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

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

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

Submitting False Claims.

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

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

Payroll Problems.

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

Not Smiling Anymore.

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

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

Click here to read the DOJ’s press release.

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

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

The attorneys of The Health Law Firm represent dentists, oral surgeons, and other health care providers in Medicaid audits, Medicare audits, insurance billing audits, ZPIC audits, RAC audits, administrative litigation and civil litigation throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in licensure complaints and investigations, DEA investigations, Medicare and Medicaid fraud investigations, audits, recovery actions and terminations from the Medicare or Medicaid Program.

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

Sources:

“All About Smiles Owners Convicted of Fraud.” Ozark Independent. (February 21, 2019). Web.
Posses, Shayna. “Couple Found Guilty Of $1M Medicaid, Payroll Tax Scheme.” Law360. (February 21, 2019). Web.

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

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

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2019 The Health Law Firm. All rights reserved.

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

Miami Man to Remain Jailed for Trial in Nation’s Largest Medicare Fraud Case

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

On December 3, 2018, a Florida judge ruled that a Miami businessman who has been jailed for more than two years on $1 billion health care fraud charges, must remain in custody through his trial next year. U.S. District Judge Robert N. Scola Jr. found no violation of his due process rights and denied Philip Esformes’ motion to dismiss several money laundering charges.

Trial Date is Set.

A February 11, 2019, trial date has been set for one of the nation’s biggest Medicare fraud cases that Esformes allegedly orchestrated through nursing homes and assisted living facilities he owned. According to the government, the scheme resulted in $1 billion in false billing and at least $464 million in improper reimbursement payments from Medicare and Medicaid.

Esformes, has been in federal custody since his arrest in July 2016, and prosecutors voiced concerns early on about him being a risk for flight, possible witness tampering and his substantial resources enabling him to live comfortably overseas.

Judge Scola found that the bid for release deserved reconsideration, but ultimately found delays in the case were more attributable to giving the defense time to review the overwhelming quantity of evidence than time spent addressing the government’s conduct. He also agreed with the government that the duration of Esformes’ detention is not grounds for release under binding precedent.

Additionally, the judge rejected Esformes’ motion to dismiss nine counts of alleging money laundering concealment. Esformes had argued that the government improperly based transactions cited in other counts as alleged payments or receipts of kickbacks. You can read more about that here.

Despite problems with the conduct of prosecutors and agents, the judge is keeping the fraud case on track. The Miami businessman is charged with conspiracy, obstruction, money laundering and health care fraud. Click here to read the U.S. Department of Justice’s press release on this case.

Click here to read one of my prior blogs about a billion dollar fraud scheme in Florida.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S., as well as in civil and administrative litigation attempting to recoup claims that have been paid. 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 Medicare and Medicaid Program.

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

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

Hale, Nathan. “Miami Man To Remain Jailed For Trial In $1B Medicare Fraud.” Law360. (December 3, 2018). Web.

Weaver, Jay. “Miami federal judge keeps massive Medicare fraud case on track for trial in January.” Miami Herald. (November 14, 2018). Web.

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

Keywords: Medicare fraud defense representation attorney, legal representation for defense of Medicare fraud charges, Medicare fraud defense attorney, legal representation for allegations of Medicare fraud, legal representation for health care fraud, legal representation for fraudulent billing, legal representation for allegation of defrauding the government, legal representation for submitting false claims, Medicare audit defense attorney, Medicare billing defense attorney, health care clinic fraud audit, legal representation for false billing, legal representation for allegations of unnecessary procedures, legal representation for Medicare audits, Medicaid fraud defense attorney, legal representation for Medicaid fraud, audit defense lawyer, healthcare fraud representation, healthcare fraud lawyer, legal representation for Medicaid audit, Medicaid audit defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, Department of Justice (DOJ) investigations, DOJ representation, representation for DOJ investigations, licensure defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2019 The Health Law Firm. All rights reserved.[/fusion_text][/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]

Miami Man to Remain Jailed for Trial in Nation’s Largest Medicare Fraud Case

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

On December 3, 2018, a Florida judge ruled that a Miami businessman who has been jailed for more than two years on $1 billion health care fraud charges, must remain in custody through his trial next year. U.S. District Judge Robert N. Scola Jr. found no violation of his due process rights. He also denied Philip Esformes’ motion to dismiss several money laundering charges.

Trial Date is Set.

A February 11, 2019, trial date has been set for one of the nation’s biggest Medicare fraud cases that Esformes allegedly orchestrated through nursing homes and assisted living facilities he owned. According to the government, the scheme resulted in $1 billion in false billing and at least $464 million in improper reimbursement payments from Medicare and Medicaid.

Esformes, has been in federal custody since his arrest in July 2016, and prosecutors voiced concerns early on about him being a risk for flight, possible witness tampering and his substantial resources enabling him to live comfortably overseas.

