Medicare is at the center of many legal issues. Health care reform and regulation make Medicare an important topic for health care providers.

Man Charged with Medicare Fraud in Ambulance Scheme

By Miles Indest

A Pennsylvania man has been charged in a 23-count indictment in relation to an alleged scheme to defraud Medicare by billing for fraudulent ambulance services. The charges were announced by the Department of Justice (DOJ) on June 29, 2012.

Man Allegedly “Straw” Owner Used to Start Ambulance Company.

According to the indictment the man allegedly used a “straw” owner (someone who was not actually the owner) to fraudulently open Starcare Ambulance because he was otherwise ineligible to own the company. Between 2006 and 2011, the man allegedly billed Medicare for transporting kidney dialysis patients who did not medically need ambulance service. This indictment seeks forfeiture of over $5 million in cash as well as a GMC Hum-V (“Hummer”) vehicle.

Man Could Face Up To 10 Years in Prison for Each Count of Health Care Fraud.

If convicted of all charges, the defendant faces a statutory maximum sentence of ten years in prison on each of the health care fraud and conspiracy counts. He also faces five years in prison for aiding and abetting in false statements relating to health care fraud, a three year term of supervised release, and a fine of up to $250,000.

Ambulance Services Companies Are Target for Medicare Audits.

In recent years, and especially in 2012, ambulance services companies have become the target of Medicare audits and are frequently accused of billing Medicare for unnecessary services. Medicare and Medicaid audits can result in overpayment demands reaching into hundreds of thousands of dollars and assessment of fines. Ambulance services were included in the Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) work plan for fiscal year 2012 as an area that would be subject to scrutiny. Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) are launching audits of ambulance service providers and emergency medical transportation companies.

Contact Health Law Attorneys Experienced in Handling Medicare Audits.

Medicare fraud is a serious crime and is vigorously investigated by the FBI and the U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG). Don’t wait until its 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.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, ambulance services companies, 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.

Sources Include:

“Pennsylvania Man Charged With $5.4 Million Medicare Fraud.” San Francisco Chronicle. (June 29, 2012). From: http://www.sfgate.com/news/article/Pa-man-charged-with-5-4-million-Medicare-fraud-3674333.php

Department of Justice, Office of Public Affairs. “Pennsylvania Man Charged with Fraud in Ambulance Scheme.” Department of Justice. Press Release. (June 29, 2012). From: http://www.justice.gov/opa/pr/2012/June/12-crm-840.html

Revised Readmission Penalties are Coming Due to Calculation Errors

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

Back in August of 2012, I wrote that lower Medicare reimbursement rates were coming to more than 2,000 hospitals around the country due to excessive readmission rates. To see that blog, click here.

In October of 2012, the Centers for Medicare and Medicaid Services (CMS) announced it has discovered errors in its initial calculations. This means, 1,422 hospitals with high readmission rates will lose slightly more money than first expected, according to Kaiser Health News.

Click here to read the entire article from Kaiser Health News.

Hiccup  in Medicare’s Hospital Readmission Reduction Program.

According to Kaiser Health News, the revisions were relatively small, averaging two-hundredths of a percent of a hospital’s regular Medicare reimbursements. Florala Memorial Hospital in Alabama will see the largest increase in its reimbursements, from 0.62 to 0.73 percent.

Originally, Medicare said it would base the penalties on the readmission rates for patients who were discharged from July 2008 through June 2011. According to a notice the CMS published, the mistake happened because the agency accidentally included claims before July 1, 2008, in its evaluations. Click here to see the notice from the CMS.

Program Initiated to Lower Hospitals’ Readmission Rates.

According to CMS, nearly one out of five Medicare patients will return to the hospital within a month of being discharged, these readmissions cost the government $17.5 billion in 2010. Medicare has estimated, with this program, it will recoup about $280 million from hospitals where too many patients return.

To see an updated list of hospital penalties, click here.

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?

What do you think about this story? Does this error by the CMS leave you jaded about the program? Leave any thoughtful comments below.


