Florida Man Agrees to Plead Guilty in $110 Million Telemedicine Medicare Fraud Scheme

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

On February 16, 2024, a Parkland, Florida, man agreed to plead guilty to organizing a Medicare fraud scheme worth $110 million. The federal prosecution is taking place in the U.S. District Court for the District of Massachusetts. The fraud was allegedly perpetrated through two Florida companies the man owned, Expansion Media, LLC, and Hybrid Management Group, LLC. According to federal prosecutors in Boston, the scheme involved utilizing telemedicine and telemarketing enterprises to create fabricated orders for medical equipment, particularly knee braces. The scheme allegedly lasted from March 2016 to January 2023.

Specifics on this Medicare Fraud Scheme.

The Florida businessman and owner of Expansion Media, LLC, and Hybrid Management Group, LLC, allegedly sold medically unnecessary Durable Medical Equipment (D.M.E.) to medical staffing companies. According to the government, he used telemedicine and telemarketing companies to create false leads. The telemarketers would pay the Florida man’s companies to generate orders for the medical groups that signed off on them, even though they had no contact with any of the Medicare beneficiaries. The medical devices ordered resulted in $110 million in fraudulent claims, of which Medicare paid $52.5 million.

Prosecutors say the Florida man took many steps to conceal the scheme, including changing his business names, creating fictitious e-mails tied to those companies, and using third-party pass-through payment options.

The Florida man was ordered by the court to pay back $15.7 million and a laundry list of expensive jewelry purchases, such as multiple Patek Philippe watches and Tiffany & Co. jewelry. He agreed to plead guilty, and his deal includes a ten-year prison sentence with supervised releases for three years and fines up to $250,000.

No mention was made about what happened to the Patek Phillippe watches or the Tiffany jewelry, but I have asked the FBI to keep me advised. I have an anniversary coming up.

To view the press release from the U.S. Attorney’s Office, District of Massachusetts, click here.

Florida Man: Joyfully Spreading Florida’s Crime All Over the Place

This blog relates one of my biggest pet peeves. That scurrilous, underhanded Florida Man. Now he has spread his disease of fraud and theft all the way up to the beautiful city of Boston. Why don’t they finally lock him up once and for all?

Is Florida really going to make Florida Man the official state bird, replacing the beautiful Northern Mockingbird? Maybe that’s what he was doing up north in Massachusetts, mocking them.

This case also points out Florida’s reputation as a state which shelters and promotes the use of shell corporations and limited liability companies used to defraud the public and its protection of conmen and fraudsters.

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

The attorneys of The Health Law Firm represent physicians, pharmacists, durable medical equipment (DME) suppliers, and other health care providers in Medicare audits, investigations and subpoenas, Medicaid audits and subpoenas, Medicare and Medicaid investigations, Department of Health (DOH) subpoenas and investigations, Department of Health and Human Services (DHHS), Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) subpoenas and investigations, and Medicaid Fraud Control Unit (MFCU) subpoenas, audits and investigations, in Florida, Colorado, Louisiana, the District of Columbia, Virginia, and across the U.S. They also represent healthcare providers in actions to terminate billing privileges, termination from the Medicare or Medicaid programs, and state and federal administrative hearings and litigation.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or toll-free (888) 331-6620.

Sources:

DOM. (February 16, 2024). Owner of telemedicine companies charged with $110 million medicare fraud scheme. United States Attorney’s Office. Retrieved from https://www.justice.gov/usao-ma/pr/owner-telemedicine-companies-charged-110-million-medicare-fraud-scheme#:~:text=BOSTON%20%E2%80%93%20The%20owner%20of%20Expansion,as%20back%20and%20knee%20braces.

Dowling, B. (February 16, 2024). Telemedicine exec admits $110 Medicare fraud scheme. Law360. Retrieved from https://www.law360.com/articles/1803737/telemedicine-exec-admits-110m-medicare-fraud-scheme

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 Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620.

