiny TCM Corporation was supposed to provide targeted case-management services and link Medicaid recipients with mental health service providers. Allegedly, the business was billing for services never rendered to Medicaid recipients, which included claims for infants. The owner of Destiny TCM Corporation is also accused of paying kickbacks to people in order to access Medicaid numbers for billing, according to the Orlando Sentinel. This act violates the Medicaid fraud kickback statute, Section 409.920(2)(a)(5), Florida Statutes.

The three alleged Medicaid abusers are each charged with one count of Medicaid provider fraud. The owner was also charged for allegedly paying kickbacks for Medicaid numbers. If convicted, they all face prison time and hefty fines, according to the Orlando Sentinel.

Click here to read the entire article from the Orlando Sentinel.

Tips for Responding to a Medicaid Fraud Control Unit Investigative Subpoena.

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

Defend Yourself from Fraud Charges.

We have been consulted by many individuals similar to the subjects of this story, both before and after criminal convictions for fraud or related offenses. In many instances, we are convinced that the person is actually not guilty of fraud. However, in many cases those subject to Medicaid or Medicare fraud audits and investigations refuse to acknowledge the seriousness of the matter or they decide not to spend the money required for a top quality attorney to defend them.

If you are accused of Medicare or Medicaid fraud, realize that you are in the fight of your life. Your liberty, life and profession are at stake. You need to sell everything you own, borrow everything you can and hire the absolute best criminal defense attorney available who has experience in defending such cases to represent you.

If you win and are acquitted, at least you still have a professional license and can start over. However, if you lose, you will most probably be in prison for years. You will lose your license. You will be excluded from Medicare. You will be a convicted felon. You will have nothing and will have no way of starting over successfully.

Do not delude yourself. This is extremely serious. Be prepared to give up whatever you have if you can avoid a conviction.

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

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

The Health Law Firm’s attorneys routinely represent case managers, nurses, physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health agencies, nursing homes, group homes, medical directors, nursing directors and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

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

Comments?

Have you noticed an increase in activity by the Medicaid Fraud Control Unit (MFCU)? Please leave any thoughtful comments below.

Sources:

Pavuk, Amy. “Three Women Charged in $27,000 Medicaid-Fraud Scheme, Officials Say.” Orlando Sentinel. (July 18, 2013). From: http://www.orlandosentinel.com/news/local/breakingnews/os-medicaid-fraud-arrests-20130718,0,7659716.story

Meale, Jenn. “Attorney General Bondi’s Medicaid Fraud Control Unit Arrests Three People for $27,000 of Medicaid Fraud.” Florida Office of the Attorney General. (July 18, 2013). From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/D234C9D525CAAC1E85257BAC005D8AF2

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

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

By The Health Law Firm|2024-03-14T10:00:50-04:00June 1, 2018|Categories: Medicaid, Medicaid audit, The Health Law Firm Blog|Tags: Attorney General (AG), bribes, defense attorney, defense lawyer, florida attorney, Florida lawyer, Florida Medicaid, Florida Medicaid Program, kickbacks, medicaid, medicaid audit, Medicaid claims, Medicaid fraud, Medicaid fraud charges, Medicaid Fraud Control Unit (MFCU), Medicaid fraud defense attorney, Medicaid fraud defense lawyer, Medicaid fraud kickback statute, Medicaid investigation, Medicaid provider fraud, Medicaid recipient numbers, services never rendered, the health law firm|Comments Off

What to do if You Receive a Medicaid Fraud Control Unit Investigative Subpoena

The Medicaid Fraud Control Unit is charged with investigating and prosecuting health care providers suspected of defrauding the state’s Medicaid program. It is a division of the Florida Office of the Attorney General .When the unit opens a case against a provider, the first step is usually the issuance of an investigative subpoena, requesting specific patient records. The practice tips below were prepared to assist a health care provider in properly responding to and defending against such a subpoena.

1. Immediately contact an attorney knowledgeable in Medicaid fraud and abuse prior to responding to the government’s requests.

The Medicaid Fraud Control Unit does not issue a subpoena without reason. An investigation by the Medicaid Fraud Control Unit is a very serious matter that can lead to both the recoupment of Medicaid reimbursements and criminal charges. It is essential that you immediately retain an attorney experienced in Medicaid fraud and abuse claims when served with such a subpoena. If retained early, an experienced health care attorney can review the requested records and determine what concerns the government may have and how best to defend against them. An experienced attorney can also determine if the subpoena has been properly served and what documents will be most responsive to the government’s requests.

2. The Medicaid Fraud Control Unit can only subpoena and seize the records of Medicaid patients.

The Medicaid Fraud Control Unit has the right to subpoena and review the patient records for Medicaid patients only. The records of a non-Medicaid patient may not be reviewed by the government without the patients’s prior written consent.

3. The government investigator is not on your side.

It is not uncommon for a government investigator to notify you that the subpoena you have been served with is a routine matter and that there is nothing to fear. The investigator may also tell you that your practice is not the subject of the investigation and that retaining counsel is unnecessary. A subpoena issued by the Medicaid Fraud Control Unit is always a very serious matter and should be treated as such. Remember, the investigator’s job is to build a case against you and, in our experience, they will use whatever tactics are at their disposal to do so.

4. DO NOT provide the Medicaid Fraud Control Unit with more documents than have been requested.

It is almost never advisable to provide the Medicaid Fraud Control Unit with more documents than requested in the subpoena. Providing the government investigator with additional information beyond what was requested will only provide the government with more evidence to use against you at a later date.

