Florida Attorney General Targets Targeted Case Management Fraud

DPP_12By Christopher E. Brown, J.D., The Health Law Firm

Due to increased fraud throughout the system, the Florida Attorney General (AG), through the Medicaid Fraud Control Unit (MFCU), is focusing its attention on Medicaid targeted case management (TCM) services.

TCM services were created to assist children with documented mental health conditions in gaining access to medical, social, educational, and other support services. To be eligible for such services a child must meet very strict criteria.

Eligibility Criteria for Children’s Mental Health TCM Services:

1. Must be enrolled in a Department of Children and Families (DCF) children’s mental health target population (birth through 17 years);
2. Has a mental health disability (i.e., serious emotional disturbance) that requires advocacy for and coordination of services to maintain or improve level of functioning;
3. Requires services to assist in attaining self sufficiency and satisfaction in the living, learning, work, and social environments of choice;
4. Lacks a natural support system for accessing needed medical, social, educational, and other services;
5. Requires ongoing assistance to access or maintain needed care consistently within the service delivery system;
6. Has a mental health disability (i.e., serious emotional disturbance) that, based upon professional judgment, will last for a minimum of one year;
7. Is in out-of-home mental health placement or at documented risk of out-of-home mental health treatment placement; and
8. Is not receiving duplicate case management services from another provider.

Unfortunately, many of the children TCM providers assist and bill Medicaid for do not meet these criteria. In addition, a lack of oversight by the Medicaid program has led to numerous improper and fraudulent payments to TCM providers.

Florida TCM Fraud Cases.

Improper and fraudulent payments are often related to TCM providers billing for services that were never performed and paying kickbacks for client referrals.

According to the Florida AG, the three owners of Destiny TCM Corporation in Central Florida were arrested by the MFCU for $27,000 worth of Medicaid fraud. The corporation is accused of falsely billing the Medicaid program for illegitimate targeted case management services and bribing individuals in order to obtain Medicaid recipient numbers. Click here to read the press release from the AG.
In another similar case, the owners of Kingdom Builders Ministries in Lake County, Florida, were also arrested for allegedly defrauding Florida Medicaid out of $80,000. The MFCU revealed that the two owners allegedly directed employees to bill for an entire family when only one member received services. Employees were also allegedly instructed to bill for unauthorized expenses, such as travel time, employee staff meetings and phone calls. Additionally, records indicate that Kingdom Builders Ministries received payment for services allegedly provided to young children who did not have any documented mental health condition and continued to submit invoices months after terminating services. Click here to read more from the AG.

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

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

Defend Yourself from Fraud Charges.

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

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

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

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

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

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

The Health Law Firm’s attorneys routinely represent speech therapists, occupational therapists, vocational therapists, therapy groups, physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions. To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

Did you know the eligibility criteria for children’s mental health TCM services? Were you aware that the AG is targeting these services? Please leave any thoughtful comments below.

About the Author: Christopher E. Brown, J.D., 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 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.

American Medical Association Joins Minnesota Medical Staff in Its Fight for Autonomy

7 Indest-2008-4By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The American Medical Association (AMA) and several other physician organizations announced support of a court appeal by physicians at Avera Marshall Regional Medical Center in Minnesota. The medical staff at Avera alleged the hospital’s governing board amended the medical staff’s bylaws and took away the medical staff’s right to self-govern. On February 6, 2013, the AMA, the Minnesota Medical Association, the American Academy of Family Physicians, the American Osteopathic Association and the Minnesota Academy of Family Physicians filed a friend-of-the-court brief on behalf of the hospital’s medical staff.

Click here to read the press release from the AMA announcing its support of the medical staff at Avera.

Background on the Case at Avera Marshall Regional Medical Center.

In January 2012, the Avera medical staff filed a lawsuit alleging the new bylaws created by the hospital’s governing board left the physicians without “nearly all rights and responsibilities” and gave Avera’s governing board controlling power in processes that required medical staff direction. On September 26, 2012, a Minnesota District Court judge issued a final order on a lawsuit refusing to recognize the medical staff’s lawsuit and refusing to recognize the bylaws as a contract.

