Palm Beach Speech Pathologist Arrested for Alleged Medicaid Fraud

By Dr. Thu Pham, O.D., Law Clerk, The Health Law Firm

A Palm Beach, Florida, speech pathologist has allegedly been charged with Medicaid fraud and grand theft by the Attorney General’s (AG) Office of Statewide Prosecution. According to the press release posted on June 29, 2012, from the AG’s office, the speech pathologists is accused of attempting to defraud Medicaid out of more than $459,000.


To read the entire press release from the Florida Attorney General, click here.

Speech Therapy was Performed by Unsupervised Assistants.
The speech pathologist allegedly allowed her assistants to perform unsupervised speech therapy to Medicaid recipients, many of whom were children.  She then proceeded to bill Medicaid for their services, which was against Medicaid rules. 

Charges for Speech Pathologist Inlcude a Fine and Jail Time.
If convicted, the speech pathologist could face up to $1.5 million dollars in fines and up to 60 years in prison.
This case was investigated by the Attorney General’s Medicaid Fraud Control Unit (MFCU).  Please remember, all persons are considered innocent until proven guilty in a court of law.

To learn more about Medicaid audit defense visit our website by clicking here.

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, 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:
My Florida Legal. “Attorney General Pam Bondi Announces Arrest of a Palm Beach Speech Language Pathologist for Medicaid Fraud.” AG. From:
http://www.myfloridalegal.com/newsrel.nsf/newsreleases/E6129E7B45E2590385257A2C006A280C
Turner, Jim. “Attorney General: Speech Language Pathologist Arrested for Medicaid Fraud.” Sunshine State News. (July 2, 2012). From: http://www.sunshinestatenews.com/blog/attorney-general-speech-language-pathologist-arrested-medicaid-fraud

About the Author: Dr. Thu Pham, OD, is a law clerk 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.

Florida Participates in Largest Healthcare Fraud Settlement in U.S. History

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

GlaxoSmithKline (GSK), a prescription drug manufacturer, has agreed to pay $3 billion in fines to resolve healthcare fraud allegations in what has become largest healthcare fraud settlement in U.S. history. The settlement was announced by federal prosecutors on July 1, 2012, and in a press release from the Florida Attorney General on July 2, 2012.

Florida to Receive $56 Million In Settlement.

Florida will receive more than $56 million as part of the settlement with GSK. Florida Attorney General, Pam Bondi, announced the state's participation in the settlement on July 2, 2012.

Settlement Resolves List of Allegations Related to Healthcare Fraud.

The settlement resolves allegations that GSK:

• Marketed the depression drug Paxil for off-label uses, such as use by children and adolescents; 
• Marketed the depression drug Wellbutrin for off-label uses, such as for weight loss and treatment of sexual dysfunction, and at higher-than-approved dosages; 
• Marketed the asthma drug Advair for off-label uses, including first-line use for asthma;
• Marketed the seizure medication Lamictal for off-label uses, including bipolar depression, neuropathic pain, and various other psychiatric conditions; 
• Marketed the nausea drug Zofran for off-label uses, including pregnancy-related nausea; 
• Made false representations regarding the safety and efficacy of Paxil, Wellbutrin, Advair, Lamictal, Zofran, and the diabetes drug Avandia;
• Offered kickbacks to healthcare professionals to induce them to promote and prescribe certain prescription drugs; and
• Submitted incorrect pricing data for various prescription drugs, thereby underpaying rebates owed to Medicaid and other federal healthcare programs.

GSK to Plead Guilty to Criminal Charges.

As part of the settlement, GSK has agreed to plead guilty to criminal charges that it violated the federal Food, Drug, and Cosmetic Act (FDCA). Allegedly, GSK introduced Wellbutrin and Paxil into interstate commerce when the drugs contained labels that were not in accordance with their FDA approvals. Additionally, GSK allegedly failed to report certain clinical data regarding Avandia to the FDA.

Settlement Originated From Whistleblower Actions.

The settlement is based on four qui tam, or whistleblower, actions brought by individuals pursuant to state and federal false claims. To view the federal False Claims Act, click here. A National Association of Medicaid Fraud Control Units team, along with several other federal agencies, investigated the matter and conducted settlement negotiations with the defendants. Florida’s civil investigation was handled by the Attorney General’s Complex Civil Enforcement Bureau, which is part of the Medicaid Fraud Control Unit.

Contact Health Law Attorneys Experienced in Healthcare Fraud Cases.

The Health Law Firm represents physicians, medical practices, pharmacists, pharmacies, and other health providers in healthcare fraud cases, including investigations, regulatory matters, litigation, and audits involving government health programs (Medicare, Medicaid, TRICARE).

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

Sources Include:

Meale, Jenn. "Attorney General Bondi's Office Reaches Historic Healthcare Fraud Settlement." Florida Office of the Attorney General. (July 2, 2012). Press Release. From:
http://www.myfloridalegal.com/newsrel.nsf/newsreleases/E494FDADFF113AC885257A2F0068F790

Schmidt, Michael S. and Katie Thomas. "GlaxoSmithKline Agrees to Pay $3 Billion in Fraud Settlement." New York Times. (July 2, 2012). From:
http://www.nytimes.com/2012/07/03/business/glaxosmithkline-agrees-to-pay-3-billion-in-fraud-settlement.html?pagewanted=all

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.  http://www.thehealthlawfirm.com/  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

What You Should Know About Medicaid Audits

The Agency for Health Care Administration (AHCA), Office of Inspector General, Bureau of Medicaid Program Integrity, is the Florida agency responsible for routine audits of Medicaid health care providers to ensure that the Medicaid Program was properly billed for services. Health care professionals receiving the greatest amounts of Medicaid payments are also the ones most likely to be audited. These include pediatricians, Ob/Gyns, family practice physicians and dentists. The Medicaid audit usually requests information in a questionnaire that the medical practice is required to complete, as well as a request for copies of medical records (including x-rays and other diagnostic studies) on the list of Medicaid patients selected for the audit.

