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Mental Health Professionals: You Must Challenge Overpayment Demands from Medicare and Medicaid Audits

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
We have gotten calls from many mental health professionals who have been placed on prepayment review after failing to challenge Medicare or Medicaid audit results. Once placed on prepayment review, the payments are held up for many months. Some providers are even forced out of business as a result.

Failing to challenge, follow-up on, and appeal any adverse audit results can be very detrimental. An error rate above 15% will usually result in the provider being placed on prepayment review.

What Happens During Prepayment Review.

While on prepayment review, the provider will be required to submit documentation for medical records by mail to support each claim submitted. Additionally, they must have those claims and supporting documentation audited, before any claims are paid. Often, the auditing agency will come back to the provider repeatedly to demand additional information and documentation on claims instead of immediately processing them. This can hold up the processing of the claim for months. Often, the resulting termination of income flow will force the provider out of business. This saves the government lots of money because the provider has then provided services to Medicare or Medicaid recipients for many months without getting paid for it.

These are some of the reasons why we recommend that healthcare providers always hire a Board Certified Health Law Attorney experienced in Medicare and Medicaid audits from the very beginning.

A Real-Life Example of the Trouble Caused by a Medicare Audit.

In one case we are familiar with, a therapist was audited by Medicare. The audit by the Medicare administrative contractor (MAC) requested only 30 records. The therapist provided copies of the records he thought the auditors wanted. He did not number the pages or keep an exact copy of what he provided. The MAC came back and denied 1% of the claims audited.

However, since the amount demanded back by the MAC was only a few thousand dollars, the therapist never hired an attorney and never challenged the results. Instead of retaining legal counsel and appealing the results, the therapist paid the entire amount, thinking that was the easy way out.

Unfortunately, because of the high error rate, the MAC immediately placed the therapist on a prepayment review of all claims, assuming the prior audit had disclosed fraud or intentional false coding. All claims the provider submitted from that point on had to be submitted on paper with supporting medical records sent in by mail. The MAC refused to decide on any of the claims, instead, holding them and requesting additional documentation and information from time to time. As a result, the therapist has most of his claims tied up in prepayment review, some for as long as five months with no-decision.

The therapist conveyed to me that he contacted the auditor to attempt to obtain decisions on some of his claims so that he could at least begin the appeal process if the claims are denied. He advised me that the auditor at the MAC expressed surprise that he was still in business.

Challenge Improperly Denied or Reduced Claims.

These situations are very unfair and unjust, especially to smaller healthcare providers. The reduced cash flow even for a month or two may be enough to drive some small providers out of business. Larger healthcare providers have vast resources sufficient to handle such audit situations on a routine basis. They may have similar problems but are better equipped and have more resources to promptly handle it. Rather than immediately pay whatever amount is demanded on an audit and waive any appeal/review rights, the provider should review each claim denied or reduced and challenge the ones that have been improperly denied or reduced. Otherwise, you may wind up with a high error rate which will cause you to be placed into prepayment review. Once placed in the prepayment review, it is difficult to get out of it. Often, it takes six months or longer.

Don’t Get Caught Up in the Audit Cycle.

The audit contractors will keep you on an audit cycle for many future audits if they are successful in obtaining any sort of recovery from you on the initial audit. This is similar to what happens if your tax return is audited by the Internal Revenue Service (IRS). If they recover a significant payment from you because you did not have the documentation to support your deductions, you can expect to be audited for at least the next two years.

The value of competent legal representation at the beginning of an audit cannot be overestimated. It is usually long after the audit is over, and the time to appeal the audit agency’s findings has passed, that the health care provider realizes he should have retained an audit consultation.

Click here to read one of my prior blogs about Medicare audits and challenging an OIG exclusion.

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.

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.

KeyWords: Healthcare fraud representation, healthcare fraud defense lawyer, Office of Inspector General (OIG) Medicare exclusion attorney, OIG investigation legal defense representation, OIG exclusion defense attorney, OIG exclusion defense lawyer, Medicare audit defense legal counsel, Office of Inspector General (OIG) Medicare exclusion defense counsel, Medicare audit defense attorney, Office of Inspector General (OIG) Medicare exclusion legal defense counsel, attorney legal representation for OIG notice of intent to exclude, Medicare exclusion hearing defense attorney, Medicare administrative law judge hearing legal representation, Medicare administrative law judge hearing defense attorney, Medicare and Medicaid audit defense attorney, legal representation for Medicare and Medicaid audits, health care fraud defense attorney, legal representation for health care fraud, Centers for Medicare and Medicaid (CMS), legal representation for CMS investigations, health care professional defense attorney, legal representation for health care professionals, legal representation for fraud investigations, reviews for The Health Law Firm, The Health Law Firm attorney reviews, healthcare fraud representation, allegations of healthcare fraud, representation for CMS investigations, representation for healthcare investigations, representation for medical overbilling, False Claims attorney, FCA lawyer, FCA attorney, representation for submitting False Claims, representation for overbilling Medicare, medical overbilling, allegations of overbilling Medicaid, FCA 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 The Health Law Firm. All rights reserved.

By |2019-12-05T23:32:46+00:00December 5th, 2019|Categories: Mental Health Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Florida Compounding Pharmacy Reaches $21 Million Settlement to End FCA Kickback Suit

George IndestBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On September 19, 2019, a Florida compounding pharmacy reached a $21.4 million settlement with the U.S. Department of Justice (DOJ) in the Southern District of Florida to resolve claims they orchestrated a $70 million kickback scheme. Diabetic Care Rx LLC, which does business as Patient Care America, and private equity firm Riordan Lewis & Haden Inc. agreed to pay to bring the False Claims Act (FCA) lawsuit to a close.

According to the DOJ, the Florida pharmacy, two executives and the private equity firm schemed to recruit beneficiaries of Tricare for medically unnecessary prescriptions such as expensive pain creams.

Details of the Case.

The DOJ claimed PCA used marketers to help recruit beneficiaries of Tricare. They allegedly paid kickbacks to solicit medically unnecessary prescriptions for expensive compounded drugs that were filled by the pharmacy and then charged to Tricare.

