By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
A co-owner and operator of three Miami-area pharmacies pleaded guilty on December 6, 2012, for his part in a $23 million health care fraud scheme. The pharmacy owner allegedly admitted in the Florida Southern Federal District Court to one count of conspiracy to commit health care fraud and one count of conspiracy to pay illegal health care kickbacks, according to a Department of Justice (DOJ) press release.
Click here to read the entire press release from the DOJ.
Owner and Co-Conspirators Allegedly Paid for Referrals.
According to court documents, the pharmacy owner allegedly admitted to paying illegal kickbacks to an unnamed number of co-conspirators in return for Medicare and Medicaid beneficiary information. That information was then used to submit fraudulent claims. A majority of the beneficiaries referred to the owner’s pharmacies reportedly resided at assisted living facilities (ALFs) in Miami.
The court documents state that the pharmacy owner also allegedly paid kickbacks to physicians in exchange for prescription referrals which were also billed to Medicare.
Pharmacy Owner Allegedly Submitted More Than $23 Million in False Claims.
As part of the scheme, the pharmacy owner allegedly instructed drivers working for his pharmacies to pick up unused medications from ALFs around Miami. The medications were then allegedly placed back into pill bottles. Unused and partially used medications were billed back to Medicare and Medicaid, according to court documents.
Click here to read the court documents on this case.
The pharmacy owner and his co-conspirators allegedly submitted more than $23 million in false and fraudulent claims to Medicare and Florida Medicaid programs.
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.
Sound Off.
What do you think of this case? Is the Miami area just a hotbed for Medicare and Medicaid schemes? Please leave any thoughtful comment below.
Sources:
United States of America v. Jose Carlos Morales. Case Number 12-23374, Preliminary Injunction and Supporting Memorandum of Law. (September 14, 2012). From: http://www.thehealthlawfirm.com/uploads/USA%20v%20Morales.pdf
Department of Justice. “Pharmacy Owner Pleads Guilty in Miami for Role in $23 Million Health Care Fraud Scheme.”
Department of Justice . (December 6, 2012). From: http://www.justice.gov/opa/pr/2012/December/12-crm-1461.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.
Showing posts with label Medicare investigation. Show all posts
Showing posts with label Medicare investigation. Show all posts
Thursday, January 10, 2013
Tuesday, November 20, 2012
CVS Pharmacies Possibly Under Investigation for Practice Used to Refill Prescriptions
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 Notified of 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 weren’t 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.
Tempest in a Teapot?
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 actually is 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, Florida CVS Pharmacies in the News.
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 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 Notified of 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 weren’t 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.
Tempest in a Teapot?
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 actually is 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, Florida CVS Pharmacies in the News.
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.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.
Friday, August 3, 2012
The CMS Recovery Audit Prepayment Review (RAPR) Will Kick Off on August 27, 2012
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On July 31, 2012, the Centers for Medicare and Medicaid Services (CMS) announced on its website that hospitals should brace themselves for prepayment audits beginning August 27, 2012.
The CMS originally announced the Recovery Audit Prepayment Review (RAPR) Demonstration Project in November of 2011 for a January 1, 2012 start date, then delayed it to June 1, 2012, then again to, “summer of 2012.”
To see the official announcement from the CMS, click here.
Recovery Audit Contractors (RACs) will Review Claims with High Rates of Improper Billing.
The Recovery Audit Prepayment Review allows Recovery Audit Contractors (RACs), (commonly known to attorneys representing provers as “bounty hunters) to review claims before they are paid to ensure that the provider has complied with all Medicare payment rules. RACs will conduct prepayment reviews on certain types of claims that have been found to result in high rates of improper payments. The goal is to cut improper payments before they even happen.
Initial Launch of Recovery Audit Prepayment Reviews Will Focus on Seven States.
