The Biggest Healthcare Fraud Case Ever Prosecuted in 2019: Big Surprise! Florida Wins!

George Indest HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
For years, Florida has topped the lists with the highest rates of Medicare and Medicaid fraud and abuse. But even by the standards of Florida’s rampant healthcare fraud, this 2019 case stands out for its sheer size, making Florida, once again, the leader in fakes and frauds. Often joked and written about by Florida novelists such as Carl Hiassin and Tim Dorsey, this case serves to highlight why the “Debtor’s Haven” state often excels in cases of healthcare fraud.

In April 2019, after decades of alleged schemes, illegal kickbacks and money laundering in connection with fraudulent claims to Medicare and Medicaid, Phillip Esformes was sentenced to 20 years in prison. He was also ordered to pay $44.2 million in money forfeitures and restitution, and forfeiture of his ownership interests in several skilled nursing homes.

A federal district judge sentenced the South Florida health care facility owner after he was found guilty in the largest health care fraud scheme ever charged by the U.S. Justice Department (DOJ).

A Case of “Epic” Fraud.

The nursing home mogul was accused of paying bribes and receiving kickbacks in a massive $1 billion Medicare fraud case touted by federal prosecutors as the largest in the nation. During an eight-week jury trial, prosecutors argued that Esformes himself made $38 million from Medicare and Medicaid payments between 2010 and 2016. Additionally, his South Florida network received more than $450 million through bribes and though services that weren’t medically necessary or which were never provided, according to the prosecution’s case.

To learn more about this case, click here to read one of my prior blogs.

Convicted, But Not of Healthcare Fraud.

The shocker, in this case, is that the federal jury convicted Esformes on 20 counts of conspiracy to defraud the taxpayer-funded Medicare program. The lack of a conviction for healthcare fraud itself was puzzling. Many of his alleged co-conspirators had already pled guilty to health care fraud and some had even testified against him at trial. To learn more, click here to read one of my prior blogs on another individual involved in the case.

Despite being billed as the largest healthcare fraud case prosecuted in U.S. history, it is also a stark reminder to prosecutors of how tricky it can be to secure a conviction on any particular charge.

To read the DOJ’s press release about this case in full, click here.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare and Medicaid audits, and in ZPIC and RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, recovery actions and administrative actions seeking termination from Medicare and Medicaid Programs.

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

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


Sources:

Weaver, Jay. “Miami healthcare exec Esformes sentenced to 20 years in biggest Medicare fraud case.” Miami Herald. (September 12, 2019). Web.

Hale, Nathan. “The Biggest Stories In Florida Legal News Of 2019.” Law360. (December 20, 2019). Web.

Jackson, David. “Nursing home mogul Philip Esformes sentenced to 20 years for $1.3 billion Medicaid fraud.” Chicago Tribune. (September 13, 2019). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Medicare and Medicaid fraud defense attorney, legal representation for Medicare and Medicaid fraud defense, Medicare and Medicaid fraud defense legal counsel, Medicare and Medicaid fraud defense lawyer, defense of Medicare and Medicaid fraud charges, CMS, ZPIC and RAC audit defense attorney, CMS, ZPIC and RAC audit defense lawyer, CMS, ZPIC and RAC audit legal representation, Medicaid Fraud Control Unit (MFCU) defense attorney, health care clinic fraud audit, Medicaid Fraud Control Unit (MFCU) defense lawyer, Medicaid Fraud Control Unit (MFCU) defense legal counsel, Medicaid Fraud Control Unit (MFCU) subpoena defense attorney, Medicaid Fraud Control Unit (MFCU) subpoena legal representation, Medicaid Fraud Control Unit (MFCU) subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense attorney, OIG, HHS, DOJ and U.S. Attorney subpoena legal representation, legal representation for allegations of Medicare fraud, legal representation for health care fraud, healthcare fraud defense attorney, healthcare fraud defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney, healthcare fraud defense legal representation, legal representation for submitting false claims, false claims defense lawyer, false claims legal defense representation, false claims defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, Department of Justice (DOJ) investigation defnse, DOJ defense representation, False Claims Act (FCA) legal defense attorney lawyer, False Claims Act (FCA) defense legal representation counsel, Anti-Kickback Statute (AKS) defense attorney, AKS legal defense representation, AKS defense lawyer

“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 © 2019/2020 The Health Law Firm. All rights reserved.

2019-12-30T19:48:35-05:00March 23rd, 2020|Categories: Dental Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Taking a Look at 2019’s Largest Healthcare Fraud Case Ever Prosecuted

George Indest HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
For years, Florida has topped the lists with the highest rates of Medicare and Medicaid fraud and abuse. But even by the standards of Florida’s rampant healthcare fraud, this 2019 case stands out for its sheer size, making Florida, once again, the leader in fakes and frauds. Often joked and written about by Florida novelists such as Carl Hiassin and Tim Dorsey, this case serves to highlight why the “Debtor’s Haven” state often excels in cases of healthcare fraud.