As a result, the pharmacy allegedly billed Tricare about $68 million for compounded drugs over eight months in 2014 and 2015.
For more information, click here to read the press release issued by the DOJ.

The lawsuit resolved by the settlement was originally filed under the whistleblower (or “qui tam”) provisions of the False Claims Act by two former employees of PCA. To learn more about whistleblower or qui tam cases, click here to read one of my prior blogs.

Contact Health Law Attorneys Experienced in Representing Pharmacies and Pharmacists.

The Health Law Firm represents pharmacists and pharmacies in DEA, DOH and FDA investigations, qui tam and whistleblower cases, regulatory matters, licensing issues, litigation, administrative hearings, inspections, and audits. The Firm also represents both plaintiffs (whistle blowers or relators) and defendants in False Claims Act (whistleblower or qui tam) cases. The firm’s 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.

Sources:

Stawiki, Steve. “Pharmacy, PE Fund Ink $21M Deal To End FCA Kickback Suit.” Law360. (September 20, 2019). Web.

Bolado, Carolina. “Pharmacy, PE Fund Near Deal To End Feds’ FCA Kickback Suit.” Law360. (July 1, 2019). Web.

“Compounding Pharmacy, Two of Its Executives, and Private Equity Firm Agree to Pay $21.36 Million to Resolve False Claims Act Allegations.” Florida Record. (September 24, 2019). Web.

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

KeyWords: legal representation for pharmacists, legal representation for pharmacies, pharmacy defense attorney, pharmacist defense lawyer, representation for False Claims Act investigation, False Claims Act representation, FCA defense lawyer, board representation for pharmacists, board representation for pharmacies, board representation for physicians, Board of Pharmacy investigation representation, legal representation for board investigations, administrative hearing defense attorney, representation for administrative hearings, administrative complaint representation, Board of Medicine representation, Board of Medicine attorney, Board of Medicine defense attorney, representation for Board of Medicine investigations, representation for Board of Medicine complaints, DEA hearing defense attorney, DEA investigation attorney, DEA hearing representation, DEA investigation representation, representation for DEA investigations against physicians, representation for pill mill allegations, representation for allegations of overprescribing, representation for overbilling, DOJ defense lawyer, representation for DOJ investigations, representation for health care professionals, reviews of The Health Law Firm, The Health Law Firm attorney reviews

“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.

Dentists: Challenge Overpayment Demands from Medicare, Medicaid Audits!

Attorney Indest headshotDuring our years of experience, we have gotten many calls from dentists who have been placed on prepayment review after failing to challenge the results of Medicare and Medicaid audits. Once placed on prepayment review, the payments are held up for many months. Some providers are even forced out of business as a result.

Failing to challenge, follow-up on, and appeal any adverse results of Medicare and Medicaid audits can be very detrimental. An error rate above 15% will usually result in the provider being placed on prepayment review.


What Happens During Prepayment Review.

While on prepayment review, the dentist or provider will be required to submit documentation for medical records by mail to support each claim submitted. Additionally, they must have those claims and supporting documentation audited, before any claims are paid. Often, the auditing agency will come back repeatedly to demand additional information and documentation on claims instead of immediately processing them. This can hold up the processing of the claim for months. Often, the resulting termination of income flow will force the dentist or other healthcare providers out of business. This saves the government lots of money because the provider has then provided services to Medicare or Medicaid recipients for many months without getting paid for it.

These are some of the reasons why we recommend that dentists and all healthcare providers always hire a Board Certified Health Law Attorney experienced in Medicare and Medicaid audits from the very beginning.

Here’s an Example of the Trouble Caused by a Medicare Audit.

In one case we are familiar with, a therapist was audited by Medicare. The audit by the Medicare administrative contractor (MAC) requested only 30 records. The therapist provided copies of the records he thought the auditors wanted. He did not number the pages or keep an exact copy of what he provided. The MAC came back and denied 1% of the claims audited.

However, since the amount demanded back by the MAC was only a few thousand dollars, the therapist never hired an attorney and never challenged the results. Instead of retaining legal counsel and appealing the results, the therapist paid the entire amount, thinking that was the easy way out.

Unfortunately, because of the high error rate, the MAC immediately placed the therapist on a prepayment review of all claims, assuming the prior audit had disclosed fraud or intentional false coding. All claims the provider submitted from that point on had to be submitted on paper with supporting medical records sent in by mail. The MAC refused to decide on any of the claims, instead, holding them and requesting additional documentation and information from time to time. As a result, the therapist has most of his claims tied up in prepayment review, some for as long as five months with no-decision.

The therapist conveyed to me that he contacted the auditor to attempt to obtain decisions on some of his claims so that he could at least begin the appeal process if the claims are denied. He advised me that the auditor at the MAC expressed surprise that he was still in business.

You Must Challenge All Improperly Denied or Reduced Claims.

These situations are very unfair and unjust, especially to smaller healthcare providers. The reduced cash flow even for a month or two may be enough to drive some small providers out of business. Larger healthcare providers have vast resources sufficient to handle such audit situations on a routine basis. They may have similar problems but are better equipped and have more resources to promptly handle it. Rather than immediately pay whatever amount is demanded on an audit and waive any appeal/review rights, the provider should review each claim denied or reduced and challenge the ones that have been improperly denied or reduced. Otherwise, you may wind up with a high error rate which will cause you to be placed into prepayment review. Once placed in the prepayment review, it is difficult to get out of it. Often, it takes six months or longer.

Don’t Let Yourself Get Caught Up in the Never-Ending Audit Cycle.

The audit contractors will keep you on an audit cycle for many future audits if they are successful in obtaining any sort of recovery from you on the initial audit. This is similar to what happens if your tax return is audited by the Internal Revenue Service (IRS). If they recover a significant payment from you because you did not have the documentation to support your deductions, you can expect to be audited for at least the next two years.

The value of competent legal representation at the beginning of an audit cannot be overestimated. It is usually long after the audit is over, and the time to appeal the audit agency’s findings has passed, that the health care provider realizes he should have retained an audit consultation.

Click here to read one of my prior blogs about Medicare audits and challenging an OIG exclusion.

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.

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.

