20 Tips to Help You Survive Facing Peer Review for Your Hospital Clinical Privileges-Part 2 of 2

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

In Part 1 of this blog I began a list of tips that should serve you well if you are notified by your hospital or medical staff that you are the subject of an internal or external peer review action. Click here to read Part 1.

20 Tips For Successful Outcome in Peer Review (Continued):

10.    If you are given the opportunity to meet with the reviewers or provide information to them, do so.  If you haven’t been offered this, ask for it in writing.

11.    Make sure any written response is provided in a typewritten letter formal not via e-mail, text or YouTube posting or handwritten note.

12.    In your written statement or response, if you use any abbreviations, spell them out completely the first time you use them and place the abbreviation after, in parentheses.  Remember, future reviews of your statement may not be physicians (e.g., a judge) or may not be in your medical specialty.

13.    It is never too early to engage experienced health car legal counsel to assist you in such matter.  But if you do, make sure you do hire an actual health law attorney who has experience with medical staff peer review actions.  This is no place for a plaintiff’s personal injury attorney, a criminal defense attorney or your tax, or business lawyer.

14.    If you find out that your matter is being sent out to an external peer review organization you should retain an experienced health law attorney immediately and obtain your own medical expert review.

15.    If the care being examined involved another physician as well as you, or if the care was of a patient referred by another physician, see if that physician supports the care you provided and will provide you a letter or statement saying that.

16.    If the allegation being reviewed involves facts that you know are not true, see if you can obtain evidence of this.  For example, I had a case where nursing staff filed a complaint against my client a male OB/GYN claiming that the mother of a minor female patient had demanded that her daughter only be examined by a female doctor.  We are able to obtain an affidavit from the mother swearing that she had never stated that.  The peer review matter was dismissed and closed.

17.    If it appears that you are being targeted for repeated peer review complaints or investigations, it is time to get out of that place.  Read the handwriting on the wall.  However , see #1 above.  Do not resign with any type of peer review pending.

18.    Remember that peer review proceedings are supposed to be confidential.  Therefore work through your legal counsel in obtaining outside reviews.  Do not discuss the matter with those outside the medical staff.

19.    Although the peer review process is confidential, it is not supposed to be “secretive.”  The person who is the subject of peer review should have access to the complaint and medical records involved.  This should not be a Star Chamber proceeding.  Make a polite written request for copies of such materials or to be allowed to review them and make notes.

20.    In many cases, you may find that you did make a mistake, violate a policy or procedure, skip a step in an algorithm, fall below the standard of care, or otherwise screw up.  Except in cases of the most egregious situations, your best course o action may be to admit this, explain how this happened, and outline steps you are taking to make sure it does not happen again.  This is especially true when it is your first “offense” and you have many years of otherwise excellent performance.  The medical staff usually wants to make sure that when a mistake occurs, the health provider has the ability to recognize it and learn from it.

Follow These Tips for The Best Results in a Peer Review Matter.

If you follow these tips, you have the best chance of coming out of the peer review without problems.  However, in a really serious case, where many records are being reviewed and the allegations appear to be very serious, then it is most important to retain an experienced health care attorney at the earliest opportunity and take that attorney’s advice.  You will be in for the fight of your professional life.

Click here to read Part 1 of this Blog
.

For more information, read one of my prior blogs on peer review, avoiding the disruptive physician label and clinical privileges.


Don’t Wait Until It’s Too Late, Contact a Health Law Attorney Experienced in the Process of Peer Reviews.

If you are the subject of a peer review proceeding, immediately retain experienced, knowledgeable health care counsel to represent you. The attorneys of The Health Law Firm have experience in most, if not all, types of “fair hearings” involving health care issues and health care providers.

At the Health Law Firm we provide legal services for physicians and other health care providers. This includes nurse practitioners, nurses, dentists, psychologists, psychiatrists, mental health counselors, medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other health care provider. We represent facilities, individuals, groups and institutions in contracts, sales, mergers and acquisitions.  We also represent physicians and health care providers in complex litigation in both state and federal courts.

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.

Keywords: Legal representation for peer review, peer review defense attorney, medical staff peer review confidentiality, medical staff fair hearing legal representation, medical staff fair hearing attorney, clinical privileges hearing defense attorney, clinical privileges hearing legal representation, clinical privileges hearing attorney, legal counsel on peer review process, legal representation for physician defamation, health law defense attorney, economic credentialing, sham peer review attorney, health law peer review attorney, legal representation for peer review investigations, health care litigation legal counsel, complex health care litigation attorney, legal representation for health care employment issues, disruptive physician representation, legal representation for disruptive physicians,  health care employment defense attorney, The Health Law Firm reviews, reviews of The Health Law Firm Attorneys

“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 © 2018 The Health Law Firm. All rights reserved.