In April 2019, after decades of alleged schemes, illegal kickbacks and money laundering in connection with fraudulent claims to Medicare and Medicaid, Phillip Esformes was sentenced to 20 years in prison. He was also ordered to pay $44.2 million in money forfeitures and restitution, and forfeiture of his ownership interests in several skilled nursing homes.

A federal district judge sentenced the South Florida health care facility owner after he was found guilty in the largest health care fraud scheme ever charged by the U.S. Justice Department (DOJ).

A Case of “Epic” Fraud.

The nursing home mogul was accused of paying bribes and receiving kickbacks in a massive $1 billion Medicare fraud case touted by federal prosecutors as the largest in the nation. During an eight-week jury trial, prosecutors argued that Esformes himself made $38 million from Medicare and Medicaid payments between 2010 and 2016. Additionally, his South Florida network received more than $450 million through bribes and though services that weren’t medically necessary or which were never provided, according to the prosecution’s case.

To learn more about this case, click here to read one of my prior blogs.

Convicted, But Not of Healthcare Fraud.

The shocker, in this case, is that the federal jury convicted Esformes on 20 counts of conspiracy to defraud the taxpayer-funded Medicare program. The lack of a conviction for healthcare fraud itself was puzzling. Many of his alleged co-conspirators had already pled guilty to health care fraud and some had even testified against him at trial. To learn more, click here to read one of my prior blogs on another individual involved in the case.

Despite being billed as the largest healthcare fraud case prosecuted in U.S. history, it is also a stark reminder to prosecutors of how tricky it can be to secure a conviction on any particular charge.

To read the DOJ’s press release about this case in full, click here.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare and Medicaid audits, and in ZPIC and RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, recovery actions and administrative actions seeking termination from Medicare and Medicaid Programs.

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

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


Sources:

Weaver, Jay. “Miami healthcare exec Esformes sentenced to 20 years in biggest Medicare fraud case.” Miami Herald. (September 12, 2019). Web.

Hale, Nathan. “The Biggest Stories In Florida Legal News Of 2019.” Law360. (December 20, 2019). Web.

Jackson, David. “Nursing home mogul Philip Esformes sentenced to 20 years for $1.3 billion Medicaid fraud.” Chicago Tribune. (September 13, 2019). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Medicare and Medicaid fraud defense attorney, legal representation for Medicare and Medicaid fraud defense, Medicare and Medicaid fraud defense legal counsel, Medicare and Medicaid fraud defense lawyer, defense of Medicare and Medicaid fraud charges, CMS, ZPIC and RAC audit defense attorney, CMS, ZPIC and RAC audit defense lawyer, CMS, ZPIC and RAC audit legal representation, Medicaid Fraud Control Unit (MFCU) defense attorney, health care clinic fraud audit, Medicaid Fraud Control Unit (MFCU) defense lawyer, Medicaid Fraud Control Unit (MFCU) defense legal counsel, Medicaid Fraud Control Unit (MFCU) subpoena defense attorney, Medicaid Fraud Control Unit (MFCU) subpoena legal representation, Medicaid Fraud Control Unit (MFCU) subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense attorney, OIG, HHS, DOJ and U.S. Attorney subpoena legal representation, legal representation for allegations of Medicare fraud, legal representation for health care fraud, healthcare fraud defense attorney, healthcare fraud defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney, healthcare fraud defense legal representation, legal representation for submitting false claims, false claims defense lawyer, false claims legal defense representation, false claims defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, Department of Justice (DOJ) investigation defnse, DOJ defense representation, False Claims Act (FCA) legal defense attorney lawyer, False Claims Act (FCA) defense legal representation counsel, Anti-Kickback Statute (AKS) defense attorney, AKS legal defense representation, AKS defense lawyer

“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 © 2019/2020 The Health Law Firm. All rights reserved.

2019-12-30T19:44:19-05:00March 6th, 2020|Categories: Nursing Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Taking a Looking at 2019’s Largest Healthcare Fraud Case Ever Prosecuted: No Surprise, Florida Wins!

George Indest HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
For years, Florida has topped the lists with the highest rates of Medicare and Medicaid fraud and abuse. But even by the standards of Florida’s rampant healthcare fraud, this 2019 case stands out for its sheer size, making Florida, once again, the leader in fakes and frauds. Often joked and written about by Florida novelists such as Carl Hiassin and Tim Dorsey, this case serves to highlight why the “Debtor’s Haven” state often excels in cases of healthcare fraud.

In April 2019, after decades of alleged schemes, illegal kickbacks and money laundering in connection with fraudulent claims to Medicare and Medicaid, Phillip Esformes was sentenced to 20 years in prison. He was also ordered to pay $44.2 million in money forfeitures and restitution, and forfeiture of his ownership interests in several skilled nursing homes.

A federal district judge sentenced the South Florida health care facility owner after he was found guilty in the largest health care fraud scheme ever charged by the U.S. Justice Department (DOJ).

A Case of “Epic” Fraud.