KeyWords: Healthcare fraud representation, healthcare fraud defense lawyer, Office of Inspector General (OIG) Medicare exclusion attorney, OIG investigation legal defense representation, OIG exclusion defense attorney, OIG exclusion defense lawyer, Medicare audit defense legal counsel, Office of Inspector General (OIG) Medicare exclusion defense counsel, Medicare audit defense attorney, Office of Inspector General (OIG) Medicare exclusion legal defense counsel, attorney legal representation for OIG notice of intent to exclude, Medicare exclusion hearing defense attorney, Medicare administrative law judge hearing legal representation, Medicare administrative law judge hearing defense attorney, Medicare and Medicaid audit defense attorney, legal representation for Medicare and Medicaid audits, health care fraud defense attorney, legal representation for health care fraud, Centers for Medicare and Medicaid (CMS), legal representation for CMS investigations, health care professional defense attorney, legal representation for health care professionals, legal representation for fraud investigations, reviews for The Health Law Firm, The Health Law Firm attorney reviews, healthcare fraud representation, allegations of healthcare fraud, representation for CMS investigations, representation for healthcare investigations, representation for medical overbilling, False Claims attorney, FCA lawyer, FCA attorney, representation for submitting False Claims, representation for overbilling Medicare, medical overbilling, allegations of overbilling Medicaid, FCA 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 The Health Law Firm. All rights reserved.

By |2019-11-12T17:55:46+00:00November 6th, 2019|Categories: Dental Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Doctor Sentenced to 40 Years For Alleged Interstate Pill Mill

By Carole C. Schriefer, R.N., J.D.

On October 2, 2019, a physician in Virginia received a 40-year prison sentence for illegally prescribing more than half a million opioid pills over 19 months. The U.S. District Court for the Western District of Virginia handed down the sentence to Joel Smithers, who reportedly operated a “pill mill” out of Virginia, according to authorities. In addition to prison time, he was given an $86,000 fine and will serve three years of supervised release upon the completion of his prison time, according to court documents.

The sentence is lighter than it could have been. He was facing up to life in prison and a fine of more than $200 million, according to officials at the U.S. Justice Department (DOJ). Click here to view the court’s sentencing document in full.

The Alleged Interstate Pill Mill Operation.

In May 2019, Smithers was convicted by a jury on more than 859 federal drug charges, including one count of possessing with the intent to distribute controlled substances and one count of maintaining a place for the purpose of unlawfully distributing controlled substances. Additionally, he was convicted on hundreds of counts of unlawfully distributing a controlled substance without a legitimate medical purpose or beyond the bounds of medical practice.

When he opened his Virginia practice in 2015, officials said he prescribed controlled substances to “every patient in his practice, resulting in over 500,000 Schedule II controlled substances being distributed.” Authorities say that he allegedly ran an operation that was less a medical practice and more an interstate drug distribution network.

Smithers was able to rake in over $700,000 in cash and credit card payments before the search warrant was executed at his office on March 7, 2017. Click here to read the press release issued by the U.S. Attorney’s Office in the Western District of Virginia.

To learn about a similar case involving two Florida doctors, click here.


The Problems I See in This Case.

I tell you that I take issue with many of the cases of this sort. I do not know enough about the actual facts of this physician’s case, but I can comment generally based on other similar cases I have had in the past. The government, both state and federal, has come down like a hammer on individual physicians and pharmacists in its over-zealous campaign to crack down on opioids. Many physicians and pharmacists, just trying to do a good job and legitimately treat their patients, are being caught up and persecuted. Chronic pain patients, many of whom are disabled veterans or people injured on the job, are unable to find physicians to treat them anymore or, if they can, any pharmacists willing to fill their prescriptions.

All sorts of under-handed techniques are used to try to make a case against conscientious health professionals who are merely trying to do their jobs. These do include the tactic seen in the case we are reporting on, which I call “bean counting.” The government comes in and, instead of proving how many allegedly illegal prescriptions were written or how many patients the physician gave the prescriptions to, breaks these out into the number of pills. This greatly exaggerates the case and these large numbers alone make it look like the doctor (or pharmacist) is doing something wrong or extremely way out of the norm.

For example, if a patient was receiving a low dose of a pain killer, say 10 mg Oxycodone every 4 to 6 hours, prescribed for four times a day, the ordinary monthly prescription for this medication alone (and such patients rarely receive one type of medication alone) this equates to 120 pills per month. If 10 mg pills are not available and/or the prescription is filled with 5 mg pills, instead, this is 240 pills a month. A years’ worth is 1,440 pills or 2,880 pills for just one patient. If the physician has 50 similar patients, this is 72,000 pills or 144,000 pills a year that the physician is writing and a pharmacy or pharmacies are filling.

This does not seem extreme or unusual to me, at all, and these amounts are on the low side. Yet just as government agencies love to inflate the “street value” or contraband drugs they seize, they love to break down the number of opioids a physician writes so it seems to a layperson to be extraordinarily large. Furthermore, a pain management physician or any other kind of physician cannot survive with just 50 patients a month. It is far more likely for a physician to have a thousand (1,000) or more patients a month. I call this type of numerical exaggeration “bean counting.” But it has put a number of physicians and pharmacists in jail.

Judges should not allow such exaggerated numbers to be introduced into evidence in the absence of further information that places them in context. It is unfairly prejudicial to the defendant to do so.


Contact Health Law Attorneys Experienced with DEA Cases.

The attorneys of The Health Law Firm are experienced in handling Drug Enforcement Administration (DEA) cases, board of medicine cases and board of pharmacy cases regarding allegations of over-prescribing and illegal prescribing. If you are currently being investigated or facing other adverse actions by the DEA contact one of our attorneys by calling (407) 331-6620 or (850) 439-1001. You can also visit our website for more information at www.TheHealthLawFirm.com.

Sources:

Booker, Brakkton. “Doctor Gets 40 Years For Illegally Prescribing More Than Half A Million Opioid Doses.” NPR. (October 2, 2019). Web.

“Virginia doctor could get life in prison today for prescribing 500,000 opioid pills.” RTV6. (October 2, 2019). Web.

Almasy, Steve. “Virginia doctor who illegally prescribed 500,000 opioid pills sentenced to 40 years in prison.” CNN. (October 2, 2019). Web.