To read more on the final order by the judge in the Minnesota District Court, click here.

AMA and Other Physician Organizations in Favor of Self-Governance by a Medical Staff.

The brief supports reestablishing the independence of the hospital’s medical staff to ensure their right and responsibility to uphold the quality of patient care, without interference by the hospital’s governing board. The AMA president said the judge’s ruling gave unchecked power to Avera’s governing board over the medical staff. The brief urges the state’s court of appeals to revise this ruling and allow the medical staff to present its case for self-governance. The AMA believes giving the medical staff the right to self-govern will restore balance between patient care and corporate interests at the hospital.

Click here to read the friend-of-the-court brief file by the AMA.

My Input on a Self-Governing Medical Staff.

By law the medical staff in a hospital is supposed to be self-governing. The AMA, along with other medical associations, created a minimum standard to govern hospitals and to lay out what health care professionals need to do to improve the quality of care in the hospitals. Self-governing includes allowing the medical staff to discipline its own members when necessary, conduct peer reviews, and take action when they see hospital issues.

To watch a video explaining medical staff self-governance in more detail, click here.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals.

The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the Drug Enforcement Administration (DEA), Federal Bureau of Investigation (FBI), 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?

What are your thoughts on medical staff self-governance? Please leave any thoughtful comments below.

Sources:

Mills, Robert. “AMA and Other Support Physician Fight for Autonomy.” American Medical Association. (February 15, 2013). From: http://www.ama-assn.org/ama/pub/news/news/2013-02-15-physician-fight-autonomy.page

Medical Staff of Avera Marshall Regional Medical Center on Its Own Behalf and in Its Representative Capacity for Its Members v. Avera Marshall d/b/a Avera Marshall Regional Medical Center. Case No. A12-2117. State of Minnesota Court of Appeals. February 6, 2013. From: http://www.thehealthlawfirm.com/uploads/2012-12-05-amicus-brief-avera-marshall.2.pdf

Gau, Deb. “Judge Issues Final Order in Avera Lawsuit.” Marshall Independent. (September 26, 2012). From: http://www.marshallindependent.com/page/content.detail/id/536152/Judge-issues-final-order-in-Avera-lawsuit.html?nav=5015

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.

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.

The Affordable Care Act Offers the Government New Tools to Fight Healthcare Fraud

By Catherine T. Hollis, J.D., The Health Law Firm

In 2013, the government reported recovery of a record-breaking $10.7 billion in healthcare fraud in the past three years, according to the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ). The HHS credits the Affordable Care Act’s tough stance on fraud for improving the efforts to fight Medicare fraud.

The increase in fraud recovery is attributed in part to the Act’s proactive approach to preventing fraud. The Act contains several initiatives that address Medicare fraud, resulting in increased fraud-fighting tools available to the government. The joint effort between the HHS, the DOJ and the Health Care Fraud Prevention and Enforcement Action Team has been a primary driving force in seeking out fraud and securing recoveries. The HHS and DOJ’s website highlights some of the Act’s “powerful steps” toward fighting fraud, waste and abuse. Click here to read more from www.stopmedicarefraud.gov.

Tougher Punishment.

The Act increases federal sentencing guidelines for healthcare fraud by twenty percent (20%) to fifty percent (50%) for crimes that involve more than $1 million in losses. The Act also establishes penalties for obstructing a fraud investigation or an audit.

Stricter Screening for Enrollment and Revalidation.

According to the HHS, the new screening procedures include licensure checks and site visits for all providers and suppliers. In addition, the Act imposes higher scrutiny on providers and suppliers who may pose a higher risk of fraud or abuse. High risk providers and suppliers can be subject to unscheduled site visits and fingerprint-based criminal background checks.

The Center for Medicare & Medicaid Services (CMS) has started to revalidate the enrollment of all 1.5 million existing Medicare providers and suppliers, using the new screening requirements set forth by the Act. Thousands of enrollments have already been deactivated or revoked as the result of this effort. There is a blog on our website about the devastating and far reaching effects of being excluded from the Medicare program. Click here to read that blog.

