Fight Back in National Practitioner Data Bank Disputes and Appeal Adverse Reports

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

The National Practitioner Data Bank (NPDB), created in 1986, was part of the Health Care Quality Improvement Act (HCQIA). Its purpose is to improve the quality of health care by encouraging state licensing boards, hospitals, health care entities, and professional societies to report into a national data bank those physicians and health professionals who demonstrate substandard skills or engage in unprofessional behavior.  In part, it is used to make sure that incompetent physicians do not move from one state to another in order to avoid the consequences.

Adverse Reports Stay in the NPDB for Life.

How long does an adverse NPDB report stay in the Data Bank?  I have received two (2) different answers to this question from different authorities.  I was originally informed that adverse NPDB reports are for life, and believed that for my first 25 or so years of practice.  However, more recently I have been informed that they only stay in the Data Bank for 50 years.  However, there is little difference whether it is actually 50 years or for life.  For most physicians 50 years is a lifetime for a medical career.

A Negative NPDB Report Has the Ability to Ruin Your Career.

All reports in the NPDB on an individual can and are queried by state licensing boards, hospitals, and other health care facilities to assist in investigating adverse incidents and disciplinary actions that may have been taken against a physician applying for a license or clinical privileges. Therefore, adverse NPDB reports can have long-lasting, devastating effects on the career of a health care provider.

Additionally, the real-world consequences of being the subject of an NPDB report include possible exclusion from the panels of health plans and independent physician organizations, termination for cause from state Medicaid programs, loss of medical staff privileges at hospitals and health facilities, increases in professional liability insurance premiums, exclusion from the Medicare Program, and additional licensing investigations and potential discipline by other organizations and states.

If you are the subject of an adverse NPDB report, there are several actions you should take to correct any errors, provide your side of the facts, and possibly have the adverse report removed or corrected.

What Happens If You Disagree With Your Report?

Reports to the NPDB are, for all practical purposes for life, as explained above.  But healthcare professionals may appeal adverse reports through a dispute resolution process involving the Secretary of the Department of Health and Human Services (HHS). You can dispute reports if you disagree with factual accuracy of the report or if the event reported are not proper under NPDB guidelines.  For example, getting fired from a job or having a contract terminated for cause are not proper events to cause an adverse NPDB report. We have had to represent physicians in the past having these types of reports removed from the NPDB.

It’s important to note that entering the report into dispute status does not automatically trigger a review. When in dispute status, you have to notify the reporting organization.  The reporting organization can correct, void, or choose to leave the report unchanged. If after 60 days you have received no response from the reporting organization, or you are unsatisfied with the response you received, you can elevate the report to dispute resolution (appeal).

Visit the NPDB website here for more details on this process.

For more reference, you can see what a successful voided NPDB report looks like here. This example results from The Health Law Firm’s recent successful appeal of an adverse NPDB report for a client.

Your Career May Depend On Having Legal Counsel Who Understands the NPDB.

If you have received a negative National Practitioner Data Bank report and wish to appeal it, contact The Health Law Firm. Our attorneys routinely represent physicians, dentists, and other healthcare professionals in disputing and appealing NPDB reports. To learn more, click here to read one of my prior blogs.

Don’t Wait Until It’s Too Late, Contact Experienced Health Law Attorneys.

The Health Law Firm attorneys routinely represent physicians, physician assistants (PAs), nurses, nurse practitioners (NPs), dentists, and other health professionals in dealing with reports being made to the NPDB, disputing NPDB reports and appealing NPDB reports, hospital clinical privileges hearings, medical staff fair hearings, medical staff peer reviews. Its attorneys include those who are board-certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

To contact The Health Law Firm, please call (407) 331-6620 or Toll-Free (888) 331-6620 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 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.

NPDB Disputes and Appeals: Fight Back Against Adverse Reports

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

The National Practitioner Data Bank (NPDB), created in 1986, was part of the Health Care Quality Improvement Act (HCQIA). Its purpose is to improve the quality of health care by encouraging state licensing boards, hospitals, health care entities, and professional societies to report into a national data bank those physicians and health professionals who demonstrate substandard skills or engage in unprofessional behavior. In part, it is used to make sure that incompetent physicians do not move from one state to another in order to avoid the consequences.

Adverse Reports Stay in the NPDB for Life.