About the Author: Carole C. Schriefer is an attorney and registered nurse. She practices with The Health Law Firm, which has a national practice. Its regional office is in the Northern Colorado, area. www.TheHealthLawFirm.com The Health Law Firm, 155 East Boardwalk Drive, Fort Collins, Colorado 80525. Phone: (970) 416-7456. Its main office is in the Orlando, Florida area.

KeyWords: legal representation for pain management physicians and pharmacists, legal representation for pharmacies, pharmacy defense attorney, pain management physician defense attorney, pharmacist defense lawyer, pain management physician defense lawyer, representation for False Claims Act (FCA) investigation, False Claims Act representation, FCA defense lawyer, board representation for pharmacists, board representation for pharmacies, board representation for physicians, Board of Pharmacy investigation representation, legal representation for board investigations, Drug Enforcement Administration (DEA) defense attorney, board of medicine attorney, board of pharmacy attorney, Department of Health investigations, pain clinics, over prescribing painkillers, Drug Enforcement Administration (DEA) investigation attorney, The Health Law Firm, administrative hearing defense attorney, DEA order to show cause (OSC) defense lawyer, legal representation for administrative hearings, administrative complaint representation, Board of Medicine representation, Board of Medicine attorney, Board of Medicine defense attorney, representation for Board of Medicine investigations, representation for Board of Medicine complaints, DEA hearing defense attorney, DEA investigation attorney, DEA hearing representation, DEA investigation representation, representation for DEA investigations against physicians, representation for pill mill allegations, representation for allegations of overprescribing, representation for overbilling, DOJ defense lawyer, representation for DOJ investigations, representation for health care professionals, reviews of The Health Law Firm, The Health Law Firm attorney reviews, DEA order to show cause (OSC) defense attorney

“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.

By |2019-11-06T20:48:18+00:00November 6th, 2019|Categories: Colorado Health Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Physician Sentenced to 40 Years in Prison For Illegally Prescribing Opioid Pills

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

On October 2, 2019, a Virginia doctor received a 40-year prison sentence for illegally prescribing more than half a million opioid pills over 19 months. The U.S. District Court for the Western District of Virginia handed down the sentence to Joel Smithers, who was reported to have operated a “pill mill” out of Virginia, according to authorities. In addition to prison time, he was given an $86,000 fine and will serve three years of supervised release upon the completion of his prison time, according to court documents.

The sentence is lighter than it could have been. He was facing up to life in prison and a fine of more than $200 million, according to officials at the U.S. Justice Department. Click here to view the court’s sentencing document in full.

Alleged Interstate Pill Mill.

In May 2019, Smithers was convicted by a jury on more than 859 federal drug charges, including one count of possessing with the intent to distribute controlled substances and one count of maintaining a place for the purpose of unlawfully distributing controlled substances. Additionally, he was also convicted on hundreds of counts of unlawfully distributing a controlled substance without a legitimate medical purpose or beyond the bounds of medical practice.

When he opened his Virginia practice in 2015, Justice Department officials said he prescribed controlled substances to “every patient in his practice, resulting in over 500,000 Schedule II controlled substances being distributed.” Authorities say that he allegedly ran an operation that was less a medical practice and more an interstate drug distribution network.

Smithers was able to rake in over $700,000 in cash and credit card payments before the search warrant was executed at his office on March 7, 2017. Click here to read the press release issued by the U.S. Attorney’s Office in the Western District of Virginia.

To learn about a similar case involving two Florida doctors, click here.

The Problems I See.

I tell you that I take issue with many of the cases of this sort. I do not know enough about the actual facts of this physician’s case, but I can comment generally based on other similar cases I have had in the past. The government, both state and federal, has come down like a hammer on individual physicians and pharmacists in its over-zealous campaign to crack down on opioids. Many physicians and pharmacists, just trying to do a good job and legitimately treat their patients, are being caught up and persecuted. Chronic pain patients, many of whom are disabled veterans or people injured on the job, are unable to find physicians to treat them anymore or, if they can, any pharmacists willing to fill their prescriptions.

All sorts of under-handed techniques are used to try to make a case against conscientious health professionals who are merely trying to do their jobs. These do include the tactic seen in the case we are reporting on, which I call “bean counting.” The government comes in and, instead of proving how many allegedly illegal prescriptions were written or how many patients the physician gave the prescriptions to, breaks these out into the number of pills. This greatly exaggerates the case and these large numbers alone make it look like the doctor (or pharmacist) is doing something wrong or extremely way out of the norm.

For example, if a patient was receiving a low dose of a pain killer, say 10 mg Oxycodone every 4 to 6 hours, prescribed for four times a day, the ordinary monthly prescription for this medication alone (and such patients rarely receive one type of medication alone) this equates to 120 pills per month. If 10 mg pills are not available and/or the prescription is filled with 5 mg pills, instead, this is 240 pills a month. A years’ worth is 1,440 pills or 2,880 pills for just one patient. If the physician has 50 similar patients, this is 72,000 pills or 144,000 pills a year that the physician is writing and a pharmacy or pharmacies are filling.

This does not seem extreme or unusual to me, at all, and these amounts are on the low side. Yet just as government agencies love to inflate the “street value” or contraband drugs they seize, they love to break down the number of opioids a physician writes so it seems to a layperson to be extraordinarily large. Furthermore, a pain management physician or any other kind of physician cannot survive with just 50 patients a month. It is far more likely for a physician to have a thousand (1,000) or more patients a month. I call this type of numerical exaggeration “bean counting.” But it has put a number of physicians and pharmacists in jail.

Judges should not allow such exaggerated numbers to be introduced into evidence in the absence of further information that places them in context. It is unfairly prejudicial to the defendant to do so.

Contact Health Law Attorneys Experienced with DEA Cases.

The attorneys of The Health Law Firm are experienced in handling Drug Enforcement Administration (DEA) cases, board of medicine cases and board of pharmacy cases regarding allegations of over-prescribing and illegal prescribing. If you are currently being investigated or facing other adverse actions by the DEA contact one of our attorneys by calling (407) 331-6620 or (850) 439-1001. You can also visit our website for more information at www.TheHealthLawFirm.com.