The nursing home mogul was accused of paying bribes and receiving kickbacks in a massive $1 billion Medicare fraud case touted by federal prosecutors as the largest in the nation. During an eight-week jury trial, prosecutors argued that Esformes himself made $38 million from Medicare and Medicaid payments between 2010 and 2016. Additionally, his South Florida network received more than $450 million through bribes and though services that weren’t medically necessary or which were never provided, according to the prosecution’s case.

To learn more about this case, click here to read one of my prior blogs.

Convicted, But Not of Healthcare Fraud.

The shocker, in this case, is that the federal jury convicted Esformes on 20 counts of conspiracy to defraud the taxpayer-funded Medicare program. The lack of a conviction for healthcare fraud itself was puzzling. Many of his alleged co-conspirators had already pled guilty to health care fraud and some had even testified against him at trial. To learn more, click here to read one of my prior blogs on another individual involved in the case.

Despite being billed as the largest healthcare fraud case prosecuted in U.S. history, it is also a stark reminder to prosecutors of how tricky it can be to secure a conviction on any particular charge.

To read the DOJ’s press release about this case in full, click here.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare and Medicaid audits, and in ZPIC and RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, recovery actions and administrative actions seeking termination from Medicare and Medicaid Programs.

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

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


Sources:

Weaver, Jay. “Miami healthcare exec Esformes sentenced to 20 years in biggest Medicare fraud case.” Miami Herald. (September 12, 2019). Web.

Hale, Nathan. “The Biggest Stories In Florida Legal News Of 2019.” Law360. (December 20, 2019). Web.

Jackson, David. “Nursing home mogul Philip Esformes sentenced to 20 years for $1.3 billion Medicaid fraud.” Chicago Tribune. (September 13, 2019). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Medicare and Medicaid fraud defense attorney, legal representation for Medicare and Medicaid fraud defense, Medicare and Medicaid fraud defense legal counsel, Medicare and Medicaid fraud defense lawyer, defense of Medicare and Medicaid fraud charges, CMS, ZPIC and RAC audit defense attorney, CMS, ZPIC and RAC audit defense lawyer, CMS, ZPIC and RAC audit legal representation, Medicaid Fraud Control Unit (MFCU) defense attorney, health care clinic fraud audit, Medicaid Fraud Control Unit (MFCU) defense lawyer, Medicaid Fraud Control Unit (MFCU) defense legal counsel, Medicaid Fraud Control Unit (MFCU) subpoena defense attorney, Medicaid Fraud Control Unit (MFCU) subpoena legal representation, Medicaid Fraud Control Unit (MFCU) subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense attorney, OIG, HHS, DOJ and U.S. Attorney subpoena legal representation, legal representation for allegations of Medicare fraud, legal representation for health care fraud, healthcare fraud defense attorney, healthcare fraud defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney, healthcare fraud defense legal representation, legal representation for submitting false claims, false claims defense lawyer, false claims legal defense representation, false claims defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, Department of Justice (DOJ) investigation defnse, DOJ defense representation, False Claims Act (FCA) legal defense attorney lawyer, False Claims Act (FCA) defense legal representation counsel, Anti-Kickback Statute (AKS) defense attorney, AKS legal defense representation, AKS defense lawyer

“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 © 2019/2020 The Health Law Firm. All rights reserved.

2019-12-30T19:40:55-05:00February 24th, 2020|Categories: Mental Health Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

One of 2019’s Largest Healthcare Fraud Case Ever: No Surprise, Florida Wins!

George Indest HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
For years, Florida has topped the lists with the highest rates of Medicare and Medicaid fraud and abuse. But even by the standards of Florida’s rampant healthcare fraud, this 2019 case stands out for its sheer size, making Florida, once again, the leader in fakes and frauds. Often joked and written about by Florida novelists such as Carl Hiassin and Tim Dorsey, this case serves to highlight why the “Debtor’s Haven” state often excels in cases of healthcare fraud.

In April 2019, after decades of alleged schemes, illegal kickbacks and money laundering in connection with fraudulent claims to Medicare and Medicaid, Phillip Esformes was sentenced to 20 years in prison. He was also ordered to pay $44.2 million in money forfeitures and restitution, and forfeiture of his ownership interests in several skilled nursing homes.

A federal district judge sentenced the South Florida health care facility owner after he was found guilty in the largest health care fraud scheme ever charged by the U.S. Justice Department (DOJ).

A Case of “Epic” Fraud.

The nursing home mogul was accused of paying bribes and receiving kickbacks in a massive $1 billion Medicare fraud case touted by federal prosecutors as the largest in the nation. During an eight-week jury trial, prosecutors argued that Esformes himself made $38 million from Medicare and Medicaid payments between 2010 and 2016. Additionally, his South Florida network received more than $450 million through bribes and though services that weren’t medically necessary or which were never provided, according to the prosecution’s case.

To learn more about this case, click here to read one of my prior blogs.

Convicted, But Not of Healthcare Fraud.

