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Florida’s New E-Prescribing Law: How It May Affect You and Your Career

George Indest HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
In 2019, Florida’s Governor Ron DeSantis signed House Bill 831 (2019), Electronic Prescribing, into law. The new bill provides important requirements for prescribers to generate and transmit all prescriptions electronically upon their license renewal or by July 1, 2021, whichever is earlier. The bill will go into effect on January 1, 2020.

Summary of New Law, HB 831.

The new law applies to any health care practitioner who is licensed by law to prescribe a medicinal drug. The law, HB 831 sets forth the following general rule for prescribing:

If you are licensed to prescribe a medicinal drug, and you:

(1) Maintain a system of electronic health records; or

(2) Are an owner, employee or contractor of a licensed healthcare facility or practice that maintains a system of electronic health records and are prescribing in your capacity as an owner, employee or contractor of the licensed healthcare facility;
then you must electronically transmit your prescriptions unless an exception applies.

 

How the New Law May Affect You, a Licensed Health Professional.

The law requires prescribers to generate and transmit all prescription electronically, unless:

• The practitioner and the dispenser are the same entity;

• The prescription cannot be transmitted electronically under the most recently implemented version of the National Council for Prescription Drug Programs SCRIPT Standard;

• The practitioner has been issued a waiver by the Department of Health, not to exceed one year, due to demonstrated economic hardship, technology limitations that are not reasonably within the control of the practitioner, or another exceptional circumstance demonstrated by the practitioners;

• The practitioner reasonably determines that it would be impractical for the patient in question to obtain a medicinal drug prescribed by electronic prescription promptly and such delay would adversely impact the patient’s medical condition;

• The practitioner is prescribing a drug under a research protocol;

• The prescription is for a drug for which the U.S. Food and Drug Administration (FDA) requires the prescription to contain elements that may not be included in electronic prescribing;

• The prescription is issued to an individual receiving hospice care or who is a resident of a nursing home facility; or

• The practitioner determines that it is in the best interest of the patient, or the patient determines that it is in his or her own best interest to compare prescription drug prices among area pharmacies. The practitioner must document such determination in the patient’s medical record.

About half of Florida’s medical doctors must renew their licenses by January 31, 2020. Medical doctors that renew their licenses between January 1, 2020, and January 31, 2020, must comply with the new law by the date they renew their licenses.

View the full text of HB 831 – Electronic Prescribing here.

For more information, including a list of frequently asked questions, visit the Florida Board of Medicine’s website.

Contact Health Law Attorneys Experienced in the Representation of Health Professionals and Providers.

The attorneys of The Health Law Firm provide legal representation to physicians, nurses, nurse practitioners, CRNAs, pain management doctors, dentists, pharmacists, psychologists and other health providers in Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations, Medicare investigations, Medicaid investigations and other types of investigations of health professionals and providers.

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

Sources:

“ALERT: Electronic Prescribing Requirements.” Florida Board of Medicine. (October 21, 2019). Web.

Scott, Jeff. “What Florida’s new e-prescribing law means for you.” Florida Medical Association (FMA). (June 18, 2019). Web.

About the Authors: 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.
Michael L. Smith, R.R.T., J.D., is Board Certified by The Florida Bar in Health Law
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: 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, Board of Pharmacy representation, Board of Pharmacy investigation representation, Board of Pharmacy attorney, Board of Nursing representation, Board of Nursing attorney, Board of Nursing investigation representation, nurse attorney, representation for nurses, nurse defense attorney, Board of Dentistry representation, Board of Dentistry attorney, representation for dentists, dentist defense lawyer, representation for e-prescribing, physician attorney, health care professional defense attorney, representation for health care professionals, professional licensure defense attorney, professional licensure representation, licensure defense attorney, representation for licensure issues, license renewal representation, license renewal defense lawyer, pharmacy defense lawyer, representation for pharmacists, representation for pharmacies, review 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.

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

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

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.

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

Follow These Steps to Challenge OIG Exclusion From Medicare

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

Many health professionals don’t understand the significant repercussions that an exclusion action by the Office of the Inspector General (OIG) can have on their professional careers and future employment. Whether you are a physician, nurse, dentist, psychologist or other health professionals, if you allow yourself to be excluded from the Medicare program, devastating economic results may follow.