Sources:

Booker, Brakkton. “Doctor Gets 40 Years For Illegally Prescribing More Than Half A Million Opioid Doses.” NPR. (October 2, 2019). Web.

“Virginia doctor could get life in prison today for prescribing 500,000 opioid pills.” RTV6. (October 2, 2019). Web.

Almasy, Steve. “Virginia doctor who illegally prescribed 500,000 opioid pills sentenced to 40 years in prison.” CNN. (October 2, 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., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: legal representation for pain management physicians and pharmacists, legal representation for pharmacies, pharmacy defense attorney, pain management physician defense attorney, pharmacist defense lawyer, pain management physician defense lawyer, representation for False Claims Act (FCA) investigation, False Claims Act representation, FCA defense lawyer, board representation for pharmacists, board representation for pharmacies, board representation for physicians, Board of Pharmacy investigation representation, legal representation for board investigations, Drug Enforcement Administration (DEA) defense attorney, board of medicine attorney, board of pharmacy attorney, Department of Health investigations, pain clinics, over prescribing painkillers, Drug Enforcement Administration (DEA) investigation attorney, The Health Law Firm, administrative hearing defense attorney, DEA order to show cause (OSC) defense lawyer, legal representation for administrative hearings, administrative complaint representation, Board of Medicine representation, Board of Medicine attorney, Board of Medicine defense attorney, representation for Board of Medicine investigations, representation for Board of Medicine complaints, DEA hearing defense attorney, DEA investigation attorney, DEA hearing representation, DEA investigation representation, representation for DEA investigations against physicians, representation for pill mill allegations, representation for allegations of overprescribing, representation for overbilling, DOJ defense lawyer, representation for DOJ investigations, representation for health care professionals, reviews of The Health Law Firm, The Health Law Firm attorney reviews, DEA order to show cause (OSC) defense attorney

“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.

By |2019-11-06T20:33:34+00:00November 6th, 2019|Categories: Pharmacy Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Compounding Pharmacy Agrees to Pay $21 Million to End FCA Kickback Suit

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

On September 19, 2019, a Florida compounding pharmacy reached a $21.4 million settlement with the U.S. Department of Justice (DOJ) in the Southern District of Florida to resolve claims they orchestrated a $70 million kickback scheme. Diabetic Care Rx LLC, which does business as Patient Care America, and private equity firm Riordan Lewis & Haden Inc. agreed to pay to bring the False Claims Act (FCA) lawsuit to a close.

According to the DOJ, the Florida pharmacy, two executives and the private equity firm schemed to recruit beneficiaries of Tricare for medically unnecessary prescriptions such as expensive pain creams.

Details of the Case.

The DOJ claimed PCA used marketers to help recruit beneficiaries of Tricare. They allegedly paid kickbacks to solicit medically unnecessary prescriptions for expensive compounded drugs that were filled by the pharmacy and then charged to Tricare.

As a result, the pharmacy allegedly billed Tricare about $68 million for compounded drugs over eight months in 2014 and 2015.
For more information, click here to read the press release issued by the DOJ.

The lawsuit resolved by the settlement was originally filed under the whistleblower (or “qui tam”) provisions of the False Claims Act by two former employees of PCA. To learn more about whistleblower or qui tam cases, click here to read one of my prior blogs.

Contact Health Law Attorneys Experienced in Representing Pharmacies and Pharmacists.

The Health Law Firm represents pharmacists and pharmacies in DEA, DOH and FDA investigations, qui tam and whistleblower cases, regulatory matters, licensing issues, litigation, administrative hearings, inspections, and audits. The Firm also represents both plaintiffs (whistle blowers or relators) and defendants in False Claims Act (whistleblower or qui tam) cases. The firm’s 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.

Sources:

Stawiki, Steve. “Pharmacy, PE Fund Ink $21M Deal To End FCA Kickback Suit.” Law360. (September 20, 2019). Web.

Bolado, Carolina. “Pharmacy, PE Fund Near Deal To End Feds’ FCA Kickback Suit.” Law360. (July 1, 2019). Web.

“Compounding Pharmacy, Two of Its Executives, and Private Equity Firm Agree to Pay $21.36 Million to Resolve False Claims Act Allegations.” Florida Record. (September 24, 2019). Web.

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

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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.
Copyright © 2019 The Health Law Firm. All rights reserved.

CMS Announces Final Rule to Reduce Criminal Behavior in Medicare, Medicaid

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

On September 5, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that strengthens the ability to stop fraud and abuse before it happens. The “Program Integrity Enhancements to the Provider Enrollment Process” goes into effect on November 4, 2019, and will help keep untrustworthy providers out of federal health insurance. The new affiliations provision will allow CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse and repeat offenders.

Details on the Rule.

The final rule, (CMS-6058-FC), creates several new revocation and denial authorities to enhance CMS’ efforts to stop fraud and abuse.

Similar to the affiliations component, these authorities provide a basis for administrative action to revoke or deny, as applicable, Medicare enrollment if:

• A provider or supplier circumvents program rules by coming back into the program, or attempting to come back in, under a different name (e.g. the provider attempts to “reinvent” itself);

• A provider or supplier bills for services/items from non-compliant locations;

• A provider or supplier exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs; or

• A provider or supplier has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

Additionally, the rule gives CMS the ability to prevent applicants from enrolling in the program for up to three years if found to have submitted false or misleading information in its initial enrollment application.

Furthermore, the new rule expands the re-enrollment bar that prevents fraudulent or otherwise problematic providers from re-entering the Medicare program. CMS can now block providers and suppliers who are revoked from re-entering the Medicare program for up to 10 years. Previously, revoked providers could only be prevented from re-enrolling for up to three years.

Additionally, if a healthcare provider or supplier is revoked from Medicare for a second time, CMS can now block him/her from re-entering the program for up to 20 years. These new authorities and restrictions are effective on November 4, 2019.

For more information, click here to view the final rule with comment.

To learn more about the Medicare enrollment application process, click here to read my prior 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.

Sources:

Kacik, Alex. “CMS targets healthcare providers’ affiliates in new rule.” Modern Healthcare. (September 5, 2019). Web.

