audit | The Health Law Firm Blog

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

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

OUTCOME: […]

By The Health Law Firm|2024-03-14T10:00:55-04:00June 1, 2018|Administrative law, Assisted Living Facilities, Medicaid, Medicaid audit, The Health Law Firm Blog|

OIG Audit Finds Federal Database of Terminated Medicaid Providers Needs Improvement

By Lenis L. Archer, J.D., M.P.H., The Health Law Firm

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

The MCSIS is supposed to collect data from every state Medicaid program on providers that were terminated […]

By The Health Law Firm|2024-03-14T10:00:56-04:00June 1, 2018|Department of Health, Health Care Industry, MCSIS, Medicaid, Medicaid audit, Our Firm, The Health Law Firm Blog|

Are You Ready for HIPAA and HITECH Audits?

The Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) is launching a pilot program this month to make sure covered entities are in compliance with HIPAA privacy and security rules and breach notification standards, according to the OCR. The OCR will perform up to 150 audits to assess HIPAA compliance.

The HITECH Act requires HHS to perform periodic audits to check for HIPAA compliance. The audits will be conducted from November 2011 through December 2012. Initially these audits will likely focus on hospitals and insurance companies, but HMEs could also be a target.

Though early audits are likely to be educational, in order to get a […]

By The Health Law Firm|2024-03-14T10:00:27-04:00June 1, 2018|Health Care Industry, HIPAA, Hitech Act, The Health Law Firm Blog|

WellCare Health Plans Reaches Settlement in False Claims Act Case

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

WellCare Health Plans Inc.(WellCare) has reached a $137.5 million settlement with the federal government and nine states. The settlement resolves four lawsuits alleging violations of the False Claims Act.

WellCare is based in Tampa, Florida. The company provides managed health care services for approximately 2.6 million Medicare and Medicaid beneficiaries across the United States.

Lawsuits Allege WellCare Submitted False Claims to Medicare, Medicaid Programs.

The lawsuits allege that WellCare submitted false claims to Medicare and Medicaid programs. WellCare allegedly falsely inflated the amount it claimed to be spending on medical care. Allegedly, this was done in order […]

By The Health Law Firm|2024-03-14T10:00:32-04:00June 1, 2018|Medicaid, Medicare, The Health Law Firm Blog|

Settlement Reached in GlaxoSmithKline Healthcare Fraud Case

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

GlaxoSmithKline (GSK), a prescription drug manufacturer, will pay $3 billion in fines to resolve allegations of healthcare fraud. The settlement was announced by federal prosecutors on July 1, 2012, and in a press release from the Florida Attorney General on July 2, 2012. This is the largest healthcare fraud settlement in U.S. history.

Settlement Resolves Allegations Against GSK Related to Healthcare Fraud.

The settlement resolves allegations that GSK:

Marketed the depression drug Paxil for off-label uses, such as use by children and adolescents;
Marketed the depression drug Wellbutrin for off-label uses, such as for […]

By The Health Law Firm|2024-03-14T10:00:32-04:00June 1, 2018|In the News, The Health Law Firm Blog|

Whistleblower Lawsuit Alleges Florida Adventist Hospitals Overbilled Millions of Dollars

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

A whistleblower lawsuit based on information from a former Florida Hospital Orlando billing employee and a former staff physician alleges that seven of Adventist’s Florida hospitals overbilled the federal government between 1995 and 2009, resulting in tens of millions of dollars in false or padded medical claims, according to an article in the Orlando Sentinel and other sources.

To read the entire False Claims Act complaint filed, click here.

Hospital Allegedly Used Improper Coding to Overbill Medicare, Medicaid and Tricare.

The suit claims that seven Adventist Florida hospitals […]

By The Health Law Firm|2024-03-14T10:00:35-04:00June 1, 2018|In the Know, In the News, Medicaid audit, Medicare, The Health Law Firm Blog, Whistleblower|

Office of Inspector General (OIG) Scrutinizes Billing at South Florida Mental Health Clinics

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

On August 16, 2012, the Office of Inspector General (OIG) released a report on questionable billing by mental health centers. The report focuses on the nation’s mental health clinics that overbilled Medicare in 2010, some by tens of millions of dollars. The majority of these clinics were located in South Florida, Texas and Louisiana.

To see the full report from the OIG, click here.

Two Big Busts in Florida Mental Health Clinics for Medicare Fraud.

According to an article in the […]

By The Health Law Firm|2024-03-14T10:00:36-04:00June 1, 2018|In the News, Medicare, Medicare Audit, Mental Health, The Health Law Firm Blog|

Hospice of the Comforter Inc., Faces Whistleblower Lawsuit

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

On September 6, 2012, the Department of Justice (DOJ) announced it will join in a whistleblower lawsuit alleging false Medicare billings against Hospice of the Comforter Inc., (HOTCI). The hospice is located in Altamonte Springs, a suburb of the Orlando area, and provides hospice services to local patients.

To read the entire whistleblower complaint filed, click here.

Allegations in the Lawsuit Against HOTCI.

According to the DOJ, the lawsuit was filed by the former vice president of finance for HOTCI. The case alleges HOTCI submitted false claims to […]

By The Health Law Firm|2024-03-14T10:00:36-04:00June 1, 2018|Health Care Industry, In the Know, In the News, Medicare, Medicare Audit, The Health Law Firm Blog, Whistleblower|

Whistleblower Lawsuit Alleging Medicare Fraud Against Blackstone Medical, Inc., Dismissed

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

A whistleblower lawsuit against Blackstone Medical, Inc., alleging Medicare fraud against Parrish Medical Center, was dismissed by a U.S. District Judge in Tampa, Florida, on August 15, 2012. According to Orthopedics This Week, the case was unsealed on August 8, 2012, but dismissed without prejudice, all pending motions were denied as moot, and the clerk was directed to close the case, just one week after.

To see a copy of the order of dismissal, click here.

Whistleblower Originally Filed False Claims and Kickback Complaint.

According to the […]

By The Health Law Firm|2024-03-14T10:00:37-04:00June 1, 2018|Medicare, Medicare Fraud, The Health Law Firm Blog, Whistleblower|

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 […]

By The Health Law Firm|2024-03-14T10:00:38-04:00June 1, 2018|In the Know, Medicare, Medicare Audit, The Health Law Firm Blog|