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So, the ZPIC Medicare Auditor Wants to Talk to You? What You Should Expect

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

You are a physician, nurse or other health care provider who bills Medicare. You have received that dreaded letter from the Zone Program Integrity Contractor (ZPIC) for Medicare advising you that it is auditing you for the Centers for Medicare and Medicaid Services (CMS). You know that the words “Program Integrity” by themselves mean that possible fraud is being investigated, at least that is the suspicion giving rise to this particular audit.

To read an earlier blog which I wrote on tips for responding to ZPIC audits, click here.

You have dutifully contacted an experienced health law attorney to aid you in responding to the ZPIC’ s request for records and information. You have obtained all of the requested medical records documentation, authoritative medical journal articles and other information that may be useful in supporting the care you delivered and for which you billed, added explanatory notes (clearly and contemporaneously dated, of course) where necessary or where records were missing, and done all you can to fully and completely respond to the audit.

After the Initial Audit Response and Site Visit.

Now, several weeks later, the ZPIC auditor/investigator contacts you and advises you that he would like you to come to his office to answer a few questions. The ZPIC auditor/investigator states that this is “just routine” and should only take approximately 20 minutes.

After discussing this with your attorney, knowing that you have committed no fraud and that your medical records are in pretty good shape to support your billing, you decide to go to the ZPIC office for the interview. (Note: I know that many attorneys would recommend against this action, but often we advise a client, with the right set of facts, of course, to do this.) What should you expect?

What to Expect When You Show up to Be Interviewed by the ZPIC Auditor.

Although we cannot guarantee you that you will experience the same as we have in the past, this is what happened often enough with us where it seems to be somewhat common practice in such audits.

1. Expect the ZPIC office to be in a building with good security, including magnetic/electronic scanning for guns and weapons, like at the airport or court house. Do not attempt to take any type of weapon inside the building, including pen knives on key chains and tear gas or pepper spray canisters.

2. Bring a valid government identification card with your photograph. If you are with an attorney or a consultant, that person will also need one. One of the first things that will happen is that you will be asked to show your identification cards to prove you are who you say you are.

3. Be sure you have your correct office address on file with Medicare. If the auditors show up at an address you have listed and your practice is not there, you will either get a letter automatically terminating your Medicare billing privileges or you will be called down for this interrogation by the ZPIC. This is a primary reason for such ZPIC interrogations. Be sure your physical office address, including suite number, apartment number, office number, etc., are correctly reflected in the Provider Enrollment and Chain/Ownership System (PECOS), the electronic portal through which Medicare providers enroll in Medicare.

4. You aren’t going to be interviewed by just one person and it isn’t going to be just “20 minutes.”

5. In most cases, there will be three or more auditors/investigators involved in the interview with you. This is why it is a good idea to bring your attorney and her paralegal so that you also have some support, as well. The least number of auditor/investigators that we have ever seen involved in such interviews is two. Don’t be surprised if there are three or four.

6. The questioning and interviewing will take much longer than you expected. Plan on taking the rest of the day off so that you are not rushed and do not feel pressured to get it over with fast. It is not going to be over with fast.

7. Don’t joke around with the ZPIC auditors. This is a very serious matter. Many talented government investigators will attempt to joke and make light of things in order to get you to let your guard down. Do not play into this. Be serious and act seriously at all times.

8. You are not in an endurance contest. Ask for bathroom breaks, water breaks or just a break to talk with your attorney, as many times as you desire. Do this at least once each hour. This will help to keep your blood circulating and keep you alert.

9. You will be confronted with what the ZPIC auditors believe they have found that violates Medicare regulations. This may include, for example, billing services for patients who were dead at the time, billing for services on dates after the patient was no longer qualified to receive them, billing for services that were billed by another provider, etc. Do not guess at why this happened if you did not know for a fact. You can advise the investigator that you will take down the investigation, look into it and provide the information to him or her at a later date.

10. Don’t be surprised if the ZPIC auditor has incorrect information. Often the ZPIC will have confused information on two different Medicare beneficiaries with the same names or whose Medicare numbers were incorrectly recorded. For example, in one recent ZPIC investigator interview with my client, the investigator accused the physician of billing for services provided to a patient who had been deceased for two years. The physician had just seen the patient on a follow-up visit a month prior to the interview. The ZPIC had confused a dead patient who had the same name with the live patient. This is not uncommon.