Sources:

Rau, Jordan. “Medicare Revises Hospitals’ Readmissions Penalties.” Kaiser Health News. (October 2, 2012). From: http://www.kaiserhealthnews.org/Stories/2012/October/03/medicare-revises-hospitals-readmissions-penalties.aspx

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.

Department of Justice Seeks up to $600 Million in Whistleblower Case Against Halifax Health in Daytona Beach, Florida

1 Indest-2008-1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The U.S. Department of Justice (DOJ) is asking for between $350 million and $600 million in damages and penalties from Halifax Health Medical Center in Daytona Beach, according to The Daytona Beach News-Journal. A Halifax employee filed the whistleblower lawsuit in 2009, accusing the hospital of illegal kickbacks to doctors, improper admissions and unnecessary spinal surgeries. The DOJ joined the case in 2011. Click here to read a previous blog on the DOJ joining the lawsuit.

If the government wins this case, it would amount to the largest whistleblower case of its kind in the nation.

Claims Against Halifax.

Halifax is accused of overbilling Medicare by inappropriately admitting patients and having 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 whistleblower was recently interviewed in an Orlando Sentinel article. She claims neurosurgeons at Halifax allegedly received illegal kickbacks tied to their performance. The whistleblower claims a similar pattern existed with six of the hospital’s oncologists. The suit also alleges one surgeon performed spinal fusion surgeries that were not medically necessary.

To read more from the whistleblower in an Orlando Sentinel article, click here.

Halifax Denies All Claims.

Halifax denies all of the DOJ’s allegations. The hospital has filed two motions to dismiss the case. However, both have been denied. According to The Daytona Beach News-Journal, the case is set for trial in November 2013. Click here to read the entire article from The Daytona Beach News-Journal.

Whistleblowers Who Report Fraud and False Claims Against the Government Stand to Receive Large Rewards.

Since the Halifax whistleblower filed her action under a federal law, she is entitled to recoup fifteen percent (15%) to twenty-five percent (25%) of the damages. Similarly, individuals working in the health care industry, whether for hospitals, nursing homes, medical groups, home health agencies or others, often become aware of questionable activities. Often they are even asked to participate in it. In many cases the activity may amount to fraud on the government.

In a two-part blog, I explain types of false claims, the reward programs for coming forward with a false claim, who can file a whistleblower/qui tam lawsuit and what is needed to be a successful whistleblower. Click here for part one, and click here for part two.

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 whistleblower 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 of this qui tam/whistleblower lawsuit? Please leave any thoughtful comments below.

Sources:

Swisher, Skyler. “Justice Department Seeks up to $600 Million in Lawsuit Against Halifax.” The Daytona Beach News Journal. (June 3, 2013). From: http://www.news-journalonline.com/article/20130603/NEWS/306039975/1040?p=1&tc=pg

Jameson, Marni. “Halifax Hospial Whistleblower at Forefront of $200M Alleged Fraud.” Orlando Sentinel. (April 15, 2013). From: http://articles.orlandosentinel.com/2013-04-15/news/os-halifax-hospital-whistleblower-20130415_1_marlan-wilbanks-illegal-kickbacks-halifax-health

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.

Why Have You Received a Denial on Your Medicare Enrollment Application?

Headshot of The Health Law Firm's attorney George F. Indest IIIBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Did you receive a denial on your Medicare enrollment application and can’t figure out why? You may be surprised to find out that even the smallest punctuation error, such as a missing comma or period, could be the reason Medicare rejected your application.

The Centers for Medicare and Medicaid Services (CMS) will deny Medicare applications of physicians, medical groups, home health agencies (HHAs), pharmacies and durable medical equipment (DME) suppliers because the name on file with the National Plan & Provider Enumeration System (NPPES) is not the same legal business name as reported to the Internal Revenue Service (IRS). The use of punctuation marks and abbreviations in your name with NPPES could produce a no match in the CMS records. It is imperative when filling out the Medicare enrollment forms that you use the exact legal business name on file with the IRS.