The Recovery Audit Prepayment Reviews will focus on seven states with high volumes of fraud and error-prone providers. These states are: California, Florida, Illinois, Louisiana, Michigan, New York, and Texas. The Recovery Audit Prepayment Reviews will also include four states with a high volume of claim with short inpatient hospital stays. These states are Missouri, North Carolina, Ohio, and Pennsylvania.
Here are the RACs for those states from the CMS:
HealthDataInsights serves California and Missouri
7501 Trinity Peak Street, Suite 120
Las Vegas, NV 89128
(866) 590-5598
Connolly Inc. serves Florida, Louisiana, Texas, and North Carolina
One Crescent Drive, Suite 300-A
Philadelphia, PA 19112
(866) 360-2507
CGI Federal Inc. serves Illinois, Michigan, and Ohio
1001 Lakeside Ave., Suite 800
Cleveland, OH 44114
(877) 316-RACB
Diversified Collection Services serves New York and Pennsylvania
2819 Southwest Blvd
San Angelo, TX 76904
(866) 201-0580
To see the name of the RAC for your state, click here.
Other States May be Included in the Recovery Audit Prepayment Review Demonstration Project.
CMS is expecting that the prepayment reviews will help lower error rates by preventing improper payments instead of searching for improper payments after they occur. If these reviews are successful, other states will be included in subsequent roll-outs of the Recovery Audit Prepayment Review Demonstration.
Recovery Audit Prepayment Review Demonstration to Help Cut Improper Payments.
In 2012, President Obama set three goals for cutting improper payments this year: curbing overall payment errors by $50 billion, cutting Medicare error rate in half and recovering $2 billion in improper payments, according to CMS. The prepayment review program is intended to help achieve those goals. It will also play a big part in preventing fraud, waste and abuse.
The demonstration project will last for three years.
Click here to learn more on the Recover Audit Prepayment Review Demostration.
Our Issues with Widespread Prepayment Reviews.
Our concerns with the widespread use of prepayment reviews are many. Prepayment reviews, especially when used where there is no indication of any fraud or a high error rate, can slow down a health provider’s cash flow to the point that it is put out of business. This is especially true for those that are predominately reimbursed by Medicare. The small business provider is at a greater risk.
In addition, the increase in professional time, salaries, copy costs, handling costs and postage greatly increase the administrative burden and the cost of doing business. To date, we have not seen or heard of any proposal by CMS to reimburse the provider for this additional unnecessary and unplanned expense.
Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.
The Health Law Firm's attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in 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:
Cheung, Karen. “Prepayment Audits Start Aug. 27.” Fierce Healthcare. (July 31, 2012). From: http://www.fiercehealthcare.com/story/prepayment-audits-start-aug-27/2012-07-31
CMS.gov. “Recovery Audit Prepayment Review.” CMS.gov. (July 31, 2012). From: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.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.
On July 31, 2012, the Centers for Medicare and Medicaid Services (CMS) announced on its website that hospitals should brace themselves for prepayment audits beginning August 27, 2012.
The CMS originally announced the Recovery Audit Prepayment Review (RAPR) Demonstration Project in November of 2011 for a January 1, 2012 start date, then delayed it to June 1, 2012, then again to, “summer of 2012.”
To see the official announcement from the CMS, click here.
Recovery Audit Contractors (RACs) will Review Claims with High Rates of Improper Billing.
The Recovery Audit Prepayment Review allows Recovery Audit Contractors (RACs), (commonly known to attorneys representing provers as “bounty hunters) to review claims before they are paid to ensure that the provider has complied with all Medicare payment rules. RACs will conduct prepayment reviews on certain types of claims that have been found to result in high rates of improper payments. The goal is to cut improper payments before they even happen.
Initial Launch of Recovery Audit Prepayment Reviews Will Focus on Seven States.