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

“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 © 2024 George F. Indest III, The Health Law Firm. All rights reserved. No part of this work may be reproduced in any way in any medium without the written permission of the copyright owner. The author of this work reserves the right to have his name associated with any use or publication of this work or any part of it.

Humana Agrees To Pay $11.2 Million to End Nurses’ Overtime Suit

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

On September 27, 2021, Humana agreed to pay $11.2 million to end claims that the health insurance company denied a group of nurses overtime pay by misclassifying them as exempt employees. A Wisconsin federal judge approved the deal with Humana, and a group of more than 200 nurses reached, securing a $36,000 average payment for each nurse involved in the suit.

A Violation of the Fair Labor Standards Act (FLSA).

This dispute stems from a class-action lawsuit filed in 2017 alleging that Humana misclassified its clinical nurse advisers as exempt employees and denied them overtime compensation, violating the Fair Labor Standards Act.  Many professionals and supervisors or managerial employees are considered to be exempt from overtime laws.

In the suit, the company faced allegations from nurses who claimed they were never paid for overtime even though they were required to work more than 40 hours per week to meet Humana’s production goals and expectations.

The Settlement.

The settlement agreement will allocate almost $3 million to cover attorney fees and costs. Additionally, the 221 nurses that are part of the settling class will get nearly $8 million based on the number of full-time weeks the nurses worked. According to the motion, the average payment per nurse for unpaid overtime and liquidated damages will be over $36,000.

The case is O’Leary v. Humana Insurance Co., et al., case number 17-cv-1774, in the U.S. District Court for the Eastern District of Wisconsin. Click here to view the court’s brief in full.

To read about another case dealing with alleged pay discrimination in the healthcare field, click here to read one of my prior blogs.

Contact Health Law Attorneys Experienced in Representing Nurses and Other Healthcare Professionals.

The Health Law Firm’s attorneys routinely provide legal representation to nurses, pharmacists, pharmacy technicians, dentists, dental assistants, physicians, physician assistants, mental health counselors, and other health providers. We also provide legal representation for employers in EEOC complaints, workplace discrimination complaints, and suits involving harassment or discrimination complaints. We also provide legal representation in Department of Health, Board of Medicine, Board of Nursing investigations and complaints, DORA investigations and complaints. We provide litigation services in state and federal courts and state and federal administrative hearings. We provide legal representation across the U.S., not just in Colorado, Florida, Louisiana, Virginia, and Washington, D.C.

To contact The Health Law Firm please call (407) 331-6620 or Toll-Free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Spezzemonte, Irene. “Humana To Pay $11.2M To End Nurses’ Misclassification Suit.” Law360. (September 27, 2021). Web.

Webster, Katherine. “Court OKs $11.2M Overtime Settlement Between Humana, Nurses.” Top Class Actions. (September 30, 2021). 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. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620.

 

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 © 2021 The Health Law

 

 

 

 

 

Florida Man Agrees to Plead Guilty in $110 Million Telemedicine Medicare Fraud Scheme

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

On February 16, 2024, a Parkland, Florida, man agreed to plead guilty to organizing a Medicare fraud scheme worth $110 million. The federal prosecution is taking place in the U.S. District Court for the District of Massachusetts. The fraud was allegedly perpetrated through two Florida companies the man owned, Expansion Media, LLC, and Hybrid Management Group, LLC. According to federal prosecutors in Boston, the scheme involved utilizing telemedicine and telemarketing enterprises to create fabricated orders for medical equipment, particularly knee braces. The scheme allegedly lasted from March 2016 to January 2023.

Specifics on this Medicare Fraud Scheme.

The Florida businessman and owner of Expansion Media, LLC, and Hybrid Management Group, LLC, allegedly sold medically unnecessary Durable Medical Equipment (D.M.E.) to medical staffing companies. According to the government, he used telemedicine and telemarketing companies to create false leads. The telemarketers would pay the Florida man’s companies to generate orders for the medical groups that signed off on them, even though they had no contact with any of the Medicare beneficiaries. The medical devices ordered resulted in $110 million in fraudulent claims, of which Medicare paid $52.5 million.