New Detection Technology.

CMS is using the Fraud Prevention System to screen all fee-for-service Medicare claims. This system uses advanced predictive technology, similar to that used by credit card companies, to analyze claims prior to payment. It also scans for suspicious billing patterns. Claims identified by the Fraud Prevention System as suspect are reviewed by CMS for possible fraud.

Increased Resources.

The Act provides an additional $350 million over ten years (2011 through 2020) through the Health Care Fraud and Abuse Control Account.

These steps represent a more proactive approach to Medicare fraud. The government is focusing on preventing fraud before it happens, rather than paying fraudulent claims and seeking reimbursement after the fact. The tools contained in the Act, as implemented by CMS and HHS, further the goal of the Act to reduce fraud, waste and abuse in the Medicare system. To read a summary of the anti-fraud provisions in the Affordable Care Act, click here.

Anti-Fraud Provisions At Work.

On May 14, 2013, the HHS and DOJ announced the arrest of 89 people, including doctors, nurses and other medical professionals, in eight cities. These people are allegedly charged in separate Medicare fraud schemes. According to the DOJ, the scans involve approximately $223 million in false billing. Click here to read a blog on these arrests. To read more blogs on Medicare and Medicaid fraud, visit our website.

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

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

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

Comments?

Do you think the Affordable Care Act will help cut down on healthcare fraud? Why or why not? Please leave any thoughtful comments below.

Sources:

Sjoerdsma, Donald. “The Affordable Care Act Bolstered, Didn’t Drive Medicare Anti-Fraud Efforts.” The Medicare Newsgroup. (March 22, 2013). From: http://medicarenewsgroup.com/context/understanding-medicare-blog/understanding-medicare-blog/2013/03/22/the-affordable-care-act-bolstered-didn-t-drive-medicare-anti-fraud-efforts

“The Affordable Care Act and Fighting Fraud.” U.S. Department of Health & Human Services and U.S. Department of Justice. From: http://www.stopmedicarefraud.gov/aboutfraud/aca-fraud/index.html

 

Health Benefits ABCs. “Summary of Anti-Fraud Provisions in the Affordable Care Act.” U.S. Administration on Aging, Department of Health and Human Services. From: http://www.smpresource.org/Content/NavigationMenu/ConsumerProtection/HealthCareReform/Anti-Fraud_Provisions_in_Health_Care_Reform.docx

“New Tools to Fight Fraud, Strengthen Federal and Private Health Programs, and Protect Consumer and Taxpayer Dollars.” U.S. Department of Health & Human Services. (March 15, 2011). From: http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html

About the Author: Catherine T. Hollis 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.

Supreme Court Rules that Government Regulators Can Sue Over Pay-for-Delay Agreements Between Brand and Generic Drug Manufacturers

George F. Indest III, Board Certified by The Florida Bar in Health Law

George F. Indest III, Board Certified by The Florida Bar in Health Law

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

The U.S. Supreme Court ruled on June 17, 2013, that pay-for-delay agreements between brand name and generic drug manufacturers are subject to anti-trust scrutiny. These pay-for-delay agreements, or reverse payments, are usually a form of settlement between the two manufacturers in patent litigation. The Supreme Court decided that each instance must be considered on a case-by-case basis. This verdict rewrites the rules governing the release of generic drugs. It is likely to increase the number of generic drugs in the marketplace and reduce the price of generic drugs.

To read a previous blog on pay-for-delay agreements, click here.

What is a Pay-for-Delay Agreement?

Pay-for-delay agreements came as the result of the Drug Price Competition and Patent Term Restoration Act of 1984, also known as the Hatch-Waxman Act. The Hatch-Waxman Act gives generic drug manufacturers an incentive to challenge brand name drug patents because the first generic drug manufacturer to received U.S. Food and Drug Administration (FDA) approval to launch a generic copy of a brand name drug can receive a 180-day marketing exclusivity period for the product. The FDA cannot approve any other generic applications for the same drug until the first-to-file generic manufacturer has sold its product for 180 days or has given up its exclusivity period. Click here to read the Hatch-Waxman Act.