The easiest way for a health care provider or facility to apply for enrollment or make changes to enrollment information is to use the internet-based Provider Enrollment Chain and Ownership System (PECOS). Click here to utilize PECOS.

Other Reasons Why a Medicare Enrollment Application can be Denied.

Here are some more situations that can cause a provider’s application to be denied:

1. The form CMS-855 or PECOS certification statement is unsigned; it is undated; contains a copied or stamped signature; or for the paper form CMS-855I and form CMS-855O submissions, someone other than the physician or non-physician practitioner signed the form.
2. The submitted paper application is an outdated version.
3. The applicant failed to submit all of the forms needed to process a reassignment package within 15 calendar days of receipt.
4. The form CMS-855 was completed in pencil.
5. The wrong application was submitted (for example, a form CMS-855B was submitted for Part A enrollment).
6. If a web-generated application is submitted, it does not appear to have been downloaded from the CMS website.
7. The health care provider sent in an application or PECOS certification statement via fax or e-mail when he/she was not otherwise permitted to do so.
8. The health care provider failed to submit an application fee (if applicable to the situation).

Update All of Your Information with Medicare.

If you are already a Medicare provider, I urge you to personally go into the PECOS and NPPES and print out a copy of the existing information to check it.

If anything is incorrect, including an incorrect or incomplete name for your medical group, corporation or business, immediately fix this. Everything should be consistent. All of your state licenses and corporation/company information on file with your Secretary of State should also contain the same information as well.

Incorrect Information Could Lead to the Termination of Your Medicare Provider Number.

The consequences of not checking your information on file are severe and can include termination of your Medicare provider number and billing privileges.

The effect of this termination includes:

-You are prohibited from reapplying to Medicare for at least two years.
-You may have to pay back any money received from the Medicare program since the effective date of the termination (often many months prior to the notification letter).
-Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPICs) and the state Medicaid Fraud -Control Unit (MFCU).
-You may no longer contract with Medicare or anyone who does.
-You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.
-You may and probably will be terminated from skilled nursing facilities (SNFs) and HHAs with which you have contracts.
-You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs).

To read our recommendations on what to do if your Medicare provider number is terminated, click here to read my previous blog.

 

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 (850) 439-1001 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 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 and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2019 The Health Law Firm. All rights reserved.

Hospital to Pay $3.59 Million to Settle False Claims Act Allegations Involving Ambulance Services

By Miles Indest

A hospital located in Columbia, Tennesse, has agreed to pay the federal government over $3.5 million to settle False Claims Act allegations that occurred between 2004 and 2009. The hospital submitted a voluntary self-disclosure to the U.S. Attorney’s Office and the Department of Health and Human Services (DHHS) Office of Inspector General (OIG).

Hospital Voluntarily Self-Reported After Compliance Program Revealed Billing Errors.

The hospital self-reported after its own compliance program revealed billing problems for ambulance services. The hopsital’s audit of billings reported faulty claims and payment for:

  • Ambulance services that were billed with incorrect mileage units;
  • Ambulance services that were not medically necessary or for which medical necessity was not documented;
  • Ambulance services for which a physician certification statement (PCS) was not obtained;
  • Ambulance services for which the requisite signatures were not obtained; and
  • Ambulance services that were assigned an incorrect transport level.

Hospital Works With U.S. Attorney’s Office to Resolve Billing Errors.

After notifying the U.S. Attorney’s Office that billing issues had been discovered, Maury Regional outlined a plan to determine the scope of these issues. The hospital then worked with the U.S. Attorney’s Office to bring the matter to resolution.

Ambulance Services Flagged for Medicare Audits.

In a Medicare audit of a hospital or ambulance company, ambulance services are frequently chosen for review. Ambulance services companies have increasingly become a target for Medicare audits and are often accused of billing Medicare for unnecessary services. Ambulance companies should have a compliance plan in place to assist in detecting any errors. Ambulance companies should also take all measures to prepare for a Medicare audit, before notice of an audit is received. To learn more about preparing for Medicare audits, click here.

Contact Health Law Attorneys Experienced with Medicare Audits and False Act Claims Cases.

