Medicare abuse | The Health Law Firm Blog

CMS Fights Medicare Fraud With Ban on New Home Health Agencies and Ambulance Suppliers in Three Cities

By 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

The Centers for Medicare and Medicaid Services (CMS) announced it will temporarily ban new home health providers and ambulance suppliers from enrolling in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) in three fraud “hot spots.” According to CMS, the six-month moratorium begins July 30, 2013. It applies to newly enrolling home health agencies (HHAs) in Miami, Florida, and Chicago, Illinois. It also applies to newly enrolling ambulance suppliers in Houston, Texas. Existing providers and suppliers can continue to deliver and bill for services. The goal of the ban is to fight healthcare fraud.

Click here to read the press release from CMS.

Authority to impose a moratorium was included in the Patient Protection and Affordable Care Act (PPACA). According to a summary of the anti-fraud provisions in the Affordable Care Act, the Act allows CMS to prohibit new providers from joining the program where necessary to prevent or fight fraud, waste or abuse in certain geographic areas or for certain categories of services. This is the first time CMS is exercising its authority.

Why Moratorium Was Imposed in These Areas.

According to CMS, the decision to impose the moratorium was based on a number of factors, including a disproportional number of providers and suppliers relative to beneficiaries, a quick increase in enrollment applications from providers and suppliers, and extremely high utilization in these areas.

Miami Area a Hot Bed for Healthcare Fraud and Abuse.

The Miami area has stood out as one of the nation’s hubs of Medicare fraud, according to CMS. For example, in May 2013, a Miami patient recruiter for an HHA was sentenced to 37 months in prison for participating in a $20 million Medicare fraud scheme. Click here to read a previous blog. In that same month, workers from a Miami-area HHA were accused of bribing Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. To read more, click here.

According to the Miami Herald, with a large number of elderly Medicare beneficiaries living in Miami, it’s not a surprise that healthcare fraud is so prevalent. South Florida allegedly accounts for one-third (1/3) of all healthcare fraud prosecutions in the nation. Click here to read the entire Miami Herald article.

The Affordable Care Act Offers the Government New Tools to Fight Healthcare Fraud.

In 2011 and 2012, the government reported recovery of $14.9 billion in healthcare fraud judgments, settlements and administrative impositions, according to CMS. In addition, CMS has revoked 14,663 providers and suppliers’ ability to bill the Medicare Program since 2011. The Affordable Care Act seeks to improve anti-fraud and abuse measures by focusing on prevention rather than the traditional “pay-and-chase” model of catching crooks after they have committed fraud. Click here to read a blog on the Affordable Care Act’s other fraud fighting tools.

What This Means for Health Care Professionals and Providers.

By knowing the government is beefing up measures to fight healthcare fraud, providers can attempt to avoid practices that are likely to lead to Zone Program Integrity Contractor (ZPIC) or Recovery Audit Contractor (RAC) audits. Additionally, a provider can be prepared for potential audits by increasing its documentation and compliance efforts.

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

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think of CMS’ decision to invoke the moratorium? Do you think this should have been done sooner? Please leave any thoughtful comments below.

Sources:

Centers for Medicare and Medicaid Services. “CMS Imposes First Affordable Care Act Enrollment Moratoria to Combat Fraud.” CMS.gov. (July 26, 2013). From: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-26.html

Chang, Daniel. “Feds Ban New Home Healthcare Agencies in Miami to Fight Medicare Fraud.” Miami Herald. (July 26, 2013). From: http://www.miamiherald.com/2013/07/26/3524612/feds-ban-new-home-healthcare-agencies.html

Beasley, Deena. “U.S. Bans New Home Health, Ambulance Providers in Three Regions.” Miami Herald. (July 26, 2013). From: http://www.reuters.com/article/2013/07/26/us-medicare-moratoria-idUSBRE96P14P20130726

About the Authors: Lance O. Leider is an 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.