11. Don’t be surprised if the ZPIC auditor asks you about other Medicare provider’s billings for the same patient. This also happened to a client of mine in a recent case. The ZPIC investigator questioned why the XYZ company would have billed for the same services as those provided by my client, a solo practitioner. My client did not know. He correctly told the auditor that he did not know why the other party had billed Medicare for the same services, but he had provided the services to his patient and he had billed for the services. He could not know whey someone else did something.

12. If there have been intervening factors affecting your billing practices, disclose these to the investigator. In one case, my client had changed software for her electronic health records and billing. One of the reasons this was necessary was because of bugs that made the billings sometimes unreliable. Records more than four (4) years old were no longer available. The client disclosed this.

13. Be sure you are able to reconcile the number of patients seen per day, the number of hours the CPT codes billed to Medicare are supposed to reflect, and that these seem reasonable. If you are billing time-based CPT codes for patients that it would take you 27 hours to see in a day, you are in trouble. You must know this ahead of time and either have a reasonable answer to address the problem (e.g., an incorrect date entry in the billing software caused two days worth of services to accidentally be billed for the same date of service) or correct the over-billing error.

14. Know what rules, regulations and guidelines apply to the billings for the CPT codes you are billing. Check to see if there are local coverage decisions (LCDs) from your area Medicare Administrative Carrier (MAC) or National Coverage Decisions (NCDs) from CMS and know them. Be sure you have followed them and are following them.

15. Know the licensure rules and regulations for your profession, as well as the Medicare guidelines for billing for your profession. Sometimes billing for what an assistant, trainee, or ancillary provider does is allowed, and sometimes it isn’t. If you bill for what an assistant does, be sure you know the rules and are properly billing. The ZPIC investigator certainly will ask questions about this.

16. Your health record entries, assessments, evaluations, progress notes, etc., are required to be made contemporaneously with your delivery of the services. This generally means within 24 hours, as a rule of thumb. Records made a week or a month later are not considered to be reliable or accurate. So be sure you have made and are making your records contemporaneously with seeing the patient or providing the services.

17. Check the location code for the claims you have submitted. Make sure they reflect the correct site that the services were delivered. There could be differences in payments based on the site/location code. You will be asked about this if there are discrepancies.

18. If you identify problems and issues when preparing for your ZPIC interview, go ahead and correct them. This way you will be able to show you have made an honest mistake, have changed your procedures and the mistake(s) will not happen again in the future. Sometimes this may require terminating your billing company, purchasing new software, retaining a professional consultant, asking for an educational site visit from the MAC, and obtaining additional continuing education on billing practices and procedures for you and your staff (some of which CMS offers online).

We have many helpful resources on our webpage and YouTube page. Click here to view our video Q&A on ZPIC audits for more information.

To read an additional blog I wrote on preparing for an audit, click here.

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.

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 © 2019 The Health Law Firm. All rights reserved.

South Florida Man Admits to a $42 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

The owner and operator of a Miami home health care agency pleaded guilty for his part in a $42 million home health Medicare fraud scheme, according to the Department of Justice (DOJ), the FBI and the Department of Health and Human Services (DHHS). The 43 year-old man pleaded guilty before a U.S. district court judge to one count of conspiracy to commit health care fraud on August 2, 2012.

To see the entire press release from the Department of Justice (DOJ), click here.

First Part of the Fraud Operation Involved Kickbacks and Bribes.

The Miami man was the owner of a Florida home health agency that claimed to provide home health care and physical therapy services to eligible Medicare recipients.

In the first part of the scheme, he allegedly would pay kickbacks and bribes to recruiters. In return, the recruiters would provide patients to the home health care agency. His patients, who received Medicare, were used to bill Medicare for $42 million in unnecessary home health care and therapy services, the government alleged.

The plea documents show that patients’ files were falsified to make it appear that these Medicare recipients qualified for the services when many actually did not.

Second Part of the Fraud Operation Included Paying off Doctors.

The second part of this operation involved the owner of the home health agency and his accomplices allegedly paying off doctors. In this exchange, the doctors would allegedly provide the schemers home health and therapy prescriptions, and medical certifications.

The Opertation Busted by the Medicare Fraud Strike Force.