The Health Law Firm represents ambulance companies, emergency transport services, physicians, medical practices, pharmacists, pharmacies, home health agencies, nursing facilities, hospitals, and other health provider in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving government health programs (Medicare, Medicaid, TRICARE). The Health Law Firm also represents health providers in False Claims Act cases.

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

Sources Include:

Humbles, Andy. “Maury Regional to Pay $3.5 Million to Settle False Claims Act Allegations.” Tennessean. (June 29, 2012). From: http://www.tennessean.com/article/20120629/NEWS21/306290078/Maury-Regional-pay-3-5-million-settle-False-Claims-Act-allegations

Staff. “Maury Regional Hospital to Pay $3.59 Million to Settle False Claims Act Allegations.” The Daily Herald. (June 29, 2012). From: http://www.columbiadailyherald.com/sections/news/local/maury-regional-hospital-pay-359-million-settle-false-claims-act-allegations.html

American Hospital Association (AHA) Sues U.S. Government for Denied Medicare Payments by RACs, ZPICs and Other Auditors

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

On November 1, 2012, the American Hospital Association (AHA) filed a lawsuit against the U.S. Department of Health and Human Services (HHS) claiming that private auditors hired to crack down on improper Medicare payments are denying hospitals millions of dollars in medically necessary care, this is according to a number of sources. The AHA is seeking a court order declaring the practice invalid, saying it violates the Medicare Act.

Four hospital systems in Michigan, Missouri and Pennsylvania have joined the AHA as plaintiffs in the suit. The suit has been filed in federal court in Washington, D.C.

To read the AHA complaint against the HHS, click here.

AHA Wants Doctors to Be Able to Focus on Patient Care.

The lawsuit alleges Recovery Audit Contractors (RACs), private auditors used by the HHS, forced hospitals to repay Medicare for the costs of in-patient services by determining that Medicare beneficiaries should have been treated as out-patients instead of being admitted into hospitals as in-patients. The services provided to out-patients are much less, of course, and the bills for out-patient services are usually much lower.

In the official press release AHA argues when patients need treatment, the first step for a doctor is to decide whether to admit the patient to the hospital or to provide care in an out-patient facility. AHA believes doctors’ decisions are often more complicated for Medicare beneficiaries because the doctor is routinely second-guessed by RACs months or even years later. The president and CEO of AHA said this practice is “indefensible.”

Click here to read the entire press release from the AHA.

Neither the Centers for Medicare and Medicaid (CMS) nor the Department of HHS has commented on the pending litigation.

AHA Fed Up with Redundant Audits that Drain Time, Funding and Patient Care.

In October 2012, prior to the lawsuit, the executive vice president of the AHA wrote a letter to the Office of Inspector General (OIG) in response to the Work Plan for Fiscal Year 2013. In the work plan the OIG reviewed the effectiveness of various Medicare contractors, including RACs, Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs).

The letter states that these programs auditing payment accuracy are well intentioned, but hospitals are fed up with the RACs’ inaccuracy in determining whether the hospital received any overpayments. The letter also claims that hospitals are overwhelmed by the significant overlap and duplication of efforts between the RACs, MACs and ZPICs. These redundant audits drain time, funding and attention to patient care, according to the AHA.

According to the OIG review, hospitals reported appealing more than forty percent (40%) of all RAC denials, with a seventy-five percent (75%) success rate in the appeals process.

Click here to read the letter from the AHA to the OIG.

How to Take Action Once a Notice of a Medicare Audit Has Been Received.
When a physician, medical group or other healthcare provider receives a notice of an audit and site visit from a RAC, MAC or ZPIC, things happen fast with little opportunity to prepare. To help, read our checklist of what to do when notified of a Medicare or ZPIC audit. Click here for part one and click here for part two.

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?

What you think about the lawsuit again the HHS? Do you support AHA’s decision to question the RACs’ auditing system? Please leave any thoughtful comments below.