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|2024-03-14T10:00:51-04:00June 1, 2018|Categories: Affordable Care Act, In the Know, In the News, Medicare, Medicare Fraud, The Health Law Firm Blog|Tags: ambulance providers, ban on ambulance providers, ban on home health agencies, Centers for Medicare and Medicaid Services (CMS), Chicago, Children’s Health Insurance Program (CHIP), defense lawyer, healthcare fraud, healthcare fraud hot spots, HHA fraud, home health agencies (HHAs), home health agency (HHA), Houston, medicaid, medicare, Medicare abuse, Medicare defense, Medicare defense attorney, Medicare defense lawyer, Medicare fraud, Medicare schemes, Miami, moratoria, moratorium, RAC audits defense attorney, Recovery Audit Contractor (RAC), the health law firm, Zone Program Integrity Contractor (ZPIC), zpic audit|Comments Off

Doctors’ Medicare Payment Data to be Released Spring 2014

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

For years, the Centers for Medicare and Medicaid Services (CMS) has kept private its records on Medicare claims payments made to individual physicians. However, beginning March 18, 2014, the government may disclose the payment data on a case-by-case basis. According to CMS, this directive is a push by the Obama Administration to crack down on doctors who are making a habit out of repeatedly overcharging Medicare. On January 15, 2014, CMS stated that recalcitrant providers could face civil fines and exclusion from Medicare and other federal health care programs. According to CMS, a recalcitrant provider is defined as one who is abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.

Data Made Public to Fight Healthcare Fraud.

According to The New York Times, federal officials estimate that 10 percent (10%) of payments in the fee-for-service Medical program are improper. Supporters of releasing the data say it could help identify patterns of waste and fraud. The Medicare payment data, combined with data from other sources, could be enormously useful to consumers, researchers and whistleblowers analyzing patterns of health spending.

Physician groups express caution in Medicare releasing individual payment information, saying it could lead to public misunderstanding and unintended consequences, according to The New York Times.

Click here to read the entire article from The New York Times.

Data Prohibited From Being Release for Past Thirty Years.

In 1979, a federal district judge in Jacksonville, Florida, issued an injunction that prohibited Medicare officials from releasing what Medicare pays individual doctors. The ruling, in a lawsuit filed by doctors, said such disclosure would violate the Privacy Act and constitute a clearly unwarranted invasion of personal privacy. In May 2013, the judge lifted the injunction.

According to a MedPage Today article, the decision does not require the wholesale release of Medicare payment data but allows Medicare officials and courts to consider the merits of each request.

To read the entire article from MedPage Today, click here.

Healthcare Providers Should Prepare for Possible Public Scrutiny.

Although it remains to be seen how CMS will implement its new policy, health care providers should be prepared for the possibility that their coding, billing and reimbursement patterns will become the subject of public scrutiny, particularly those providers in specialized areas including internal medicine, radiation oncology and ophthalmology.

Contact Health Law Attorneys Experienced with Healthcare Fraud Cases.

Attorneys with The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program. We also handle Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S.

Our attorneys also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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 about the decision to release payment data for physicians? How will this effect health care providers? Please leave any thoughtful comments below.

Sources:

Pear, Robert. “Doctors Abusing Medicare Face Fines and Expulsion.” The New York Times. (January 25, 2014). From: http://nyti.ms/1cpIaOg

Pittman, David. “Medicare to Release Doc Pay Data This Spring.” MedPage Today. (January 14, 2014). From: http://bit.ly/1ndaCHu

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|2024-03-14T10:00:54-04:00June 1, 2018|Categories: Health Care Industry, Medicare, The Health Law Firm Blog|Tags: Centers for Medicare and Medicaid, CMS, defense attorney, defense lawyer, doctor attorney, doctor lawyer, doctor payment information, doctors, exclusion from Medicare, expelled from Medicare, health law firm, improper payments, internal medicine, medically necessary claims, medically unnecessary claims, medicare, Medicare abuse, Medicare doctor services, Medicare fraud, Medicare payment data, Medicare payments, Medicare physician services, ophthalmology, overcharge Medicare, physician attorney, physician lawyer, physician payment information, physicians, radiation oncology, Recalcitrant providers, the health law firm|Comments Off

Dentists: Tightened Controls on Prescribing to Medicare Part D Patients Could Affect Your Practice

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

Starting June 1, 2015, Medicare Part D will no longer reimburse patients or pharmacies for prescriptions unless the dentist opts in and enrolls in Medicare, or opts out and enters into a private contract with the patient. This measure is part of a rule finalized by the Centers for Medicare and Medicaid Services (CMS). The purpose of the rule is to assist CMS in cracking down on doctors, dentists and other health care providers that are improperly prescribing drugs to Medicare patients.