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20 Tips to Help You Survive Facing Peer Review for Your Hospital Clinical Privileges-Part 1 of 2

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

If you are a physician, nurse practitioner, psychologist, clinical pharmacist, oral surgeon, ophthalmologist, or other licensed health professional with clinical privileges in a hospital, chances are that one day you will be subject to a peer review action or investigation.  It may be a simple one-time matter based on a patient complaint or adverse outcome, or it may be a lengthy process involving a large number or your cases and records.

A peer review action action may be initiated because of a patient complaint.  It may be commenced because of complaints filed by hospital staff.  It may be begun because of an unexpected adverse outcome.  It may be begun because a patient files s medical malpractice lawsuit.  It may result from a statistical review by the Utilization Review office or from the Quality Improvement office.

This is part 1 of a 2 part blog series. Click here to read part 2.

A Notice of A Peer Review Must Be Treated Seriously.

Regardless of the source, or how petty or meritless it may seem, the health professional who is the subject of the peer review must treat it seriously.  The actions you take may resolve the matter at a preliminary stage or it may cause an escalation to a hearing, adverse action, and a National Practitioner Data Bank (NPDB) Report, with career-ending results.


Tips to Survive Peer Review.

Following are tips that the individual who is the subject of a peer review action that may help you to resolve it at the lowest level feasible under the circumstances.

The following tips assume that you have been notified of an initial peer review matter ant the facts or subject being investigated.

1.    Do not resign or allow your clinical privileges to expire while the matter is pending. If you do so, this will be treated in a similar manner to having your privileges revoked in a clinical privileges matter and it will be reported out as such to the NPDB and other reporting organizations.

2.    Provide a response or explanation if given the opportunity.  But make sure you have reviewed the records, researched the medical issues as appropriate, and provide a well-organized, thought-out, objective and professional response.

3.    Remember that this review is only about you and your actions.  It is not about anyone else and this is not the place to make accusations about others.  Discuss what you did (or did not do);  do not point the finger at others and argue that they have done the same thing or worse.

4.    Remain objective.  Do not lose your temper and respond in a defensive, inflammatory matter.  Assume that everyone is just trying to do their jobs.

5.    In any written response, address the facts.  Do not address what you think the motives of other individuals are.

6.    Make sure your response is objective.  Try to avoid subjective statements.  Speak in terms of provable facts and what the record or other documents show.  If you have documents (e.g., office records, algorithms, standards, guidelines) that those conducting the peer review do not have, attach them to your response.

7.    Make sure your response is professional.  Follow the rules for professional correspondence, that I wrote about in a prior blog about this.  [Note:  Add link.]

8.    If you don’t have all of the records on the matter, ask for them.  Also, obtain and review any applicable hospital or department policies and procedures.  Review the medical staff Rules and Regulations, as well.

9.    Support and explain what you did logically and with reference to medical journal articles and medical treatises.  Attach legible copies of any relevant medical literature (or relevant portions of it).  Be sure to completely identify any medical literature you attach by including title page, publication info, date, volume, pages, etc.

I will continue these tips in Part 2 of this blog.

For more information, read one of my prior blogs on peer review, avoiding the disruptive physician label and clinical privileges.

Don’t Wait Until It’s Too Late, Contact a Health Law Attorney Experienced in the Process of Peer Reviews.

If you are the subject of a peer review proceeding, immediately retain experienced, knowledgeable health care counsel to represent you. The attorneys of The Health Law Firm have experience in most, if not all, types of “fair hearings” involving health care issues and health care providers.

At the Health Law Firm we provide legal services for physicians and other health care providers. This includes nurse practitioners, nurses, dentists, psychologists, psychiatrists, mental health counselors, medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other health care provider. We represent facilities, individuals, groups and institutions in contracts, sales, mergers and acquisitions.  We also represent physicians and health care providers in complex litigation in both state and federal courts.

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.

Keywords: Legal representation for peer review, peer review defense attorney, medical staff peer review confidentiality, medical staff fair hearing legal representation, medical staff fair hearing attorney, clinical privileges hearing defense attorney, clinical privileges hearing legal representation, clinical privileges hearing attorney, legal counsel on peer review process, legal representation for physician defamation, health law defense attorney, economic credentialing, sham peer review attorney, health law peer review attorney, legal representation for peer review investigations, health care litigation legal counsel, complex health care litigation attorney, legal representation for health care employment issues, disruptive physician representation, legal representation for disruptive physicians,  health care employment defense attorney, The Health Law Firm reviews, reviews of The Health Law Firm Attorneys

“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 © 2018 The Health Law Firm. All rights reserved.