The Recovery Audit Prepayment Reviews will focus on seven states with high volumes of fraud and error-prone providers. These states are: California, Florida, Illinois, Louisiana, Michigan, New York, and Texas. The Recovery Audit Prepayment Reviews will also include four states with a high volume of claim with short inpatient hospital stays. These states are Missouri, North Carolina, Ohio, and Pennsylvania.
Here are the RACs for those states from the CMS:
HealthDataInsights serves California and Missouri
7501 Trinity Peak Street, Suite 120
Las Vegas, NV 89128
(866) 590-5598
Connolly Inc. serves Florida, Louisiana, Texas, and North Carolina
One Crescent Drive, Suite 300-A
Philadelphia, PA 19112
(866) 360-2507
CGI Federal Inc. serves Illinois, Michigan, and Ohio
1001 Lakeside Ave., Suite 800
Cleveland, OH 44114
(877) 316-RACB
Diversified Collection Services serves New York and Pennsylvania
2819 Southwest Blvd
San Angelo, TX 76904
(866) 201-0580
To see the name of the RAC for your state, click here.
Other States May be Included in the Recovery Audit Prepayment Review Demonstration Project.
CMS is expecting that the prepayment reviews will help lower error rates by preventing improper payments instead of searching for improper payments after they occur. If these reviews are successful, other states will be included in subsequent roll-outs of the Recovery Audit Prepayment Review Demonstration.
Recovery Audit Prepayment Review Demonstration to Help Cut Improper Payments.
In 2012, President Obama set three goals for cutting improper payments this year: curbing overall payment errors by $50 billion, cutting Medicare error rate in half and recovering $2 billion in improper payments, according to CMS. The prepayment review program is intended to help achieve those goals. It will also play a big part in preventing fraud, waste and abuse.
The demonstration project will last for three years.
Click here to learn more on the Recover Audit Prepayment Review Demostration.
Our Issues with Widespread Prepayment Reviews.
Our concerns with the widespread use of prepayment reviews are many. Prepayment reviews, especially when used where there is no indication of any fraud or a high error rate, can slow down a health provider’s cash flow to the point that it is put out of business. This is especially true for those that are predominately reimbursed by Medicare. The small business provider is at a greater risk.
In addition, the increase in professional time, salaries, copy costs, handling costs and postage greatly increase the administrative burden and the cost of doing business. To date, we have not seen or heard of any proposal by CMS to reimburse the provider for this additional unnecessary and unplanned expense.
Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.
The Health Law Firm's attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in 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:
Cheung, Karen. “Prepayment Audits Start Aug. 27.” Fierce Healthcare. (July 31, 2012). From: http://www.fiercehealthcare.com/story/prepayment-audits-start-aug-27/2012-07-31
CMS.gov. “Recovery Audit Prepayment Review.” CMS.gov. (July 31, 2012). From: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.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.
Thursday, July 26, 2012
25 Mistakes Dentists Make After Being Notified of a Department of Health Complaint
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
The investigation of a complaint which could lead to the revocation of a dentist's license to practice and the assessment of tens of thousands of dollars in fines, usually starts with a simple letter from the Department of Health (DOH). This is a very serious legal matter and it should be treated as such by the dentist who receives it. Yet, in many cases, attorneys are consulted by dentists after the entire investigation is over, and they have attempted to represent themselves throughout the case. Often, the mistakes that have been made severely compromise an attorney's ability to achieve a favorable result for the dentist.
Here are the 25 biggest mistakes we see dentists make in cases after a DOH investigation has been initiated:
Not every case will require submission of materials to the Probable Cause Panel after the investigation is received and reviewed. There will be a few where the allegations made are not "legally sufficient" and do not constitute an offense for which the dentist may be disciplined.
In other cases, an experienced health care attorney may be successful in obtaining a commitment from the DOH attorney to recommend a dismissal to the Probable Cause Panel. In other cases (usually the most serious ones), for tactical reasons, the experienced health care attorney may recommend that you waive your right to have the case submitted to the Probable Cause Panel and that you proceed directly to an administrative hearing. The key to a successful outcome in all of these cases is to obtain the assistance of a health care lawyer who is experienced in appearing before the Board of Medicine in such cases and does so on a regular basis.
