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Update All of Your Addresses with Medicare Immediately!

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

Have You Checked Your Addresses on File with CMS/Medicare Recently?

Do you remember the last time you checked all four of the addresses you should have on file for any individual or any group/company Medicare number you may have? The consequences of not updating these addresses can be severe. In addition to your mailing (or correspondence address), and your billing address, you also should have a physical address that is complete, accurate and timely. The telephone number for that physical address should also be in the system. You must ensure that not only is the street address accurate, but also that any suite, office or apartment number on it is accurate. Check the zip code, too, just to be certain you did not transpose digits when you entered it.

Auditors, surveyors, inspectors and investigators are often sent out by Medicare and its contractors, including the Medicare Administrative Contractors (or “MACs”) and the Zone Program Integrity Contractors (or “ZPICs”), to the physical address on file. This is done as a fraud prevention tool to make sure that medical practices, durable medical equipment companies (DMEs), home health agencies (HHAs), and other businesses that receive payments from Medicare are legitimate and are actually operating.

Termination of Medicare Billing Privileges Often Results From Incorrect Addresses.

Site inspections and audits are also conducted by sending auditors on short notice or no notice to the physical address on file. If your physical address is incomplete (e.g., no suite number) or wrong (e.g., incorrect street address) or is not up to date (e.g., you moved and forgot to update it), the consequences could be severe. What we have seen most often recently is an action that terminates the Medicare billing privileges. The provider then is not allowed to reapply for a period of two (2) years from the date of termination.

Update All of Your Addresses with Medicare Immediately.

I urge you to personally and immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information to check it. If your address is incorrect or incomplete, immediately submit a correction or have your administrator practice manager do this.

If anything is incorrect, including an incorrect or incomplete name for your medical group, corporation or business, immediately have this corrected, as well. Everything should be consistent, and all of your state licenses and corporation/company information on file with your Secretary of State should also contain the same information, as well.

What to Do if You Receive a Notice of Termination of Your Medicare Provider Number.

Have you received a notice of termination of your Medicare provider number? Medicare has been revoking the Medicare billing privileges of many different Medicare providers including physicians, medical groups, home health agencies (HHAs), pharmacies, and durable medical equipment (DME) providers, based on returned mail sent to old addresses which have not been updated or based on inspection team site visits to old, incorrect addresses.

Often the termination is retroactive to an earlier date when the change or move may have been determined to have occurred. Even if the mailing address is correct or was changed, the physical address of the business must have been updated, as well. It is usually an incorrect or old physical address which causes this to occur.

The effect of this termination includes:

1. You are prohibited from reapplying to Medicare for at least two (2) years.

2. You may have to pay back any monies received from the Medicare Program since the effective date of the termination (often many months prior to the notification letter).

3. Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPIC) and the state Medicare Fraud Control Unit (MFCU).

4. You may no longer contract with Medicare or anyone who does.

5. You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.

6. You may and probably will be terminated from skilled nursing facilities (SNFs) and home health agencies (HHAs) with which you have contracts.

7. You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs) where you have them.

What you should not do includes:

1. Don’t bother to write letters or start e-mailing anyone, including CMS or the Medicare Administrative Contractor (or MAC) (previously called the “carrier” or “fiscal intermediary”).

2. Don’t bother to call the Centers for Medicare & Medicaid Services (CMS) or the MAC.

3. Don’t bother to file a new CMS Form 855 (application) or a CMS Form 855C (change).

4. Don’t bother to start communicating with CMS or the MAC about your situation and what you need to do about it.

5. Don’t bother to complete and file the short, one-page Corrective Action Plan (CAP) form that is on the CMS or Carrier/MAC website (unless you are close to the deadline and don’t have representation; then you must.)

What we recommend is:

1. Immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information. Then update or correct any incorrect information on you or your company, if you can. Print out the information as it existed before and print out the information after you have corrected it. (Note: Medicare will act shortly after the letter to you to terminate your access to this, so it may be too late).

2. Hire an experienced health attorney immediately to assist you in putting together and submitting a comprehensive Corrective Action Plan (CAP), a Request for Reconsideration (RFR) and a request for an Appeal Hearing.

3. Note that there is a thirty (30) day deadline for submitting the CAP and a sixty (60) day deadline for requesting an appeal hearing. Do not miss these.

4. Implement formal, written internal policies and procedures to prevent a recurrence of the type of error, oversight or event that caused the termination. Train your management and staff on these.