The shocker, in this case, is that the federal jury convicted Esformes on 20 counts of conspiracy to defraud the taxpayer-funded Medicare program. The lack of a conviction for healthcare fraud itself was puzzling. Many of his alleged co-conspirators had already pled guilty to health care fraud and some had even testified against him at trial. To learn more, click here to read one of my prior blogs on another individual involved in the case.

Despite being billed as the largest healthcare fraud case prosecuted in U.S. history, it is also a stark reminder to prosecutors of how tricky it can be to secure a conviction on any particular charge.

To read the DOJ’s press release about this case in full, click here.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare and Medicaid audits, and in ZPIC and RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, recovery actions and administrative actions seeking termination from Medicare and Medicaid Programs.

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

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


Sources:

Weaver, Jay. “Miami healthcare exec Esformes sentenced to 20 years in biggest Medicare fraud case.” Miami Herald. (September 12, 2019). Web.

Hale, Nathan. “The Biggest Stories In Florida Legal News Of 2019.” Law360. (December 20, 2019). Web.

Jackson, David. “Nursing home mogul Philip Esformes sentenced to 20 years for $1.3 billion Medicaid fraud.” Chicago Tribune. (September 13, 2019). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Medicare and Medicaid fraud defense attorney, legal representation for Medicare and Medicaid fraud defense, Medicare and Medicaid fraud defense legal counsel, Medicare and Medicaid fraud defense lawyer, defense of Medicare and Medicaid fraud charges, CMS, ZPIC and RAC audit defense attorney, CMS, ZPIC and RAC audit defense lawyer, CMS, ZPIC and RAC audit legal representation, Medicaid Fraud Control Unit (MFCU) defense attorney, health care clinic fraud audit, Medicaid Fraud Control Unit (MFCU) defense lawyer, Medicaid Fraud Control Unit (MFCU) defense legal counsel, Medicaid Fraud Control Unit (MFCU) subpoena defense attorney, Medicaid Fraud Control Unit (MFCU) subpoena legal representation, Medicaid Fraud Control Unit (MFCU) subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense attorney, OIG, HHS, DOJ and U.S. Attorney subpoena legal representation, legal representation for allegations of Medicare fraud, legal representation for health care fraud, healthcare fraud defense attorney, healthcare fraud defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney, healthcare fraud defense legal representation, legal representation for submitting false claims, false claims defense lawyer, false claims legal defense representation, false claims defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, Department of Justice (DOJ) investigation defnse, DOJ defense representation, False Claims Act (FCA) legal defense attorney lawyer, False Claims Act (FCA) defense legal representation counsel, Anti-Kickback Statute (AKS) defense attorney, AKS legal defense representation, AKS defense lawyer

“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 © 2019/2020 The Health Law Firm. All rights reserved.

2019-12-30T19:35:03-05:00February 10th, 2020|Categories: Health Facilities Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

2019’s Largest Healthcare Fraud Case Ever Prosecuted: No Surprise, Florida Wins!

George Indest HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
For years, Florida has topped the lists with the highest rates of Medicare and Medicaid fraud and abuse. But even by the standards of Florida’s rampant healthcare fraud, this 2019 case stands out for its sheer size, making Florida, once again, the leader in fakes and frauds. Often joked and written about by Florida novelists such as Carl Hiassin and Tim Dorsey, this case serves to highlight why the “Debtor’s Haven” state often excels in cases of healthcare fraud.

In April 2019, after decades of alleged schemes, illegal kickbacks and money laundering in connection with fraudulent claims to Medicare and Medicaid, Phillip Esformes was sentenced to 20 years in prison. He was also ordered to pay $44.2 million in money forfeitures and restitution, and forfeiture of his ownership interests in several skilled nursing homes.

A federal district judge sentenced the South Florida health care facility owner after he was found guilty in the largest health care fraud scheme ever charged by the U.S. Justice Department (DOJ).

A Case of “Epic” Fraud.

The nursing home mogul was accused of paying bribes and receiving kickbacks in a massive $1 billion Medicare fraud case touted by federal prosecutors as the largest in the nation. During an eight-week jury trial, prosecutors argued that Esformes himself made $38 million from Medicare and Medicaid payments between 2010 and 2016. Additionally, his South Florida network received more than $450 million through bribes and though services that weren’t medically necessary or which were never provided, according to the prosecution’s case.

To learn more about this case, click here to read one of my prior blogs.

Convicted, But Not of Healthcare Fraud.

The shocker, in this case, is that the federal jury convicted Esformes on 20 counts of conspiracy to defraud the taxpayer-funded Medicare program. The lack of a conviction for healthcare fraud itself was puzzling. Many of his alleged co-conspirators had already pled guilty to health care fraud and some had even testified against him at trial. To learn more, click here to read one of my prior blogs on another individual involved in the case.

Despite being billed as the largest healthcare fraud case prosecuted in U.S. history, it is also a stark reminder to prosecutors of how tricky it can be to secure a conviction on any particular charge.