Prosecutors say the Florida man took many steps to conceal the scheme, including changing his business names, creating fictitious e-mails tied to those companies, and using third-party pass-through payment options.

The Florida man was ordered by the court to pay back $15.7 million and a laundry list of expensive jewelry purchases, such as multiple Patek Philippe watches and Tiffany & Co. jewelry. He agreed to plead guilty, and his deal includes a ten-year prison sentence with supervised releases for three years and fines up to $250,000.

No mention was made about what happened to the Patek Phillippe watches or the Tiffany jewelry, but I have asked the FBI to keep me advised. I have an anniversary coming up.

To view the press release from the U.S. Attorney’s Office, District of Massachusetts, click here.

Florida Man: Joyfully Spreading Florida’s Crime All Over the Place

This blog relates one of my biggest pet peeves. That scurrilous, underhanded Florida Man. Now he has spread his disease of fraud and theft all the way up to the beautiful city of Boston. Why don’t they finally lock him up once and for all?

Is Florida really going to make Florida Man the official state bird, replacing the beautiful Northern Mockingbird? Maybe that’s what he was doing up north in Massachusetts, mocking them.

This case also points out Florida’s reputation as a state which shelters and promotes the use of shell corporations and limited liability companies used to defraud the public and its protection of conmen and fraudsters.

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

The attorneys of The Health Law Firm represent physicians, pharmacists, durable medical equipment (DME) suppliers, and other health care providers in Medicare audits, investigations and subpoenas, Medicaid audits and subpoenas, Medicare and Medicaid investigations, Department of Health (DOH) subpoenas and investigations, Department of Health and Human Services (DHHS), Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) subpoenas and investigations, and Medicaid Fraud Control Unit (MFCU) subpoenas, audits and investigations, in Florida, Colorado, Louisiana, the District of Columbia, Virginia, and across the U.S. They also represent healthcare providers in actions to terminate billing privileges, termination from the Medicare or Medicaid programs, and state and federal administrative hearings and litigation.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or toll-free (888) 331-6620.

Sources:

DOM. (February 16, 2024). Owner of telemedicine companies charged with $110 million medicare fraud scheme. United States Attorney’s Office. Retrieved from https://www.justice.gov/usao-ma/pr/owner-telemedicine-companies-charged-110-million-medicare-fraud-scheme#:~:text=BOSTON%20%E2%80%93%20The%20owner%20of%20Expansion,as%20back%20and%20knee%20braces.

Dowling, B. (February 16, 2024). Telemedicine exec admits $110 Medicare fraud scheme. Law360. Retrieved from https://www.law360.com/articles/1803737/telemedicine-exec-admits-110m-medicare-fraud-scheme

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 Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620.

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

“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 © 2024 George F. Indest III, The Health Law Firm. All rights reserved. No part of this work may be reproduced in any way in any medium without the written permission of the copyright owner. The author of this work reserves the right to have his name associated with any use or publication of this work or any part of it.

Centene Agrees to Pay $19 Million to Washington State For Medicaid Fraud Allegations

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

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

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“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

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Maryland & Missouri Become 20th and 21st States to Legalize Recreational Marijuana

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

Five states had proposals to legalize recreational marijuana on the ballot in the midterm elections held on November 8, 2022. Voters in Maryland and Missouri approved the legalization, while Arkansas, North Dakota, and South Dakota rejected similar proposals. As a result of the vote, Maryland and Missouri became the 20th and 21st states to legalize cannabis for adult recreational use.

Maryland.

Maryland’s voters overwhelmingly approved Question 4 as it passed, with 65% of voters casting ballots in favor. The amendment creates a right to possess and use marijuana and directs the state Legislature to enact laws governing its sale. Following its passage, adults in the state will be allowed to possess up to 1.5 ounces, or two marijuana plants, beginning July 1, 2023.

Additionally, it allows for the expungement of records for people arrested for marijuana possession and for people serving time for simple possession to have their sentences reconsidered. It would also establish a cannabis business assistance fund for small businesses and minority- and women-owned companies entering the cannabis industry.