Sources:

Mitchell, Alicia. “Hospitals Sue Federal Government for Unfair Medicare Practices.” American Hospital Association. (November 1, 2012). Press Release from: http://www.thehealthlawfirm.com/uploads/AHA%20Sues%20Govnt%20PR.pdf

Pollack, Richard. “Letter: AHA Supports OIG Review of Effectiveness of Medicare Contractors, Including RACs, In 2013 Work Plan.” American Hospital Association. (October 24, 2012). Letter from: http://www.thehealthlawfirm.com/uploads/AHA%20letter%20to%20OIG%20on%20RACs.pdf

Morgan, David. “Hospitals Sue Government Over Private Medicare Audits.” Reuters. (November 1, 2012). From: http://uk.reuters.com/article/2012/11/01/us-usa-healthcare-medicare-idUKBRE8A01BZ20121101

Harris, Andrew. “American Hospital Association Sues U.S. Over Medicare.” Bloomberg. (November 1, 2012). From: http://www.bloomberg.com/news/print/2012-11-01/american-hospital-association-sues-u-s-over-unpaid-medicare.html

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.

Health Care Professionals and Providers Beware: The Health Care Fraud Prevention and Enforcement Action Team (HEAT) Is Catching Fire

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

In May 2009, the Department of Health and Humans Services (HHS) and the Department of Justice (DOJ) created the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT’s mission is to focus its efforts on preventing and deterring fraud and to enforce current anti-fraud laws around the country. To date, almost 1,400 individuals have been charged in connection with schemes involving more than $4.8 billion in fraudulent billings in these HEAT takedown operations.

To learn more about HEAT, click here to visit the website.

The Success of the HEAT Team.

According to the website, between 2008 and 2011, HEAT actions led to a seventy-five percent (75%) increase in individuals charged with criminal health care fraud. So far there have been six nationwide HEAT sting operations.

In 2011, HEAT agents led the largest-ever federal health care fraud takedown involving $530 million in fraudulent billing. To read more on this sting, click here.

On May 14, 2013, the DOJ announced that more than 400 law enforcement officials with HEAT spread out between eight cities including Miami and Tampa Bay to arrest 89 people accused of false billing. A majority of these arrests were allegedly of health care professionals. Click here to read a blog with more information on this takedown.

HEAT Captures One of Medicare’s Most-Wanted Fugitives.

On June 1, 2013, a former Los Angeles physical therapy clinic owner, and one of Medicare’s most-wanted fugitives, was arrested by HEAT agents at the Los Angeles International Airport on his return flight. According to a Los Angeles Times article, the clinic owner was an acupuncturist who billed Medicare for $2.1 million in false claims and was paid about $1.2 million. To read more from the Los Angeles Times, click here.

Expanding the Medicare Fraud Strike Force Efforts.

HEAT is a multi-agency team of federal, state and local investigators who combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing.

The Affordable Care Act has given HEAT additional tools to preserve Medicare by expanding the team’s authority to suspend Medicare payments and reimbursements when fraud is suspected.

To better combat fraud, the government has established HEAT in a number of cities, such as Los Angeles, Miami, Tampa Bay, Houston, Dallas, Chicago, Brooklyn, Baton Rouge and Detroit.

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 health care 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 heard of HEAT? Do you think the team’s efforts are curbing Medicare fraud around the country? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Medicare Fraud Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing.” Department of Justice. (May 14, 2013). From: http://www.justice.gov/opa/pr/2013/May/13-crm-553.html

Terhune, Chad. “One of Medicare’s Most-Wanted Fugitives is Arrested in L.A.” Los Angeles Times. (June 3, 2013). From: http://www.latimes.com/business/money/la-fi-mo-medicare-most-wanted-fugitive-arrest-20130603,0,7474342.story

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.

The RACs, They’re Back! The Return of Medicare Recovery Audits

Patricia's Photos 013By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

All good things must come to an end. This includes the two-month hiatus from Recovery Audit Contractors (RACs) that healthcare professionals enjoyed. The Centers for Medicare and Medicaid Services (CMS) is restarting audits of Medicare fee-for-service claims on a limited basis. The program has been suspended since June 1, 2014, due to expired contracts.