In the end, the crimes resulted in $42 million in false and fraudulent Medicare claims that were filed between January 2006 and November 2009, according to the government. Medicare paid approximately $27 million on those false claims, according to plea documents.

As part of his plea agreement, the home health agency owner has agreed to forfeit two residential properties and cash proceeds of the fraud over to the government.

This case was investigated as part of the Medicare Fraud Strike Force. The Strike Force is a joint effort of the Department of Justice (DOJ) and the Department of Health and Human Services (DHHS) designed to combat fraud through the use of Medicare data analysis techniques.

To learn more on the Medicare Fraud Strike Force, click here.

Contact Health Law Attorneys Experienced in Handling Medicare Audits.

Medicare fraud is a serious crime and is vigorously investigated by 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), state Medicaid Fraud Control Units (MFCUs) 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.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, 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:

Department of Justice, Office of Public Affairs. “Miami Home Health Care Agency Owner Pleads Guilty in $42 Million Medicare Fraud Scheme.” Department of Justice. Press Release. (August 2, 2012). From: http://www.justice.gov/opa/pr/2012/August/12-crm-965.html

CBS Miami “Health Care Agency Owner Pleads Guilty In $42M Medicare Scheme.” Miami CBS 4 Local. (August 2, 2012). From: http://miami.cbslocal.com/2012/08/02/health-care-agency-owner-pleads-guilty-in-42m-medicare-scheme/

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.

MedVance Institute Must Retrain Students and Donate Direct Scholarships to Florida

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

MedVance Institute, which is a healthcare training school with four Florida campuses, reached an agreement with the Florida Office of the Attorney General (AG) on June 13, 2012. MedVance was alleged to have made misleading marketing claims to students. Under the agreement, the for-profit college is required to offer retraining to eligible students who attended specific programs between January 1, 2008, and March 31, 2012, at no cost. MedVance also agreed to direct $600,000 to Florida scholarships.

MedVance Institute has campuses in Fort Lauderdale, Miami, Port St. Lucie, and West Palm Beach.

Click here to see the full press release from the AG.

Students Complained of School’s Misrepresentation in Marketing Campaigns.

The AG initiated the investigation due to complaints about alleged misrepresentation in the school’s marketing to potential students relating to the admission process, deadlines for enrollment, and cost of programs.

Full Terms of the Agreement Between AG and MedVance.

According to the agreement between the AG’s office and MedVance, the school has agreed to:

– clearly and conspicuously disclose specific information relating to the school’s accreditation, state licensing requirements, and financial aid;

– not make certain representations;

– modify its arbitration provisions so that students can receive quick resolutions to pending grievances;

– offer retraining to students who attended specific MedVance programs between January 1, 2008, and March 31, 2012, and were unable to find employment despite diligent efforts.

To view the full agreement, click here.

 MedVance Offers a Number of Course in the HealthCare Field.

According to its online materials, MedVance has programs in the following healthcare professions:

 – Cardiovascular Technology

 – Dental Assisting

 – Medical Office Basic X-Ray Technician

 – Medical Billing and Coding Specialist

 – Medical Office Administration

 – Information Technology & Biomedical Technician

 – Medical Assistant/Medical Assisting

 – Medical Laboratory Technology

 – Pharmacy Technician

 – Radiologic Technology

 – Surgical Technology

 – Practical Nursing

Contact a Health Care Attorney that is Experienced in the Representation of Medical Students, Interns, Residents and Applicants.

The Health Law Firm and its attorneys represent medical school students in disputes with their medical schools, internship supervisors, and in dismissal hearings. We have represented residents, interns and fellows in various disputes regarding their academic and clinical performance, allegations of substance abuse, failure to complete integral parts training, alleged false or incomplete statements on applications, allegations of impairment (because of abuse or addiction to drugs or alcohol or because of mental or physical issues), because of discrimination due to race, sex, national origin, sexual orientation and on other matters.

To learn more about our experience in the representation of medical students, click here.

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

Sources:

Kamph, Stefan and Parker, Chris. “For-Profit Colleges Cheat Students and Get Away With It.” Miami News Times. (August 2, 2012). From: http://www.miaminewtimes.com/2012-08-02/news/for-profit-colleges-cheat-students-and-get-away-with-it/2/

Turner, Jim. “Pam Bondi: MedVance to Offer Retraining, Direct Scholarships to Florida.” Sunshine State News. (June 13, 2012). From: http://www.sunshinestatenews.com/print/4987463

Meale, Jenn. “Attorney General Bondi’s Office Reaches Agreement with MedVance Institute to Retrain Students and Donate $600,000 to Florida Scholarships.” Florida Office of the Attorney General. (June 13, 2012). From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/F3599CFFCC64359A85257A1C006A3B0C

About the Authors: 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.