The CAP should address every element of the applicable conditions of participation (COP) contained in the Code of Federal Regulations (CFR). It should include and be supported by all relevant documents, including but not limited to:

1. Documents showing how the error occurred or past efforts to comply.

2. Surety bond guarantees and documents (where required).

3. Insurance coverage documents showing current coverage (general liability, professional liability, vehicle/auto liability).

4. Current licenses and permits.

5. Certificates of good standing and latest annual reports for any corporation or limited liability company.

6. Print-outs from PECOS/NPPES Registry discussed above.

7. Accident reports, insurance claims, police reports, fire reports or other documentation showing why a relocation was required (if this was an issue).

8. Certificates of compliance training for you and your staff, if available.

9. Copies of policies and procedures that you have adopted to keep there from being a recurrence of the situation that led to the termination.

10. An authorization form for your consultant or attorney to represent you in the matter.

All copies should be clear, legible, complete, straight, no corners cut off and no handwriting on them, to the greatest extent possible.

Organize, Label and Index Professionally.

Everything should be professionally assembled, typed, indexed and labeled. It should include a table of contents or an index. Number every page. It should be submitted to the MAC (or the agency/address given in the termination letter) by two (2) reliable means that document both sending and receipt. Keep copies of everything, including postal receipts, airbills, Federal Express labels, courier receipts, etc. It must be received at the address given in the termination letter you received (usually MAC) by the deadline given above. Keep copies of online tracking reports and return receipts.

In most instances, should you show a legitimate reason for the error, show you are currently in compliance, and show what remedial measures you have taken to keep there from being a repeat, the MAC will accept your corrective action plan (CAP) and will reinstate your Medicare number, as things stand currently.

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

The lawyers of The Health Law Firm routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicare and Medicaid investigations, audits and recovery actions. They also represent them in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge. Attorneys of The Health Law Firm represent health providers in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.

Call now at (407) 331-6620 or (850) 439-1001 or visit our website www.TheHealthLawFirm.com.

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.

Disclaimer: Please note this article is for general education and information purposes only and does not constitute legal advice or solicitation for clients. Our opinions stated herein are just that, our opinion.

By The Health Law Firm|2024-03-14T10:00:30-04:00June 1, 2018|Categories: Medicare, The Health Law Firm Blog|Tags: administrative law judge(ALJ), Centers for Medicare & Medicaid Services (CMS), clinic, corrective action plan (CAP), durable medical equipment (DME) suppliers, fraud prevention, home health agencies, investigators, Medicaid Fraud Control Unit (MFCU), medical groups, medical practices, medicare, Medicare Administrative Contractors (MAC), Medicare administrative hearing, Medicare audits, Medicare number revocation, Medicare Provider Enrollment Chain and Ownership System (PECOS), Medicare site visits, Medicare termination, National Plan & Provider Enumeration System (NPPES), NPI Registry, nursing homes and other healthcare providers, OIG special agents, pharmacies, physicians, request for reconsideration, termination of Medicare billing privileges, Zone Program Integrity Contractors (ZPIC), zpic audit, ZPIC site visit|2 Comments

Federal Jury Convicts South Florida Doctors of Medicare Fraud

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

Two South Florida doctors, one Miami-area therapist, and two other individuals were convicted by a federal jury for their participation in a Medicare fraud scheme. The scheme allegedly involved more than $205 million in fraudulent billings by American Therapeutic Corporation (ATC), a corporation which provided mental health care services. The jury reached a decision on June 1, 2012. To see the Department of Justice press release, click here.

The two doctors and the therapist were each found guilty of one count of conspiracy to commit health care fraud. The other two individuals were each found guilty of one count of health care kickbacks. Sentencing has not yet been scheduled. The maximum penalty for each conspiracy count and each count of health care fraud is ten years in prison plus a fine. The maximum penalty for each count of health care kickbacks is five years in prison plus a fine.

Doctors, Therapist, and Others Allegedly Created False Documents for Medicare Reimbursements.

One of the federal indictments charged more than 14 separate defendants with criminal violations. To see this indictment click here.

Allegedly, ATC billed Medicare for hundreds of millions of dollars in services, for thousands of patients who were not qualified. The charges alleged fraudulent documents were created by the doctors and others associated with ATC. The doctors allegedly would sign patient documents without having seen or treated the patients.

ATC operated partial hospitalization programs (PHPs) throughout Florida and would allegedly bill Medicare for PHP treatments for patients in the names of the doctors. Included in these submissions to Medicare were claims for patients who were allegedly ineligible for PHP treatments. ATC allegedly did not provide legitimate PHP treatment, but illegally changed patient medical records to justify claims that were submitted.