Judge Scola found that the bid for release deserved reconsideration, but ultimately found delays in the case were more attributable to giving the defense time to review the overwhelming quantity of evidence than time spent addressing the government’s conduct. He also agreed with the government that the duration of Esformes’ detention is not grounds for release under binding precedent.

Additionally, the judge rejected Esformes’ motion to dismiss nine counts of alleging money laundering concealment. Esformes had argued that the government improperly based transactions cited in other counts as alleged payments or receipts of kickbacks. You can read more about that here.

Despite problems with the conduct of prosecutors and agents, the judge is keeping the fraud case on track. The Miami businessman is charged with conspiracy, obstruction, money laundering and health care fraud. Click here to read the U.S. Department of Justice’s press release on this case.

Click here to read one of my prior blogs about a billion dollar fraud scheme in Florida.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S., as well as in civil and administrative litigation attempting to recoup claims that have been paid. 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 Medicare and Medicaid Program.

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

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

Hale, Nathan. “Miami Man To Remain Jailed For Trial In $1B Medicare Fraud.” Law360. (December 3, 2018). Web.

Weaver, Jay. “Miami federal judge keeps massive Medicare fraud case on track for trial in January.” Miami Herald. (November 14, 2018). Web.

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

Keywords: Medicare fraud defense representation attorney, legal representation for defense of Medicare fraud charges, Medicare fraud defense attorney, legal representation for allegations of Medicare fraud, legal representation for health care fraud, legal representation for fraudulent billing, legal representation for allegation of defrauding the government, legal representation for submitting false claims, Medicare audit defense attorney, Medicare billing defense attorney, health care clinic fraud audit, legal representation for false billing, legal representation for allegations of unnecessary procedures, legal representation for Medicare audits, Medicaid fraud defense attorney, legal representation for Medicaid fraud, audit defense lawyer, healthcare fraud representation, healthcare fraud lawyer, legal representation for Medicaid audit, Medicaid audit defense attorney, Medicare and Medicaid investigation defense attorney, legal representation for Medicare and Medicaid investigations, OIG investigation defense attorney, legal representation for OIG investigations, Department of Justice (DOJ) investigations, DOJ representation, representation for DOJ investigations, licensure defense lawyer, reviews of the Health Law Firm, The Health Law Firm attorney reviews, Health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2018 The Health Law Firm. All rights reserved.

 

Responding to a Medicaid Audit: Important Tips You Should Know

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

The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), Bureau of Medicaid Program Integrity, is the Florida agency responsible for routine audits of Medicaid health care providers. Each state has a similar state agency, though it may have a different name.  The agency’s job is to ensure that the Medicaid Program was properly billed for services. Health care professionals receiving large payments from Medicaid or who practice in areas that typically see the most abuse or fraudulent billings, are the ones most likely to be audited.  These include pediatricians, Ob/Gyns, family practice physicians and pediatric dentists.

A different state agency that may also conduct Medicaid audits is the state Medicaid Fraud Control Unit (MFCU).  However, by definition, the MFCU is investigating allegations that there is substantial fraud going on.  You should know that if you are contacted by the MFCU, this is a very serious matter.  This is not a routine audit.
However, on the “routine” audits conducted by the Medica agency, the Medicaid audit usually requests information in a questionnaire that the medical practice is required to complete. Additionally, copies of medical records (including x-rays and other diagnostic studies) on the list of Medicaid patients selected for the audit.

If AHCA (or the state Medicaid agency) determines that Medicaid overpaid for services, it will use a complex mathematical extrapolation formula to determine the repayment amount. The amount of the repayment to the Medicaid Program can be considerably greater than (30 to 100 times as much as) the actual amount of overpayment disclosed by the sample of records audited. Additionally, fines and penalties can be added by the Medicaid Program. However, you can eliminate or reduce the amount of any such repayment by actions taken both before and during the Medicaid audit.

 

General Practice Tips:
There are various ways to manage your practice that will help you in the event that you are selected for a Medicaid Audit.

1. Every patient record entry should be clearly dated and signed or initialed by the provider. Make sure this is always done.

2. When documenting in the patient’s record, make sure that you document exactly what services were needed and completed in order to support what was billed to Medicaid.

3. Communicate with the person responsible for your billing so that the actual services provided are billed for. Do not bill in advance for anticipated services needed as indicated in the appointment calendar or on a treatment plan.

4. Keep the patient records organized and ready for copying if necessary. Use only one sided documents and securely fasten small forms (prescriptions, telephone memos, small sticky notes) onto 8-1/2″ by 11″ paper. Scan all such documents into the patient record if using an electronic health record (EHR).

5. Services provided by a physician who is not enrolled in the Medicaid Program to a Medicaid patient may not be billed to or paid by the Medicaid Program. Therefore, never allow any other physician associated with your practice who is not enrolled as a Medicaid provider to provide services to Medicaid patients. Do not allow a new physician coming into your practice to treat Medicaid patients until he or she actually has received his or her Medicaid provider number. The group may not bill for the services nor may another physician bill for the services.