CMS announced the return of RACs on August 4, 2014.

Click here to read the latest announcements on Medicare recovery audits from CMS.

From what we have heard, there were serious problems with some of the audits that had been conducted by the RACs and CMS desired to start over with a clean slate. Just saying!

What Does Limited Basis Mean?

According to CMS, current RACs will conduct a limited number of automated reviews and a small number of complex reviews on certain claims including, but not limited to:

– Spinal fusions;
– Outpatient therapy services;
– Durable medical equipment;
– Prosthetics;
– Orthotics; and
– Supplies and cosmetic procedures.

RACs will not conduct any inpatient hospital patient status reviews for now. In the past, short inpatient stays accounted for 91 percent of the money the program recovered for Medicare.

Controversial Program.

According to an article on HealthData Management, in February 2014, members of congress argued that parts of the RAC program are unfair and violate the way that the Medicare program was intended to operate by raising out-of-pocket costs for beneficiaries. To address this concern, CMS established a provider relations coordinator to increase program transparency. This was announced in June 2014, so it is too soon to determine if this position will help providers affected by the medical review process. Click here to read more from HealthData Management.

Healthcare providers have complained that they are fed up with Medicare recovery audits tying up crucial funds and physician time in endless appeals. Currently, appeals can take up to five years. There is also a two-year moratorium in place preventing new appeals from being filed. You may remember my previous blog on the enormous backlog of Medicare recovery audit appeals. Click here to read that post.

What Exactly is a RAC?

RACs are often referred to as “bounty hunters.” They are private companies contracted by CMS, used to identify Medicare overpayments and underpayments, and return Medicare overpayments to the Medicare Trust Fund. Since the program began in 2009, it has brought in more than $8 billion in allegedly fraudulent, wasteful and abusive payments to healthcare providers.

How to Prepare for a Medicare Recovery Audit.

There is no such thing as a routine Medicare audit. The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.

I previously wrote a blog highlighting some of the actions we recommend you take in responding to a Medicare audit. The most important step you should take is to consult an experienced health law attorney early in the audit process to assist in preparing the response. Click here to read more on how to respond to a Medicare audit.

We Told You RACs Would Be Back.

RACs apparently caught $3.7 billion in allegedly wasteful payments that Medicare made to healthcare providers in 2013, and was allegedly on pace to bring back $5 billion this year. That’s why the government was eager to get RACs back to work.

It is extremely common for state and federal regulators to enforce even the smallest violations, resulting in investigations, monetary fines and penalties. If found in violation, you will not only have to pay fines and face disciplinary action, you will also lose revenue because you will have to spend time dealing with the investigation, instead of practicing medicine. Whether you are trying to prevent Medicare and Medicaid audits, Zone Program Integrity Contractor (ZPIC) audits, or any other kind of healthcare audits, there are steps you can implement in your practice today that may save you down the line. Click here to read more on self audits.

Comments?

What do you think about the return of Medicare recovery audits? What are you thoughts on Recovery Audit Contractors? Please leave any thoughtful comments below.

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.

Sources:

Demko, Paul. “Controversial Medicare Recovery Audits Make Limited Return.” Modern Healthcare. (August 5, 2014). From: http://www.modernhealthcare.com/article/20140805/NEWS/308059962/controversial-medicare-recovery-audits-make-limited-return

Goedert, Joseph. “CMS Restarts Parts of the RAC Program.” HealthData Management. (August 5,2014). From: http://www.healthdatamanagement.com/news/CMS-Restarts-Parts-of-the-RAC-Program-48553-1.html

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 © 1996-2014 The Health Law Firm. All rights reserved.

Responding to a Medicare Audit – Practice Tips

Although you may speak of a “routine” Medicare audit, there is really no such creature. This is like saying you have a “routine IRS audit.”  The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.