ATC Executive Sentenced to 50 Years in Prison.

Since ATC was shut down nearly two years ago, 35 defendants have faced charges relating to the alleged fraud scheme. The majority of the defendants have pleaded guilty. Last year a third doctor pleaded guilty, accepting responsibility for more than $19 million of false claims submitted by the clinics.

Four ATC executives were sentenced to 50 years, 35 years, 35 years, and 91 months in prison, respectively, for their roles in the fraud scheme.

Contact Health Law Attorneys Experienced in Handling Medicare and Medicaid Fraud Cases.

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 Medicare and Medicaid investigations, audits and recovery actions. They also represent them in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge.

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

Sources Include:

U.S. Department of Justice, Office of Public Affairs. “Doctors, Therapist, and Recruiters from Miami-Area Mental Health Care Corporation Convicted for Participating in $205 Million Medicare Fraud Scheme.” FBI. (June 01, 2012). Press Release. From:
http://www.fbi.gov/miami/press-releases/2012/doctors-therapist-and-recruiters-from-miami-area-mental-health-care-corporation-convicted-for-participating-in-205-million-medicare-fraud-scheme

Weaver, Jay. “Two South Florida Doctors, 3 Others Convicted on Medicare Fraud Charge.” Miami Herald. (June 01, 2012). From
http://www.miamiherald.com/2012/06/01/2827660/miami-medicare-fraud-jurors-tell.html#storylink=misearch/

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.

$24 Million Medicaid Fraud Scheme Alleged by Connecticut Attorney General

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

Connecticut’s Attorney General, George Jepsen, alleges that 28 individuals, dental practices and corporations were involved in a $24 million Medicaid fraud scheme. He filed a civil action on May 31, 2012. It is the first case the state has initiated under the Connecticut False Claims Act. The Connecticut False Claims Act gives the state the ability to seek compensation for taxpayers from those who submit false claims for reimbursements they are not eligible to receive. To view the Connecticut False Claims Act, click here.

The complaint seeks restitution, treble damages and civil penalties as well as a permanent injunction against the unlawful acts and practices alleged in the complaint. To view the complaint, click here.

Accused Individual Allegedly Found Ways to Bill Medicaid for Services, Despite Being Excluded from Medicare and Medicaid Programs.

According to the complaint, one of the individuals involved in the alleged fraud scheme was previously convicted of a felony in another state for submitting false health care claims. He was then permanently excluded by the U.S. Department of Health and Human Services (DHHS) from participation in Medicare and Medicaid, as a result of his conviction. Any entity with which he serves as an employee, administrator, operator or in any other capacity, were also excluded from state healthcare programs.

The state alleges that, despite the exclusion, he established a number of dental practices in Connecticut that were operated by practicing dentists who billed Medicaid for services.

Allegedly, the excluded individual was actively involved in managing the practices and received millions of dollars in Medicaid reimbursements. The dental providers allegedly knew of the exclusion and did not disclose it on enrollment and re-enrollment forms for the Connecticut Medical Assistance Program.

Florida Has Similar False Claims Act.

Florida has a Medicaid False Claims Act similar to the one that Connecticut has. Florida’s Medicaid False Claims Act can be found here. However, in Florida, a separate provision of the state’s Medicaid law provides an award to a whistle-blower of up to 25% of any recovery. This is in Section 409.9203, Florida Statutes. In addition, Florida has a law that allows civil recovery for criminal acts such as Medicaid fraud, which is sometimes used by the Florida Attorney General and private individuals to recover money lost as a result of certain criminal conduct. For the Florida Civil Remedies for Criminal Actions law, click here.

As a general rule state false claims acts are modeled after the federal False Claims Act used to pursue Medicare fraud. For the federal Medicare Fraud False Claims Act, 31 U.S.C. § 3729, click here.

Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Fraud Cases.

The Health Law Firm’s attorneys routinely represent physicians, dentists, nurses, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits, hearings and recovery actions. In addition The Health Law Firm represents health providers in Medicare exclusion actions and in being reinstated to the Medicare Program or being removed from the exclusion list.

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

Sources:

Rees, Nick. “Jepsen alleges $24M Medicaid fraud.” Legal Newsline. (June 4, 2012). From: http://www.legalnewsline.com/news/contentview.asp?c=236342

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.