“CMS Announces New Enforcement Authorities to Reduce Criminal Behavior in Medicare, Medicaid, and CHIP.” Orlando Medical News. (September 5, 2019). Web.

“CMS takes action to keep fraudsters out of Medicare and Medicaid.” CMS.gov. (September 5, 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 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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“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.

By |2019-09-24T17:57:33+00:00September 24th, 2019|Categories: The Health Law Firm Blog, Uncategorized|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Dental Clinic Owners Found Guilty of $1 Million Medicaid, Tax Scheme

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

On February 21, 2019, a federal jury found the owners of several dental clinics in Missouri guilty of a $1 million scheme to defraud the government. The owners of All About Smiles LLC, were convicted of submitting false claims to Medicaid for dentures and other services and payroll tax fraud, according to prosecutors.

Submitting False Claims.

Prosecutors alleged that the couple that owned the practice ran several schemes through the dental clinics from 2010 to 2015, including conspiring to defraud Medicaid. A main part of the scheme was to provide dentures and other services to adults who didn’t qualify for Medicaid. They would then bill the Medicaid program anyway, receiving more than $720,000, according to the DOJ.

The pair also allegedly ran a similar scheme with orthodontic equipment, racking up an estimated 241 false claims, said prosecutors. All About Smiles was paid approximately $165,700 during the the duration of the scheme.

Payroll Problems.

In addition to the fraud, the owners allegedly failed to forward payroll taxes to the Internal Revenue Service (IRS) even though the money was withheld from employee paychecks. Instead, the married pair used the almost $195,000 to cover lavish personal expenses and make payments on a variety of vehicles, said the DOJ.

Not Smiling Anymore.

Jurors found the couple guilty on all charges detailed in a 40-count indictment accusing them of fraudulently operating three All About Smiles LLC dental clinics, said the DOJ. Additionally, their legal woes continued to stack up as each was also convicted on a count of theft of public money for collecting unemployment benefits while working.

The female owner faces up to 10 years in prison on every count besides the payroll tax conspiracy charge, which comes with a maximum penalty of five years. The husband owner could get up to a decade for obtaining unemployment benefits and five years for each additional charge, prosecutors said.

Click here to read the DOJ’s press release.

To read one of my prior blogs on a similar case about a dentist defrauding medicaid, click here.

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

The attorneys of The Health Law Firm represent dentists, oral surgeons, and other health care providers in Medicaid audits, Medicare audits, insurance billing audits, ZPIC audits, RAC audits, administrative litigation and civil litigation 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 licensure complaints and investigations, DEA investigations, Medicare and Medicaid fraud investigations, audits, recovery actions and terminations 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:

“All About Smiles Owners Convicted of Fraud.” Ozark Independent. (February 21, 2019). Web.
Posses, Shayna. “Couple Found Guilty Of $1M Medicaid, Payroll Tax Scheme.” Law360. (February 21, 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., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: legal representation for improper billing, improper billing defense attorney, Medicaid audit defense attorney, legal representation for Medicaid fraud, Medicaid fraud defense lawyer, legal representation for false claims, false claims legal defense representation, Medicaid fraud defense lawyer, Medicaid overpayment demand defense attorney, Medicaid Fraud Control Unit (MFCU) defense attorney, Medicaid Fraud Control Unit (MFCU) subpoena defense lawyer, Medicaid Fraud Control Unit (MFCU) search warrant defense attorney, False Clams Act (FCA) attorney, FCA defense lawyer, representation for allegations of false claims, Board of dentistry defense lawyer, dentist defense attorney, board of dentistry defense legal representation, Medicaid provider defense attorney, ZPIC audit defense attorney, Medicaid audit defense lawyer, dentist defense attorney, Board of Dentistry defense attorney, representation for health care professionals, representation for dental clinics, health law defense lawyer, health defense attorney, legal representation for dentists, The Health Law Firm reviews, Dentist Advantage Insurance defense attorney, The Health Law Firm attorney reviews, The Health Law Firm, Department of Health complaint investigation attorney, Health Providers Service Organization (HPSO) Insurance defense lawyer, the Doctors Company Insurance defense lawyer, Department of Justice (DOJ) investigation attorney, representation in DOJ investigations, DOJ defense lawyer, healthcare fraud 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 The Health Law Firm. All rights reserved.

By |2019-04-18T18:44:05+00:00April 18th, 2019|Categories: Centers for Medicare and Medicaid Services, Dental Law Blog, Dentist Defense attorney, Health Care Fraud, Health care Law, Medicaid Fraud, Medicaid fraud|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Walgreens Agrees to Pay $269 Million to Settle Two FCA Suits

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

On January 22, 2019, Walgreens agreed to pay more than $269 million to settle allegations of False Claims Act (FCA) violations for overbilling of various drugs. The deals are some of the largest pay-outs ever by a retail pharmacy, according to the United States Department of Justice (DOJ).

The Two Settlements.

There were two separate complaints involving Walgreens to settle federal and state lawsuits that accused the pharmacy of overbilling federal healthcare programs. Both were unsealed by U.S. District Court judges in Manhattan, according to the DOJ.

In the first settlement, Walgreens agreed to pay $209.2 million to the U.S. and several state governments for improperly billing Medicare, Medicaid and other federal healthcare programs. The pharmacy is accused of excessive dispensing of insulin pens to beneficiaries who didn’t need them, according to U.S. officials. It reaped improper payments by understating the amount of treatment days covered by supplies of insulin pens. That allowed it to bill for prescriptions that should have been denied as premature, the DOJ said. Click here to visit our website and read the complaint and the stipulation for the first settlement.

In the second settlement, Walgreens agreed to pay $60 million to settle claims of overbilling Medicaid programs through bogus Medicaid price reporting. The retail pharmacy never disclosed or charged the lower drug prices it offered the public through a pharmacy discount program.

According to the DOJ, Walgreens obtained inflated reimbursement amounts because it failed to disclose discounted drug prices in its “Prescription Savings Club.” However, federal prosecutors said Walgreens didn’t disclose the discounted drug price when filing for reimbursement from Medicaid. Click here to visit our website and read the complaint and stipulation for the second settlement.