The administrative process by which you may challenge a proposal from the OIG for most permissive or mandatory exclusion is challenging. In most cases, you will need experienced legal representation.  Below are the steps in the process you must follow to protect your career and your livelihood.

How to Challenge OIG Exclusion Actions.

1.    Notice of Intent (NOI) received: If the OIG is proposing to exclude a person or entity from Medicare, it will send out a letter called a “Notice of Intent” or “NOI.” This will contain the reasons for the exclusion and will detail hearing or appeal rights.  It is very important to make sure that your state licensing board and Medicare have your correct current address on file because the address which Medicare has will be where the NOI is mailed.  (Note:  the OIG may not send a NOI for mandatory exclusions which carry a 5-year minimum exclusion period.)  You will not have a second chance. Regardless, you usually only have 30 days to submit a written response requesting a hearing and containing information the OIG will consider in making its decision.  In some cases, providers may have the opportunity to present oral arguments before OIG officials. You must make sure that your request is received by the deadline, not just mailed by the deadline.  Send your request by a fast, reliable means (such as Federal Express or U.S. express mail) that you can track; or register for and file it electronically online.  Read the instructions in the letter and follow them. Be sure you get a receipt when you file.

2.    Notice of Exclusion (NOE): Sometimes the OIG will send a “Notice of Exclusion” or “NOE” if it decides to exclude a provider regardless of the response provided to a NOI or in certain cases of mandatory exclusions or certain permissive exclusions where no NOI is ever sent. Medicare exclusions usually take effect 20 days after the NOE is mailed. In cases involving fraud, kickbacks and other prohibited activities, a Notice of Proposal to Exclude or NOPE may be sent instead.

3.    Administrative Law Judge (ALJ) Hearing: Providers have the right to appeal a proposed exclusion by requesting an administrative hearing (similar to a trial) before an “Administrative Law Judge” or “ALJ.” ALJ’s are part of the Department of Health and Human Services (HHS). If you wish to request an ALJ hearing, you must do so within 60 days of receiving the Notice of Exclusion (or according to the instructions), and you must be prepared to raise all of your arguments over issues regarding the decision itself, the proposed exclusion period, mitigating factors or other aspects of the action.

4.    Department Appeals Board (DAB): If you disagree with the ALJ hearing decision, you can further appeal to the HHS “Departmental Appeals Board” or “DAB.” This is a written appeal which will be required to set forth legal errors which were made in the ALJ hearing.

5.    Judicial Review: If you disagree with the decision made by the DAB, your only option is to challenge the final decision in a U.S. District Court.

MOST IMPORTANT, consult a health law attorney experienced in such matters. The consequences of  Medicare exclusion, even a permissive exclusion for one year or three years, are severe. Most people do not realize this until it is too late; then it is too late (in many, but not all, cases).

To learn more about the consequences of OIG exclusion, click here to read one of my prior blogs.

Contact Attorney Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program.

The attorneys of The Health Law Firm have experience in dealing with the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

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


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

KeyWords: 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

“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.

The Administrative Process to Challenge OIG Exclusion Actions

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

Many health professionals don’t understand the significant repercussions that an exclusion action by the Office of the Inspector General (OIG) can have on their professional careers and future employment. Whether you are a physician, nurse, dentist, psychologist or other health professionals, if you allow yourself to be excluded from the Medicare program, devastating economic results may follow.

The administrative process by which you may challenge a proposal from the OIG for most permissive or mandatory exclusion is challenging. In most cases, you will need experienced legal representation.  Below are the steps in the process you must follow to protect your career and your livelihood.

How to Challenge OIG Exclusion Actions.

1.    Notice of Intent (NOI) received: If the OIG is proposing to exclude a person or entity from Medicare, it will send out a letter called a “Notice of Intent” or “NOI.” This will contain the reasons for the exclusion and will detail hearing or appeal rights.  It is very important to make sure that your state licensing board and Medicare have your correct current address on file because the address which Medicare has will be where the NOI is mailed.  (Note:  the OIG may not send a NOI for mandatory exclusions which carry a 5-year minimum exclusion period.)  You will not have a second chance. Regardless, you usually only have 30 days to submit a written response requesting a hearing and containing information the OIG will consider in making its decision.  In some cases, providers may have the opportunity to present oral arguments before OIG officials. You must make sure that your request is received by the deadline, not just mailed by the deadline.  Send your request by a fast, reliable means (such as Federal Express or U.S. express mail) that you can track; or register for and file it electronically online.  Read the instructions in the letter and follow them. Be sure you get a receipt when you file.