Brand name manufacturers often challenge generic drug manufacturers who try to sell their product prior to patent expiration. This results in litigation to determine whether the generic manufacturer is violating the brand name manufacturer’s patents.

Instead of going to court over this, brand name manufacturers often choose to pay a settlement to the generic drug manufacturers for agreeing to delay the launch of its competing product.

Why the Supreme Court Overruled Court of Appeals Decision.

The 5-3 vote overruled the 11th Circuit Court of Appeals decision that said pharmaceutical companies can’t be sued unless the patent litigation is a sham or a generic drug maker agrees to delay introduction of a generic drug into the market even after the patent has expired.

A Med Page Today article lists the Supreme Court’s five reasons why the appellate court made a mistake in giving blanket immunity to pay-for-delay agreements from the decision written by Justice Stephen Breyer:

–  “A reverse payment, where large and unjustified, can bring with it the risk of significant anticompetitive effects.”

–  “One who makes such a payment may be unable to explain and to justify it.”

–  “Such a firm or individual may well possess market power derived from the patent.”

–  “A court, by examining the size of the payment, may well be able to assess its likely anticompetitive effects along with its potential justifications without litigating the validity of the patent.”

–  “Parties may well find ways to settle patent disputes without the use of reverse payments.”

Click here to read the entire Med Page Today article.

Pay-for-Delay Agreements Allegedly Cost Patients Millions of Dollars a Year.

According to Bloomberg, the high court’s decision may discourage brand name and generic pharmaceutical companies from reaching settlements. It’s been found that pay-for-delay agreements can delay a generic drug almost 17 months before it can be put on the market. In the meantime, patients must pay higher prices for the brand name version. This also impacts Medicare and Medicaid programs. The Federal Trade Commission (FTC) claims pay-for-delay agreements cost consumers $3.5 billion a year in the form of higher drug prices.

To read the Bloomberg article, click here.

The Case of the FTC v. Solvay Pharmaceuticals.

The Supreme Court case center around AndroGel, a treatment for low testosterone in men, made by Solvay Pharmaceuticals, Inc. The FTC sued Solvay and three generic drug companies. According to Bloomberg, the FTC said that a payment made by Solvay, the holder of a patent on AndroGel, to the generic drug manufacturers represented an unlawful restraint of trade because it was intended to keep cheaper, generic versions of AndroGel off the market until 2020.

FTC Enthusiastic About the Decision.

In a statement, the FTC Chairwoman said the Supreme Court’s decision is a “significant victory for American consumers, American taxpayers and free market.” She also stated, “The court made it clear that pay-for-delay agreements are subject to antitrust scrutiny.”

Click here to read the full statement from the FTC.

Contact Health Law Attorneys Experienced in Representing Pharmacies and Pharmacists.

The Health Law Firm represents pharmacists and pharmacies in investigations, regulatory matters, licensing issues, litigation, inspections and audits. 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.

Comments?

What do you think of the Supreme Court’s ruling? Do you agree or disagree? What effect do you think it will have on the pharmaceutical industry? Please leave any thoughtful comments below.

Sources:

Stohn, Greg. “Drugmakers Opened to ‘Pay for Delay’ Suits by High Court.” Bloomberg. (June 17, 2013). From: http://www.bloomberg.com/news/2013-06-17/drugmakers-opened-to-pay-for-delay-suits-by-high-court.html

Frieden, Joyce. “Supreme Court Split on Pharma ‘Pay for Delay’ Deals.” Med Page Today. (June 17, 2013). From: http://bit.ly/18SfhKb

Kaplan, Peter. “Statement of FTC Chairwoman Edith Ramirez of the U.S. Supreme Court’s Decision in FTC v. Actavis, Inc.” (June 17,2 013). From: http://www.ftc.gov/opa/2013/06/actavis.shtm

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.