6. Ensure that all health care professionals’ licenses and permits are kept up to date. Ensure that all x-ray, clinical, lab and diagnostic equipment is permitted and kept up to date. Ensure that any CLIA license or exemption certificate is correct and kept up to date. Services billed by unlicensed personnel or services provided by improperly licensed facilities may not be paid by the Medicaid Program.

7. Use only standard abbreviations in your medical records, documentation, orders, and reports. While an abbreviation may seem common to you or your practice, if it is not a universally accepted abbreviation, the auditors may not recognize it.

8. Make sure all records are timely made, accurate and legible. Safeguard them and never let the original leave your office. Illegible records are treated as a non-record, and payment completely disallowed for an illegible note or order. A missing record, x-ray or chart entry will result in a complete repayment being directed for those services.

The Medicaid Audit:

If you are being audited, AHCA will send you a letter notifying you of the audit. AHCA will also supply you with a list of patients to be sampled a standard sample will include a list of anywhere from 30 to 150 patient names, depending on the size of the practice. Regular audits routinely request 30 to 50 patient records. The audit letter will also include a questionnaire to be completed (Medicaid Provider Questionnaire) and a “Certification of Completeness of Records” form to complete and return with the copies of the patient records. (Please note: this will be used against you in the future if you attempt to add to or supplement the copies of the records you provided).

It is crucial that you retain the services of an expert consultant or experienced health care attorney in correctly and accurately completing the questionnaire. The letter will also request that you provide copies of the patient records for the list of patients included with the letter. You will only be given a short time to provide these documents.

1. When receiving a notice of a Medicaid audit, time is of the essence. Be sure to calendar the date that the records need to be in the AHCA office and have the records there by that date. Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be received at AHCA.

2. Obtain and review a copy of the claims you submitted and what Medicaid has paid on each of the patients being audited. This information can be found in the Medicaid portal, in your billing system, or in the Explanation of Benefits. Compare this information to the medical records to see if any issues may arise when AHCA reviews the records. (Keep this for your use, do not provide it as part of the audit records).

3. Provide a complete copy of the entire record, not just the parts from the period of time covered by the audit. Remember that other physician records obtained as history, including reports and consultations should be included. Consent forms, medical history questionnaires, histories, physicals, and other physicians’ orders, may be a crucial part of the record.

4. If you suspect that an issue may arise with a particular patient, prepare a separate explanation to submit with the patient’s file. AHCA will have an expert review the records, so an explanation in advance will help the expert to assess if there is in fact an issue. Any explanatory notes or other explanations should be clearly labeled as such and dated as of the date actually prepared, so there is no confusion as to whether or not it was part of the original record.

5. If your practice involves taking x-rays or using other diagnostic studies, these procedures are part of the patient’s record. If the x-rays are digital, they can be submitted on a compact disc. Be sure to include the number of x-rays on the compact discs in the Certification of Completeness of Records.
6. Complete the Medicaid Provider Questionnaire in its entirety to send with the patient records. Do not leave any section blank. Use “not applicable” or “none” if necessary. Attach all required documents. Consult with an experienced health law attorney to assist in completing the form.

To learn more about the Medicaid audit process and how The Health Law Firm can assist you, click here to watch our short video blog.

Don’t Wait Until It’s Too Late, Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.
If you or your practice has been sent notice of a Medicaid or Medicare audit, please contact us at (407) 331-6620 or (850) 439-1001 or visit our website at www.TheHealthLawFirm.com for more information.

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

KeyWords: Legal representation for Medicaid audits, Medicaid audit defense attorney, health care fraud defense attorney, health care fraud investigation defense attorney, legal representation for health care fraud investigation, legal representation for health care fraud, Medicaid fraud defense attorney, legal representation for Medicaid fraud, legal representation for fraudulent billing, legal representation for submitting false claims to the government, legal representation for overbilling, health care fraud attorney, The Health Law Firm, reviews of The Health Law Firm attorneys, reviews of The Health Law Firm
“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 © 2017 The Health Law Firm. All rights reserved.

Michigan Dentist Accused of Million Dollar Medicaid Fraud Scheme Captured in Caribbean

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A Michigan dentist accused of Medicaid fraud was recently captured in the Dominican Republic after evading charges for months, state authorities announced. Dr. David Johnson operated the alleged scheme through Livernois Dental in Detroit, which he owned at the time but has since sold.

27 Charges.

Dr. Johnson was charged by Michigan Attorney General Bill Schuette in May 2017, after allegedly using another dentist’s information to improperly bill Medicaid $1.7 million over a three year period of time. The charges include one count of racketeering, punishable by up to 20 years in prison; 20 counts of false Medicaid claims, punishable by up to 10 years in prison; and six counts of false health care claims, punishable by up to four years in prison.