By The Health Law Firm|2024-03-14T10:00:31-04:00June 1, 2018|Categories: Medicaid, The Health Law Firm Blog|Tags: Centers for Medicare & Medicaid Services (CMS), civil recovery for criminal actions, dental practice, dental services, dentist, dentist Medicaid fraud, Department of Health and Human Services, false claims act defense, fraud prevention, legal defense, medicaid, Medicaid exclusion, Medicaid fraud, Medicaid fraud defense attorney, medical groups, medical practices, medicare, Medicare defense attorneys and lawyers, Medicare exclusion, Medicare fraud, nurse, nursing, OIG exclusion, permanent exclusion, physicians, qui tam, state healthcare programs, whistle-blower|Comments Off

Industry Trend: Hospital Systems Merging and Acquiring Private Practices All Over the Country

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

There’s a structural shift that is sweeping the health care system – hospitals are acquiring private physician practices. It is happening all over the U.S., including right here in Central Florida. On December 31, 2012, Orlando Health – a nonprofit, multi-hospital system that owns Orlando Regional Medical Center and eight other hospitals – will allegedly merge with Physician Associates – Central Florida’s largest medical practice, according to the Orlando Sentinel. The alleged price tag on this sale is $50 million, with each of the group’s 95 physicians receiving about $500,000 a piece.

Critics Believe the Merger will Hurt Patients.

Orlando Health maintains the goal of the merger is to move toward a new payment model and reduce health care costs, but critics interviewed in the Orlando Sentinel article disagree.

The trend around the country is that after a merger patients will see a facility fee tacked onto a doctor’s fee, even if patients go to the same doctor’s office. Critics also believe providers will feel obligated, or will be required, to only refer patients to the hospital that employs them. Another fear is job loss, as hospitals take over office management.

To read the article from the Orlando Sentinel, click here.

An Investigation into Acquisitions.

In August 2012, the Wall Street Journal took a closer look at what happens after an acquisition of a private practice by a hospital system.

The article stated as physicians are absorbed into hospital systems, they can get paid for services at the hospital systems’ rates, which are typically higher than what insurers pay to independent doctors. Some services that physicians previously performed at their facilities may start to be billed as hospital outpatient procedures, this can double or triple the cost.

Medicare pays more for certain services if they are performed at hospital facilities. According to the Wall Street Journal, if a hospital system transforms a private clinic to become an outpatient facility or moves services onto a hospital site, the hospital’s Medicare reimbursement rates will increase.

To read the entire Wall Street Journal article, click here.

Physician Associates Writes Letter to Patients.

On November 15, 2012, the Physician Associates Chairman of the Board of Directors posted a letter to patients on the practice’s website. The letter assures patients nothing about the service they receive will change. The letter says the sale is about patients receiving the best possible care in a new, fast-paced health care environment. In response to the sale price, the chairman said a large component of the purchase price reflects the sale of all of the Physician Associates’ assets to Orlando Health, along with an agreement to provide future employment.

Click here to read the entire letter.

Contact Health Law Attorneys Experienced in Business Transactions and Contracts.
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, Durable Medical Equipment suppliers, medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other health care provider. We represent facilities, individuals, groups and institutions in contracts, sales, mergers and acquisitions.

The services we provide include reviewing and negotiating contracts, business transactions, professional license defense, representation in investigations, credential defense, representation in peer review and clinical privileges hearings, Medicare and Medicaid audits, commercial litigation, and administrative hearings.

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

Comments?

What do you think of the merger between Physician Associates and Orlando Health? Who do you think it will benefit more, the patients or the doctors? Please leave any thoughtful comments below.

Sources:

Jameson, Marni. “$50M sale of Physician Associates Signals Major Shift in Orlando Health Care.” Orlando Sentinel. (November 13, 2012). From: http://articles.orlandosentinel.com/2012-11-13/news/os-physician-associates-orlando-health-20121109_1_orlando-health-health-care-physicians

Wilde Matthews, Anna. “Same Doctor Visit, Double the Cost.” Wall Street Journal. (August 27, 2012). From: http://online.wsj.com/article/SB10000872396390443713704577601113671007448.html

Walker, M.D., Erik. “Letter to Our Patients Regarding Potential Orlando Health Merger.” Physician Associates. (November 15, 2012). From: http://www.paof.com/news/2012/11/letter-our-patients-regarding-potential-orlando-health-merger

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.

By The Health Law Firm|2024-03-14T10:00:40-04:00June 1, 2018|Categories: In the Know, In the News, Physician Contracts, The Health Law Firm Blog|Tags: business transactions, closing attorney, contract attorney, contract lawyer, Florida health care attorney, Florida health care lawyer, hospital acquisitions, medical groups, merger legal counsel, Orlando Health, Physician Associates, physician contract attorney, physician contract lawyer, private practice mergers, reviewing and negotiating contracts, sale of practice|Comments Off

Hospitals Allegedly Enforcing Questionable Practices to Increase Bottom Line

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

Doctors and hospitals around the country seem to be butting heads. In the past month, an article in The New York Times and a segment on the television “magazine” show 60 Minutes shed light on some questionable practices being enforced by hospitals on physicians working for them.