Joanne Kenna, J.D., R.N., 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 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.

Office of Inspector General (OIG) Scrutinizes Billing at South Florida Mental Health Clinics

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

On August 16, 2012, the Office of Inspector General (OIG) released a report on questionable billing by mental health centers. The report focuses on the nation’s mental health clinics that overbilled Medicare in 2010, some by tens of millions of dollars. The majority of these clinics were located in South Florida, Texas and Louisiana.

To see the full report from the OIG, click here.

Two Big Busts in Florida Mental Health Clinics for Medicare Fraud.

According to an article in the Miami Herald: “No area of the country cheats Medicare quite like South Florida.” To see this article from the Miami Herald, click here.

In the report, the OIG specifically named a bust of two Miami-area doctors, one Miami-area therapist and two others for their participation in a Medicare fraud scheme. The case involved the nation’s biggest mental health chain and more than $205 million in fraudulent billing. Executives of the company were sentence in June 2012, to anywhere from 50 years to 91 months.

We previously blogged about this news story. Click here to read that blog. To see a copy of the press release on this case from the Department of Justice (DOJ), click here.

The Miami Herald article outlines the case of another South Florida mental-health clinic. The clinic’s owner, his son, his daughter and five others were found guilty on August 31, 2012, of conspiring to cheat $57 million from the federal program for the elderly and disabled. The owner, his son, an operating officer and another manager were also convicted of conspiracy to commit health care fraud by collecting $11 million in Medicare payments for therapy services that were not needed or provided from 2007 to 2011.

Click here to see the full press release on this case from the DOJ.

OIG Scrutinizes Medicare for Lack of Regulations.

In the report, the Inspector General (IG) said these two instances of Medicare fraud are examples of the federal program’s “vulnerabilities.” The report scrutinizes the Medicare program for it’s lack of regulating about 200 mental health centers in 25 states that received an estimated $218.6 million in 2010.

Medicare Officials Admit Mental Health Services are Susceptible  to Fraud and Abuse.

In the Miami Herald article, Medicare officials responded to the OIG by acknowledging that mental health services have been vulnerable to fraud and abuse in the past, but said Medicare is currently taking steps to address these issues. These steps include adopting a computer program that will screen prospective clinic operators; it will perform criminal background checks and closely examine claims which are paid within 14 days.

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 health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

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

Sources:

Weaver, Jay. “Feds Spotlight South Florida Mental Health Clinics for Medicare Fraud.” The Miami Herald. (August 28, 2012). From: http://www.miamiherald.com/2012/08/28/2972637/feds-spotlight-south-floridas.html

Levinson, Daniel. “Questionable Billing By Community Mental Health Centers.” Office of Inspector General. (August 2012). From: /uploads/OIG on Medicare fraud in Mental Health Clinics.pdf

Department of Justice. “Eight Individuals and a Corporation Convicted at Trial in Florida in $50 Million Medicare Fraud.” United States Department of Justice. (August 24, 2012). From: http://www.justice.gov/opa/pr/2012/August/12-crm-1048.html.

Valle, Alicia. “Doctors, Therapist and Recruiters from Miami-Area Mental Health Care Corporation Convicted for Participating in $205 Million Medicare Fraud Scheme” U.S. Attorney’s Office for the Southern District of Florida. (June 1, 2012). From: http://www.justice.gov/usao/fls/PressReleases/120601-03.html

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.

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 Government About an Investigation.

A related article in Reuters states that CVS said it has not been contacted by the government about the investigation. The pharmacy also said, as a policy, the company does not condone unauthorized refills. Officials said to allow unauthorized prescription refills could be considered insurance fraud, especially if insurers were not refunded for any drugs rejected by patients.

The probe might be, in part, related to the programs offered by many drugstores that allows a pharmacy to refill prescriptions even before a refill request has been made by the patient.

Click here to read the entire article from Reuters.

So far there is no news from the OIG for the HHS officially confirming this investigation.

Cause for Investigation?