According to the Attorney General’s press release, since the charges were issued, the dentist was living outside of the United States in an attempt to evade arrest. To read the AG’s press release in full, click here.

Unfortunately, this is not the only case of a health care professional trying to evade arrest. To read about another case, click here to read one of my prior blogs.

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.

Sources:

Rahal, Sarah. “Macomb dentist accused of fraud faces 27 felonies.” The Detroit News. (October 3, 2017). Web.

“Chesterfield Township dentist accused of Medicaid fraud captured in Caribbean.” Baltimore Voice Newspaper. (October 3, 2017). Web.

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

KeyWords: Legal representation for Medicaid fraud, Medicaid defense attorney, Medicaid fraud defense attorney, legal representation for health care fraud, Medicaid Fraud Control Unit (MFCU) defense attorney, dentist defense counsel, legal representation for dentist, dental board defense attorney, dental license defense attorney, legal representation for dentist, legal representation for allegations of health care fraud, legal representation for improper billing, legal representation for defrauding the government, legal representation for defrauding Medicaid, legal representation for dentists, dentist attorney, defense attorney for dentists, The Health Law Firm, reviews of The Health Law Firm, The Health Law Firm attorney reviews, board of dentistry defense counsel, Medicaid Fraud Control Unit (MFCU) legal representation, Medicaid Fraud Control Unit (MFCU) defense counsel

“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 © 2017 The Health Law Firm. All rights reserved.

 

Owner of Louisiana Health Care Company To Pay Nearly $7 Million for Medicaid Fraud

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

On December 20, 2016, the owner of Louisiana-based Millennium Health Care Services (Millennium) must pay the state nearly $7 million in restitution and will spend 10 years behind bars for his role in a scheme to defraud the Medicaid system, according to Louisiana Attorney General Jeff Landry.

Millennium’s owner, Dwaine Woods, was ordered to pay $6,985,249 in restitution after his wife and the company were all found guilty of engaging in a criminal conspiracy to create multiple fake CPR cards for Millennium staff. The staff did not undergo training to be properly certified in CPR, Landry said.

The Dangerous Scheme.

Millennium operated from 2004 to 2010 and was solely funded by the government program Medicaid. According to Landry, the fake CPR card scheme was not only illegal but also extremely dangerous. “Instead of service workers learning necessary skills, they were fraudulently getting certifications without any training — greatly jeopardizing the health and safety of patients.”

Millennium was convicted of 19 counts of forgery, one count of theft by fraud, and one count of conspiracy to commit forgery. In addition to the restitution payment, the company was also ordered to pay $17,500 in fines.

Dynetta Woods was also convicted of 19 counts of forgery and one count of conspiracy to commit forgery. She was reportedly sentenced to five years of supervised probation and ordered to pay $54,730 in restitution and $5,000 in fines. Additionally, she is forever barred from doing business with the state of Louisiana, according to Landry. Dwaine Woods was convicted of theft by fraud.

To learn about a similar case of Medicaid fraud and the repercussions, click here to read one of my prior blogs.

Never Falsify Any Documents if You Are a Medicare or Medicaid Provider.

We have represented a number of owners of Medicare and Medicaid providers that were investigated, charged and convicted of fraud because they had falsified, forged, created or changed documents that were in their employees’ files. These have included items so simple as the expiration date on a CPR card, but have also included forging diplomas and other qualifying credentials. State Medicaid programs and the Medicare Program takes such matters very seriously. Often prison time will result for the owners of the company.

This can also be the basis for large recoveries under federal and state whistle blower (false claims act) laws. Submission of a false statement or false document to a federal official is a felony. Employees of Medicare and Medicaid providers who are aware that their employers have falsified documents can blow the whistle on them and collect large rewards under one of the applicable false claims acts (whistle blower laws).

Fraud Investigations Are a Very Serious Matter.

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

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

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

Do not delude yourself. This is extremely serious. Be prepared to give up whatever you have if you can avoid a conviction.
Contact Health Law Attorneys Experienced in Handling Medicaid Audits, Investigations and other Legal Proceedings.

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

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

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

Sources:

Kennedy, John. “La. Medicaid Fraudster Will Pay Nearly $7M In Restitution.” Law360. (December 20, 2016). Web.

Gyan, Joe. “Prairieville couple sentenced in $7 million Medicaid fraud scheme.” The Advocate. (December 20, 2016). Web.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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The Health Law Firm” is a registered fictitious business name of The Health Law Firm, P.A., a Florida professional service corporation, since 1999, and is also a registered service mark.
Copyright © 2017 The Health Law Firm. All rights reserved

Responding to a Medicaid Audit: Important Tips You Should Know

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

The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), Bureau of Medicaid Program Integrity, is the Florida agency responsible for routine audits of Medicaid health care providers. Each state has a similar state agency, though it may have a different name.  The agency’s job is to ensure that the Medicaid Program was properly billed for services. Health care professionals receiving large payments from Medicaid or who practice in areas that typically see the most abuse or fraudulent billings, are the ones most likely to be audited.  These include pediatricians, Ob/Gyns, family practice physicians and pediatric dentists.