I previously wrote a blog on this structural shift in the practice of medicine. Click here to read that blog.

The effects of this trend are examined in these two news stories. Doctors and former employees from a number of hospitals around the country were interviewed and all seem to be dealing with the same issues. The biggest concerns addressed were: pressure to order unnecessary tests, admitting patients to fill hospital quotas and drive hospital profits, and the feeling of being controlled by hospital executives and administrators instead of practicing effective medicine.

Doctors Allegedly Pressured to Fill Emergency Room Beds to Increase Profits.

On December 2, 2012, 60 Minutes aired an investigative segment on one of the largest for-profit hospital chains in the country. Former employees and physicians alleged this hospital system thrived by buying urban-area hospitals and turning them into profit centers by filing empty beds from emergency rooms. A former emergency medicine doctor stated that the hospital in which he worked required an admission rate of twenty percent (20%) for patients seen in the ER and fifty percent (50%) for patients who were 65 years old and older (most of whom are Medicare patients) seen in the ER.

A former hospital system employee interviewed by 60 Minutes claimed he was in charge of auditing the hospital chain in question. He stated that he was convinced that doctors were under an extraordinary amount of pressure to fill hospital beds. He stated that he personally audited hospitals in Texas, Florida and Oklahoma, and concluded there were hundreds of thousands of dollars submitted to Medicare and Medicaid for hospital stays that did not meet standards for reimbursement, including medical necessity.

Doctors interviewed for The New York Times article had similar stories. They stated in interviews that hospital administrators created quotas for how many patients should be admitted, because more admissions allegedly meant more money. Doctors who met or exceeded quotas were rewarded with increased compensation, while doctors who did not felt in danger of losing their jobs.

Click here to read the entire New York times article.

Consequences of Ordering Unnecessary Tests.

The New York Times article looked at a number of lawsuits filed by former employees who allege the hospitals they worked for compensated doctors for ordering more tests than necessary.

The Department of Justice (DOJ) recently settled with a hospital group in Joplin, Missouri. According to the DOJ press release, the hospital system had to pay more than $9.3 million for rewarding doctors partly based on how many tests they ordered. This is in direct violation of the Stark Law and the False Claims Act.

Click here to read the entire press release from the DOJ.

I recently wrote an article for Medical Economics on the legal ramifications of ordering unnecessary tests. To read that article, click here.

If you want to know more on the Stark Law, click here.

Doctors Feel Controlled By Hospital Executives.

Doctors also stated they felt controlled by hospital executives. This was due, in part, to a corporate wide computer software system that was customized to automatically order an extensive battery of tests, some unnecessary, as soon as a patient walked into the hospital. It’s also stated that the software would prompt a physician to reconsider when he or she decided to send an emergency room patient home.

Most doctors interviewed were upset that the program also generated reports that evaluated each doctor’s performance and productivity.

To watch the segment from 60 Minutes, click here.

Hospitals Say They are Embracing the New Model of Health Care.

The hospital system in question by 60 Minutes maintains that these allegations are not correct. The executive vice president said that as a whole admission rates haven’t changed in four years and are near or below industry averages. The hospital systems believe that by consolidating they are embracing the new model of health care and state patient care comes first.

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, Durable Medical Equipment suppliers, medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other health care provider. We represent facilities, individuals, groups and institutions in contracts, sales, mergers and acquisitions.

The services we provide include reviewing and negotiating contracts, business transactions, professional license defense, representation in investigations, credential defense, representation in peer review and clinical privileges hearings, Medicare and Medicaid audits, commercial litigation, and administrative hearings.

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

Comments?

Do you think there are constant battles between doctors and hospitals? As a health professional, have you experienced the pressure to admit patients, order unnecessary tests or refer a patient inside your network? Please leave any thoughtful comments below.

Sources:

Creswell, Julie and Abelson, Reed. “A Hospital War Reflects a Bind of Doctors in the U.S.” The New York Times. (November 30, 2012). From: http://www.nytimes.com/2012/12/01/business/a-hospital-war-reflects-a-tightening-bind-for-doctors-nationwide.html?pagewanted=all

Kroft, Steve. “Hospitals: The Cost of Admission.” 60 Minutes. (December 2, 2012). From: http://www.cbsnews.com/video/watch/?id=50136261n

Department of Justice. “Missouri Hospital System Agrees to Pay $9.3 Million to Resolve False Claims Act and Stark Law Violations.” DOJ. (November 5, 2012). From: http://www.justice.gov/printf/PrintOut3.jsp

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.