Contact Health Law Attorneys Experienced with Department of Health Investigations of Dentists.
The attorneys of The Health Law Firm provide legal representation to dentists in Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations and other types of investigations of health professionals and providers.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620
The investigation of a complaint which could lead to the revocation of a dentist's license to practice and the assessment of tens of thousands of dollars in fines, usually starts with a simple letter from the Department of Health (DOH). This is a very serious legal matter and it should be treated as such by the dentist who receives it. Yet, in many cases, attorneys are consulted by dentists after the entire investigation is over, and they have attempted to represent themselves throughout the case. Often, the mistakes that have been made severely compromise an attorney's ability to achieve a favorable result for the dentist.
Here are the 25 biggest mistakes we see dentists make in cases after a DOH investigation has been initiated:
1. Failing to keep a current, valid address on file with the DOH (as required by law), which may seriously delay the receipt of the Uniform Complaint (notice of investigation), letters, and other important correspondence related to the investigation.
2. Contacting the DOH investigator and providing him/her an oral statement or oral interview. (Note: There is no legal requirement to do this.)
3. Making a written statement in response to the "invitation" extended by the DOH investigator to do so. (Note: There is no legal requirement to do this.)
4. Failing to carefully review the complaint to make sure it has been sent to the correct dentist. (Note: Check name and license number).
5. Failing to ascertain whether or not the investigation is on the "Fast Track" which may then result in an emergency suspension order (ESO) suspending the dentist's license until all proceedings are concluded. (Note: This will usually be the case if there are allegations regarding drug abuse, alcohol abuse, sexual contact with a patient, mental health issues, or failure to comply with PRN instructions.)
6. Providing a copy of the dentist's curriculum vitae (CV) or resume to the investigator because the investigator requested them to do so. (Note: There is no legal requirement to do this.)
7. Believing that if they "just explain it," the investigation will be closed and the case dropped.
8. Failing to submit a timely objection to a DOH subpoena when there are valid grounds to do so.
9. Failing to forward a complete copy of the patient dental record when subpoenaed by the DOH investigator as part of the investigation, when no objection is going to be filed.
10. Delegating the task of providing a complete copy of the patient dental record to office staff, resulting in an incomplete or partial copy being provided.
11. Failing to keep an exact copy of any dental records, documents, letters or statements provided to the investigator.
12. Believing that the investigator has knowledge or experience in health care matters or procedures being investigated.
13. Believing that the investigator is merely attempting to ascertain the truth of the matter and this will result in the matter being dismissed.
14. Failing to check to see if their medical malpractice insurance carrier will pay the legal fees to defend them in this investigation.
15. Talking to DOH investigators, staff or attorneys, in the mistaken belief that they are capable of doing so without providing information that can and will be used against them.
16. Believing that because they haven't heard anything for six months or more the matter has "gone away." The matter does not ever just go away.
17. Failing to submit a written request to the investigator at the beginning of the investigation for a copy of the complete investigation report and file and then following up with additional requests until it is received.
18. Failing to wisely use the time while the investigation is proceeding to interview witnesses, obtain witness statements, conduct research, obtain experts, and perform other tasks that may assist defending the case.
19. Failing to exercise the right of submitting documents, statements, and expert opinions to rebut the findings made in the investigation report before the case is submitted to the Probable Cause Panel of your licensing board for a decision.
20. Taking legal advice from their colleagues regarding what they should do (or not do) in defending themselves in the investigation.
21. Retaining "consultants" or other non-lawyer personnel to represent them.
22. Believing that the case is indefensible so there is no reason to even try to have it dismissed by the Probable Cause Panel.
23. Attempting to defend themselves.
24. Believing that because they know someone with the Department of Health or a state legislator, that influence can be exerted to have the case dismissed.