Medicare Part D plans provide supplemental optional coverage for prescription medication used in dentistry, are administered by private health plans and are paid for by way of premiums. As a dentist, if you have patients with Medicare Part D, you need to choose whether to enroll as a Medicare provider or to opt out. Click here to read the final rule from CMS.

Specifics of the New Rule.

Dentists have until June 2015 to either enroll in Medicare or formally opt out. When a dentist enrolls, the government verifies his or her professional license and credentials, and checks his or her criminal history. In addition, the final rule expands rewards and incentive programs focusing on participation in activities that promote improved health, efficient use of health-care resources and preventing injuries and illness.

One new stipulation is that the federal government has the authority to expel physicians from Medicare if found to be prescribing drugs in an abusive manner or in violation of Medicare rules. In addition, CMS will be able to terminate a dentist’s Medicare enrollment if his or her Drug Enforcement Administration (DEA) certification has been revoked, or if the state licensing board has stripped his or her authority to prescribe drugs.

To read more on how abusive prescribing patterns will be determined, click here.

Enrolling Versus Opting Out.

If you enroll in Medicare Part D as a treating provider, then you are going to be subject to increased oversight and regulations, including:

– Fraud investigations;
– The minimum patient record retention increases from four to five years;
– You must be careful when denying services to Medicare recipients;
– You can’t charge Medicare for missed appointments; and
– You may have a percentage of your Medicare reimbursement withheld beginning next year if you don’t have electronic health records (EHRs).

On the other hand, if you opt out of part of Medicare, then you opt out of other parts as well, which may lead to a loss in revenue and disgruntled patients.

Examine Your Practice and Make Your Own Decision.

Your decision to enroll in or opt out of Medicare should be determined by the types of patients you treat and the services you provide. If your practice consists of patients under the age of 65, you may be unaffected by this rule. However, if you practice in an area with an older population, Medicare coverage is more likely to be part of your practice. The important point is to understand how it may or may not affect your practice’s bottom line. If you need some guidance or have questions, call an attorney experienced in representing dentists.

Comments?

Will this final rule affect you? If so, how? Please leave any thoughtful comments below.

Consult With An Attorney Experienced in the Representation of Dentists.

We routinely provide deposition coverage to dentists, dental hygienists and other health professionals being deposed in criminal cases, negligence cases, civil cases or disciplinary cases involving other health professionals.

The lawyers of The Health Law Firm are experienced in both formal and informal administrative hearings and in representing dentists and dental hygienists and other health professionals in investigations and at Board of Dentistry hearings. Call now or visit our website www.TheHealthLawFirm.com.

By The Health Law Firm|2024-03-14T10:01:09-04:00May 15, 2018|Categories: Dental Law, Dentistry Law, Dentists, Insurance|Tags: abusive prescribing, Administrative Hearing, applying to Medicare, audits, Board of Dentistry, Centers for Medicare and Medicaid Services, CMS, CMS audits, controlled substances, DEA investigation, defense attorney, defense lawyer, dental board, dentist attorney, dentist defense, dentist lawyer, dentist’s license, DOH investigations, enroll in Medicare, health law, health law firm, medicare, Medicare abuse, Medicare fraud, Medicare overpayments, Medicare Part D, over-prescribing, pharmacies, prescribing painkillers, prescribing practices, prescription drug abuse, RAC audit, revocation, revoked license, suspended license, suspicious prescribing practices, termination from Medicare, the health law firm, zpic audit|1 Comment