2.    Notice of Exclusion (NOE): Sometimes the OIG will send a “Notice of Exclusion” or “NOE” if it decides to exclude a provider regardless of the response provided to a NOI or in certain cases of mandatory exclusions or certain permissive exclusions where no NOI is ever sent. Medicare exclusions usually take effect 20 days after the NOE is mailed. In cases involving fraud, kickbacks and other prohibited activities, a Notice of Proposal to Exclude or NOPE may be sent instead.

3.    Administrative Law Judge (ALJ) Hearing: Providers have the right to appeal a proposed exclusion by requesting an administrative hearing (similar to a trial) before an “Administrative Law Judge” or “ALJ.” ALJ’s are part of the Department of Health and Human Services (HHS). If you wish to request an ALJ hearing, you must do so within 60 days of receiving the Notice of Exclusion (or according to the instructions), and you must be prepared to raise all of your arguments over issues regarding the decision itself, the proposed exclusion period, mitigating factors or other aspects of the action.

4.    Department Appeals Board (DAB): If you disagree with the ALJ hearing decision, you can further appeal to the HHS “Departmental Appeals Board” or “DAB.” This is a written appeal which will be required to set forth legal errors which were made in the ALJ hearing.

5.    Judicial Review: If you disagree with the decision made by the DAB, your only option is to challenge the final decision in a U.S. District Court.

MOST IMPORTANT, consult a health law attorney experienced in such matters. The consequences of  Medicare exclusion, even a permissive exclusion for one year or three years, are severe. Most people do not realize this until it is too late; then it is too late (in many, but not all, cases).

To learn more about the consequences of OIG exclusion, click here to read one of my prior blogs.

Contact Attorney Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program.

The attorneys of The Health Law Firm have experience in dealing with the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

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


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

KeyWords: 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

“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 |2019-06-18T20:09:54+00:00August 14th, 2019|Categories: Mental Health Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

Steps to Challenge OIG Exclusion Action from Medicare Program

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

Many health professionals don’t understand the significant repercussions that an exclusion action by the Office of the Inspector General (OIG) can have on their professional careers and future employment. Whether you are a physician, nurse, dentist, psychologist or other health professionals, if you allow yourself to be excluded from the Medicare program, devastating economic results may follow.

The administrative process by which you may challenge a proposal from the OIG for most permissive or mandatory exclusion is challenging. In most cases, you will need experienced legal representation.  Below are the steps in the process you must follow to protect your career and your livelihood.

The Administrative Process to Challenge OIG Exclusion Actions.

1.    Notice of Intent (NOI) received: If the OIG is proposing to exclude a person or entity from Medicare, it will send out a letter called a “Notice of Intent” or “NOI.” This will contain the reasons for the exclusion and will detail hearing or appeal rights.  It is very important to make sure that your state licensing board and Medicare have your correct current address on file because the address which Medicare has will be where the NOI is mailed.  (Note:  the OIG may not send a NOI for mandatory exclusions which carry a 5-year minimum exclusion period.)  You will not have a second chance. Regardless, you usually only have 30 days to submit a written response requesting a hearing and containing information the OIG will consider in making its decision.  In some cases, providers may have the opportunity to present oral arguments before OIG officials. You must make sure that your request is received by the deadline, not just mailed by the deadline.  Send your request by a fast, reliable means (such as Federal Express or U.S. express mail) that you can track; or register for and file it electronically online.  Read the instructions in the letter and follow them. Be sure you get a receipt when you file.

2.    Notice of Exclusion (NOE): Sometimes the OIG will send a “Notice of Exclusion” or “NOE” if it decides to exclude a provider regardless of the response provided to a NOI or in certain cases of mandatory exclusions or certain permissive exclusions where no NOI is ever sent. Medicare exclusions usually take effect 20 days after the NOE is mailed. In cases involving fraud, kickbacks and other prohibited activities, a Notice of Proposal to Exclude or NOPE may be sent instead.