To read the DOJ’s press release about this case in full, click here.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare and Medicaid audits, and in ZPIC and RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, recovery actions and administrative actions seeking termination from Medicare and Medicaid Programs.

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

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


Sources:

Weaver, Jay. “Miami healthcare exec Esformes sentenced to 20 years in biggest Medicare fraud case.” Miami Herald. (September 12, 2019). Web.

Hale, Nathan. “The Biggest Stories In Florida Legal News Of 2019.” Law360. (December 20, 2019). Web.

Jackson, David. “Nursing home mogul Philip Esformes sentenced to 20 years for $1.3 billion Medicaid fraud.” Chicago Tribune. (September 13, 2019). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Medicare and Medicaid fraud defense attorney, legal representation for Medicare and Medicaid fraud defense, Medicare and Medicaid fraud defense legal counsel, Medicare and Medicaid fraud defense lawyer, defense of Medicare and Medicaid fraud charges, CMS, ZPIC and RAC audit defense attorney, CMS, ZPIC and RAC audit defense lawyer, CMS, ZPIC and RAC audit legal representation, Medicaid Fraud Control Unit (MFCU) defense attorney, health care clinic fraud audit, Medicaid Fraud Control Unit (MFCU) defense lawyer, Medicaid Fraud Control Unit (MFCU) defense legal counsel, Medicaid Fraud Control Unit (MFCU) subpoena defense attorney, Medicaid Fraud Control Unit (MFCU) subpoena legal representation, Medicaid Fraud Control Unit (MFCU) subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense lawyer, OIG, HHS, DOJ and U.S. Attorney subpoena defense attorney, OIG, HHS, DOJ and U.S. Attorney subpoena legal representation, legal representation for allegations of Medicare fraud, legal representation for health care fraud, healthcare fraud defense attorney, healthcare fraud defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney, healthcare fraud defense legal representation, legal representation for submitting false claims, false claims defense lawyer, false claims legal defense representation, false claims defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, Department of Justice (DOJ) investigation defnse, DOJ defense representation, False Claims Act (FCA) legal defense attorney lawyer, False Claims Act (FCA) defense legal representation counsel, Anti-Kickback Statute (AKS) defense attorney, AKS legal defense representation, AKS defense lawyer

“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 © 2019/2020 The Health Law Firm. All rights reserved.

2020-01-23T17:31:06-05:00January 27th, 2020|Categories: Pharmacy Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Looking Back at 2019’s Largest Healthcare Fraud Case Ever Prosecuted: Surprise! No Surprise, Florida Wins!

George Indest HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
For years, Florida has topped the lists with the highest rates of Medicare and Medicaid fraud and abuse. But even by the standards of Florida’s rampant healthcare fraud, this 2019 case stands out for its sheer size, making Florida, once again, the leader in fakes and frauds. Often joked and written about by Florida novelists such as Carl Hiassin and Tim Dorsey, this case serves to highlight why the “Debtor’s Haven” state often excels in cases of healthcare fraud.

In April 2019, after decades of alleged schemes, illegal kickbacks and money laundering in connection with fraudulent claims to Medicare and Medicaid, Phillip Esformes was sentenced to 20 years in prison. He was also ordered to pay $44.2 million in money forfeitures and restitution, and forfeiture of his ownership interests in several skilled nursing homes.

A federal district judge sentenced the South Florida health care facility owner after he was found guilty in the largest health care fraud scheme ever charged by the U.S. Justice Department (DOJ).

A Case of “Epic” Fraud.

The nursing home mogul was accused of paying bribes and receiving kickbacks in a massive $1 billion Medicare fraud case touted by federal prosecutors as the largest in the nation. During an eight-week jury trial, prosecutors argued that Esformes himself made $38 million from Medicare and Medicaid payments between 2010 and 2016. Additionally, his South Florida network received more than $450 million through bribes and though services that weren’t medically necessary or which were never provided, according to the prosecution’s case.

To learn more about this case, click here to read one of my prior blogs.

Convicted, But Not of Healthcare Fraud.

The shocker, in this case, is that the federal jury convicted Esformes on 20 counts of conspiracy to defraud the taxpayer-funded Medicare program. The lack of a conviction for healthcare fraud itself was puzzling. Many of his alleged co-conspirators had already pled guilty to health care fraud and some had even testified against him at trial. To learn more, click here to read one of my prior blogs on another individual involved in the case.

Despite being billed as the largest healthcare fraud case prosecuted in U.S. history, it is also a stark reminder to prosecutors of how tricky it can be to secure a conviction on any particular charge.

To read the DOJ’s press release about this case in full, click here.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare and Medicaid audits, and in ZPIC and RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, recovery actions and administrative actions seeking termination from Medicare and Medicaid Programs.

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

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


Sources:

Weaver, Jay. “Miami healthcare exec Esformes sentenced to 20 years in biggest Medicare fraud case.” Miami Herald. (September 12, 2019). Web.

Hale, Nathan. “The Biggest Stories In Florida Legal News Of 2019.” Law360. (December 20, 2019). Web.

