medicare | The Health Law Firm Blog

Internal Medicine Specialists Should Be Aware of Impending Medicare Audits

Coming to a medical practice near you. . . It’s scary, it’s horrible, and it could cost you a lot of money!

It’s the dreaded Comprehensive Error Rate Testing (CERT) audit.

The Horror! The Horror!

First Coast Service Options, the Medicare contractor for Florida, announced a new prepayment audit program that will impact Internal Medicine Specialists. The prepayment program is focused on Initial and Subsequent Hospital Evaluation and Management Services, CPT Codes 99223 and 99233. The program is being launched due to the high CERT error rate associated with these codes.

The audits will start on October 21, 2014.

What is the CERT Program?

CMS created the CERT program to measure the paid claims error rate for Medicare claims submitted to Medicare administrative contractors, carriers, durable medical equipment regional carriers, and Medicare Administrative Contractors (MACs). CMS receives more than two billion claims annually. The CERT program […]

Walgreens Reaches Settlement in False Claims Act Case

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

Walgreens has reached a $7.9 million settlement with the United States and participating states that resolves allegations that Walgreens violated the False Claims Act. The DOJ announced the settlement on April 20, 2012. To view the DOJ’s press release concerning the settlement with Walgreens, click here. To view the False Claims Act, click here.

Walgreens Allegedly Offered Illegal Inducements to Medicare and Medicaid Beneficiaries.

The settlement was reached after Walgreens was accused of offering illegal inducements to beneficiaries of government health programs (Medicare, Medicaid, the Federal Employees Health Benefits Program (FEHBP), and TRICARE ). Walgreens allegedly offered gift cards to government health program beneficiaries when they transferred a prescription from another pharmacy to Walgreens. The government […]

By The Health Law Firm|2024-03-14T10:00:31-04:00June 1, 2018|Categories: Medicaid, Medicare, The Health Law Firm Blog|Tags: billing, Department of Justice, doctor, DOJ, false claims act, fraud prevention, government health programs, health care fraud, inducements, kickbacks, medicaid, medical practice, medicare, pharmacies, pharmacist, pharmacists, pharmacy, physician, qui tam, TRICARE, walgreens, Walgreens settlement, whistleblower, whistleblower suit|Comments Off

Revised Readmission Penalties are Coming Due to Calculation Errors

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

Back in August of 2012, I wrote that lower Medicare reimbursement rates were coming to more than 2,000 hospitals around the country due to excessive readmission rates. To see that blog, click here.

In October of 2012, the Centers for Medicare and Medicaid Services (CMS) announced it has discovered errors in its initial calculations. This means, 1,422 hospitals with high readmission rates will lose slightly more money than first expected, according to Kaiser Health News.

Click here to read the entire article from Kaiser Health News.

Hiccup in Medicare’s Hospital Readmission Reduction Program.

According to Kaiser Health News, the revisions were relatively small, averaging two-hundredths of a percent of a hospital’s regular Medicare […]

Tips for Responding to a Medicaid Audit

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

Should you find yourself, your facility or your health practice the subject of a Medicaid audit by your state Medicaid agency or audit contractor, there are a few things you should know.

The most important thing is that just because you are being audited, it does not mean that you or your business has done anything wrong. State and federal governments conduct audits for many different reasons. Typical reasons include: special audits of high-fraud geographic areas, auditing of particular billing codes, randomly selected provider auditing, and complaints of possible fraud.

Medicaid Audits in Florida.

The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG) and Bureau of Medicaid Program Integrity are the Florida agencies responsible for routine audits of Medicaid health care providers to ensure […]

Tuomey Healthcare System Ordered to Pay a Reduced $238 Million in Damages for Allegedly Violating Stark Law and False Claims Act

Lance O. Leider, J.D., The Health Law Firm and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On September 30, 2013, a federal judge ordered Tuomey Healthcare System in Sumter, South Carolina, to pay $238 million in penalties and fines. The hospital system is accused of paying doctors to refer Medicare patients for treatments at the hospital, according to a number of media sources. The judge granted the government’s request to impose Stark law penalties and False Claims Act fines. The lawsuit against Tuomey was initially filed in 2005, by a whistle-blowing physician.

This corrected fine actually lowers the amount originally ordered by the federal judge, reducing it by $39 million. The original judgement was for approximately $277 million. The reduction in the damages was an acknowledgment that there was an error […]

By The Health Law Firm|2024-03-14T10:00:52-04:00June 1, 2018|Categories: False Claims Act, The Health Law Firm Blog, Whistleblower|Tags: defense attorney, defense lawyer, doctor referrals, false claims act, Florida defense attorney, Florida defense lawyer, health law lawyer, heath law attorney, illegal doctor referrals, medicare, Medicare false claims, Medicare fraud, Medicare fraud prevention, Medicare patients, paying doctors for referrals, physician self-referral, qui tam, qui tam lawsuits, self-referral, settlement agreement, Stark compliance, Stark compliance issues, stark law, Stark penalties, the health law firm, Tuomey, Tuomey Healthcare System, violation of stark law, whistleblower, whistleblower attorney, whistleblower lawyer, whistleblower protection|Comments Off

CMS Extends Waivers under the ACO Shared Savings Program

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

On November 2, 2011, the Centers for Medicare and Medicaid Services (CMS) promulgated the interim final rule on fraud and abuse waivers for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. The interim rule can be found at 76 Fed. Reg. 67801. The waiver was granted pursuant to the agency’s authority under the Affordable Care Act, specifically, 42 U.S.C. § 1899(f).

You can read our prior blog postings on the ACO waiver programs here.