It is unclear to me why there would be any cause to investigate CVS, if Medicare was not being billed until the customer actually picked up the prescription. If the customer fails to pickup the prescription, every drug store I know of restocks the medication after a short period and no one is ever billed for it. It seems that it would be a quick and simple matter for the OIG to check this.

Furthermore, it could also be argued that CVS  is actually promoting good health by this practice. Patients may forget to renew or refill their prescriptions or may fail to notice they are running low.

Two Sanford, Fla., CVS Stores Make Headlines.

On September 12, 2012, the U.S. Drug Enforcement Administration (DEA) revoked the registrations (controlled substance licenses) from two CVS pharmacies in Sanford, Florida. The two pharmacies are no longer able to fill prescriptions for drugs such as oxycodone, Dilaudid, Vicodin, Ritalin and Xanax. This decision was in response to a government crackdown on the distribution of painkillers. Click here to read a blog on this story.

Contact Health Law Attorneys Experienced in Representing Pharmacies and Pharmacists.

The Health Law Firm represents pharmacists and pharmacies in DEA investigations, regulatory matters, licensing issues, litigation, administrative hearings, inspections and audits. The firm’s 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 (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of this story? Do you think CVS is doing anything wrong? How is this any different from the practice of many managed care plans mailing out 90 days of medications to its patients at a time? Please leave any thoughtful comments below.

Sources:

Lazarus, David. “CVS Caremark Prescription Refills Under Scrutiny, Source Says.” Los Angeles Times. (October 12, 2012). From: http://www.latimes.com/business/la-fi-lazarus-20121012,0,1032269.column

Alawadhi, Neha, Wohl, Jessica, and Morgan, David. “CVS Unaware of Any Government Prescription Refill Probe.” Reuters. (October 12, 2012). From: http://www.reuters.com/assets/print?aid=USBRE89B19520121012

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.

American Hospital Association (AHA) Sues U.S. Government for Denied Medicare Payments by RACs, ZPICs and Other Auditors

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

On November 1, 2012, the American Hospital Association (AHA) filed a lawsuit against the U.S. Department of Health and Human Services (HHS) claiming that private auditors hired to crack down on improper Medicare payments are denying hospitals millions of dollars in medically necessary care, this is according to a number of sources. The AHA is seeking a court order declaring the practice invalid, saying it violates the Medicare Act.

Four hospital systems in Michigan, Missouri and Pennsylvania have joined the AHA as plaintiffs in the suit. The suit has been filed in federal court in Washington, D.C.

To read the AHA complaint against the HHS, click here.

AHA Wants Doctors to Be Able to Focus on Patient Care.

The lawsuit alleges Recovery Audit Contractors (RACs), private auditors used by the HHS, forced hospitals to repay Medicare for the costs of in-patient services by determining that Medicare beneficiaries should have been treated as out-patients instead of being admitted into hospitals as in-patients. The services provided to out-patients are much less, of course, and the bills for out-patient services are usually much lower.

In the official press release AHA argues when patients need treatment, the first step for a doctor is to decide whether to admit the patient to the hospital or to provide care in an out-patient facility. AHA believes doctors’ decisions are often more complicated for Medicare beneficiaries because the doctor is routinely second-guessed by RACs months or even years later. The president and CEO of AHA said this practice is “indefensible.”

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

Neither the Centers for Medicare and Medicaid (CMS) nor the Department of HHS has commented on the pending litigation.

AHA Fed Up with Redundant Audits that Drain Time, Funding and Patient Care.

In October 2012, prior to the lawsuit, the executive vice president of the AHA wrote a letter to the Office of Inspector General (OIG) in response to the Work Plan for Fiscal Year 2013. In the work plan the OIG reviewed the effectiveness of various Medicare contractors, including RACs, Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs).

The letter states that these programs auditing payment accuracy are well intentioned, but hospitals are fed up with the RACs’ inaccuracy in determining whether the hospital received any overpayments. The letter also claims that hospitals are overwhelmed by the significant overlap and duplication of efforts between the RACs, MACs and ZPICs. These redundant audits drain time, funding and attention to patient care, according to the AHA.

According to the OIG review, hospitals reported appealing more than forty percent (40%) of all RAC denials, with a seventy-five percent (75%) success rate in the appeals process.

Click here to read the letter from the AHA to the OIG.