Jackson, David. “Nursing home mogul Philip Esformes sentenced to 20 years for $1.3 billion Medicaid fraud.” Chicago Tribune. (September 13, 2019). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
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Helpful Tips to Speed Up the Medicare Prepayment Review Process

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

For Medicare providers, being notified of an impending audit is not welcome news. Being notified of a prepayment review is even worse. In a prepayment review, the health care provider must submit documentation to the Centers for Medicare & Medicaid Services (CMS) contractor before ever receiving payment. The health care provider will only receive payment (typically months later) if the contractor is satisfied with the provider’s documentation. This can be financially disastrous for the health care provider, who still must pay day-to-day expenses while waiting for a decision.

CMS Contractors.

If you have received notice of prepayment review, you first need to determine the contractor that has initiated the review. CMS contracts with four types of contractors:

– Medicare Administrative Contractors (MACs);
– Comprehensive Error Rate Testing (CERT) contractors;
– Recovery Audit Contractors (RACs); and
– Zone Program Integrity Contractors (ZPICs).

Both the Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) can initiate prepayment reviews.

MAC Prepayment Reviews.

MACs will initiate prepayment reviews of health care providers suspected of improper billing for services. If the MAC detects anything resembling fraud during the process, the prepayment review can extend for up to a year or more. However, MACs will generally terminate the prepayment review when the health care provider demonstrates a pattern of correct billing. Health care providers who are notified of a MAC prepayment review should consult with an experienced health care attorney from the beginning of the process. An experienced health attorney will be able to assist the health care provider to ensure everything is in place for a speedy prepayment review.

ZPIC Prepayment Reviews.

A MAC may refer a health care provider to a ZPIC for a benefit integrity prepayment review if they suspect fraud. A ZPIC can also initiate a benefit integrity prepayment review based on data analysis.  Unlike MACs, ZPICs generally are less willing to communicate with health care providers about the prepayment review.

Additionally, there are different time limitations for a benefit integrity prepayment review. The MAC prepayment review is governed by Medicare Manual provisions that stipulate a maximum length of time on a prepayment review. However, a benefit integrity prepayment review can last indefinitely, if the basis for the review is not timely and properly addressed by the health care provider.

Further, ZPICs make fraud referrals to the Department of Health and Human Services (HHS) Office of the Inspector General (OIG). Thus, health care providers should view ZPIC correspondence as the start of a potentially larger investigation. An experienced health care attorney should be contacted immediately after a health care provider receives any contact from ZPIC.

How to Accomplish a Speedy Review.

In many cases, the health care provider will be on Medicare prepayment review until its billing accuracy reaches a certain percentage. However there are other steps to help speed up the Medicare prepayment audit process.

1.  Read all Correspondence from the Contractor Carefully.

Pay close attention to all correspondence sent by the contractor. Make a note of the due date given and make sure your response is sent well within the time limits. Denials will usually occur if a response is not received by the given deadline. Also be sure that you send your response to the correct office.

2.  Be Familiar with Local Coverage Determinations (LCDs).

You should read and be familiar with any and all applicable local coverage determinations (LCDs) and national coverage determinations (NCDs) for any codes, services, supplies or equipment you are billing.

3.  Contact an Experienced Health Care Attorney Immediately.

A health care attorney who is experienced in prepayment reviews will be able to help you file a proper response in a timely fashion. An attorney will also be able to help find out additional information on why you have been placed on prepayment review and exactly what documentation the auditor is looking for. Alternatively, a health care consultant who has actual experience in working on Medicare cases and who has been an expert witness in Medicare hearings may be able to assist, as well.

4.  Contact the Contractor Responsible for the Review.

After you have consulted with an attorney, schedule a call with the contractor responsible for your prepayment review. During the call learn as many details about the audit as you can and find out what the reviewer wants in the documentation.

However, do not:
a. Argue with the auditor.
b. Berate or demean the auditor.
c. Challenge the auditor’s knowledge, competence or credentials.
d. Ask the auditor to prove anything to you.
e. Demand to speak to the auditor’s supervisor.

5.  Do Not File Duplicate Claims.

Keep track of all requests for additional documentation and when they were received. Do not think that you need to file another claim for the same items just because you have not received a response as quickly as other claims where additional documentation was not requested. If you provide duplicate claims, the contractor’s decision can be delayed.

6.  Organize all Submissions and Results.

You must keep track of the date you receive the document request for a claim, the date you submitted the documentation for review, the result of the audit and the date the result was received. This will help you realize how quickly claims are reviewed. If a one claim’s review has taken longer than the others you’ve submitted, you can contact the reviewer to make sure they have received the claim and everything is in order.

7.  Follow-up with the Contractor for Feedback.

Keep in contact with the contractor throughout the review. This will help to maintain the relationship you initiated after first receiving notice of the prepayment review. This will also help you keep track of any issues and resolve them. Be sure to discuss how you can improve your claim submissions to meet the standards of your particular reviewer.