5. DO NOT provide the Medicaid Fraud Control Unit with your original records.

Unless required by the government, do not provide the Medicaid Fraud Control Unit with your original records. These investigations can often taken years to reach a final resolution and once the original records have been produced it is very difficult to get them back. In most cases, if the government is provided with an organized bates stamped copy of the requested records, they will not require you to produce the originals.

6. If proper and lawful, you must respond to the subpoena.

If the Medicaid Fraud Control Unit properly serves you with a lawful subpoena, you must produce the written records within the time prescribed. If the subpoena is not obeyed, the government will petition the court to compel compliance, and you will likely have to pay the government’s attorney’s fees and costs associated with enforcing the investigative subpoena.

7. Your employees are not required to speak with government investigators unless subpoenaed.

After your records have been produced, it is important to remember that neither you nor your employees are required to speak with government investigators, absent a subpoena. As noted above, it is rarely advisable to volunteer information to the Medicaid Fraud Control Unit, and in most cases, this information will be used to build a case against you.

8. Remain patient after complying with the subpoena.

Finally, it is important to remain patient after you have submitted your records to the government for review. The Medicaid Fraud Control Unit investigates hundreds of cases each year, involving thousands of records, and it is not uncommon for an investigation to go years without a final determination. Legal representation is extremely important at this time, as the communications between the your counsel and the government can make the difference between a civil penalty and criminal charges.

For more information on the Medicaid Fraud Control Unit and Medicaid audits, please visit our website at www.TheHealthLawFirm.com.

By The Health Law Firm|2024-03-14T10:00:29-04:00June 1, 2018|Categories: Medicaid, The Health Law Firm Blog|Tags: medicaid, medicaid audit, medicaid fraud control unit, medicaid fraud control until subpoena, mfcu, mfcu subpoena|1 Comment

Florida Hospice to Pay $1 Million to Settle Whistleblower Lawsuit Over False Billing Claims

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

The Hernando-Pasco Hospice (HPH Hospice) in Hudson, Florida, agreed to pay $1 million to resolve allegations that it violated the False Claims Act by submitting false claims for services to the Medicare and Medicaid Programs. According to the U.S. Attorney’s Office for the Middle District of Florida, the hospice allegedly admitted patients that did not meet the requirements for end-of-life care. This lawsuit was originally filed in 2010, by two former hospice employees. The announcement was made on July 22, 2013.

Click here to read the entire press release from the U.S. Attorney’s Office for the Middle District of Florida.

Hospice Accused of Admitting Ineligible Patients to Meet Targets.

HPH Hospice is accused of admitting ineligible patients in order to meet targets imposed by the management team, according to federal authorities. The settlement also resolves allegations that the hospice billed the government at higher rates than it was entitled to receive. It’s also accused of providing illegal kickbacks by giving services to skilled nursing facilities at no cost, in exchange for patient referrals.

Two former employees of the hospice first stepped forward with these allegations. The employees were longtime social workers at HPH Hospice. They filed a lawsuit alleging the facility’s management instructed the staff to make false or misleading statements in patients’ medical records to make them appear eligible for hospice care. The two former employees will share $250,000 of the settlement.

HPH Hospices Claims No Wrongdoing.

According to the Tampa Bay Times, the HPH Hospice spokesperson said the allegations were completely false. The organization stated that the settlement was the better option for patients and staff. As a result of these allegations, HPH Hospice said that it has hired three registered nurses to review and monitor all admission documentation, according to the Tampa Bay Times.

To read the entire Tampa Bay Times article, click here.

Under the False Claims Act, Whistleblowers Can Come Out on Top.

Whistleblowers stand to gain substantial amounts, sometimes as much as thirty percent (30%), of the award under the False Claims Act (31 U.S.C. Sect. 3730). Such awards encourage employees to come forward and report fraud.

You can learn more read our two part blog on whistleblowers. Click here for part 1, and click here for part 2.

Contact Health Law Attorneys Experienced with Medicaid and Medicare Qui Tam or Whistleblower Cases.

In addition to our other experience in Medicare, Medicaid and Tricare cases, attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblowers cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

To learn more on our experience with Medicaid and Medicare quit tam or whistleblower cases, visit our website. To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think about this settlement agreement? Do you think settling was a better option for the hospice? Please leave any thoughtful comments below.

Sources:

Department of Justice. “HPH Hospice to Pay $1 Million to Resolve False Claims Act Allegations.” Department of Justice. (July 22, 2013). From: http://www.justice.gov/usao/flm/press/2013/july/20130722_HPH.html

Tillman, Jodie. “Hernando-Pasco Hospice Agrees to Pay $1 Million to Settle False Billing Cliams.” Tampa Bay Times. (July 22, 2013). From: http://www.tampabay.com/news/health/hernando-pasco-hospice-agrees-to-pay-1-million-to-settle-false-billing/2132592?utm_source=twitterfeed&utm_medium=twitter

By The Health Law Firm|2024-03-14T10:00:50-04:00June 1, 2018|Categories: Medicaid, Medicare, The Health Law Firm Blog, Whistleblower|Tags: audit, defense attorneys, Department of Justice (DOJ), false claims act, FCA, Florida Medicare, fraud defense, fraud prevention, fraud schemes, government health programs, hospice, hospice care, kickbacks, legal representation, medicare, Medicare fraud, Medicare overbilling, qui tam suits, settlement, the health law firm, U.S. Attorney’s Office for the Middle District of Florida, whistleblower, whistleblower protection|Comments Off