A different state agency that may also conduct Medicaid audits is the state Medicaid Fraud Control Unit (MFCU).  However, by definition, the MFCU is investigating allegations that there is substantial fraud going on.  You should know that if you are contacted by the MFCU, this is a very serious matter.  This is not a routine audit.
However, on the “routine” audits conducted by the Medica agency, the Medicaid audit usually requests information in a questionnaire that the medical practice is required to complete. Additionally, copies of medical records (including x-rays and other diagnostic studies) on the list of Medicaid patients selected for the audit.

If AHCA (or the state Medicaid agency) determines that Medicaid overpaid for services, it will use a complex mathematical extrapolation formula to determine the repayment amount. The amount of the repayment to the Medicaid Program can be considerably greater than (30 to 100 times as much as) the actual amount of overpayment disclosed by the sample of records audited. Additionally, fines and penalties can be added by the Medicaid Program. However, you can eliminate or reduce the amount of any such repayment by actions taken both before and during the Medicaid audit.

 

General Practice Tips:
There are various ways to manage your practice that will help you in the event that you are selected for a Medicaid Audit.

1. Every patient record entry should be clearly dated and signed or initialed by the provider. Make sure this is always done.

2. When documenting in the patient’s record, make sure that you document exactly what services were needed and completed in order to support what was billed to Medicaid.

3. Communicate with the person responsible for your billing so that the actual services provided are billed for. Do not bill in advance for anticipated services needed as indicated in the appointment calendar or on a treatment plan.

4. Keep the patient records organized and ready for copying if necessary. Use only one sided documents and securely fasten small forms (prescriptions, telephone memos, small sticky notes) onto 8-1/2″ by 11″ paper. Scan all such documents into the patient record if using an electronic health record (EHR).

5. Services provided by a physician who is not enrolled in the Medicaid Program to a Medicaid patient may not be billed to or paid by the Medicaid Program. Therefore, never allow any other physician associated with your practice who is not enrolled as a Medicaid provider to provide services to Medicaid patients. Do not allow a new physician coming into your practice to treat Medicaid patients until he or she actually has received his or her Medicaid provider number. The group may not bill for the services nor may another physician bill for the services.

6. Ensure that all health care professionals’ licenses and permits are kept up to date. Ensure that all x-ray, clinical, lab and diagnostic equipment is permitted and kept up to date. Ensure that any CLIA license or exemption certificate is correct and kept up to date. Services billed by unlicensed personnel or services provided by improperly licensed facilities may not be paid by the Medicaid Program.

7. Use only standard abbreviations in your medical records, documentation, orders, and reports. While an abbreviation may seem common to you or your practice, if it is not a universally accepted abbreviation, the auditors may not recognize it.

8. Make sure all records are timely made, accurate and legible. Safeguard them and never let the original leave your office. Illegible records are treated as a non-record, and payment completely disallowed for an illegible note or order. A missing record, x-ray or chart entry will result in a complete repayment being directed for those services.

The Medicaid Audit:

If you are being audited, AHCA will send you a letter notifying you of the audit. AHCA will also supply you with a list of patients to be sampled a standard sample will include a list of anywhere from 30 to 150 patient names, depending on the size of the practice. Regular audits routinely request 30 to 50 patient records. The audit letter will also include a questionnaire to be completed (Medicaid Provider Questionnaire) and a “Certification of Completeness of Records” form to complete and return with the copies of the patient records. (Please note: this will be used against you in the future if you attempt to add to or supplement the copies of the records you provided).

It is crucial that you retain the services of an expert consultant or experienced health care attorney in correctly and accurately completing the questionnaire. The letter will also request that you provide copies of the patient records for the list of patients included with the letter. You will only be given a short time to provide these documents.

1. When receiving a notice of a Medicaid audit, time is of the essence. Be sure to calendar the date that the records need to be in the AHCA office and have the records there by that date. Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be received at AHCA.

2. Obtain and review a copy of the claims you submitted and what Medicaid has paid on each of the patients being audited. This information can be found in the Medicaid portal, in your billing system, or in the Explanation of Benefits. Compare this information to the medical records to see if any issues may arise when AHCA reviews the records. (Keep this for your use, do not provide it as part of the audit records).

3. Provide a complete copy of the entire record, not just the parts from the period of time covered by the audit. Remember that other physician records obtained as history, including reports and consultations should be included. Consent forms, medical history questionnaires, histories, physicals, and other physicians’ orders, may be a crucial part of the record.