3.    Administrative Law Judge (ALJ) Hearing: Providers have the right to appeal a proposed exclusion by requesting an administrative hearing (similar to a trial) before an “Administrative Law Judge” or “ALJ.” ALJ’s are part of the Department of Health and Human Services (HHS). If you wish to request an ALJ hearing, you must do so within 60 days of receiving the Notice of Exclusion (or according to the instructions), and you must be prepared to raise all of your arguments over issues regarding the decision itself, the proposed exclusion period, mitigating factors or other aspects of the action.

4.    Department Appeals Board (DAB): If you disagree with the ALJ hearing decision, you can further appeal to the HHS “Departmental Appeals Board” or “DAB.” This is a written appeal which will be required to set forth legal errors which were made in the ALJ hearing.

5.    Judicial Review: If you disagree with the decision made by the DAB, your only option is to challenge the final decision in a U.S. District Court.

MOST IMPORTANT, consult a health law attorney experienced in such matters. The consequences of  Medicare exclusion, even a permissive exclusion for one year or three years, are severe. Most people do not realize this until it is too late; then it is too late (in many, but not all, cases).

To learn more about the consequences of OIG exclusion, click here to read one of my prior blogs.

Contact Attorney Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program.

The attorneys of The Health Law Firm have experience in dealing with the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

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


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

KeyWords: 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

“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 |2019-06-18T20:03:35+00:00July 30th, 2019|Categories: Health Facilities Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

How to Challenge an OIG Exclusion Action from Medicare

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

Many health professionals don’t understand the significant repercussions that an exclusion action by the Office of the Inspector General (OIG) can have on their professional careers and future employment. Whether you are a physician, nurse, dentist, psychologist or other health professionals, if you allow yourself to be excluded from the Medicare program, devastating economic results may follow.

The administrative process by which you may challenge a proposal from the OIG for most permissive or mandatory exclusion is challenging. In most cases, you will need experienced legal representation.  Below are the steps in the process you must follow to protect your career and your livelihood.

The Administrative Process to Challenge OIG Exclusion Actions.

1.    Notice of Intent (NOI) received: If the OIG is proposing to exclude a person or entity from Medicare, it will send out a letter called a “Notice of Intent” or “NOI.” This will contain the reasons for the exclusion and will detail hearing or appeal rights.  It is very important to make sure that your state licensing board and Medicare have your correct current address on file because the address which Medicare has will be where the NOI is mailed.  (Note:  the OIG may not send a NOI for mandatory exclusions which carry a 5-year minimum exclusion period.)  You will not have a second chance. Regardless, you usually only have 30 days to submit a written response requesting a hearing and containing information the OIG will consider in making its decision.  In some cases, providers may have the opportunity to present oral arguments before OIG officials. You must make sure that your request is received by the deadline, not just mailed by the deadline.  Send your request by a fast, reliable means (such as Federal Express or U.S. express mail) that you can track; or register for and file it electronically online.  Read the instructions in the letter and follow them. Be sure you get a receipt when you file.

2.    Notice of Exclusion (NOE): Sometimes the OIG will send a “Notice of Exclusion” or “NOE” if it decides to exclude a provider regardless of the response provided to a NOI or in certain cases of mandatory exclusions or certain permissive exclusions where no NOI is ever sent. Medicare exclusions usually take effect 20 days after the NOE is mailed. In cases involving fraud, kickbacks and other prohibited activities, a Notice of Proposal to Exclude or NOPE may be sent instead.

3.    Administrative Law Judge (ALJ) Hearing: Providers have the right to appeal a proposed exclusion by requesting an administrative hearing (similar to a trial) before an “Administrative Law Judge” or “ALJ.” ALJ’s are part of the Department of Health and Human Services (HHS). If you wish to request an ALJ hearing, you must do so within 60 days of receiving the Notice of Exclusion (or according to the instructions), and you must be prepared to raise all of your arguments over issues regarding the decision itself, the proposed exclusion period, mitigating factors or other aspects of the action.

4.    Department Appeals Board (DAB): If you disagree with the ALJ hearing decision, you can further appeal to the HHS “Departmental Appeals Board” or “DAB.” This is a written appeal which will be required to set forth legal errors which were made in the ALJ hearing.