How long does an adverse NPDB report stay in the Data Bank? I have received two (2) different answers to this question from different authorities. I was originally informed that adverse NPDB reports are for life, and believed that for my first 25 or so years of practice. However, more recently I have been informed that they only stay in the Data Bank for 50 years. However, there is little difference whether it is actually 50 years or for life. For most physicians, 50 years is a lifetime for a medical career.

 

A Negative NPDB Report Has the Ability to Ruin Your Career.

All reports in the NPDB on an individual can and are queried by state licensing boards, hospitals, and other health care facilities to assist in investigating adverse incidents and disciplinary actions that may have been taken against a physician applying for a license or clinical privileges. Therefore, adverse NPDB reports can have long-lasting, devastating effects on the career of a health care provider.

Additionally, the real-world consequences of being the subject of an NPDB report include possible exclusion from the panels of health plans and independent physician organizations, termination for cause from state Medicaid programs, loss of medical staff privileges at hospitals and health facilities, increases in professional liability insurance premiums, exclusion from the Medicare Program, and additional licensing investigations and potential discipline by other organizations and states.

If you are the subject of an adverse NPDB report, there are several actions you should take to correct any errors, provide your side of the facts, and possibly have the adverse report removed or corrected.

What Happens If You Disagree With Your Report?

Reports to the NPDB are, for all practical purposes for life, as explained above. But healthcare professionals may appeal adverse reports through a dispute resolution process involving the Secretary of the Department of Health and Human Services (HHS). You can dispute reports if you disagree with factual accuracy of the report or if the event reported are not proper under NPDB guidelines. For example, getting fired from a job or having a contract terminated for cause are not proper events to cause an adverse NPDB report. We have had to represent physicians in the past having these types of reports removed from the NPDB.

It’s important to note that entering the report into dispute status does not automatically trigger a review. When in dispute status, you have to notify the reporting organization. The reporting organization can correct, void, or choose to leave the report unchanged. If after 60 days you have received no response from the reporting organization, or you are unsatisfied with the response you received, you can elevate the report to dispute resolution (appeal).

Visit the NPDB website here for more details on this process.

For more reference, you can see what a successful voided NPDB report looks like here.  This example results from The Health Law Firm’s recent successful appeal of an adverse NPDB report for a client.

Your Career May Depend On Having Legal Counsel Who Understands the NPDB.

If you have received a negative National Practitioner Data Bank report and wish to appeal it, contact The Health Law Firm. Our attorneys routinely represent physicians, dentists, and other healthcare professionals in disputing and appealing NPDB reports. To learn more, click here to read one of my prior blogs.

Don’t Wait Until It’s Too Late, Contact Experienced Health Law Attorneys.

The Health Law Firm attorneys routinely represent physicians, physician assistants (PAs), nurses, nurse practitioners (NPs), dentists and other health professionals in dealing with reports being made to the NPDB, disputing NPDB reports and appealing NPDB reports, hospital clinical privileges hearings, medical staff fair hearings, medical staff peer reviews. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

To contact The Health Law Firm, please call (407) 331-6620 or Toll-Free (888) 331-6620 and visit our website at http://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 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.

 

OIG Exclusion: Do You Know if You’re on the List?

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

Have you ever faced a disciplinary action against your professional license? Have you ever been arrested or convicted of a criminal offense? If yes, then you may have also been terminated from the federal Medicare Program or your state Medicaid Program.

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

First, Check the List.

The first step is to check if you are on the federal government’s List of Excluded Individuals and Entities (LEIE). You can check that list here: http://exclusions.oig.hhs.gov/.

Next, to see if you are on Florida’s list of individuals and entities who have been terminated from Florida’s Medicaid Program, click here.

Collateral Consequences to OIG Exclusion or Termination.

Termination or exclusion can have many collateral consequences about which most health care professionals and providers are not aware. These Include:

– Termination for cause from all state Medicaid Programs.

– Loss of state professional licenses in other states and jurisdictions.

– Loss of hospital, ambulatory surgical center (ASC), and nursing home clinical privileges.

– Removal from the provider panels of health insurers.

– Loss of ability to contract or work for any individual or entity that contracts with the Medicare Program in any capacity. This includes physicians, medical groups, hospitals, healthcare systems, ambulatory surgical centers, skilled nursing facilities, health insurance companies, etc.

– Placement on the General Services Administration (GSA) Exclusions List (or “Debarred” List) from government contracting.

– Loss of ability to contract or work for any individual or entity that contracts with the federal government in any capacity.

To learn more on the consequences of being excluded, click here.

You’re On the List, Now What?