4. If you suspect that an issue may arise with a particular patient, prepare a separate explanation to submit with the patient’s file. AHCA will have an expert review the records, so an explanation in advance will help the expert to assess if there is in fact an issue. Any explanatory notes or other explanations should be clearly labeled as such and dated as of the date actually prepared, so there is no confusion as to whether or not it was part of the original record.

5. If your practice involves taking x-rays or using other diagnostic studies, these procedures are part of the patient’s record. If the x-rays are digital, they can be submitted on a compact disc. Be sure to include the number of x-rays on the compact discs in the Certification of Completeness of Records.
6. Complete the Medicaid Provider Questionnaire in its entirety to send with the patient records. Do not leave any section blank. Use “not applicable” or “none” if necessary. Attach all required documents. Consult with an experienced health law attorney to assist in completing the form.

To learn more about the Medicaid audit process and how The Health Law Firm can assist you, click here to watch our short video blog.

Don’t Wait Until It’s Too Late, Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.
If you or your practice has been sent notice of a Medicaid or Medicare audit, please contact us at (407) 331-6620 or (850) 439-1001 or visit our website at www.TheHealthLawFirm.com for more information.

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

KeyWords: Legal representation for Medicaid audits, Medicaid audit defense attorney, health care fraud defense attorney, health care fraud investigation defense attorney, legal representation for health care fraud investigation, legal representation for health care fraud, Medicaid fraud defense attorney, legal representation for Medicaid fraud, legal representation for fraudulent billing, legal representation for submitting false claims to the government, legal representation for overbilling, health care fraud attorney, The Health Law Firm, reviews of The Health Law Firm attorneys, reviews of The Health Law Firm
“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 © 2017 The Health Law Firm. All rights reserved.

Michigan Dentist Accused of Million Dollar Medicaid Fraud Scheme Captured in Caribbean

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A Michigan dentist accused of Medicaid fraud was recently captured in the Dominican Republic after evading charges for months, state authorities announced. Dr. David Johnson operated the alleged scheme through Livernois Dental in Detroit, which he owned at the time but has since sold.

27 Charges.

Dr. Johnson was charged by Michigan Attorney General Bill Schuette in May 2017, after allegedly using another dentist’s information to improperly bill Medicaid $1.7 million over a three year period of time. The charges include one count of racketeering, punishable by up to 20 years in prison; 20 counts of false Medicaid claims, punishable by up to 10 years in prison; and six counts of false health care claims, punishable by up to four years in prison.

According to the Attorney General’s press release, since the charges were issued, the dentist was living outside of the United States in an attempt to evade arrest. To read the AG’s press release in full, click here.

Unfortunately, this is not the only case of a health care professional trying to evade arrest. To read about another case, click here to read one of my prior blogs.

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.

Sources:

Rahal, Sarah. “Macomb dentist accused of fraud faces 27 felonies.” The Detroit News. (October 3, 2017). Web.

“Chesterfield Township dentist accused of Medicaid fraud captured in Caribbean.” Baltimore Voice Newspaper. (October 3, 2017). Web.

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

KeyWords: Legal representation for Medicaid fraud, Medicaid defense attorney, Medicaid fraud defense attorney, legal representation for health care fraud, Medicaid Fraud Control Unit (MFCU) defense attorney, dentist defense counsel, legal representation for dentist, dental board defense attorney, dental license defense attorney, legal representation for dentist, legal representation for allegations of health care fraud, legal representation for improper billing, legal representation for defrauding the government, legal representation for defrauding Medicaid, legal representation for dentists, dentist attorney, defense attorney for dentists, The Health Law Firm, reviews of The Health Law Firm, The Health Law Firm attorney reviews, board of dentistry defense counsel, Medicaid Fraud Control Unit (MFCU) legal representation, Medicaid Fraud Control Unit (MFCU) defense counsel

“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 © 2017 The Health Law Firm. All rights reserved.

 

If You Are a Dentist Facing Legal Challenges, Choose an Attorney Who is Board Certified by The Florida Bar in Health Law

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

Dentists, nurses, pharmacists, health professionals, and health facilities often face legal challenges from many different sources. These challenges can come from federal and state regulators, medical malpractice trial lawyers, hospitals, clinics and colleagues. If you find yourself faced with a legal problem, the first person you should contact is an attorney who is Board Certified by The Florida Bar in Health Law.

A Board Certified Health Law Attorney is Your Legal Specialist.

To find a lawyer who has expertise in the area of law relating to your legal needs, the Supreme Court of Florida directed The Florida Bar to offer a “Board Certification” program for Florida Bar members. The program is designed to help the public make an informed decision when seeking and selecting a lawyer. Not all states use board certification to designate attorneys, and those that do may not have board certification in the area of Health Law. However, both Florida and Texas are states that do offer a board certification program for their health lawyers.