5.    Judicial Review: If you disagree with the decision made by the DAB, your only option is to challenge the final decision in a U.S. District Court.

MOST IMPORTANT, consult a health law attorney experienced in such matters. The consequences of  Medicare exclusion, even a permissive exclusion for one year or three years, are severe. Most people do not realize this until it is too late; then it is too late (in many, but not all, cases).

To learn more about the consequences of OIG exclusion, click here to read one of my prior blogs.

Contact Attorney Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program.

The attorneys of The Health Law Firm have experience in dealing with the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

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


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

KeyWords: 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

“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 |2019-06-18T19:59:06+00:00July 9th, 2019|Categories: Pharmacy Law Blog, Uncategorized|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |0 Comments

So, the ZPIC Medicare Auditor Wants to Talk to You? What You Should Expect

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

You are a physician, nurse or other health care provider who bills Medicare. You have received that dreaded letter from the Zone Program Integrity Contractor (ZPIC) for Medicare advising you that it is auditing you for the Centers for Medicare and Medicaid Services (CMS). You know that the words “Program Integrity” by themselves mean that possible fraud is being investigated, at least that is the suspicion giving rise to this particular audit.

To read an earlier blog which I wrote on tips for responding to ZPIC audits, click here.

You have dutifully contacted an experienced health law attorney to aid you in responding to the ZPIC’ s request for records and information. You have obtained all of the requested medical records documentation, authoritative medical journal articles and other information that may be useful in supporting the care you delivered and for which you billed, added explanatory notes (clearly and contemporaneously dated, of course) where necessary or where records were missing, and done all you can to fully and completely respond to the audit.

After the Initial Audit Response and Site Visit.

Now, several weeks later, the ZPIC auditor/investigator contacts you and advises you that he would like you to come to his office to answer a few questions. The ZPIC auditor/investigator states that this is “just routine” and should only take approximately 20 minutes.

After discussing this with your attorney, knowing that you have committed no fraud and that your medical records are in pretty good shape to support your billing, you decide to go to the ZPIC office for the interview. (Note: I know that many attorneys would recommend against this action, but often we advise a client, with the right set of facts, of course, to do this.) What should you expect?

What to Expect When You Show up to Be Interviewed by the ZPIC Auditor.

Although we cannot guarantee you that you will experience the same as we have in the past, this is what happened often enough with us where it seems to be somewhat common practice in such audits.

1. Expect the ZPIC office to be in a building with good security, including magnetic/electronic scanning for guns and weapons, like at the airport or court house. Do not attempt to take any type of weapon inside the building, including pen knives on key chains and tear gas or pepper spray canisters.

2. Bring a valid government identification card with your photograph. If you are with an attorney or a consultant, that person will also need one. One of the first things that will happen is that you will be asked to show your identification cards to prove you are who you say you are.

3. Be sure you have your correct office address on file with Medicare. If the auditors show up at an address you have listed and your practice is not there, you will either get a letter automatically terminating your Medicare billing privileges or you will be called down for this interrogation by the ZPIC. This is a primary reason for such ZPIC interrogations. Be sure your physical office address, including suite number, apartment number, office number, etc., are correctly reflected in the Provider Enrollment and Chain/Ownership System (PECOS), the electronic portal through which Medicare providers enroll in Medicare.

4. You aren’t going to be interviewed by just one person and it isn’t going to be just “20 minutes.”

5. In most cases, there will be three or more auditors/investigators involved in the interview with you. This is why it is a good idea to bring your attorney and her paralegal so that you also have some support, as well. The least number of auditor/investigators that we have ever seen involved in such interviews is two. Don’t be surprised if there are three or four.

6. The questioning and interviewing will take much longer than you expected. Plan on taking the rest of the day off so that you are not rushed and do not feel pressured to get it over with fast. It is not going to be over with fast.

7. Don’t joke around with the ZPIC auditors. This is a very serious matter. Many talented government investigators will attempt to joke and make light of things in order to get you to let your guard down. Do not play into this. Be serious and act seriously at all times.

8. You are not in an endurance contest. Ask for bathroom breaks, water breaks or just a break to talk with your attorney, as many times as you desire. Do this at least once each hour. This will help to keep your blood circulating and keep you alert.