How to Take Action Once a Notice of a Medicare Audit Has Been Received.
When a physician, medical group or other healthcare provider receives a notice of an audit and site visit from a RAC, MAC or ZPIC, things happen fast with little opportunity to prepare. To help, read our checklist of what to do when notified of a Medicare or ZPIC audit. Click here for part one and click here for part two.

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 you think about the lawsuit again the HHS? Do you support AHA’s decision to question the RACs’ auditing system? Please leave any thoughtful comments below.

Sources:

Mitchell, Alicia. “Hospitals Sue Federal Government for Unfair Medicare Practices.” American Hospital Association. (November 1, 2012). Press Release from: http://www.thehealthlawfirm.com/uploads/AHA%20Sues%20Govnt%20PR.pdf

Pollack, Richard. “Letter: AHA Supports OIG Review of Effectiveness of Medicare Contractors, Including RACs, In 2013 Work Plan.” American Hospital Association. (October 24, 2012). Letter from: http://www.thehealthlawfirm.com/uploads/AHA%20letter%20to%20OIG%20on%20RACs.pdf

Morgan, David. “Hospitals Sue Government Over Private Medicare Audits.” Reuters. (November 1, 2012). From: http://uk.reuters.com/article/2012/11/01/us-usa-healthcare-medicare-idUKBRE8A01BZ20121101

Harris, Andrew. “American Hospital Association Sues U.S. Over Medicare.” Bloomberg. (November 1, 2012). From: http://www.bloomberg.com/news/print/2012-11-01/american-hospital-association-sues-u-s-over-unpaid-medicare.html

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.

Signing False Medicare Claims Lands Nurse Behind Bars for 30 Months

10 Indest-2008-7By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A Detroit-area registered nurse was sentenced on November 19, 2012, to 30 months in federal prison for his alleged part in a nearly $13.8 million Medicare fraud scheme. According to a Department of Justice (DOJ) press release, he will serve probation after being released from prison. He was also ordered to pay more than $450,000 in restitution, together with his co-defendants.

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

Nurse Signed Medical Records for Services Never Rendered.

According to the nurse’s plea agreement, from December 2008 through September 2011, he was paid to sign medical records for a home health care agency that billed Medicare for services that were allegedly never rendered. The man reportedly admitted to not seeing or treating the Medicare beneficiaries for whom he signed medical documentation. He also admitted to knowing that the documents he signed were being used for false claims. According to an article from Health Exec News, the man was paid around $150 for each fake file that he signed.

To read the article from Health Exec News, click here.

A Handful of Alleged Co-Conspirators Waiting to Be Sentenced.

Nine alleged co-defendants in this case have pleaded guilty and are waiting to be sentenced, while three others are fugitives and six more are awaiting trial, according to the DOJ. In total, the home health agency was paid close to $13.8 million by Medicare.

This case was investigated by the Federal Bureau of Investigation (FBI) and the Department of Health and Human Services (HHS) Office of Inspector General (OIG) as part of the Medicare Fraud Strike Force.

Contact Health Law Attorneys Experienced in Representing Nurses.

The Health Law Firm’s attorneys routinely represent nurses in Department of Health (DOH) investigations, Department of Justice (DOJ) investigations,  in appearances before the Board of Nursing in licensing matters and in many other legal matters. We represent nurses across the U.S., and throughout Florida.

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 the registered nurse received a sentence that was too harsh? Please leave any thoughtful comments below.

Sources:

Health Exec News. “Medicare Fraud Scheme: Nurse Gets Jail Time for Signing False Claims.” Health Exec News. (November 23, 2012). From: http://healthexecnews.com/nurse-medicare-fraud-scheme

Department of Justice. “Detroit-Area Nurse Sentenced to 30 Months in Prison for Role in $13.8 Million Home Health Care Fraud Scheme.” Department of Justice. (November 19, 2012). From: ttp://www.justice.gov/opa/pr/2012/November/12-crm-1389.html

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.

Florida Pharmacy Owner Accused of Medicare Fraud

00011_RT8By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A family that owns a number of South Florida pharmacies is allegedly under investigation for Medicare fraud, according to a number of sources. On January 17, 2013, federal authorities raided one pharmacy location in Naples, Florida. Drug Enforcement Administration (DEA) agents removed boxes of documents and computers from the pharmacy, according to Naples News. The pharmacy owner and his mother are allegedly being investigated by the U.S. Office of Inspector General (OIG) of the Department of Health and Human Services (HHS).