While all lawyers are allowed to advertise, only certified attorneys are allowed to identify themselves as “Florida Bar Board Certified” or as a “specialist.” Being certified is the highest level of recognition by The Florida Bar of the competency and experience of attorneys in health law.

A lawyer who is a member in good standing of The Florida Bar and who meets the standards set by the state’s Supreme Court, may become a “Board Certified Health Law Attorney.”

Not all qualified lawyers are certified, but those who are board certified have taken the extra step to have their competence and experience recognized. You can read more about what distinguishes “Board Certified” attorneys from others by visiting The Florida Bar website here.

Requirements for Becoming Board Certified by The Florida Bar in Health Law.

To qualify to take the health law certification examination, attorneys must:

1. be members of The Florida Bar for at least five years,
2. be engaged in the full-time practice of law,
3. be substantially involved, at least forty percent (40%), in health law for the prior three years of their practice,
4. complete at least 60 hours of advanced continuing legal education of approved health law credits and,
5. Pass a stringent peer review process.

To become certified in health law, an attorney is also required to pass a rigorous written board certification examination designed to test the attorney’s knowledge, skills and proficiency in the field of health law. All currently certified attorneys must apply for recertification every five years.

Read more on The Health Law Firm’s Board Certified Health Law attorneys here.

To view a press release on the recertification of George F. Indest III and Michael L. Smith, click here.

You Seek Specialized Medical Care from a Medical Specialist; Seek Specialized Legal Services from a Health Law Specialist.

If you have a medical issue you seek treatment from a physician who is board certified in a medical specialty, such as obstetrics and gynecology, orthopedic surgery, neurology or others. This is because they have superior education, training, knowledge and experience in that area of medicine.

Likewise, when you have a legal problem in the area of health practice, health licensing, health care regulation or other legal situations unique to the health care industry, you should seek legal advice and representation from a legal specialist in health law.
Contact The Health Law Firm to Speak with an Attorney who is Board Certified by The Florida Bar in Health Law.

The Health Law Firm currently has two Board Certified Health Law attorneys:

George F. Indest III, J.D., M.P.A., LL.M, is Board Certified by The Florida Bar in Health Law.
Michael L. Smith, J.D., R.R.T., is Board Certified by The Florida Bar in Health Law.

To learn more about all the attorneys at The Health Law Firm, click here.

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

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

KeyWords: Board Certified by The Florida Bar in Health Law, Board Certified in Health Law, health law attorneys, health law attorneys Florida, health law expert, legal specialist in health law, Health law defense lawyer, legal representation of health care professionals, Medicare fraud defense attorney, Medicare audit defense attorney, Medicaid fraud defense attorney, Medicaid audit defense attorney, Baker Act defense attorney, disruptive physician defense attorney, legal representation for disruptive physician, legal representation for Baker Act cases, legal representation for Medicare fraud, legal representation for Medicaid fraud, legal representation for clinical research investigations, legal representation for clinical research fraud, Florida health law attorney, The Health Law Firm reviews, reviews of The Health Law Firm attorneys
“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 © 2017 The Health Law Firm. All rights reserved.

Responding to a Medicaid Audit: Important Tips You Should Know

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

The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), Bureau of Medicaid Program Integrity, is the Florida agency responsible for routine audits of Medicaid health care providers. Each state has a similar state agency, though it may have a different name.  The agency’s job is to ensure that the Medicaid Program was properly billed for services. Health care professionals receiving large payments from Medicaid or who practice in areas that typically see the most abuse or fraudulent billings, are the ones most likely to be audited.  These include pediatricians, Ob/Gyns, family practice physicians and pediatric dentists.

A different state agency that may also conduct Medicaid audits is the state Medicaid Fraud Control Unit (MFCU).  However, by definition, the MFCU is investigating allegations that there is substantial fraud going on.  You should know that if you are contacted by the MFCU, this is a very serious matter.  This is not a routine audit.
However, on the “routine” audits conducted by the Medica agency, the Medicaid audit usually requests information in a questionnaire that the medical practice is required to complete. Additionally, copies of medical records (including x-rays and other diagnostic studies) on the list of Medicaid patients selected for the audit.

If AHCA (or the state Medicaid agency) determines that Medicaid overpaid for services, it will use a complex mathematical extrapolation formula to determine the repayment amount. The amount of the repayment to the Medicaid Program can be considerably greater than (30 to 100 times as much as) the actual amount of overpayment disclosed by the sample of records audited. Additionally, fines and penalties can be added by the Medicaid Program. However, you can eliminate or reduce the amount of any such repayment by actions taken both before and during the Medicaid audit.

 

General Practice Tips:
There are various ways to manage your practice that will help you in the event that you are selected for a Medicaid Audit.

1. Every patient record entry should be clearly dated and signed or initialed by the provider. Make sure this is always done.

2. When documenting in the patient’s record, make sure that you document exactly what services were needed and completed in order to support what was billed to Medicaid.