9. You will be confronted with what the ZPIC auditors believe they have found that violates Medicare regulations. This may include, for example, billing services for patients who were dead at the time, billing for services on dates after the patient was no longer qualified to receive them, billing for services that were billed by another provider, etc. Do not guess at why this happened if you did not know for a fact. You can advise the investigator that you will take down the investigation, look into it and provide the information to him or her at a later date.

10. Don’t be surprised if the ZPIC auditor has incorrect information. Often the ZPIC will have confused information on two different Medicare beneficiaries with the same names or whose Medicare numbers were incorrectly recorded. For example, in one recent ZPIC investigator interview with my client, the investigator accused the physician of billing for services provided to a patient who had been deceased for two years. The physician had just seen the patient on a follow-up visit a month prior to the interview. The ZPIC had confused a dead patient who had the same name with the live patient. This is not uncommon.

11. Don’t be surprised if the ZPIC auditor asks you about other Medicare provider’s billings for the same patient. This also happened to a client of mine in a recent case. The ZPIC investigator questioned why the XYZ company would have billed for the same services as those provided by my client, a solo practitioner. My client did not know. He correctly told the auditor that he did not know why the other party had billed Medicare for the same services, but he had provided the services to his patient and he had billed for the services. He could not know whey someone else did something.

12. If there have been intervening factors affecting your billing practices, disclose these to the investigator. In one case, my client had changed software for her electronic health records and billing. One of the reasons this was necessary was because of bugs that made the billings sometimes unreliable. Records more than four (4) years old were no longer available. The client disclosed this.

13. Be sure you are able to reconcile the number of patients seen per day, the number of hours the CPT codes billed to Medicare are supposed to reflect, and that these seem reasonable. If you are billing time-based CPT codes for patients that it would take you 27 hours to see in a day, you are in trouble. You must know this ahead of time and either have a reasonable answer to address the problem (e.g., an incorrect date entry in the billing software caused two days worth of services to accidentally be billed for the same date of service) or correct the over-billing error.

14. Know what rules, regulations and guidelines apply to the billings for the CPT codes you are billing. Check to see if there are local coverage decisions (LCDs) from your area Medicare Administrative Carrier (MAC) or National Coverage Decisions (NCDs) from CMS and know them. Be sure you have followed them and are following them.

15. Know the licensure rules and regulations for your profession, as well as the Medicare guidelines for billing for your profession. Sometimes billing for what an assistant, trainee, or ancillary provider does is allowed, and sometimes it isn’t. If you bill for what an assistant does, be sure you know the rules and are properly billing. The ZPIC investigator certainly will ask questions about this.

16. Your health record entries, assessments, evaluations, progress notes, etc., are required to be made contemporaneously with your delivery of the services. This generally means within 24 hours, as a rule of thumb. Records made a week or a month later are not considered to be reliable or accurate. So be sure you have made and are making your records contemporaneously with seeing the patient or providing the services.

17. Check the location code for the claims you have submitted. Make sure they reflect the correct site that the services were delivered. There could be differences in payments based on the site/location code. You will be asked about this if there are discrepancies.

18. If you identify problems and issues when preparing for your ZPIC interview, go ahead and correct them. This way you will be able to show you have made an honest mistake, have changed your procedures and the mistake(s) will not happen again in the future. Sometimes this may require terminating your billing company, purchasing new software, retaining a professional consultant, asking for an educational site visit from the MAC, and obtaining additional continuing education on billing practices and procedures for you and your staff (some of which CMS offers online).

We have many helpful resources on our webpage and YouTube page. Click here to view our video Q&A on ZPIC audits for more information.

To read an additional blog I wrote on preparing for an audit, click here.

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

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

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

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: Zone Program Integrity Contractors (ZPICs), ZPIC audit defense attorney, ZPIC defense lawyer, representation for ZPIC investigations, representation for ZPIC audit, ZPIC audit lawyers, ZPIC representation, ZPIC investigation representation, Medicare audit defense legal counsel, Medicare audit attorney, legal representation for ZPIC letters, legal representation for ZPIC audits, Medicare and Medicaid audits, legal representation for Medicare and Medicaid audits, health care fraud defense attorney, preparing for ZPIC audit, legal representation for health care fraud, Centers for Medicare and Medicaid (CMS), legal representation for CMS investigations, Office of Inspector General (OIG), 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, additional documentation requests (ADRs) for pre-payment and post-payment reviews, initiation of Medicare suspension of payments lawyer, healthcare fraud representation, allegations of healthcare fraud, representation for CMS investigations, representation for healthcare investigations, representation for overbilling, False Claims attorney, FCA lawyer, FCA attorney, representation for submitting False Claims

“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.