So, you just found yourself on a state’s excluded or terminated list or on the federal LEIE, don’t panic! All is not lost. There are ways to become reinstated.

The OIG exclusion list is a complicated regulatory program which requires experience and perseverance to navigate. It is highly recommended that you do not attempt to handle removal without qualified assistance. If your application is denied, even for hyper-technical reasons, you may be barred from reapplying for one full calendar year. Therefore, it is crucial that your application is complete and correct, and you are fully eligible for removal. To read a past blog about reinstatement after OIG removal, click here.

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

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

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

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

KeyWords:  Office of Inspector General, OIG, OIG exclusion list, OIG reinstatement representation, representation for physicians, representation for physician reimbursement, licensure defense attorney, professional license representation, licensure defense representation, representation for health care professionals, investigations analyst, applying for reinstatement, application for reinstatement, Medicare exclusion attorney, OIG hearing, request for reinstatement, removal from list of excluded individuals and entities (LEIE), application to OIG, Medicare reinstatement representation, Medicaid reinstatement representation, healthcare fraud lawyers, Medicare defense attorney, Medicaid defense lawyer, Florida defense attorney, Florida defense lawyer, The Health Law Firm reviews, health law blog, OIG Exclusion, healthcare fraud,

“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.

OIG Exclusion: What You Need to Know if You’re on the List

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

Have you ever had disciplinary action against your license as a health care professional? Have you ever been arrested or convicted of a criminal offense? Have you ever been convicted of fraud or patient neglect? If so, then you may have also been terminated or excluded from the federal Medicare Program or your state Medicaid Program.

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

Check the List.

To check if you are on the federal government’s List of Excluded Individuals and Entities (LEIE), click here.

To see if you are on Florida’s list of individuals and entities who have been terminated from Florida’s Medicaid Program, click here.

Collateral Consequences to OIG Exclusion or Termination.

Termination or exclusion can have many collateral consequences about which most health care providers are not aware. These Include:

– Termination for cause from all state Medicaid Programs.

– Loss of state professional licenses in other states and jurisdictions.

– Loss of hospital, ambulatory surgical center (ASC), and nursing home clinical privileges.

– Removal from the provider panels of health insurers.

– Loss of ability to contract or work for any individual or entity that contracts with the Medicare Program in any capacity (officer agent, shareholder, director, employee or independent contractor, even for non-Medicare products and services such as office supplies, building and construction services, software and systems support, etc.), including physicians, medical groups, hospitals, healthcare systems, ambulatory surgical centers, skilled nursing facilities, health insurance companies, etc.

– Placement on the General Services Administration (GSA) Exclusions List (or “Debarred” List) from government contracting.

– Loss of ability to contract or work for any individual or entity that contracts with the federal government in any capacity (officer agent, shareholder, director, employee or independent contractor, even for such services as construction projects, janitorial contracts, computer equipment and software services, real estate brokers on federally underwritten housing loans, sales of motor vehicles, products and services to the government, etc.

To learn more on the consequences of being excluded, click here.

You’re on the List, Now What?

If you find yourself on a state’s excluded or terminated list or if you find yourself on the federal LEIE, all is not lost. There are ways to become reinstated.

The OIG exclusion list is a complicated regulatory program which requires experience and perseverance to navigate. It is highly recommended that you do not attempt to handle removal without qualified assistance. If your application is denied, even for hyper-technical reasons, you may be barred from reapplying for one full calendar year. Therefore, it is crucial that your application is complete and correct, and you are fully eligible for removal. To read a past blog about reinstatement after OIG removal, click here.

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

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

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

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

KeyWords: Exclusion list, Office of Inspector General, OIG, OIG exclusion list, OIG reinstatement representation, representation for physicians, representation for physician reimbursement, licensure defense attorney, professional license representation, licensure defense representation, representation for health care professionals, investigations analyst, applying for reinstatement, Application for Reinstatement, Medicare Exclusion attorney, OIG Hearing, Request for Reinstatement, Removal from List of Excluded Individuals and Entities (LEIE), Application to OIG, Medicare Reinstatement representation, Medicaid Reinstatement representation, healthcare fraud lawyes, Medicare defense attorney, Medicaid defense lawyer, Florida defense attorney, Florida defense lawyer, The Health Law Firm reviews

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

New Update to the Medicare Program Integrity Manual Issued by CMS

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

On June 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued further guidance for reporting and reviewing final adverse legal actions (ALAs) in provider enrollment applications. Section 15.5.3 of the Medicare Program Integrity Manual (MPIM) was updated through Transmittal 797 to provide more guidance on the types of final adverse actions that must be disclosed. It also provides additional instruction to Medicare Administrative Contractors (MACs) on how to process disclosed final adverse actions.