Fifty-Five Hospitals Around the Country to Pay the Government $34 Million Settlement for False Claims Allegations

10 Indest-2008-7By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Fifty-five (55) hospitals in twenty-one (21) states have agreed to pay the Department of Justice (DOJ) more than $34 million to settle allegations of Medicare fraud in a whistleblower case, according to the DOJ on July 2, 2013. The false claims allegations involve a back procedure called a kyphoplasty. The kyphoplasty can be performed safely and effectively as an outpatient procedure. However, it is alleged that hospitals were using more expensive, inpatient procedures to increase Medicare billings.

To read the press release from the DOJ, click here.

A kyphoplasty is used to treat spinal fractures usually caused by osteoporosis.

Fourteen (14) Florida Hospitals to Pay $11 Million to Government.

According to an article on Health News Florida, fourteen (14) Florida hospitals have agreed to pay around $11 million to settle the DOJ’s false claims charges.

One of the Florida hospitals was Mount Sinai Medical Center in Miami, which will pay $1.84 million. A number of HCA hospitals in Florida were included in the settlement. These hospitals will pay $7.14 million collectively. Another group that settled was the hospitals in the Morton Plant Mease group, which is part of the Baycare Health System in Tampa Bay. This settlement was listed at $2.37 million.

To see all of the Florida hospitals allegedly involved, click here to read the Health News Florida article.

Whistleblower Lawsuit Filed by Two Former Employees.

According to the DOJ, all but four of the settling facilities were named as defendants in a whistleblower lawsuit brought under the False Claims Act. The lawsuits were filed by a former reimbursement manager for Kyphon and a former regional sales manager for Kyphon. The DOJ stated that Kyphon is the company that allegedly advised hospitals to do kyphoplasty procedures as inpatient instead of outpatient procedures. These two will receive a total of about $5.5 million from the settlements.

If you want to know more about whistleblower/qui tam lawsuits, click here to read the first part of a two-part blog, and click here for the second part.

Previous Settlements from Kyphoplasty Procedures.

A similar settlement was reached in 2012, when 14 hospitals agreed to pay a settlement of more than $12 million to the government for allegedly inflating their profits based on unnecessary hospital admissions, according to the Washington Post. Click here to read that article.

The DOJ stated that it has now reached settlements with more than 100 hospitals, for a total of about $75 million resolving allegations that the facilities fraudulently billed Medicare for kyphoplasty procedures.

The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is on Fire.

These settlements are a part of the government’s fight against health care fraud and another win for the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT’s mission is to focus its efforts on preventing and deterring fraud and to enforce current anti-fraud laws around the country. It was created in 2009, by the Department of Health and Humans Services (HHS) and the DOJ. To date, the DOJ’s total recoveries in False Claims Act cases since January 2009, are more than $14.7 billion. To learn more about HEAT, click here.

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

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

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

Comments?

What do you think of these settlements? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Fifty-Five Hospitals to Pay U.S. More Than $34 Million to Resolve False Claims Act Allegations Related to Kyphoplasty.” Department of Justice. (July 2, 2013). From: http://www.justice.gov/opa/pr/2013/July/13-civ-745.html

Associated Press. “Justice Department, 55 Hospitals Reach $34 Million Settlement Over Medicare Fraud Claims.” Washington Post. (July 2, 2013). From: http://www.washingtonpost.com/business/justice-department-55-hospitals-reach-34-million-settlement-over-medicare-fraud-claims/2013/07/02/3d3d2356-e34e-11e2-bffd-37a36ddab820_story.html

Health News Florida Staff. “14 FL Hospitals to Pay $11 Million.” Health News Florida. (July 2, 2013). From: http://health.wusf.usf.edu/post/14-fl-hospitals-pay-11-million

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.

Enforcing Your Right to Access Public Records

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

Citizens of the state of Florida enjoy broad access to the public records created by state agencies.  Those records range from information on state contracts to certain police records to information on state licensees. Almost all records created by or held by state agencies on you are considered public records with certain limited exceptions.