Normally, interim final rules are only permitted to remain in effect for a maximum of three years (see 69 Fed. Reg. 78422). CMS regulations require the agency to publish a final rule within three years of a proposed or interim final rule. As the […]

By The Health Law Firm|2024-03-14T10:00:58-04:00June 1, 2018|Categories: ACO, Affordable Care Act, The Health Law Firm Blog|Tags: accountable care organization, ACO contract, ACO contracts, ACO financial risk, ACO participation agreement, attorney, Centers for Medicare and Medicaid Services, CMS, counsel, defense attorney, defense lawyer, doctor, health law attorney, health law firm, health lawyer, healthcare business lawyer, lawyer, medicare, Medicare ACO, Medicare Payment Advisory Commission, Medicare Shared Savings Program, Medicare-contracted ACO, MedPAC, MSSP, physician, pioneer ACO, risk model, shared savings program, the health law firm|Comments Off

WellCare Health Plans Reaches Settlement in False Claims Act Case

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

WellCare Health Plans Inc.(WellCare) has reached a $137.5 million settlement with the federal government and nine states. The settlement resolves four lawsuits alleging violations of the False Claims Act.

WellCare is based in Tampa, Florida. The company provides managed health care services for approximately 2.6 million Medicare and Medicaid beneficiaries across the United States.

Lawsuits Allege WellCare Submitted False Claims to Medicare, Medicaid Programs.

The lawsuits allege that WellCare submitted false claims to Medicare and Medicaid programs. WellCare allegedly falsely inflated the amount it claimed to be spending on medical care. Allegedly, this was done in order to avoid returning money to Medicaid and other programs in various states, including the Florida Medicaid program and Florida Healthy Kids program. WellCare also allegedly knowingly retained overpayments it had […]

By The Health Law Firm|2024-03-14T10:00:32-04:00June 1, 2018|Categories: Medicaid, Medicare, The Health Law Firm Blog|Tags: audit, billing, Department of Justice, DOJ, false claims act, Florida Medicaid, fraud defense attorneys, fraud prevention, fraud schemes, government health programs, health care fraud, lawyers, legal representation, managed care, medicaid, medicare, qui tam, realtor, settlement, Wellcare Health Plans, whistleblower|5 Comments

CVS Possibly Under Investigation for Medicare Fraud

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

The Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) has reportedly launched an investigation into CVS’ practice for refilling prescriptions. According to an article in the Los Angeles Times, authorities are looking into reports that CVS has been refilling prescriptions and submitting insurance claims without patients’ permission. The Los Angeles Times article, released October 12, 2012, names an official with knowledge of this matter as the source.

We want to emphasize that this is from an unconfirmed news story. The government rarely announces investigations of specific subjects ahead of time.

Click here to read the entire article from the Los Angeles Times.

CVS Has Not Been Contacted By the […]

Two Separate Lawsuits Against Novartis Pharmaceuticals Corporation Allege Illegal Kickbacks and False Claims

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

Novartis Pharmaceuticals Corporation (NPC) is currently fielding two different lawsuits, filed just days apart from each other, by the U.S. Department of Justice (DOJ). The first lawsuit was filed on April 23, 2013, alleging the company gave illegal kickbacks to pharmacists. A second lawsuit was filed on April 26, 2013, alleging illegal kickbacks were paid by NPC to health care providers. According to the DOJ, the government’s complaint seeks damages and civil penalties under the False Claims Act, and under the common law for paying kickbacks to doctors to induce them to prescribe NPC products that were reimbursed by federal health care programs.

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

NPC Accused of Treating Health Care Professionals to Expensive Dinners, Product Discounts […]

By The Health Law Firm|2024-03-14T10:00:48-04:00June 1, 2018|Categories: Health Care Industry, In the News, Medicare, Medicare Fraud, The Health Law Firm Blog, Whistleblower|Tags: anti-kickback statute, attorney's fees, CHAMPUS, defense attorney, defense lawyer, Department of Justice (DOJ), doctor, doctor kickbacks, false billing, false claims, false claims act, Florida health care attorney, Florida health care lawyer, health law, hospital, kickbacks, legal representation, medicaid, medicaid audit, Medicaid false claims, Medicaid fraud, medical group, medicare, medicare audit, Medicare false claims, Medicare fraud, Novartis Pharmaceuticals Corporation (NPC), pharmacist, pharmacy, physician, qui taim, qui tam relator, qui tam suits, the health law firm, TRICARE, unnecessary procedures, Veterans Administration, whistleblower, whistleblower attorney, whistleblower lawyer, whistleblower protection|Comments Off

The American Academy of Family Physicians Releases Third List for Choosing Wisely Campaign

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

On September 24, 2013, the American Academy of Family Physicians (AAFP) released its third list of commonly prescribed tests and procedures that may not be necessary. This list is part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.

The Choosing Wisely Campaign was initiated to give patients a catalog of procedures, tests and treatments that have been overused, misused or have been identified as ineffective. Since its launch in April 2012, more than fifty (50) medical specialty societies have created lists of procedures, tests and drug treatments that deserve to be questioned before a physician orders them or patients accept them.

The purpose is to help patients become more discriminating about what care they receive. Physicians and health care providers […]

By The Health Law Firm|2024-03-14T10:00:52-04:00June 1, 2018|Categories: Health Care Industry, The Health Law Firm Blog, Whistleblower|Tags: American Academy of Family Physicians (AAFP), American Board of Internal Medicine (ABIM) Foundation, Choosing Wisely, defense attorney, defense lawyer, doctors, false claims cases, Florida health care attorney, Florida health law attorney, health care attorney, health care lawyer, health law attorney, health lawyer, medicaid, medicare, physicians, qui tam, the health law firm, unnecessary procedures, unnecessary tests, whistleblower|Comments Off