Having too many claims for level five CPT codes might, for example, cause you to be audited.  Having multiple claims submitted for the same date of service, may cause you to be audited.  Submitting claims for CPT codes outside of your medical speciality area, might cause you to be audited.  Having the dollar amount of claims greater than the average for a similar health practitioner in the same geographical area of the country, may cause you to get audited.  Having a greater number of claims submitted than the average for a similar health practitioner in the same geographical area of the country, may cause you to get audited.  Filing claims for services that are on the Office of Inspector General’s (OIG) annual work list may cause you to be audited.

“Routine” audits, those that do not involve some suspicion of false billings or fraudulent activities, should, nevertheless, be treated extremely seriously and the physician, group or health provider being audited should give the matter personal attention.  Examples of some contractors that may be involved in “routine” audits include DelMarva Foundation, Palmetto GBA, Cigna GBA, or First Coast Service Options, Inc.

However, if the audit letter or audit notice is from a Zone Program Integrity Contractor (ZPIC), such as SafeGuard Services, LLC, or AdvanceMed, the matter is very serious and should not be treated as a routine audit.  If the “audit” comes in the form of a subpoena, then it is extremely serious.  If any FBI agent or OIG special agent is involved in it, then it is extremely serious.  In any of these three cases, an experienced health attorney should be retained immediately.

Even on a “routine” audit, given the possible consequences, we recommend you immediately retain the services of an experienced health attorney to guide you through the audit process, to communicate with the auditors, and to be prepared if it is necessary to challenge the audit findings.

These are some of the items actions we recommend you take and which we take in representing a physician or other health provider in responding to a Medicare audit.

1. All correspondence from Medicare, or the Medicare contractor, should be taken seriously.  Avoid the temptation to consider the request from Medicare, or the Medicare contractor, just another medical records request.  Avoid the temptation to delegate this as a routine matter to an administrative employee.

2. Read the audit letter carefully and provide all the information requested in the letter.  In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you.

3. Include a copy of the complete record and not just those from the dates of service requested in the audit letter.  Include any diagnostic tests and other documents from the chart that support the services provided.  Many practices document the medications and immunizations given to the patient in a separate part of the chart and not in the progress notes; all documents, the complete record, should be provided to the auditor.  Remember that even other physicians records obtained as history, including reports, consultants and records from other physicians or hospitals, should also be included.  Consent forms, medical history questionnaires, histories, physicals, other physicians’ orders, all may be a crucial part of the record and should be included.  If hospital or nursing home discharge orders or other orders referred the patient to you, obtain these to provide to the auditors.

4. Make sure all the medical records are legible and legibly copied.  If the record is not legible, have the illegible record transcribed and include the transcription along with the hand-written or illegible records.  Make sure than any such transcriptions are clearly marked as a transcription with the current date it is actually transcribed.  Label it accurately.  Do not allow any room for there to be any confusion that the newly transcribed part was part of the original record.

5. If your practice involves taking or interpreting x-rays or other diagnostic studies, include these studies.  They are part of the patient’s record.  If the x-rays are digital, they can be submitted on a compact disc (CD).

6. Never alter the medical records after a notice of an audit.  However, if there are consults, orders, test reports, prescriptions, etc., that have not been filed into the chart, yet, have these filed into it, as you normally would, so that the record is complete.  Altering a medical record can be the basis for a fraud claim including criminal penalties.

7. Make sure each page of the record is copied correctly and completely.  If the copy of the record has missing information because it was cut off, the original needs to be recopied to ensure it includes all the information.  Don’t submit copies that have edges cut off, have bottom margins cut off, are copied slanted on the page, or for which the reverse side is not copied.  Reduce the copied image to 96% if necessary to prevent edges and margins from being cut off.

8. Make color copies of medical records when the original record includes different colored ink of significance.  Colors other than blue and black rarely copy well and may be illegible on standard photocopiers.

9. Include a brief summary of the care provided to the patient with each record.  The summary is not a substitute for the medical records, but will assist an auditor that may not be experienced in a particular specialty or practice area.  Make sure that any such summaries are clearly marked as summaries with the current date they are actually prepared.  Label it accurately.  Do not allow any room for there to be any confusion that this new portion was part of the original record.