Next up, the state’s lawmakers will decide on licensing and taxation.

Missouri.

Missouri voters passed Amendment 3, with 53% of voters in favor. The measure removes existing state prohibitions on marijuana and legalizes the purchase, possession, consumption, use, delivery, manufacture, and sale of marijuana for personal use for adults 21 and older. It also allows individuals with certain marijuana-related offenses to be released from prison, parole, or probation. More specifically, it levies a 6% state tax rate on sales and allows local governments to impose an additional tax rate of up to 3%.

Other States With Drugs On The Ballot.

Three other states with existing medical marijuana programs also saw voters head to the polls to decide whether to legalize recreational marijuana. At the same time, voters in Colorado considered a historic bill to decriminalize certain psychedelics.

Voters in Arkansas, North Dakota, and South Dakota rejected proposals to bring the states from medical marijuana use to full recreational legalization.

Lastly, in Colorado, Proposition 122, a bill to decriminalize plant and fungi-based psychedelic compounds, appeared to pass with approximately 51% of the vote narrowly. The passing of this historic measure comes ten years after Colorado made history as one of the first states to legalize retail marijuana by ballot initiative.

For updates on important marijuana laws and policies, check out our Marijuana Law Blog and YouTube page.

Contact Experienced Health Law Attorneys for Medical Marijuana Regulatory Matters and Other Health Care Licensing Matters.

The Health Law Firm attorneys can assist health care providers and facilities, such as doctors, pharmacists, and pharmacies, participating in the medical marijuana industry. We represent doctors, pharmacies, and pharmacists facing proceedings brought by state regulators or agencies. We represent health-related businesses and medical professionals in all types of licensing and regulatory matters, including state and federal administrative hearings. Several of our attorneys, including Mr. Indest, act as expert witnesses in attorney’s fee litigation and in health law litigation.

To contact The Health Law Firm please call (407) 331-6620 or Toll-Free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Reisman, Sam. “Maryland And Missouri Legalize Pot, 3 Others Just Say No.” Law360. (November 9, 2020).

Sykes, Stefan. “Here’s how five states voted on the legalization of recreational marijuana.” CNBC. (November 9, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Current Open Positions with The Health Law Firm. The Health Law Firm always seeks qualified individuals interested in health law. Its main office is in the Orlando, Florida, area. If you are a current member of The Florida Bar or a qualified professional who is interested, please forward a cover letter and resume to: [email protected] or fax them to (407) 331-3030

“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 © 2022 The Health Law Firm. All rights reserved.

 

Centene Will Pay $19 Million to Washington State For Medicaid Fraud Allegations

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

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

KeyWords: Medicare Medicaid audit defense lawyer, legal representation in Medicaid managed care plan audit defense, Medicaid managed care plan audit legal defense attorney, Medicare Medicaid overpayment demand defense attorney, legal representation in Medicaid managed care plan overpayment demand, Medicaid managed care plan audit appeal attorney, legal representation in Medicaid managed care plan audit appeal, Medicare Medicaid audit appeal lawyer, Medicare Medicaid audit overpayment demand defense attorney, Centene Sunshine State Health Plan audit legal defense attorney, legal representation in Centene Sunshine State Health Plan audit, Centene Sunshine State Health Plan audit overpayment demand defense lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment demand, Centene Sunshine State Health Plan audit overpayment appeal lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment appeal, healthcare fraud defense legal representation, Medicare Medicaid audit defense attorney, Medicare Medicaid investigation defense lawyer, legal representation in Medicaid managed care plan HMO audit, Medicaid managed care plan HMO audit defense attorney, Medicaid managed care plan HMO audit appeal attorney, Medicaid managed care plan HMO overpayment defense lawyer, Centers for Medicare & Medicaid Services (CMS) defense attorney, CMS legal defense representation, health insurance audit defense attorney, CMS defense attorney, CMS legal defense lawyer, legal representation for CMS investigation, Medicaid Fraud Control Unit (MFCU) defense attorney, Medicaid Fraud Control Unit (MFCU) defense legal representation, Office of Inspector General (OIG) investigation defense attorney, civil monetary penalty hearing, reviews of The Health Law Firm, The Health Law Firm attorney reviews, False Claims Act (FCA) suit defense attorney, Office of Inspector General (OIG) interview defense attorney, Department of Health and Human Services (HHS) subpoena defense attorney, Department of Health and Human Services (HHS) civil investigative demand (CID) defense attorney, legal representation for healthcare professionals, Florida health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