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 prepayment reviews. 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:

Baird, Jeff. “Q&A with Jeff Baird: How to Prepare for and Survive Prepayment Reviews.” Home Care. (Sept. 13, 2010). From http://homecaremag.com/news/prepayment-review-faq-20100913/

Greene, Stephanie Morgan. “5 Steps to Get Off Pre-Payment Audit – Quickly!” Harrington Managment Group. (Mar. 18, 2011). From
http://homecaremag.com/news/prepayment-review-faq-20100913/

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.

Tag Words: prepayment audit, prepayment review, Medicare audits, Medicare, Centers for Medicare & Medicaid Services, CMS, RAC, Recovery Audit Contractor, ZPIC, Zone Program Integrity Contractor, MAC, Medicare Administrative Contractor, CERT contractor, Comprehensive Error Rate Testing contractor, overpayment, prepayment reviews, First Coast Service Options, Medicare contractor, Medicare fraud, Medicare investigation, Medicare overbilling, OIG

“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 © 2018 The Health Law Firm. All rights reserved.

Internal Revenue Service Decides Electronic Health Record Incentive Payments are Taxable

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The Internal Revenue Service (IRS) has taken the position that electronic health record (EHR) incentive payments are taxable. Previously it was not specified how EHR incentive payments were to be treated or reported to the IRS. On January 14, 2013, the IRS issued guidance on this issue in a memorandum from the Office of Chief Counsel. This memorandum lists tax issues facing those who have received or who will receive EHR incentive payments. It also states the IRS’s position on those issues.

IRS Considered Three Different Issues and Gave its Stance on Each Issue.

In its memorandum, the Office of Chief Counsel considered the following three issues:

1. Whether recipients must include in gross income electronic health record
incentive payments paid by the Centers for Medicare and Medicaid Services
(CMS) pursuant to the American Recovery and Reinvestment Act (ARRA).

2. Whether CMS has a reporting requirement with regard to payments made under the EHR Incentive Program.

3. Whether the reporting requirement is altered if the payment is assigned to a third party.

The Summary of the Office of Chief Counsel’s Position on Each of the Issues.

1. The recipients must include the incentive payments in gross income unless they receive the payments as a conduit or an agent of another and are thus unable to keep the payments.

2. CMS has a reporting requirement under section 6041 of the Internal Revenue Code with respect to the eligible providers.

3. In the event of an assignment by the eligible providers to a third party, CMS would be obligated to report a payment to the eligible provider, even if the payment is assigned to a third party. The eligible provider would then likely bear a reporting obligation with respect to the assignment to a third party. CMS would not have a reporting obligation with respect to the third-party assignee unless CMS exercised managerial oversight with respect to, or had a significant economic interest in, the assignment.

Click here to read the entire memorandum.

Health Care Professionals Be Aware.

According to the IRS, taxpayers cannot avoid tax by turning over income to someone else. For example, a doctor earns an EHR incentive payment and turns it over to his/her practice. That doctor may still have to include the EHR payment on his/her personal tax return. The IRS allows an exception. If the doctor received the payment as an agent of the group practice, the doctor does not have to report it on his/her personal tax return.

Health care professionals and providers who have or will receive EHR incentive payments should plan to deal with the tax consequences of those incentives.

Contact Experienced Health Law Attorneys.

The Health Law Firm routinely represents physicians and medical groups on EHR problems. It also represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the DEA, Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

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

Comments?

As a health care professional, do you think electronic health record (EHR) incentive payments should be taxable? Please leave any thoughtful comments below.

Sources:

Goldberg, Alan. “Healthcare Reimbursement List.” American Health Lawyers Association. (April 26, 2013).

Montemurro, Michael. “Electronic Health Records Incentive Payments, POSTS-145204-12.” Internal Revenue Service. (January 14, 2013). From: http://www.thehealthlawfirm.com/uploads/1307005.pdf

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.

A New Year Means New Audits and Site Visits for Assisted Living Facilities – Protect Yourself Now

00011_RT8By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

For Assisted Living Facilities (ALFs) in Florida, it’s time to do a little brushing up on your compliance material.

Beginning in January 2015, the Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), Bureau of Medicaid Program Integrity (MPI), will conduct site visits to determine compliance with the Florida Medicaid Provider General Handbook and the Assistive Care Services Coverage and Limitations Handbook. This is just one of several initiatives aimed at ALFs to curtail fraud, waste, and abuse in the Florida Medicaid program.

Be Prepared.

The goal of a site visit is to determine if providers are rendering and documenting required services; to determine if assistive care services are being rendered by qualified and properly trained staff; to identify quality of care/environmental issues; and, to document and report ALF providers’ deficiencies to any managed care organizations with which the ALF is contracted.

According to the Florida Assisted Living Association (FALA), the majority of MPI sanctions concerning these fines are associated with the failure to have the following completed forms on file for each resident:

1. AHCA Form 1823 – The Health Assessment
2. AHCA Form 035 – The Certification of Medical Necessity
3. AHCA Form 036 – Medicaid Service Plan

Knowing is Half the Battle.