25. Failing to immediately retain the services of a health care attorney who is experienced in such matters to represent them, to communicate with the DOH investigator for them, and to prepare and submit materials to the Probable Cause Panel.
Bonus Point: 26. Communicating with the Department of Health about the pending case. 2. Contacting the DOH investigator and providing him/her an oral statement or oral interview. (Note: There is no legal requirement to do this.)
3. Making a written statement in response to the "invitation" extended by the DOH investigator to do so. (Note: There is no legal requirement to do this.)
4. Failing to carefully review the complaint to make sure it has been sent to the correct dentist. (Note: Check name and license number).
5. Failing to ascertain whether or not the investigation is on the "Fast Track" which may then result in an emergency suspension order (ESO) suspending the dentist's license until all proceedings are concluded. (Note: This will usually be the case if there are allegations regarding drug abuse, alcohol abuse, sexual contact with a patient, mental health issues, or failure to comply with PRN instructions.)
6. Providing a copy of the dentist's curriculum vitae (CV) or resume to the investigator because the investigator requested them to do so. (Note: There is no legal requirement to do this.)
7. Believing that if they "just explain it," the investigation will be closed and the case dropped.
8. Failing to submit a timely objection to a DOH subpoena when there are valid grounds to do so.
9. Failing to forward a complete copy of the patient dental record when subpoenaed by the DOH investigator as part of the investigation, when no objection is going to be filed.
10. Delegating the task of providing a complete copy of the patient dental record to office staff, resulting in an incomplete or partial copy being provided.
11. Failing to keep an exact copy of any dental records, documents, letters or statements provided to the investigator.
12. Believing that the investigator has knowledge or experience in health care matters or procedures being investigated.
13. Believing that the investigator is merely attempting to ascertain the truth of the matter and this will result in the matter being dismissed.
14. Failing to check to see if their medical malpractice insurance carrier will pay the legal fees to defend them in this investigation.
15. Talking to DOH investigators, staff or attorneys, in the mistaken belief that they are capable of doing so without providing information that can and will be used against them.
16. Believing that because they haven't heard anything for six months or more the matter has "gone away." The matter does not ever just go away.
17. Failing to submit a written request to the investigator at the beginning of the investigation for a copy of the complete investigation report and file and then following up with additional requests until it is received.
18. Failing to wisely use the time while the investigation is proceeding to interview witnesses, obtain witness statements, conduct research, obtain experts, and perform other tasks that may assist defending the case.
19. Failing to exercise the right of submitting documents, statements, and expert opinions to rebut the findings made in the investigation report before the case is submitted to the Probable Cause Panel of your licensing board for a decision.
20. Taking legal advice from their colleagues regarding what they should do (or not do) in defending themselves in the investigation.
21. Retaining "consultants" or other non-lawyer personnel to represent them.
22. Believing that the case is indefensible so there is no reason to even try to have it dismissed by the Probable Cause Panel.
23. Attempting to defend themselves.
24. Believing that because they know someone with the Department of Health or a state legislator, that influence can be exerted to have the case dismissed.
25. Failing to immediately retain the services of a health care attorney who is experienced in such matters to represent them, to communicate with the DOH investigator for them, and to prepare and submit materials to the Probable Cause Panel.
Not every case will require submission of materials to the Probable Cause Panel after the investigation is received and reviewed. There will be a few where the allegations made are not "legally sufficient" and do not constitute an offense for which the dentist may be disciplined.
In other cases, an experienced health care attorney may be successful in obtaining a commitment from the DOH attorney to recommend a dismissal to the Probable Cause Panel. In other cases (usually the most serious ones), for tactical reasons, the experienced health care attorney may recommend that you waive your right to have the case submitted to the Probable Cause Panel and that you proceed directly to an administrative hearing. The key to a successful outcome in all of these cases is to obtain the assistance of a health care lawyer who is experienced in appearing before the Board of Medicine in such cases and does so on a regular basis.