Are You Worried About Health Care Compliance Consequences? Have They Gone Too Far?

By Lance O. Leider, J.D., LL.M., The Health Law Firm

From large hospital systems to solo practitioners, there is no escaping health care compliance in the industry. The concept of compliance can spark different thoughts in different people. For example, some believe it is an unnecessary government intrusion and others believe it’s a way to improve the quality and costs of health care.

No matter your thoughts on health care compliance and government oversight, regulation of the health care industry will never be eliminated. In fact, we expect it to increase as more quality-based requirements are implemented.

We believe compliance and regulations are necessary, but we have to wonder if sometimes these laws go too far.

Those Cute Baby Photos Can Cost You.

As an example of laws going too far, photos of cooing newborn babies used to cover the bulletin boards of doctors’ offices. However, under the Health Insurance Portability and Accountability Act (HIPAA), these baby photos are considered protected health information, along the same lines as a medical chart or social security number. A report by The New York Times indicates many offices have removed these types of photos or moved them to private portions of the office. According to the Office for Civil Rights (OCR) Department of Health and Human Services (HHS), doctors’ offices are not allowed to post these photos without a specific written authorization from the parent.

To read more on this topic, click here.

Health Care Compliance Overview.

Health care compliance is the ongoing process of meeting or exceeding the legal, ethical and professional standards applicable to a particular health care organization or provider. Health care compliance requires health care organizations and providers to develop effective processes, policies, and procedures to define appropriate conduct, train the organization’s staff, and then monitor the adherence to the processes, polices and procedures.

Health care compliance covers numerous areas including patient care, billing, reimbursement, managed care contracting, OSHA, and HIPAA privacy and security to new a few.

To read a basic overview of health care compliance for organizations and providers, click here.

How to Deal with Compliance Overkill.

The primary purpose of health care compliance is to improve patient care. It is nearly impossible to overstate the complexity of health care compliance. Health care organizations and providers are not only required to comply with Medicare rules and regulations, but they are also required to comply with numerous other federal and state health care laws, rules and regulations.

When dealing with compliance issues, our recommendation is to use your common sense and best judgment. Fear usually leads to absurd situations. With all the fear and propaganda out there it is important to stick to your instincts and put patient care first.

Health care compliance is cumbersome, many may agree too cumbersome. However, it is here to stay.

Do you think health care compliance has gone too far? How do you try to keep up with health care compliance laws and regulations? Are you worried about compliance consequences?

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other health care providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

For more information about HIPAA violations, electronic health records or corrective action plans (CAPs) please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Sources:

Hartocollis, Anemona. “Baby Pictures at the Doctor’s? Cute, Sure, but Illegal.” The New York Times. (August 9, 2014). From: http://www.nytimes.com/2014/08/10/nyregion/baby-pictures-at-doctors-cute-sure-but-illegal.html?_r=0

Kirsch, M.D., Michael. “The Consequences of Zero Tolerance: Why HIPAA is Overkill.” Kevin M.D. (January 1, 2014). From: http://www.kevinmd.com/blog/2014/01/consequences-tolerance-hipaa-overkill.html

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.

KeyWords: Health Insurance Portability and Accountability Act (HIPAA), HIPAA Omnibus Rule, HIPAA compliance, HIPAA lawyer, HIPAA compliance attorney, data security lawyer, protected health information (PHI), Patient privacy, U.S. Department of Health and Human Services (HHS), Office of Civil Rights (OCR), patient rights, HIPAA compliance audit, privacy defense attorney, health care compliance lawyer, compliance defense attorney, healthcare compliance defense lawyer, health care defense lawyer, HIPAA attorney, HIPAA lawyer, compliance plans, health law firm, The Health Law Firm, health law defense attorney, health care professional defense attorney, legal representation for healthcare 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 © 2018 The Health Law Firm. All rights reserved.

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