By |2024-03-14T09:59:11-04:00February 23, 2024|Categories: Pharmacy Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Centene Will Pay $19 Million to Washington State For Medicaid Fraud Allegations

Centene Will Pay $19 Million Settlement to Washington State For Medicaid Fraud Allegations

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

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

KeyWords: Medicare Medicaid audit defense lawyer, legal representation in Medicaid managed care plan audit defense, Medicaid managed care plan audit legal defense attorney, Medicare Medicaid overpayment demand defense attorney, legal representation in Medicaid managed care plan overpayment demand, Medicaid managed care plan audit appeal attorney, legal representation in Medicaid managed care plan audit appeal, Medicare Medicaid audit appeal lawyer, Medicare Medicaid audit overpayment demand defense attorney, Centene Sunshine State Health Plan audit legal defense attorney, legal representation in Centene Sunshine State Health Plan audit, Centene Sunshine State Health Plan audit overpayment demand defense lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment demand, Centene Sunshine State Health Plan audit overpayment appeal lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment appeal, healthcare fraud defense legal representation, Medicare Medicaid audit defense attorney, Medicare Medicaid investigation defense lawyer, legal representation in Medicaid managed care plan HMO audit, Medicaid managed care plan HMO audit defense attorney, Medicaid managed care plan HMO audit appeal attorney, Medicaid managed care plan HMO overpayment defense lawyer, Centers for Medicare & Medicaid Services (CMS) defense attorney, CMS legal defense representation, health insurance audit defense attorney, CMS defense attorney, CMS legal defense lawyer, legal representation for CMS investigation, Medicaid Fraud Control Unit (MFCU) defense attorney, Medicaid Fraud Control Unit (MFCU) defense legal representation, Office of Inspector General (OIG) investigation defense attorney, civil monetary penalty hearing, reviews of The Health Law Firm, The Health Law Firm attorney reviews, False Claims Act (FCA) suit defense attorney, Office of Inspector General (OIG) interview defense attorney, Department of Health and Human Services (HHS) subpoena defense attorney, Department of Health and Human Services (HHS) civil investigative demand (CID) defense attorney, legal representation for healthcare professionals, Florida health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

By |2024-03-14T09:59:13-04:00February 1, 2024|Categories: Health Facilities Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Centene Will Pay $19 Million Settlement to Washington State For Medicaid Fraud Allegations

Centene to Pay Washington State $19 Million to Resolve Medicaid Fraud Allegations

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

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

KeyWords: Medicare Medicaid audit defense lawyer, legal representation in Medicaid managed care plan audit defense, Medicaid managed care plan audit legal defense attorney, Medicare Medicaid overpayment demand defense attorney, legal representation in Medicaid managed care plan overpayment demand, Medicaid managed care plan audit appeal attorney, legal representation in Medicaid managed care plan audit appeal, Medicare Medicaid audit appeal lawyer, Medicare Medicaid audit overpayment demand defense attorney, Centene Sunshine State Health Plan audit legal defense attorney, legal representation in Centene Sunshine State Health Plan audit, Centene Sunshine State Health Plan audit overpayment demand defense lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment demand, Centene Sunshine State Health Plan audit overpayment appeal lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment appeal, healthcare fraud defense legal representation, Medicare Medicaid audit defense attorney, Medicare Medicaid investigation defense lawyer, legal representation in Medicaid managed care plan HMO audit, Medicaid managed care plan HMO audit defense attorney, Medicaid managed care plan HMO audit appeal attorney, Medicaid managed care plan HMO overpayment defense lawyer, Centers for Medicare & Medicaid Services (CMS) defense attorney, CMS legal defense representation, health insurance audit defense attorney, CMS defense attorney, CMS legal defense lawyer, legal representation for CMS investigation, Medicaid Fraud Control Unit (MFCU) defense attorney, Medicaid Fraud Control Unit (MFCU) defense legal representation, Office of Inspector General (OIG) investigation defense attorney, civil monetary penalty hearing, reviews of The Health Law Firm, The Health Law Firm attorney reviews, False Claims Act (FCA) suit defense attorney, Office of Inspector General (OIG) interview defense attorney, Department of Health and Human Services (HHS) subpoena defense attorney, Department of Health and Human Services (HHS) civil investigative demand (CID) defense attorney, legal representation for healthcare professionals, Florida health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