Contact Health Law Attorneys Experienced with Department of Health Investigations of Dentists.
The attorneys of The Health Law Firm provide legal representation to dentists in Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations and other types of investigations of health professionals and providers.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620
Monday, July 2, 2012
CMS Medicare Providers Can Submit Documents Electronically to CMS Contractors
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
Medicare providers can submit medical documents to most of the Centers for Medicare & Medicaid Services (CMS) review contractors electronically. This includes the Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and will soon include several Zone Program Integrity Contractors (ZPICs).
CMS makes agreements with review contractors to identify and correct improper Medicare payments made to providers. Review contractors find the improper payments by selecting a small sample of claims and requesting medical documentation from the provider who submitted the claims. The review contractor then manually reviews the claims made against the medical documentation provided to verify the providers' compliance with Medicare's rules.
Medicare Providers Can Submit Medical Records to Many Review Contractors Electronically.
Currently, review contractors request medical documentation by sending a letter to the provider. These providers previously had two options for submitting the requested records:
Phase 1 of esMD Launched on September 15, 2011.
Phase 1 of the esMD program was initiated on September 15, 2011. During Phase 1 of esMD, Medicare providers still receive medical documentation requests via a letter in the mail. However, they have the option to electronically send medical records to the requesting review contractor.
During Phase 2 of esMD, providers will receive requests when their claims are selected for review electronically. CMS plans to initiate Phase 2 in the future but no specific date has been announced.
First Coast Service Options, Inc. Approved for Phase 1 of esMD.
Florida's Medicare Administrative Contractor (MAC), First Coast Service Options, Inc. (First Coast) has been approved by CMS to participate in Phase 1 of esMD. Florida Medicare providers who have been asked to submit records for review to First Coast can now submit them electronically.
Other review contractors who have been approved to participate in Phase 1 of esMD through May 2012 include:
Medicare providers do not have to submit medical documentation electronically. The esMD program is completely voluntary.
If providers do want to participate in the esMD program, they must first find out if their review contractor accepst esMD transactions. Additionally, providers will have to obtain access to an esMD gateway. To obtain access to a gateway, providers can either build their own or hire a Health Information Handler (HIH) to construct the gateway system.
To find out which HIHs offer esMD gateway services to providers, click here.
To learn more about requirements for participating in the esMD program, click here.
Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits.
The Health Law Firm's attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions. They also represent health providers in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at http://www.thehealthlawfirm.com/.
Sources Include:
Centers for Medicare & Medicaid Services. "Electronic Submission of Medical Documentation." Centers for Medicare & Medicaid Services. (Apr. 9, 2012). From:
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html?redirect=/esmd
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.
Medicare providers can submit medical documents to most of the Centers for Medicare & Medicaid Services (CMS) review contractors electronically. This includes the Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and will soon include several Zone Program Integrity Contractors (ZPICs).
CMS makes agreements with review contractors to identify and correct improper Medicare payments made to providers. Review contractors find the improper payments by selecting a small sample of claims and requesting medical documentation from the provider who submitted the claims. The review contractor then manually reviews the claims made against the medical documentation provided to verify the providers' compliance with Medicare's rules.
Medicare Providers Can Submit Medical Records to Many Review Contractors Electronically.
Currently, review contractors request medical documentation by sending a letter to the provider. These providers previously had two options for submitting the requested records:
1. Mail a hard copy of the records orNow, providers can submit medical records electronically to participating review contractors. CMS calls this new mechanism the Electronic Submission of Medical Documentation (esMD) program. For a chart illustrating how esMD words, click here.
2. Fax the records.
Phase 1 of esMD Launched on September 15, 2011.
Phase 1 of the esMD program was initiated on September 15, 2011. During Phase 1 of esMD, Medicare providers still receive medical documentation requests via a letter in the mail. However, they have the option to electronically send medical records to the requesting review contractor.