There are two whistleblowers in the insulin pen case, they will receive a roughly 19 percent cut of the $41 million portion of the settlement that will go to state, a reward of close to $8 million for blowing the whistle. The whistleblower in the Medicaid price reporting case, will receive a $11.4 million reward, according to his attorney. Not bad for a days work!

Walgreens released a statement, saying it was glad to have the matters resolved but admitted to no wrongdoing.

This isn’t the first time Walgreens has been involved in an FCA lawsuit. Click here to read one of my prior blogs on a similar case.

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

Attorneys with The Health Law Firm represent physicians, nurses and other health professionals who desire to file a False Claims Act (whistle blower or qui tam) case. This case just shows that even physicians can and should bring such claims and be rewarded for their whistle blowing activities. However, the attorneys of The Health Law Firm also defend physicians, medical groups and health facilities who have been sued in False Claims Act (whistle blower or qui tam) cases or have had administrative or civil complaints filed against them to recover civil monetary penalties. 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. We have represented doctors, nurses and others as relators in bringing qui tam or whistle blower cases, as well.

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

Sources:

Overley, Jeff. “Walgreens Pays $269M In Milestone FCA Deals.” Law360. (January 22, 2019). Web.

Thomas, Patrick. “Walgreens to Pay $269 Million on Claims It Overcharged Federal Programs.” WSJ. (January 22, 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., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: healthcare fraud, healthcare fraud representation, healthcare fraud defense lawyer, Medicare Fraud, legal representation for Medicare fraud, Medicare fraud defense attorney, legal representation for allegations of Medicare fraud, legal representation for health care fraud, legal representation for fraudulent billing, legal representation for allegation of defrauding the government, legal representation for submitting false claims, Medicare audit defense attorney, Medicare billing defense attorney, health care clinic fraud audit, legal representation for false billing, legal representation for Medicare audits, Medicaid fraud defense attorney, legal representation fr Medicaid fraud, legal representation for Medicaid audit, Medicaid audit defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, False Claims Act (FCA), FCA attorney, FCA representation, FCA defense lawyer, whistleblower representation, whistleblower defense attorney, qui tam lawyer, qui tam defense attorney, qui tam representation, legal representation for pharmacies, legal representation for pharmacists, pharmacy representation, pharmacists defense attorney, pharmacy defense lawyer, Board of Pharmacy representation, Board of Pharmacy defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney

“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.

By |2019-01-29T20:53:27+00:00January 29th, 2019|Categories: Pharmacy Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

The Most Common Cases The Health Law Firm Takes

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

One of the most common questions we get asked by doctors and lawyers alike, is about the types of cases our firm takes. They often mistake the practice of health law as medical malpractice defense. However, this is an incorrect assumption. Likewise, if we had a penny for every time we have heard “Yikes, an attorney! I hope I never need you,” we could close our doors and all retire.

As a general health law practice, we concentrate on both proactive and defensive legal issues and clients involved in the health care industry. To a certain extent our law firm does practically everything a physician, medical group, health facility or health care professional could need in the legal arena.

The types of cases we most commonly see are the following:

1. Sales, mergers and acquisitions of medical practices, health care clinics, and health facilities. We represent buyers, sellers and lenders at any stage of the process.

2. Contracts for medical and health care transactions. We prepare contracts, review contracts, negotiate contracts, help to terminate or break contracts, and we litigate contracts. We can be on either side of these transactions. Our litigation can take place in state court or federal court. We review and analyze quite a few employment contracts for medical residents and fellows going to new positions.

3. We research and prepare complex legal opinion letters on proposed health care transactions. The health care industry is the most regulated industry in the United States. There are complex layers of both federal and state laws and regulations as well as numerous federal and state agencies regulating it. Often, legal opinion letters are sought by purchasers and lenders for healthcare transactions for these reasons. We have several board certified health lawyers in our firm who have written dozens of these.

4. We represent health professionals and health facilities in Medicare audits, including fraud audits by the Zone Program Integrity Contractors (ZPICs) and by Recovery Audit Contractors (RACs). This includes representation in the appellate process, including requests for reconsideration, request for redetermination, and federal administrative law judge hearings. Preparation of the response to the audit request, completion of the audit questionnaire, response to the preliminary audit report (PAR), and defense of any repayments demanded, through administrative hearings before federal administrative law judges and appeals if necessary.

5. We represent health professionals and health facilities in Medicaid audits, including fraud audits by the zone program integrity contractors (ZPICs). This includes preparation of the initial response to the audit request, completion of the audit questionnaire, response to the preliminary audit report (PAR), and defense of any repayments demanded, through administrative hearings and appeals if necessary.

6. If there has been an action by the Centers for Medicare & Medicaid Services (CMS) to terminate the Medicare provider’s billing privileges, we aggressively represent them to have the decision reversed and have them reinstated. This includes filing requests for reconsideration and corrective action plans (CAPs). We have been very successful in obtaining relief for our clients.

7. We have represented a number of clinical investigators, primarily physicians, and defensive charges of research fraud, misconduct in science, manipulation of data, manipulating outcomes, in research investigations, and other similar proceedings brought by their institutions or and investigation review board. Whether it is at the initiation of such an investigation or in later hearings and appeals, we have navigated a number of principal investigators through these processes.

8. Our firm has represented a number of medical students, residents and fellow, including foreign medical graduates, in cases brought by the National Board of Medical Examiners (NBME), the United States Medical Licensing Examination (USMLE), and the Educational Commission for Foreign Medical Graduates (ECFMG) in cases where there is an allegation of “irregular behavior” and rules violations through the hearing process and in appeals as necessary.

9. We represent physicians and other health professionals in hospital medical staff peer review proceedings and hearings. Whether it’s the initial application for clinical privileges and medical staff membership or action being taken to revoke or limit clinical privileges, we have been involved representing physicians and other health professionals at all levels. We have also done similar work for physicians in actions initiated by HMOs, professional associations, certification bodies, and other organizations. This is an area where a physician truly needs a health lawyer experienced in this type of proceeding.
10. “Disruptive physician” defense is another area where a doctor really needs an attorney who knows what he or she is doing. When your hospital or medical staff is attempting to place the label on you “disruptive physician,” you are really in trouble. This is an area in which careful navigation is required to prevent actions that result in such a label. Other wise, the physician can be pigeon-holed for life, placed into disruptive physician programs requiring years, if not a lifetime, of close monitoring and can even have discipline commenced against his or her medical license. We can assist you in taking actions to avoid having this happen.