Click here to read the entire Naples News article.

Pharmacy Owner and Mother Allegedly Submitted False Claims to Medicare, Medicaid and Tricare.

According to NBC2, a South Florida television station, the pharmacy owner and his mother were both allegedly part of a scheme that defrauded Medicare. The family allegedly submitted claims to Medicare Part D after beneficiaries had died. This information came from a letter sent to Medicare Part D providers from the Centers for Medicare and Medicaid Services (CMS) on October 17, 2012. The letter was obtained by NBC2. The scheme allegedly also involved submitting false claims to Medicaid and Tricare.

Click here to watch the NBC2 news story.

Investigation is Ongoing.

The pharmacy that was raided is part of a chain of stores owned by the same family. So far, only the pharmacy located on Rattlesnake-Hammock Road in Naples is being investigated. That location is reportedly still closed, but the other pharmacy locations are open.

Neither the DEA nor the OIG of the HHS has released a press release on this investigation.

As in all media reports, please remember that all persons are presumed to be innocent until proven guilty in a court of law.

Pharmacies Are Being Raided and Shutdown  All Over the State.

If  you have watched the news at all lately or have been reading our blog, you can tell there have been an increased number of raids on pharmacies, arrests of pharmacists and emergency suspension orders issued from the Department of Health (DOH).

Recently, the DEA served a Walgreens distribution center in Florida with an immediate suspension order (click here to read more on this story), and pulled the controlled substance licenses from two Central Florida CVS Pharmacies (to learn more, click here).

In my personal opinion, the recent raids and investigations at pharmacies are especially hard on the independent operators. If the large retail giants can’t survive, the small independent pharmacies stand little chance.

Talk with an Experienced Health Law Attorney About Medicare, Medicaid and Tricare 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.

What Do You Think?

As a pharmacy owner, pharmacy employee or health care facility owner, what do you think of the increased effort to find fraud? Do you think all facilities, not just pharmacies, are under the microscope? Please leave any thoughtful comments below.

Sources:

Freeman, Liz. “Sunshine Pharmacy in East Naples Remains Close, Day After Federal Raid.” Naples News. (January 19, 2013). From: http://www.naplesnews.com/news/2013/jan/19/sunshine-pharmacy-east-remains-closed-raid-federal/

Ritter, Rick. “Naples Pharmacy Busted for Medicare Fraud.” NBC2. (January 20, 2013). From: http://www.nbc-2.com/story/20627104/detectives-investigating-medicare-fraud-at-naples-pharmacy

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.

Government Discovers Extensive Overbilling of Cancer Drug to Medicare

Lance Leider headshotBy 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

It’s no surprise that the government is aggressively pursuing Medicare fraud. Recently, the Department of Health and Human Services (HHS), Office of Inspector General (OIG), made a surprising discovery. An audit uncovered that more than three-quarters (3/4) of all Medicare claims for the breast-cancer drug Herceptin were billed incorrectly, according to Modern Healthcare. This was found during an audit conducted on physicians and hospitals from around the country between January 1, 2008, and December 31, 2010.

To read the entire Modern Healthcare article, click here.

Audit Results from Around the Country.

Three different audits were released to the public by the HHS OIG. All of these audits showed roughly the same information. Health care providers have been billing Medicare for full multiuse vials of the drug Herceptin, when patients actually only need a smaller portion. Medicare does not pay healthcare providers for any part of the drug that is discarded, because it can be preserved for up to 28 days and reused. The auditors suggest that payment from Medicare for an entire multiuse vial is likely to be incorrect. We saw a similar situation with the drug Avastin and Lucentis being used by ophthalmologists several years ago.

The results of the audits were released in January 2013. One audit found eighty-five percent (85%) of 1,073 Herceptin vials used in Ohio and Kentucky were billed incorrectly. In Illinois, Indiana, Michigan and Wisconsin, the government auditors found that seventy-eight (78%) of 713 claims investigated were wrong. The overpayment amount was around $682,000, for these audits.

Florida’s District Found to Have Overcharged 78% of Bills.