By The Health Law Firm|2024-03-14T10:00:42-04:00June 1, 2018|Categories: Health Care Industry, The Health Law Firm Blog|Tags: business transactions, closing attorney, contract attorney, contract lawyer, Department of Justice (DOJ), false claims act, Florida health care attorney, Florida health care lawyer, hospital acquisitions, Medicaid fraud, medical groups, Medicare fraud, merger legal counsel, overbilling, physician contract attorney, physician contract lawyer, private practice mergers, qui tam, reviewing and negotiating contracts, sale of practice, stark law, unnecessary tests, whistleblower|Comments Off

Medicare and Medicaid Audits of Psychologists and Other Mental Health Professionals – Part 2

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

Over the past year I have observed an increasing number of Medicare and Medicaid audits being initiated against psychologists and other mental health professionals.

I have recently seen a number of audits initiated against psychologists and mental health professionals who treat assisted living facility (ALF) and skilled nursing facility (SNF) residents. Most often these are audits by the Medicare Administrative Contractor (MAC), because this area of medical practice has been identified as one fraught with fraud and abuse. Sometimes these are only “probe” audits, initial audits requesting one (1) to five (5) medical records. Other times the MAC has been requesting anywhere from 120 to 375 records.

This blog is party two in my series on Medicare and Medicaid audits initiated against psychologist and other mental health professionals. Click here to see part one.

Areas Being Targeted.

In state Medicaid audits, I have recently seen increased scrutiny in the following areas:

1. Pediatric care

2. Therapy (speech therapy, physical therapy, occupational therapy) especially to pediatric patients and developmentally disabled patients.

3. Small assisted living facilities (ALFs), group homes, homes for the developmentally disabled (DD) and other small facilities.

4. Home health agencies.

5. Pediatric dentistry.

6. Optometry care, especially if delivered in a nursing home or assisted living facility (ALF).

7. Ambulance and medical transportation services, especially of nursing homes.

8. Psychiatric psychological and mental health.

Use of Statistical Sampling and Extrapolation Formulas to Multiply Repayment Amounts.

In both state Medicaid audits and in Medicare audits, I have experience increased reliance by the auditing agency on use of mathematical extrapolation formulas to estimate the amount that should be repaid. The formula used usually takes the overpayment that has actually been found and, based on several factors, multiplies it out to many times the actual overpayment amount. Thus, a found overpayment of $2,800 may become a demand for repayment of $280,000, based on the statistical extrapolation.

Things you should know about this are as follows.

1. Neither the Medicare program nor the state Medicaid programs should use an extrapolation formula, unless:

a. There is a “high” error rate in the claims that have been submitted; or

b. There have been prior educational efforts or prior audits of the provider, and the provider has failed to correct the problems in claims submission previously found.

2. The states each have different guidelines, rules or regulations on when they will apply the statistical formula. Some do not use it. Some use a higher percentage error rate to prompt use of the formula and some lower. North Carolina is one of the lowest we have encountered; an error rate of more than five percent (5%) will prompt its Medicaid agency to apply the statistical extrapolation to the recovery amount.

Problems Psychologists and Mental Health Professionals May Encounter Producing Records for Audits.

Many psychologists, therapists and health professionals are being audited because they are treating patients in a nursing facility or assisted living facility.

In most cases, a history, physical, comprehensive assessment, physician orders, diagnosis, medication list, medication administration records, consultations, social service notes and other medial documents being relied upon by the therapist are reviewed and assessed in connection with treatment of the patient. The big problem here is that these usually stay in the facility. When an audit occurs, these may not all be available.

The biggest issue that Medicare and Medicaid seem to be targeting is lack of documented “medical necessity.” The auditors take the position that the audited therapist must produce copies of the documents listed above, in part, to show “medical necessity” for the services provided.

Additionally, most physicians who treat patients in nursing facilities place their own assessments, plans and notes into the facility’s chart and do not retain a copy themselves. When the audit comes, they may not be able to produce copies of their own notes and evaluations.

I recommend that any provider treating residents of nursing homes and assisted living facilties (ALFs):

1. Review the local coverage decision (LCD) applicable to the code(s) you bill so you know what requirements must be met and what documentation is required.