 

 

 

 

By |2024-03-14T09:59:14-04:00January 8, 2024|Categories: Mental Health Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Centene to Pay Washington State $19 Million to Resolve Medicaid Fraud Allegations

New Study Reveals Complex Coding Structures in U.S. For Rise in Medical Billing Costs

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

A study publicized in August 2022 revealed that the complex coding structures used in the United States drive up medical billing costs. This helps to make the U.S. one of the most expensive countries for health providers to get paid. According to the study, researchers used a micro-level accounting of billing and insurance-related (often abbreviated “BIR”) expenses in different national settings at six provider locations in five nations: Australia, Canada, Germany, the Netherlands, and Singapore. This most recent study supplements a prior study measuring such costs in the U.S.

The findings, published in Health Affairs Journal, revealed “BIR (billing and insurance-related) costs in the U.S. are generally much higher than the costs in other countries.” This means that all the extra costs of coding and billing, including the related expenses, are a significant factor in driving up health care cases in the U.S. Say what you want about doctors’ hating paperwork, but this study seems to validate that feeling.

The Findings of the Study.

The study confirmed what research has established that billing and insurance-related (BIR) costs in the U.S. are much higher than in other countries. For example, prices range from $6 in Canada to $215 in the U.S. for an inpatient surgical bill. In the U.S., that represented about 3.1 percent of the total professional revenue for the procedure. Providers also spent about 100 minutes processing the claim.

To compare, only Australia had similar billing and insurance-related costs to the U.S. Australia has a mix of publicly and privately funded payers and universal coverage. Billing and insurance-related costs were significantly less in Canada than in the other nations. The study said Germany, Singapore, and the Netherlands had equal billing and insurance-related costs.

A Common Trend: Complex Coding.

The U.S. has a coding process in which each payer has its forms and documentation requirements, creating a significant burden on providers to translate clinical documentation into billable codes for reimbursement.

Because of standardization in other countries, providers spend less time coding or do not need coders to translate documentation into billable codes. Additionally, “little physician time is spent entering billing-related information into the EHR [electronic health record] system, as charge codes are either generated automatically or entered manually by a lower-wage or nonclinical teammate,” the study stated. “As a consequence, these countries’ billing systems either require fewer labor resources or much less costly labor and physician time than the one in the U.S.”

Researchers also found that financial counseling could reduce overall billing and insurance-related costs in the U.S.

You can read the study in full and learn more by visiting Health Affairs, a leading peer-reviewed journal of health policy thought and research.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals and Providers.

At the Health Law Firm, we provide legal services for all health care providers and professionals. This includes physicians, nurses, dentists, psychologists, psychiatrists, mental health counselors, home health agencies, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and other healthcare providers. It also includes medical students, resident physicians, and fellows, as well as medical school professors and clinical staff. We represent health facilities, individuals, groups, and institutions in contracts, sales, mergers, and acquisitions. The lawyers of The Health Law Firm are experienced in complex litigation and both formal and informal administrative hearings. We also represent physicians accused of wrongdoing, patient complaints, and in Department of Health investigations.

To contact The Health Law Firm, please call our office at (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.ThehealthLawFirm.com.