10. Include an explanatory note and any supporting medical literature, clinical practice guidelines, local coverage determinations (LCDs), medical/dental journal articles, or other documents to support any unusual procedures or billings, or to explain missing record entries.  See item 9 immediately above.

11. When receiving a notice of a Medicare audit, time is of the essence.  Be sure to calendar the date that the records need to be in to the auditor and have the records there by that date.  Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be at the auditor’s office.

12. Any telephone communication with the auditor should be followed up with a letter confirming the telephone conference.

13. Send all communications to the auditor by certified mail (or express mail), return receipt requested so you have proof of delivery.

14. Properly each copy of each medical record you provide and page number everything you provide the auditors, by hand, if necessary. Medical record copies often get shuffled or portions lost or damaged during copying, storage, scanning or transmission.

15. Keep complete, legible copies of all correspondence and every document you provide.  When we provide records to a Medicare auditor, we make a complete copy for the auditor, for the client, for us (legal counsel) and two for your future expert witnesses (to challenge any audit results) to use.

16. Consult an experienced health law attorney early in the audit process to assist in preparing the response.

The above check list is by no means comprehensive.  Nor do we mean to suggest that you should respond on your own.  The above is illustrative of the many actions that should be taken to help protect your interests when you are subjected to a Medicare audit.

Visit our website at www.TheHealthLawFirm.com for more information on Medicare audits, ZPIC audits, health care subpoenas, Medicare and Medicaid search warrants and Medicare and other federal administrative hearings.

New Hampshire City Auditing Ambulance Service for Allegedly Overbilling

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

On July 16, 2012, a New Hampshire city allegedly launched an audit into its primary ambulance service, American Medical Response (AMR), after the company acknowledged overbilling hundreds of patients since 2011, according to a Union Leader article.

AMR Allegedly Incorrectly Billed More Than 300 Ambulance Trips.

According to the report, an in-house audit by the city showed that 323 ambulance trips out of nearly 5,000 in 2011 and 2012 had been incorrectly billed. This amounts to slightly more than six percent (6%). AMR attributes the overbilling to human error.

After concerns that the billing problems could be more widespread, it was decided the ambulance service should be audited by an independent auditor.

AMR is reported to have forgiven any outstanding incorrect balances and issued $16,000 in refunds to patients who had already paid the incorrect bills.

Patients’ Bills Allegedly Exceeded the Amount AMR was Authorized to Charge.

Residents describe a common bill for ambulance transportation to be more than $1,000 for a single ambulance trip, which is approximately sixty-six percent (66%) more than AMR is authorized to charge under its contract with the city.

The city began its contract with AMR in January 2011, after the city’s previous ambulance service went out of business. The city’s fire chief said that under AMR’s contract, the company cannot charge more than thirty-five (35%) above the Medicare rate.

AMR is allegedly cooperating in the review, but the audit will take about a month to complete.

Ambulance Services Companies Are Easy Targets for Medicare Audits.

Recently, ambulance service companies have become the target of Medicare audits and are frequently accused of billing Medicare for unnecessary services. Medicare and Medicaid audits can result in overpayment demands reaching into hundreds of thousands of dollars and assessment of fines. Ambulance services were included in the Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) work plan for fiscal year 2012 as an area that would be subject to scrutiny. Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) are launching audits of ambulance service providers and emergency medical transportation companies.

Contact Health Law Attorneys Experienced in Handling Medicare Audits.

Medicare fraud is a serious crime and is vigorously investigated by the FBI and the U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG). Don’t wait until its 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.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, ambulance services companies, 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.

Sources:

Siefer, Ted. “Independent audit begins on Manchester ambulance service billing.” Union Leader. (July 23, 2012). From: http://www.unionleader.com/article/20120724/NEWS06/707249979

Siefer, Ted. “City will conduct audit ambulance service over overbilling.” New Hampshire.com. (July 28, 2012). From: http://www.newhampshire.com/article/20120729/NEWS0603/707299953/1007

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.

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