New Language Basics.

The update in Section 15.5.3 of the MPIM clarifies the scope of disclosure, the time frames for disclosure and the evidence needed to support a disclosure.

Per the 2018 update, the list of reportable adverse actions includes: felony and misdemeanor convictions within the last 10 years; current or past suspensions/revocations of a medical license or an accreditation; current or past suspensions or exclusions imposed by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG); current or past debarments for participation in any Federal Executive Branch procurement or non-procurement program; Medicaid exclusions, revocations, or terminations; and current or past federal sanctions of any type.

New Guidance for MACs.

The second part of the update to the Manual provides additional guidance concerning how MACs will review applications and process the disclosure of final adverse actions. The update also covers how MACs should handle both reported and unreported adverse actions. MACs are now required to use either the Provider Enrollment, Chain and Ownership System (PECOS) or the System for Award Management (SAM) to research whether individuals with ownership interest of the applicant entity are excluded.

To view all the language in Transmittal 797, which outlines the updated Section 15.5.3, click here.

For more information, visit CMS’ website.

Click here to view another recent update issued by CMS.

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, skilled nursing facilities (SNF’s) durable medical equipment (DME) suppliers, medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other healthcare provider. We represent facilities, individuals, groups and institutions in contracts, sales, mergers and acquisitions.

The lawyers of The Health Law Firm are experienced in both formal and informal administrative
hearings at both the state and the federal level. We represent health providers in Medicare and Medicaid audits and disputes on a routine basis.

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

Sources:

King & Spalding. “CMS Updates Rules for Reporting Adverse Legal Action.” JD Supra. (August 25, 2018). Web.

Dhillion, Megan. “Update to the Medicare Program Integrity Manual: New Requirements Related to Disclosing and Processing Final Adverse Actions.” AHLA. (August 24, 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: Centers for Medicare & Medicaid Services (CMS) representation, CMS defense attorney, representation for medicare issues, representation for Medicaid issues, Medicare defense lawyer, Medicaid defense lawyer, Medicare audit defense attorney, Medicaid audit defense attorney, CMS investigation representation, CMS defense representation, health care fraud representation, healthcare professional representation, representation for physicians, representation for physician reimbursement, professional license defense attorney, medical license defense attorney, professional license representation, licensure defense representation, representation for health care professionals, The Health Law Firm reviews, reviews of The Health Law Firm attorneys, Florida health law defense lawyer, AHCA audit defense lawyer, ZPIC audit defense attorney, RAC audit defense lawyer, Trust Solutions audit defense attorney, First Coast Service Options audit defense attorney, SafeGuard Services audit defense lawyer, Cahaba Safeguard Administrators audit defense lawyer, Noridian NCI audit defense attorney, Health Integrity audit 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 © 2018 The Health Law Firm. All rights reserved.

 

Speech Therapist Arrested for Billing Medicaid $500,000 for Work at Florida Day Care Centers While Living in Illinois

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

A speech therapist was arrested on March 29, 2013, for allegedly billing Medicaid more than $500,000 for services that she did not provide, according to the Florida Office of the Attorney General (AG). The speech therapist now faces charges of Medicaid fraud and grand larceny.

Click here to read the press release from the AG.

Billed Medicaid for Services Provided in Florida, While Living in Illinois.

According to an article in The Palm Beach Post, authorities began investigating the speech therapist when they received a tip that she was overbilling for services provided. During the investigation it was found that while the speech therapist reported to Medicaid she lived in Florida, she has been allegedly living in Illinois for the past eight years. The speech therapist allegedly employed two unlicensed speech therapists to work for her in two Florida day care centers. From January 2008 until February 2013, the speech therapist billed Medicaid for services she allegedly did not administer.

To read the entire article from The Palm Beach Post, click here.

Speech Therapist Faces Restitution and Prison Time.

The Florida AG’s Medicaid Fraud Control Unit (MFCU) and the West Palm Beach Police Department made the arrest. If convicted, the speech therapist faces up to $20,000 in fines, 60 years in prison and restitution.

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

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

Faced with an Medicaid Audit? Contact Health Law Attorneys Experienced in Handling Medicaid Audits.