According to the report, HHS auditors found overcharges in seventy-eight percent (78%) of bills for 1,330 vitals of Herceptin submitted to First Coast Service Options, Inc. This company serves as the Medicare Administrative Contractor (MAC) for HHS District Nine, which primarily includes providers in Florida, Puerto Rico, and the U.S. Virgin Islands. The overcharges for Herceptin were $1,325,409.

In the report, the government recommends that First Coast Service Options, Inc., do a number of things. The first is to recover the more than one million dollars in overpayments. It’s also recommended that First Coast Service Options, Inc., implement system edits that review multiuse vial drugs that are billed with units of service equivalent to the dosage of an entire vial. The government also suggests that these audit results be used as an educational tool for teaching correct billing practices to physicians and hospitals.

Click here to read the entire report on District Nine.

How to Respond to a Medicare Audit.

Remember, there is no such thing as a “routine” Medicare audit. The fact is that if you find yourself or your practice at the center of a Medicare audit, there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused the audit. We’ve come up with a list of actions that we use and recommend you take when responding to a Medicare audit. Click here to view that list.

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

The best time to respond to and defeat an allegation of overpayment is at the very beginning. That is why it is essential that you obtain qualified counsel to help you through the process. 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?

Why do you think hospitals and physicians incorrectly bill for Herceptin? Are audits like these necessary? Please leave any thoughtful comments below.

Sources:

Carlson, Joe. “OIG Finds Widespread Herceptin Overcharges.” Modern Healthcare. (January 21, 2013). From: http://www.modernhealthcare.com/article/20130121/NEWS/301219959/oig-finds-widespread-herceptin-overcharges

Jarmon, Glorida. “The Medicare Contractor’s Payments to Providers in Jurisdiction 9 for Full Vials of Herceptin were often Incorrect.” Office of Inspector General (January 2013). From: http://www.thehealthlawfirm.com/uploads/Herceptin%20FL%20Overcharges.pdf

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.

Major Medicare Offender Sentenced to Prison for Multi-Million Dollar Health Care Fraud Scheme

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

The former owner of four mental health facilities in South Florida and North Carolina was sentenced to fourteen (14) years in federal prison on February 25, 2013. The former business owner pleaded guilty to defrauding Medicare out of tens of millions of dollars from 2004 through 2011, according to the Department of Justice (DOJ). He had previously been convicted of cocaine trafficking but decided to move to Medicare fraud supposedly because he thought it would be safer. In total the former mental health facility owner was indicted for defrauding the government of nearly $63 million. As part of his plea, he was ordered to repay $28 million.

Click here to read the press release from the DOJ.

Unnecessary Services, Illegal Kickbacks and Fake Mental Health Records.

The scheme, headed by the former business owner, involved three mental health clinics in Miami, Florida, and one in Hendersonville, North Carolina. All four facilities allegedly billed Medicare and Medicaid for services that were unnecessary or otherwise not provided. The clinics also paid bribes to local assisted living facilities (ALFs) in order to provide a steady stream of patients that were in no need of services. Employees of the clinic would then fabricate entire mental health records for the patients in order to bill the government programs. The former mental health facility owner and his employees allegedly thought that creating the medical records would aid them in avoiding detection by federal auditors, according to an article in the Miami Herald.

To read the Miami Herald article, click here.

Co-Conspirators Feeling the “Heat.”

Fifteen (15) of the former business owner’s co-conspirators have been charged for their alleged roles in the health care fraud scheme. Ten (10) defendants have already pleaded guilty, according to the DOJ.

This case was investigated by the Federal Bureau of Investigation (FBI), the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) and the Medicare Fraud Strike Force. These departments help make up the Health Care Fraud Prevention and Enforcement Action Team (HEAT) that works to stop Medicare fraud across the country.

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 the former business owner’s sentence? Do you think it is enough to deter other would-be criminals from scamming the government? Please leave any thoughtful comments below.

Sources:

Weaver, Jay. “Miami Businessman Who Stole Millions from Medicare Sentenced to 14 Year.” Miami Herald. (February 26, 2013). From: http://www.miamiherald.com/2013/02/26/3254507/miami-businessman-who-pleaded.html

Department of Justice. “Owner of Mental Health Facilities Sentenced to 168 Months in Prison in Connection with $63 Million Health Care Fraud Scheme.” Department of Justice. (February 25, 2013). From: http://www.justice.gov/opa/pr/2013/February/13-crm-234.html

About the Author: 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.

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.

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