2. Review the Medicaid provider handbook or state regulations for the services you provide if you are a Medicaid provider.

3. Obtain and keep copies of all applicable histories, physicals, care plans, physician orders, physician consults, etc. This is best done by obtaining and using a portable scanner. You can then keep the copies electronically in a properly secured, protected server in your office (backed-up, off site, of course).

4. Sign all of your evaluations, prepare your reports, evaluations progress notes and consultations on your laptop or other computer and sign it electronically before you print it out. Alternatively, if you still use paper, scan the paper copy (after signed) and maintain it electronically.

5. Do not use unusual or non-standard terms and abbreviations. If you do, you must keep an “abbreviations and definitions” list and produce it with your records in any audit response.

6. In your reports, evaluations and notes, use the terminology from the LCD and Medicaid provider handbook. Also, always include the start time, stop time and total time spent with any resident in your report, evaluation and notes.

7. Be sure the patient, patient’s next of kin/surrogate, patient’s physician or nursing home administrator signs off as having received the services each time. The patient’s signature is preferred.

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.

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.

By The Health Law Firm|2024-03-14T10:01:49-04:00May 15, 2018|Categories: Medicaid audit, Medicare Audit, Medicare Fraud, Mental Health Counselor, Mental Health Counselor Law, Psychology|Tags: assisted living facility (ALF), fraud prevention, mac, medicaid, Medicaid Audits, Medicaid fraud, medical groups, medical practices, medicare, Medicare Administrative Contractor, Medicare audits, Medicare fraud, mental health professionals, physicians, psychiatrists, psychologists, review contractors, Skilled Nursing Facility (SNF), Zone Program Integrity Contracts, zpic, zpic audit|Comments Off

Jury Convicts Doctor and Medical Billing Company Owner for $28 Million Medicare Fraud Scheme

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

On May 1, 2017, a federal jury in Michigan found a Detroit-area doctor and owner of a medical billing company guilty of perpetrating a $28 million health care fraud scheme. The scheme involved billing Medicare for pain treatments that weren’t actually provided, the U.S. Department of Justice (DOJ) said.

Health Care Fraud Scheme.

Dr. Johnny Trotter and Elaine Lovett were both convicted after a four-week jury trial on one count of conspiracy to commit health care and wire fraud and three counts of health care fraud. In addition to the fraud scheme, both Trotter and Lovett also worked to dodge Medicare’s investigation into Trotter, according to the DOJ.

Evidence at the trial showed that between May 2008 and May 2014, both Trotter and Lovett fraudulently billed for services that were never provided. These services were predominantly nerve block injections, which treat pain by numbing groups of nerves.

In 2009, Medicare grew suspicious and began to require that claims submitted by Trotter satisfy a medical review prior to payment pre-payment review). As a result, both Trotter and Lovett conspired to dodge this investigation by starting fake medical centers, according to the prosecution said.

Trotter and Lovett attempted to hide their involvement by recruiting family members and employees to serve as “straw owners” of the companies. Meanwhile, the two fraudsters continued receiving payment for services that weren’t provided, the government said.

To learn more about health care fraud and the repercussions of Medicare fraud, click here to read one of my prior blogs.

Watch our short video blog on Medicare fraud and the audit process here.

Contact a Health Care Attorney Experienced in the Representation of Medicare and Medicaid Fraud.

The Health Law Firm and its 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 Medicare 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. “Jury Convicts 2 Over $28M Medicare Pain Treatment Fraud.” Law360. (May 1, 2017). Web.

“Jury Convicts 2 Over $28M Medicare Pain Treatment Fraud.” Lexis Nexis. (May 1. 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.