Access to public records is guaranteed by both Article I, Section 24, of the Florida Constitution and Chapter 119, Florida Statutes.  Those laws state that every person has the right to access any public record made or received in connection with the official business of any public body, officer or employee of the state of Florida, subject to certain specific exceptions.

What to do if Your Records Request is Refused.

Public records requests can be refused for many reasons.  The most common reason is a statutory exemption or destruction of the records due to retention policies.

If you have requested records that the custodial agency is refusing on exemption grounds, you have a right to know exactly what Florida Administrative Code Rule or Statute the agency is relying on.  You can then challenge the exemption if you believe the agency is not entitled to rely on it.

If you have requested records that the custodial agency has stated were destroyed, you have a right to a copy of the proof of destruction documentation.  Rule 1B-24.003(9)(d), Florida Administrative Code, and Florida General Records Schedule GS1-SL provide for records retention schedules and the right to the information pertaining to the disposition of records.

Many agency records are kept in both hard copy and electronic format.  It is crucial to check that the disposition of records form states how both types of information were disposed of.

It is the experience of this firm that many times the hard copies of the records are destroyed by the agency, but the electronic copies are maintained in its systems.  This can lead to an undisclosed “shadow file” being maintained.  This is especially dangerous with records such as Department of Health (DOH) disciplinary files.

In the case of the DOH, it maintains electronic records of discipline that it freely provides to other agencies (even those outside of the state).  However, when a licensee requests copies of his or her records, the DOH tells him or her that they have been destroyed.  While the paper records may have been destroyed, the electronic ones are freely accessible and disclosable.

If you believe that a state agency has electronic records you have a right to view, speak with an attorney to facilitate a supervised inspection of the records system.  This is your right under Chapter 119, Florida Statutes, and the Florida Constitution.

Enforcing Your Right to Inspect and Copy Public Records.

If the agency from which you are requesting records refuses to provide them to you or otherwise permit you to inspect or photograph them in person, you have the right to seek enforcement in court.

In order to do this, you will be required to file a Petition for Writ of Mandamus in the appropriate circuit court.  This petition is used to force a public officer to perform the duties of his or her office. Because public officers and officials are required by law to permit the inspection, copying and photographing of all non-exempt public records, a court can force them to comply with your request by issuing a Writ of Mandamus.

Public Records Actions and Attorney’s Fees and Costs.

Many people are willing to accept an agency’s refusal to provide access to public records because they are afraid of the attorney’s fees and costs associated with enforcing their rights.  However, the law in Florida strongly favors the public’s access to information and contains a robust attorney’s fees provision.

Section 119.12, Florida Statutes, provides that a person who is forced to bring a civil action (lawsuit) to enforce his or her right to public records is entitled to receive payment of his or her reasonable attorney’s fees and costs incurred in bringing the action from the agency.

Courts have further interpreted the public records laws to provide for an award of attorney’s fees even when the agency produces the records after suit but before being ordered to do so by a court.  This means that you can still recover your attorney’s fees and costs even if the agency produces the records before the court forces it to do so.

Protect Your Personal and Professional Reputation.

There is a wide range of potentially damaging information maintained by state agencies.  The first step in preventing any harm to your personal and professional reputation is to know what information is out there, in what forms, and know the possibilities of it being disseminated in harmful ways.

Navigating the many exemption and enforcement provisions of Florida’s public records laws can be daunting.  It is important to consult with an attorney experienced in handling these matters.  It is also important to remember that if you are unlawfully being denied access to public records, there is a strong chance that your enforcement costs will be awarded by a reviewing court.

Contact Attorneys Experienced in Enforcing Access to Public Records.

The attorneys of The Health Law Firm are experienced in representing citizens attempting to determine if a governmental agency has certain records it is keeping on them and obtaining copies or an inspection of such records. We have been successful in suing and obtaining access to “secret” records being kept by the Department of Health (DOH) on health professionals after their existence was denied by the agency for years.  In such cases, the citizen who is required to sue the agency is entitled to payment of his or her attorney’s fees and costs by the agency.