During Phase 2 of esMD, providers will receive requests when their claims are selected for review electronically. CMS plans to initiate Phase 2 in the future but no specific date has been announced.
First Coast Service Options, Inc. Approved for Phase 1 of esMD.
Florida's Medicare Administrative Contractor (MAC), First Coast Service Options, Inc. (First Coast) has been approved by CMS to participate in Phase 1 of esMD. Florida Medicare providers who have been asked to submit records for review to First Coast can now submit them electronically.
Other review contractors who have been approved to participate in Phase 1 of esMD through May 2012 include:
- Region A Medicare Recovery Audit (Diversified Collection Services, Inc. or "DCS")
- Region B Medicare Recovery Audit (CGI Technologies and Solutions, Inc. or "CGI")
- Medicare Administrative J1 (Palmetto GBA)
- Medicare Administrative JF (J2 & J3) (Noridan)
- Medicare Administrative J4 (Trailblazer)
- Medicare Administrative J5 (Wisconsin Physicians Service or "WPS")
- Medicare Administrative J9 (First Coast Service Options Inc. "FCSO")
- Medicare Administrative J11 (Palmetto GBA)
- Medicare Administrative J12 (Novitas Solutions)
- Medicare Administrative J14 (NHIC, Corp. or "NHIC")
- Comprehensive Error Rate Testing (CERT) Contractor
- Program Error Rate Measurement (PERM) Contractor
- DME Medicare Administrative JA (NHIC, Corp. or "NHIC")
- DME Medicare Administrative JD (Noridian)
- Medicare Administrative J13 (National Government Services or "NGS")
- DME Medicare Administrative JB (National Government Services or "NGS")
- Medicare Administrative J10 (Cahaba)
- Region D Medicare Recovery Audit (Health Data Insights or "HDI")
- Medicare Administrative J15 (CGS Administrators, LLC or "CGS")
- DME Medicare Administrative JC (CGS Administrators, LLC or "CGS")
- Region C Medicare Recovery Auditor (Connolly).
Several of the ZPICs are planning on participating in the esMD program starting summer 2012. These include:
- ZPIC Zone 1 (SafeGuard Services LLC or "SGS")
- ZPIC Zone 7 (SafeGuard Services LLC or "SGS").
Medicare providers do not have to submit medical documentation electronically. The esMD program is completely voluntary.
If providers do want to participate in the esMD program, they must first find out if their review contractor accepst esMD transactions. Additionally, providers will have to obtain access to an esMD gateway. To obtain access to a gateway, providers can either build their own or hire a Health Information Handler (HIH) to construct the gateway system.
To find out which HIHs offer esMD gateway services to providers, click here.
To learn more about requirements for participating in the esMD program, click here.
Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits.
The Health Law Firm's attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions. They also represent health providers in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at http://www.thehealthlawfirm.com/.
Sources Include:
Centers for Medicare & Medicaid Services. "Electronic Submission of Medical Documentation." Centers for Medicare & Medicaid Services. (Apr. 9, 2012). From:
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html?redirect=/esmd
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.
Monday, May 7, 2012
Over 100 Medical Professionals Arrested During Medicare Fraud Bust
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
More than 100 doctors, nurses and other licensed health professionals were arrested for alleged involvement in Medicare fraud on May 2, 2012. The arrests were made by federal agents in seven cities nationwide, but more than half took place in South Florida.
This multi-agency attack on medical professionals involved law enforcement agents from the Federal Bureau of Investigation (FBI), Department of Health and Human Services-Office of Inspector General (HHS-OIG), Medicaid Fraud Control Units (MFCU) and other state and local law enforcement agencies. In addition to arresting over 100 health professionals, these agents also executed 20 search warrants in connection with ongoing Medicare fraud investigations.