If AHCA determines that Medicaid overpaid for services, it will use a complex mathematical extrapolation formula to determine the repayment amount. The amount of the repayment to the Medicaid Program can be considerably greater than (30 to 100 times as much as) the actual amount of overpayment disclosed by the sample of records audited. Additionally, fines and penalties can be added by the Medicaid Program. However, you can eliminate or reduce the amount of any such repayment by actions taken both before and during the Medicaid audit.

Tips for Your Medical Practice:

There are ways to manage your practice that will help you in the event that you are selected for a Medicaid Audit.

1. Every patient record entry should be clearly dated and signed or initialed by the provider. Make sure this is always done.
   
   
2. When documenting in the patient's record, make sure that you document exactly what services were needed and completed in order to support what was billed to Medicaid.
   


3. Communicate with the person responsible for your billing so that the actual services provided are billed for. Do not bill in advance for anticipated services needed as indicated in the appointment calendar or on a treatment plan.


4. Keep the patient records organized and ready for copying if necessary. Use only one sided documents and securely fasten small forms (prescriptions, telephone memos, small sticky notes) onto 8-1/2" by 11" paper. Scan all such documents into the patient record if using an electronic health record (EHR).


5. Services provided by a physician who is not enrolled in the Medicaid Program to a Medicaid patient may not be billed to or paid by the Medicaid Program. Therefore, never allow any other physician associated with your practice who is not enrolled as a Medicaid provider to provide services to Medicaid patients. Do not allow a new physician coming in to your practice to treat Medicaid patients until he or she actually has received his or her Medicaid provider number. The group may not bill for the services nor may another physician bill for the services.
   


6. Ensure that all health care professionals' licenses and permits are kept up to date. Ensure that all x-ray, clinical, lab and diagnostic equipment is permitted and kept up to date. Ensure that any CLIA license or exemption certificate is correct and kept up to date. Services billed by unlicensed personnel or services provided by improperly licensed facilities may not be paid by the Medicaid Program.
   


7. Use only standard abbreviations in your medical records, documentation, orders, and reports. While an abbreviation may seem common to you or your practice, if it is not a universally accepted abbreviation, the auditors may not recognize it.
   


8. Make sure all records are timely made, accurate and legible. Safeguard them and never let the original leave your office. Illegible records are treated as a non-record, and payment completely disallowed for an illegible note or order. A missing record, x-ray or chart entry will result in a complete repayment being directed for those services.
   

The Medicaid Audit:

If you are being audited, AHCA will send you a letter notifying you of the audit. AHCA will also supply you with a list of patients to be sampled a standard sample will include a list of anywhere from 30 to 150 patient names, depending on the size of the practice. Regular audits routinely request 30 to 50 patient records. The audit letter will also include a questionnaire to be completed (Medicaid Provider Questionnaire) and a "Certification of Completeness of Records" form to complete and return with the copies of the patient records. (Please note: this will be used against you in the future if you attempt to add to or supplement the copies of the records you provided).

It is crucial that you retain the services of an expert consultant or experienced health care attorney in correctly and accurately completing the questionnaire. The letter will also request that you provide copies of the patient records for the list of patients included with the letter. You will only be given a short time to provide these documents.

1. When receiving a notice of a Medicaid audit, time is of the essence. Be sure to calendar the date that the records need to be in the AHCA office and have the records there by that date. Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be received at AHCA.


2. Obtain and review a copy of the claims you submitted and what Medicaid has paid on each of the patients being audited. This information can be found in the Medicaid portal, in your billing system, or in the Explanation of Benefits. Compare this information to the medical records to see if any issues may arise when AHCA reviews the records. (Keep this for your use, do not provide it as part of the audit records).


3. Provide a complete copy of the entire record, not just the parts from the period of time covered by the audit. Remember that other physician records obtained as history, including reports and consultations should be included. Consent forms, medical history questionnaires, histories, physicals, and other physicians' orders, may be a crucial part of the record.


4. If you suspect that an issue may arise with a particular patient, prepare a separate explanation to submit with the patient's file. AHCA will have an expert review the records, so an explanation in advance will help the expert to assess if there is in fact an issue. Any explanatory notes or other explanations should be clearly labeled as such and dated as of the date actually prepared, so there is no confusion as to whether or not it was part of the original record.


5. If your practice involves taking x-rays or using other diagnostic studies, these procedures are part of the patient's record. If the x-rays are digital, they can be submitted on a compact disc. Be sure to include the number of x-rays on the compact discs in the Certification of Completeness of Records.


6. Complete the Medicaid Provider Questionnaire in its entirety to send with the patient records. Do not leave any section blank. Use "not applicable" or "none" if necessary. Attach all required documents. Consult with an experienced health law attorney to assist in completing the form.

If you or your practice has been sent notice of a Medicaid or Medicare audit, please contact us at (407) 331-6620 or (850) 439-1001 or visit our website at www.TheHealthLawFirm.com for more information.