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

Comments?

Have you ever had issues trying to access your public records? Please leave any thoughtful comments below.

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.

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

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

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

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

Violated Medicaid Fraud Kickback Statute.

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

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

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

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

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

Defend Yourself from Fraud Charges.

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

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

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

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

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

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

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

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

Comments?

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

Sources:

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

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

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

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

Florida Nursing Home Owner Arrested for Alleged $395,000 Medicaid Fraud Scheme

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

A Miami-Dade nursing home owner was arrested for allegedly committing $395,000 worth of Medicaid fraud. The Florida Attorney General (AG) accused the nursing home owner of using the billing names of non-existent businesses to submit fraudulent invoices. The fake invoices were then allegedly paid with Medicaid funds. The nursing home owner was arrested on October 17, 2013, by the AG’s Medicaid Fraud Control Unit (MFCU) and the Miami-Dade Police Department.

To read the press release from the AG, click here.

Nursing Home Owner Allegedly Pocketed Medicaid Money.

According to the AG, the nursing home owner recorded forty-seven (47) fraudulent operating expense charges and submitted the cost report to the Agency for Health Care Administration (AHCA). The owner is accused of then writing checks to these phony businesses to “pay” the expense charges. The AG alleges that the nursing home owner was just paying himself. AHCA referred the case to the MFCU.

If convicted, the nursing home owner faces up to 90 years in prison and more than $1.9 million in fines.

MFCU and State and Federal Auditing Agencies.

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

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

Take Fraud Charges Seriously.

In many cases those subject to Medicaid or Medicare fraud audits and investigations refuse to acknowledge the seriousness of the matter or they decide not to spend the money required for a top quality attorney to defend them.

If you are accused of Medicare or Medicaid fraud, realize that you are in the fight of your life. Your liberty, life and profession are at stake. Do not delude yourself. This is extremely serious. Be prepared to give up whatever you have if you can avoid a conviction.

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

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

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

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

Comments?

Have you heard of the MFCU? Would you know how to properly respond to a Medicaid audit? Please leave any thoughtful comments below.

Source:

Ray, Whitney. “Miami-Dade Nursing Home Owner Arrested for $395,000 in Medicaid Fraud.” My Florida Legal. (October 17, 2013). From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/F652FC98C9E1BA0C85257C0700530C42
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.

Florida Respiratory Therapist Arrested for Alleged Elder Abuse

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

A Lee County, Florida, registered respiratory therapist at HealthPark Medical Center in Fort Myers, Florida, was arrested and charged with battery on an elderly patient. The respiratory therapist was arrested by the Attorney General’s (AG) Medicaid Fraud Control Unit (MFCU). The arrest was announced by the AG on February 14, 2014.

To read the news release from the AG, click here.

Respiratory Therapist Accused of Fracturing Patient’s Hand.

According to the AG, the respiratory therapist allegedly abused a 68-year-old intensive care unit patient by severely bending his fingers back resulting in a bone fracture in the patient’s hand, while the man’s arms were restrained.

The respiratory therapist is charged with battery on a person over the age of 65, which is a third-degree felony. If convicted, the alleged abuser faces a minimum sentence of three years in prison and up to $10,000 in fines.

MFCU Conducted Investigation.

The MFCU’s investigation led to the MFCU issuing a warrant for the respiratory therapist’s arrest. The case will be prosecuted by the Lee County State Attorney’s Office.

According to the AG, in addition to Medicaid fraud, the MFCU investigates abuse, neglect and exploitation of elderly or disabled people in health care facilities.

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

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

The Health Law Firm’s attorneys routinely represent speech therapists, occupational therapists, vocational therapists, therapy groups, physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions. To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of these charges? Please leave any thoughtful comments below.

Source:

Florida Attorney General. “Lee County Man Arrested for Elder Abuse.” My Florida Legal. (February 14, 2014). From: http://bit.ly/1o6vq0J

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

 

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2014 The Health Law Firm. All rights reserved.

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