Some of the charges against the medical professionals include conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of alleged Medicare fraud schemes involving medical treatments and services such as home health care, mental health services, physical and occupational therapy, durable medical equipment (DME), mental health counseling and ambulance services. These alleged Medicare fraud schemes resulted in a combined $452 million in false billings.
HHS also took other administrative action against 52 other health providers. These providers were tracked down through data analysis and are also accused of Medicare fraud. Because of the Affordable Care Act, HHS will be able to suspend payments to these providers the entire time until the investigations are completed.
Because of the severe state budget shortfalls and the federal deficit, we are seeing a tremendous increase in both Medicare and Medicaid fraud initiatives. If you are being accused of Medicare or Medicaid fraud, it is extremely important to retain an experienced health attorney immediately.
Don't Wait; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now
The Health Law Firm's attorneys routinely represent physicians and other healthcare professionals in Medicare and Medicaid investigations, audits and recovery actions. They also represent physicians and health professionals in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.
Call now at (407) 331-6620 or (850) 439-1001 or visit our website http://www.thehealthlawfirm.com/.
Sources Include:
Weaver, Jay. "Feds Arrest More Than 100 Medicare Fraud Suspects in South Florida, Nationwide." Miami Herald. (May 02, 2012). From
http://www.miamiherald.com/2012/05/02/2779369/feds-arrest-about-100-medicare.html
U.S. Department of Justice, Office of Public Affairs. "Medicare Fraud Strike Force Charges 107 Individuals for Approximately $452 Million in False Billing." U.S. Department of Justice. Press Release. (May 02, 2012). From http://www.justice.gov/opa/pr/2012/May/12-ag-568.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. http://www.thehealthlawfirm.com/ The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
More than 100 doctors, nurses and other licensed health professionals were arrested for alleged involvement in Medicare fraud on May 2, 2012. The arrests were made by federal agents in seven cities nationwide, but more than half took place in South Florida.
This multi-agency attack on medical professionals involved law enforcement agents from the Federal Bureau of Investigation (FBI), Department of Health and Human Services-Office of Inspector General (HHS-OIG), Medicaid Fraud Control Units (MFCU) and other state and local law enforcement agencies. In addition to arresting over 100 health professionals, these agents also executed 20 search warrants in connection with ongoing Medicare fraud investigations.
Some of the charges against the medical professionals include conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of alleged Medicare fraud schemes involving medical treatments and services such as home health care, mental health services, physical and occupational therapy, durable medical equipment (DME), mental health counseling and ambulance services. These alleged Medicare fraud schemes resulted in a combined $452 million in false billings.
HHS also took other administrative action against 52 other health providers. These providers were tracked down through data analysis and are also accused of Medicare fraud. Because of the Affordable Care Act, HHS will be able to suspend payments to these providers the entire time until the investigations are completed.
Because of the severe state budget shortfalls and the federal deficit, we are seeing a tremendous increase in both Medicare and Medicaid fraud initiatives. If you are being accused of Medicare or Medicaid fraud, it is extremely important to retain an experienced health attorney immediately.
Don't Wait; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now
The Health Law Firm's attorneys routinely represent physicians and other healthcare professionals in Medicare and Medicaid investigations, audits and recovery actions. They also represent physicians and health professionals in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.
Call now at (407) 331-6620 or (850) 439-1001 or visit our website http://www.thehealthlawfirm.com/.
Sources Include:
Weaver, Jay. "Feds Arrest More Than 100 Medicare Fraud Suspects in South Florida, Nationwide." Miami Herald. (May 02, 2012). From
http://www.miamiherald.com/2012/05/02/2779369/feds-arrest-about-100-medicare.html
U.S. Department of Justice, Office of Public Affairs. "Medicare Fraud Strike Force Charges 107 Individuals for Approximately $452 Million in False Billing." U.S. Department of Justice. Press Release. (May 02, 2012). From http://www.justice.gov/opa/pr/2012/May/12-ag-568.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. http://www.thehealthlawfirm.com/ The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
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