Sources:

LaPointe, Jacqueline. “Coding Drives Up Medical Billing Costs in the US.” Rev Cycle Intelligence. (August 3, 2022) Web.

Norris, Amanda. “REV CYCLE PROCESSES PUSH U.S. TO TOP OF LIST FOR HIGHEST MEDICAL BILLING COSTS.” Health Leaders Media. (August 10, 2022). 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. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

“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 © 2022 The Health Law Firm. All rights reserved.

By |2024-03-14T09:59:15-04:00December 21, 2023|Categories: Mental Health Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on New Study Reveals Complex Coding Structures in U.S. For Rise in Medical Billing Costs

How Medical Information Bureau (MIB) Reports Can Affect Your Insurance Policy Rates

Attorney Amanda ForbesBy Amanda I. Forbes, J.D.

When you apply for insurance, an insurance company will look at various factors regarding your history to determine how much your insurance policy will cost. Most insurers obtain a report from the Medical Information Bureau (“MIB”) and use this in determining the risk you pose and, hence, your policy premium.

The MIB checks past records to identify any errors, misrepresentations, or omissions made on an insurance application. An MIB report is similar to a credit report except it is specifically tailored for the insurance process. Click here to learn more.

What Does the MIB do?

Since 1902, the MIB has worked as a not-for-profit organization in the United States and Canada. Its members (e.g., life insurance companies, health insurance companies, disability insurers, etc.) use the MIB to help them determine a person’s “risk and eligibility during the underwriting of life, health, disability income, critical illness, and long-term care insurance policies.” Learn more about the organization here.

Insurance applications, whether for health, life, disability, critical illness, or long-term care, will almost always have several health questions that help the insurance company determine an appropriate risk classification for that individual. The higher the risk, the higher the premium, usually. Traditionally, some applicants in very high-risk categories (transplant patients, those with serious long-term chronic medical conditions) or in high-risk professions (e.g., parachuting instructors, trapeze artists, explosives experts) may not be able to obtain insurance at all.

Sometimes an applicant for an insurance policy may try to obtain lower premiums by knowingly omitting key information on their applications. Because of this, insurance companies started to rely on MIB reports to identify and prevent insurance fraud. The MIB provides information that can be used to identify false or incomplete applications.

It is estimated that the MIB saves its member companies over $1 billion annually (Note: I think this estimate probably comes from the MIB). It can do this because the information it provides to its members allows them to evaluate and assess risk more accurately. MIB’s members share information with MIB in a coded format to protect individuals’ privacy.

MIB Pre-Notices.

When a member company wants to search MIB’s database or report information to the MIB, it must first give the individual MIB a “pre-notice.” However, this is often buried in the fine print of the insurance application. The MIB “pre-notice” advises the individual that a report of their medical condition may be provided to MIB.

When the individual later applies for insurance with a different company that is a member of MIB, then MIB may provide that company with an MIB report.

After the individual receives MIB “pre-notice,” they are requested to sign an authorization. The authorization advises the individual that MIB is an information source, as well as others that may have records about the individual (e.g., primary care physician). The signed authorization permits the member company to receive and share information with MIB. Learn more about MIB “pre-notice” here.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals and Providers.

At the Health Law Firm, we provide legal services for all health care providers and professionals. This includes physicians, nurses, dentists, psychologists, psychiatrists, mental health counselors, home health agencies, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other healthcare provider. It also includes medical students, resident physicians, and fellows, as well as medical school professors and clinical staff. We represent health facilities, individuals, groups, and institutions in contracts, sales, mergers, and acquisitions. The lawyers of The Health Law Firm are experienced in complex litigation and both formal and informal administrative hearings. We also represent physicians accused of wrongdoing, patient complaints, and in Department of Health investigations.

To contact The Health Law Firm, please call our office at (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.ThehealthLawFirm.com

About the Author: Amanda I. Forbes, practices health law with The Health Law Firm in its Altamonte Springs, Florida, office. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com. The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or toll-free: (888) 331-6620.

“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 © 2021 The Health Law Firm. All rights reserved.

 

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