3. Communicate with the person responsible for your billing so that the actual services provided are billed for. Do not bill in advance for anticipated services needed as indicated in the appointment calendar or on a treatment plan.

4. Keep the patient records organized and ready for copying if necessary. Use only one sided documents and securely fasten small forms (prescriptions, telephone memos, small sticky notes) onto 8-1/2″ by 11″ paper. Scan all such documents into the patient record if using an electronic health record (EHR).

5. Services provided by a physician who is not enrolled in the Medicaid Program to a Medicaid patient may not be billed to or paid by the Medicaid Program. Therefore, never allow any other physician associated with your practice who is not enrolled as a Medicaid provider to provide services to Medicaid patients. Do not allow a new physician coming into your practice to treat Medicaid patients until he or she actually has received his or her Medicaid provider number. The group may not bill for the services nor may another physician bill for the services.

6. Ensure that all health care professionals’ licenses and permits are kept up to date. Ensure that all x-ray, clinical, lab and diagnostic equipment is permitted and kept up to date. Ensure that any CLIA license or exemption certificate is correct and kept up to date. Services billed by unlicensed personnel or services provided by improperly licensed facilities may not be paid by the Medicaid Program.

7. Use only standard abbreviations in your medical records, documentation, orders, and reports. While an abbreviation may seem common to you or your practice, if it is not a universally accepted abbreviation, the auditors may not recognize it.

8. Make sure all records are timely made, accurate and legible. Safeguard them and never let the original leave your office. Illegible records are treated as a non-record, and payment completely disallowed for an illegible note or order. A missing record, x-ray or chart entry will result in a complete repayment being directed for those services.

The Medicaid Audit:

If you are being audited, AHCA will send you a letter notifying you of the audit. AHCA will also supply you with a list of patients to be sampled a standard sample will include a list of anywhere from 30 to 150 patient names, depending on the size of the practice. Regular audits routinely request 30 to 50 patient records. The audit letter will also include a questionnaire to be completed (Medicaid Provider Questionnaire) and a “Certification of Completeness of Records” form to complete and return with the copies of the patient records. (Please note: this will be used against you in the future if you attempt to add to or supplement the copies of the records you provided).

It is crucial that you retain the services of an expert consultant or experienced health care attorney in correctly and accurately completing the questionnaire. The letter will also request that you provide copies of the patient records for the list of patients included with the letter. You will only be given a short time to provide these documents.

1. When receiving a notice of a Medicaid audit, time is of the essence. Be sure to calendar the date that the records need to be in the AHCA office and have the records there by that date. Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be received at AHCA.

2. Obtain and review a copy of the claims you submitted and what Medicaid has paid on each of the patients being audited. This information can be found in the Medicaid portal, in your billing system, or in the Explanation of Benefits. Compare this information to the medical records to see if any issues may arise when AHCA reviews the records. (Keep this for your use, do not provide it as part of the audit records).

3. Provide a complete copy of the entire record, not just the parts from the period of time covered by the audit. Remember that other physician records obtained as history, including reports and consultations should be included. Consent forms, medical history questionnaires, histories, physicals, and other physicians’ orders, may be a crucial part of the record.

4. If you suspect that an issue may arise with a particular patient, prepare a separate explanation to submit with the patient’s file. AHCA will have an expert review the records, so an explanation in advance will help the expert to assess if there is in fact an issue. Any explanatory notes or other explanations should be clearly labeled as such and dated as of the date actually prepared, so there is no confusion as to whether or not it was part of the original record.

5. If your practice involves taking x-rays or using other diagnostic studies, these procedures are part of the patient’s record. If the x-rays are digital, they can be submitted on a compact disc. Be sure to include the number of x-rays on the compact discs in the Certification of Completeness of Records.
6. Complete the Medicaid Provider Questionnaire in its entirety to send with the patient records. Do not leave any section blank. Use “not applicable” or “none” if necessary. Attach all required documents. Consult with an experienced health law attorney to assist in completing the form.

To learn more about the Medicaid audit process and how The Health Law Firm can assist you, click here to watch our short video blog.

Don’t Wait Until It’s Too Late, Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.
If you or your practice has been sent notice of a Medicaid or Medicare audit, please contact us at (407) 331-6620 or (850) 439-1001 or visit our website at www.TheHealthLawFirm.com for more information.

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

KeyWords: Legal representation for Medicaid audits, Medicaid audit defense attorney, health care fraud defense attorney, health care fraud investigation defense attorney, legal representation for health care fraud investigation, legal representation for health care fraud, Medicaid fraud defense attorney, legal representation for Medicaid fraud, legal representation for fraudulent billing, legal representation for submitting false claims to the government, legal representation for overbilling, health care fraud attorney, The Health Law Firm, reviews of The Health Law Firm attorneys, reviews of The Health Law Firm
“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 © 2017 The Health Law Firm. All rights reserved.

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