11. When you receive a Medicare, Department of Health and Human Services (HHS), or Office of the Inspector General (OIG) subpoena or civil investigative demand (CID), you know there is serious trouble for someone in the works. We help you to respond promptly and professionally and attempt to keep you from becoming the target of serious federal investigations.

12. We represent physicians, nurses, dentists, psychologists and other licensed health professionals in responding to Department of Health (DOH) letters of investigation. Many physicians, nurses, dentists and other licensed health professionals do not understand that when they receive a letter from the Department of Health complaints advising them that they are under investigation for a complaint that is been made against them, this is a very serious matter. There is nothing that is “routine” about this. This means that there is an investigation that has been opened against your license that could ultimately result in disciplinary action being taken against you. Any disciplinary action taken against you will be on your license forever. This is the time to obtain an attorney. This is not a time to attempt to represent yourself. You should not ever speak with the investigator or provide a statement to the investigator; this is something only your attorney should do and only if it is determined to be advisable considering the facts of the case. We have represented hundreds of licensed health professionals in such investigations and in subsequent disciplinary hearings.

13. We also represent health professionals and others who have been excluded from the Medicare program and placed on the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE). We have represented a number of healthcare professionals in completing and submitting applications to be removed from the LEIE and reinstated to the Medicare program.

14. We routinely counsel and represent physicians, dentists, psychologists, mental health counselors, and other health professionals in referrals to the Professionals Resource Network (PRN) for evaluation. We have found that often the health professional will not actually have any type of substance abuse problem or mental health issue. However, one referred for an evaluation to the PRN can wind up in a five year contract or even a lifetime contract for monitoring containing many mandatory requirements in order to continue practicing his/her profession and a lot of expenses associated with meeting such requirements.

15. We also routinely counsel and represent nurses and nurse practitioners (ARNPs), including certified registered nurse anesthetists (CRNAs) in similar referrals to the Intervention Project for Nurses (IPN). We have found that often the nurse will not actually have any type of substance abuse problem or mental health issue. However, one referred for an evaluation to the IPN can wind up in a five year contract or even a lifetime monitoring contract containing many mandatory requirements in order to continue practicing his/her profession and a lot of expenses associated with meeting such requirements.

16. We have been involved in a number of qui tam or whistle blower cases, either representing the whistle blower or representing an employer or institution that is being accused of wrongdoing. Whether this is pursuant to the Federal False Claims Act (FCA), a state false claims act or a private whistle blower act, we are experienced in investigating, prosecuting, defending, and litigating such cases in state or federal court.

17. Our firm represents physicians, pharmacists, health professionals and health facilities in administrative litigation against the Drug Enforcement Administration (DEA), the Food and Drug Administration (FDA), the Centers for Medicare and Medicaid Services (CMS), the Agency for Health Care Administration (AHCA) and the Department of Health, among other agencies. Whether the government agency is seeking to recover civil monetary penalties (CMP), attempting to recover large Medicare overpayments, seeking to revoke your DEA registration or seeking to discipline your medical license, we have experience in litigating such matters in these administrative tribunals. This can make the difference between a favorable outcome or a devastating outcome.

18. We represent Veterans Administration (VA) physicians, Army physicians, Navy physicians, Air Force physicians, and Indian Health Service physicians, in employment disputes, peer review investigations and hearings, clinical privileging investigations and hearings, and decisions to report to the National Practitioner Data Bank (NPDB).

19. Reporting a conviction for Driving under the influence (DUI) or some other criminal offense is required by most state licensing agencies. We are experienced in making such reports when required and in such a manner that a subsequent investigation and discipline on the professional license is often avoided.

20. Complex litigation involving health professionals is another area in which we routinely practice. Whether the matter involves a dispute between the shareholders of a medical clinic or practice, restraints on trade, allegations of false claims and fraud, the enforcement or avoidance of restrictive covenants (or covenants-not-to-compete), employment, pay and bonus disputes, ownership of practices or facilities, or any other of a number of different situations, we represent either side in state court or federal court.

21. Because of our experience in mental health law, we have come to represent individuals who have been incorrectly confined in mental health facilities in Florida because of allegations of impairment, drug abuse, mental health issues and other issues in which the person is initially though to be a threat to himself or to others. Both law enforcement authorities and medical personnel are being trained to take fewer chances with an individual acting unusual who may tend to hurt herself or someone else. They often tend to err to the side of ordering confinement under the Florida Mental Health Act (also known as the “Baker Act”). When this happens, the individual may be set for a long stay unless he or she has assistance in navigating the way out. We help doing this as quickly and expeditiously as possible.
22. We routinely representing physicians, pharmacists, nurses, dentists and other licensed health professionals in attempting to avoid or in disputing or in appealing adverse National Practitioner Data Bank (NPDB) Reports. There are only limited grounds for doing this so the professional needs to obtain counsel as early in the process as possible.

23. Any type of subpoena or search warrant from a government agency or law enforcement organization seeking your patient records can herald an investigation into false claims, over-prescribing, or other serious possible charges, criminal, civil or administrative. Our representation seeks to determine the reasons for this as early in the process as feasible and to protect your rights and limit your exposure as much as possible.

24. There are many, many other types of cases which we have experience with. To see some of these others, please visit our website.

As the business of health care grows, our law firm also grows. We are always seeking to expand our areas of practice within the health law field. Be sure to check back regularly for updates.

For more information on various health law topics and how The Health Law Firm can help you, visit our YouTube page to watch our video blogs.

Contact Experienced Health Law Attorneys.

The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in Centers for Medicare and Medicaid Services (CMS) investigations, Medicare Audit defense, 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.

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

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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.
Copyright © 2019 The Health Law Firm. All rights reserved.

By |2019-01-28T23:57:45+00:00January 28th, 2019|Categories: Massage Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments
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