This announcement shows that the government will continue rigorous and thorough enforcement efforts this year. ALFs should consider this a fair warning to get supporting documentation in order. If you’re worried your ALF may not be in compliance, we suggest getting a compliance assessment. If your ALF is being audited we always suggest contacting an experienced health law attorney immediately. For general tips on how to respond to a Medicaid audit, click here for a previous blog.

Comments?

Did you know about these anti-fraud initiatives? Do you feel like your ALF is prepared for a site visit? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced in Representing Assisted Living Facilities.

The Health Law Firm and its attorneys represent assisted living facilities (ALFs) and ALF employees in a number of different matters including incorporation, preparing contracts, defending the facility against malpractice claims, licensing and regulatory matters, administrative hearings, and routine legal advice.

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

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

 

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 © 1999-2015 The Health Law Firm. All rights reserved.

First Year Pioneer ACO Results: Medicare Money Saved But Some Physicians Leave Program

Lance Leider headshotBy Lance O. Leider, J.D., The Health Law Firm

On July 16, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a press release summarizing the performance results for the first year of the Pioneer Accountable Care Organization (ACO) Model. Made possible by the Patient Protection and Affordable Care Act (PPACA), the Pioneer ACO Model encourages providers and care givers to deliver more coordinated care ans services for Medicare beneficiaries. ACOs, including the Pioneer ACO Model and the Medicare Shared Savings Program, are one way CMS is providing options to providers looking to better coordinate care for patients and use health care dollars more wisely, according to CMS.

Click here to read the entire press release from CMS.

Pioneer Model ACOs Increase Quality.

The press release states that all thirty-two (32) participants in the program successfully increased the quality of care received by their beneficiaries.  Consequently, each participant received incentive payments for achieving these results.

Some examples of the quality improvements were lower readmission rates and better blood pressure and cholesterol control among diabetic patients.  Some examples of the quality control measures that were implemented were:

–    dispatch of hospital trained nurses to beneficiaries’ homes for management of prescriptions, blood-sugar readings, healthy eating education and delivery and set up of durable medical equipment (DME); and

–    care coordination by trained healthcare professionals at no cost.

Pioneer Model ACOs Increase Savings.

Of the thirty-two (32) Pioneer ACOs, thirteen (13) of them produced shared savings with CMS.  This means that they exceeded the cost reduction benchmarks and were eligible to receive a percentage of those savings from CMS as compensation additional to the fee-for-service payments.  In total CMS estimates that approximately $87.6 million in Medicare expenditures was saved.

However, two (2) of the Pioneer ACO participants had shared losses.  This means that their per beneficiary fee-for-service expenditures exceeded the stated goal and they were required to share in the losses suffered by CMS.  These losses were approximately $4 million.

Some Pioneer Model ACOs Withdrawal From Program.

Of the Pioneer ACOs that did not produce shared savings, seven (7) of them have decided to leave the Pioneer program and enroll in the standard Medicare Shared Savings Program.  This program offers lower risks and lower rewards and does not have the option of moving to a capitated payment model after the first two (2) successful years.

The two (2) Pioneer ACOs that experienced shared losses with CMS have signaled their intent to withdraw from the ACO model entirely.

The First-Year Pioneer ACO Lesson: Win Some, Lose Some.

While not a total success, the Pioneer ACO program did manage to produce net savings to Medicare and improve the quality of care provided to its beneficiaries.  Many news outlets who oppose PPACA are citing this as a failure of the program and yet more bad news for President Obama’s healthcare overhaul.  However, many other sources share CMS’s somewhat rosier view of the program.  These sources state that while the program may not have been as big a success as hoped, it was only the first year in operation and is nowhere near a failure.

According to an article in American Medical News, the American Medical Association (AMA) supports ACO programs that have allowed physicians practicing in groups of various sizes to participate in new care models. The AMA states that the first-year pioneer results are encouraging, and have the potential to improve quality and decease costs. To read the entire article from American Medical News, click here.

Data should be released on the standard Shared Savings Program ACOs in the near future.

Contact Health Law Attorneys Experienced With Healthcare Business Practices.

The Health Law Firm routinely represents physician groups and practices with issues involving establishing, licensing, selling, merging, and intergroup affiliation.  If you are considering establishing an ACO or have been approached to become a participant in one, you can contact The Health Law Firm at (407) 331-6620 or (850) 439-1001 or you can visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of the performance results summery for the first year Pioneer ACO Model? What do you think about the number of groups dropping out? Please leave any thoughtful comments below.

Sources:

Centers for Medicare and Medicaid Services. “Pioneer Accountable Care Organizations Succeed in Improving Care, Lowering Costs.” CMS.gov. (July 16, 2013). From: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html

Fiegl, Charles. “Medicare pioneer ACOs save money but lose physicians.” American Medical News. (July 29, 2013). From: http://www.amednews.com/article/20130729/government/130729933/1/?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20130729

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.

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