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

By The Health Law Firm|2024-03-14T10:01:25-04:00May 15, 2018|Categories: Health Facilities Law Blog|Tags: 1101 Douglas Ave., 2017, 5 Indest-2008-2By George F. Indest III, a federal jury in Michigan found a Detroit-area doctor and owner of a medical billing company guilty of perpetrating a $28 million health care fraud scheme. The scheme involved billing Medicare for pa, Altamonte Springs, area. www.TheHealthLawFirm.com The Health Law Firm, assisted living facilities (AFLs), both Trotter and Lovett also worked to dodge Medicare’s investigation into Trotter, both Trotter and Lovett conspired to dodge this investigation by starting fake medical centers, both Trotter and Lovett fraudulently billed for services that were never provided. These services were predominantly nerve block injections, click here to read one of my prior blogs. Watch our short video blog on Medicare fraud and the audit process here. Contact a Health Care Attorney Experienced in the Representation of Medicare and Medi, clinics, dentists, FL 32714, florida, group homes and other healthcare providers in Medicare and Medicare investigations, health care fraud defense attorney, home health care agencies, is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, J.D., John. “Jury Convicts 2 Over $28M Medicare Pain Treatment Fraud.” Law360. (May 1, legal representation for allegations of Medicare fraud, legal representation for fraudulent claims, Legal representation for Medicare fraud, legal representation for Medicare fraud investigation, legal representation for Medicare termination, legal representation for submitting false claims, LL.M., M.P.A., medical groups, Medicare audit defense lawyer, Medicare fraud defense attorney, Medicare grew suspicious and began to require that claims submitted by Trotter satisfy a medical review prior to payment pre-payment review). As a result, Medicare overbilling defense attorney, Medicare Strike Force, Medicarelegal representation for Medicare exclusion, nursing homes, OIG exclusion defense attorney, orthodontists, pharmacies, prepayment review attorneys, the health law firm, The Health Law Firm reviews, the two fraudsters continued receiving payment for services that weren’t provided, the U.S. Department of Justice (DOJ) said. Health Care Fraud Scheme. Dr. Johnny Trotter and Elaine Lovett were both convicted after a four-week jury trial on one count of conspiracy to commit health c, which has a national practice. Its main office is in the Orlando|Comments Off

Health Care Fraud Puts Miami Man in Jail

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

4.5 Year Sentence for Role in Fraud.

A Miami Man voluntarily returned to Miami from Cuba and was immediately met with a 4.5-year long prison sentence. Jose Gerardo Gonzalez, played a role in a scheme to defraud public schools and private health care insurers of $126 million.

Gonzalez allegedly created shell companies that submitted false health care claims. The private insurers were ultimately at lose for millions of dollars. Gonzalez fled to Cuba in 2015 after being charged with conspiracy and other charges. Upon voluntary return to Florida he is sentencing was reduced.
William Barzee, Gonzalez’s attorney, states its uncommon for fugitives to return once they flee to Cuba. However, our experience has been just the opposite. In our experience, quite a few individuals flee to Cuba, which has no extradition treaty with the U.S., after being notified of an investigation of Medicaid or Medicare fraud charges.

The Restitution.

The sentence included 4.5 years in prison and restitution of $13.9 million. In addition, two properties owned by Gonzalez worth several hundreds of thousands of dollars were been seized.

Conspiracy lead remains in Cuba.

Reynaldo Castillo is considered the conspiracy’s leader “employing” several people. Gonzalez played a role in a scheme to target employers offering “administrative services only” insurance plans to their employees. Gonzalez, along with several other individuals, registered businesses in his or her name and opened bank accounts and cashed checks bilking insurers. Insurers that sustained losses include Cigna, Blue Cross Blue Shield, and United Healthcare. Gonzalez and 15 other Miami residents were charged. But Reynaldo Castillo is still believed to be in Cuba, avoiding sentencing.

The conspirators submitted false claims to the insurers using medical director staffing companies to misappropriate doctors licensing information. This is something we are constantly warning physicians against, allowing someone else to use and bill under their name and provider identification numbers.

Health Care Fraud Should Not Be Taken Lightly.

We have been consulted by many individuals, both before and after criminal convictions for fraud or related offenses. In many cases, those subject to Medicaid or Medicare fraud audits and investigations refuse to acknowledge the seriousness of the matter. Individuals facing Medicare and Medicaid criminal charges should realize the severity of the offense. Some may even decide not to spend the money required for a highly experienced health attorney as part of the legal team to help defend them.
The government is serious about combating health care fraud. False claims are a growing problem in the program, costing the government billions of dollars each year. Punishments for defrauding the system can be quite severe.

If you are accused of Medicaid or Medicare fraud, realize that you are in a fight for your life. Your liberty, property/possessions and profession are all at stake. Often a Medicaid Fraud investigation will begin with a notification from the investigator. From that point on, all action to obtain legal representation should be made. The investigator will use all information from that point on against you. Be prepared to give up whatever you need to in order to avoid a conviction and preserve your liberty.

To read further about the seriousness of health care fraud you can read additional blogs of mine here.

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

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.

Sources:

Crosby, Christopher. “Miami Man In $126M Health Fraud Ring Gets 4.5 Years – Law360.”Law360 – The Newswire for Business Lawyers. LexisNexis, 13 June 2017. Web. 03 July 2017.

Keywords: Medicare Fraud, Medicaid Fraud, legal representation for fraud, False claims, legal representation, 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, 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 © 2017 The Health Law Firm. All rights reserved.