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Healthcare 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, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

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

Comments?

How did the speech therapist get away with this for so long? What are your thoughts on this story? Please leave any thoughtful comments below.

Sources:

Seltzer, Alexandra. “Authorities: Woman billed Medicaid $500,000 for working at West Palm Beach day care centers while in Illinois.” The Palm Beach Post. (March 28, 2013). From: http://www.palmbeachpost.com/news/news/crime-law/authorities-she-billed-medicaid-500k-for-working-a/nW6ht/

Meale, Jenn. “Medicaid Fraud Control Unit Arrests Speech Therapist for $500,000 of Medicaid Fraud.” Florida Office of the Attorney General. (March 29, 2013). From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/AE5D612364AD29C285257B3D004BE6B5

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

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

CMS in the Hot Seat for Lax Oversight of Medicaid Managed Care Organizations

LLA Headshot smBy Lenis L. Archer, J.D., M.P.H., The Health Law Firm

For years, each state has kept an eye on its own Medicaid managed care plans, while the Centers for Medicare and Medicaid Services (CMS) is required to monitor how well each individual state is doing. However, a recent Government Accountability Office (GAO) report claims CMS is sleeping on the job. The report, released on June 20, 2014, stresses the need for more federal oversight of these plans.

With the implementation of the Affordable Care Act (ACA), the Medicaid program is expected to expand significantly. Most of the new beneficiaries enrolled in managed care are covered almost entirely by federal funds. The need for federal oversight in this area is of growing importance to ensure accountability of taxpayers’ dollars.

To read the entire report from the GAO, click here.

Report Findings: MCOs Need to be Watched by the Feds.

The persistent theme of the GAO report is that CMS and the Department of Health and Human Services (HHS) have done little to control the integrity of managed care organizations (MCOs). Federal programs have delegated managed care supervision to each individual state, but fail to provide needed guidelines and resources. CMS has not updated its MCO program guidance since 2000.

The report found neither state nor federal programs are well positioned to identify improper payments made to MCOs. Further, these programs are unable to ensure that MCOs are taking appropriate actions to identify, prevent or discourage improper payments.

For example, the report looked at state program integrity (PI) units and Medicaid Fraud Control Units (MFCU) from seven states. These anti-fraud groups admitted to primarily focusing their efforts on Medicaid fee-for-service claims. Meanwhile, claims made to MCOs have flown under their radar.

GAO Recommendations.

The GAO recommends that CMS:

– Require states to conduct audits of payments to and by MCOs;

– Update its managed care guidance program integrity practices and effective handling of MCO recoveries; and

– Provide states with additional support in overseeing MCO program integrity.

The GAO also suggests that CMS increase its oversight, especially as states expand their Medicaid programs. The GAO report recommends CMS take a bigger role in holding states accountable to ensure adequate program integrity efforts in the Medicaid managed care program. If CMS does not step up to the plate, the report predicts a growing number of federal Medicaid dollars will become vulnerable to improper payments.

The Future of MCOs.

If this report is taken seriously, be assured that audits of MCOs will become more frequent and extensive. If CMS ramps up their efforts, claims could be reviewed in detail by Medicaid integrity contractors. Now is the time to verify you are in compliance and receiving proper payments; before CMS turns the magnifying glass on you or your facility .

Comments?

What do you think of the GAO’s assessment of MCOs? Do you think CMS needs to step up and provide more oversight? Please leave any thoughtful comments below.

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, and the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS). Other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies often participate. Don’t wait until it’s too late. If you are concerned about 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:

Mullaney, Tim. “Federal Government Needs to Boost Medicaid Managed Care Oversight, GAO Says.” McKnight’s Long-Term Care & Assisted Living. (June 20, 2014). From: http://www.mcknights.com/federal-government-needs-to-boost-medicaid-managed-care-oversight-gao-says/article/356779/

Adamopoulos, Helen. “GAI Calls on CMS to Increase Medicaid Managed Care Oversight.” Becker’s Hospital Review. (June 20, 2014). From: http://www.beckershospitalreview.com/finance/gao-calls-on-cms-to-increase-medicaid-managed-care-oversight.html

Bergal, Jenni. “Advocates Urge More Government Oversight of Medicaid Managed Care.” Kaiser Health News. (July 5, 2013). From: http://www.kaiserhealthnews.org/stories/2013/july/05/medicaid-managed-care-states-quality.aspx?referrer=search

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

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
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