Wisconsin Supermarket Violated FCA With Illegal Kickbacks, Pharmacist Claims

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On December 20, 2016, a pharmacist and whistle blower told an Illinois federal court that Wisconsin and Chicago-area chain of grocery stores, Roundy’s Supermarket, Inc. (Roundy’s), knew gift cards it was providing Medicare and Medicaid beneficiaries were actually illegal kickbacks. In defense of his False Claims Act (FCA) Suit, the whistle blower claims the chain proceeded to hand them out anyway despite knowing they were illegal.

The Whistle Blower and the Alleged Scheme.

The whistle blower in the suit, pharmacist Jefferey Kotwica, alleged the company was involved in illegal kickbacks, thus allegedly defrauding government health care programs, by offering gift cards to pharmacy customers that exceeded legal limits. Roundy’s enacted a Script Saver Program that gave all customers “pharmacy club coupons” for pharmacy purchases. When they reached five of those coupons, they could be redeemed for a $10 gift card, the complaint states. At some stores, the number of coupons necessary for a gift card was lowered to three, Kotwica said.

Roundy’s has mounted a defense to these allegations. Despite that defense, the whistle blower maintains the gift cards were more than the legal nominal value allowed. The whistle blower claimed additionally that the “retailer reward exception” failed because the gift cards were tied to the services the government health care programs reimbursed and were meant to induce customers to transfer prescriptions to the store.

The pharmacist and whistle blower in the case, claimed that he heard corporate executives discussing having Medicare and Medicaid recipients excluded from the program because they were concerned their inclusion was illegal, but never acted on that concern. Therefore, Kotwica said that this shows that Roundy’s had the intent to violate the FCA. The whistle blower also claimed that the company retaliated against him for speaking out to the point where he resigned his position as a pharmacist with it.

The case was originally filed in June 2015. Like all federal False Claims Act (FCA) cases, it remained sealed until ordered unsealed by the court. It was unsealed in July 2016 after the U.S., and the states of Illinois, Minnesota and Wisconsin declined to intervene in the case. Click here to read the response in this case.

Fighting Government Fraud and Abuse.

This case was brought under the federal False Claims Act (FCA) or federal “whistle blower law.” This law contains standards for both civil and criminal penalties against those filing false claims for services paid for by the government. False Claims Act cases, such as this recent one, are typically filed in a qui tam (or whistle blower) proceeding. This type of action involves a private party filing a lawsuit on behalf of the government against a defendant who allegedly defrauded the government. The “whistle blower” receives a percentage of the money recovered by the government (if any), through any judgment or settlement of the case. Often the amounts awarded to the whistle blower are in the millions of dollars. Whistle blowers are often protected from receiving any potential civil liability or prosecution for their involvement in the matter.

Our firm has been on both sides of both federal and state whistle blower or qui tam cases. We have represented nurses, physicians, pharmacists and other health professionals in bringing such cases. We have also defended physicians, health care providers, medical groups and health facilities in such cases.

We have also represented relators or plaintiffs bringing such actions to recover money on behalf of the government. A qui tam relator can receive up to 30% of the amount recovered on behalf of the government. This means, for example, that of a defendant settles with the government paying back $5 million, the relator or whistle blower can receive up to $1.5 million, plus his attorney’s fees and costs. Usually, the biggest obstacle to bringing any such case is being able to show an actual false claim that was filed.

If you have information concerning health care fraud by overbilling federal health care programs such as Medicare or Medicaid, do not hesitate to take action. The government urges health care providers to step forward and report illegal and fraudulent activities as soon as they are uncovered. The False Claims Act provides a system of rewards that encourages whistle blowers to bring these issues to the government’s attention.

Contact Health Law Attorneys Experienced with Health Care Fraud and Qui Tam or Whistleblower Cases.

The Health Law Firm’s attorneys routinely represent physicians, nurses, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in bringing or defending against False Claims Act, whistle blower or qui tam cases. We also defend health care providers in Medicare and Medicaid investigations, audits and recovery actions. We represent plaintiffs and defendants in complex health care litigation in state or federal courts.

Attorneys with The Health Law Firm also represent health care professionals and others who may desire to file a qui tam, False Claims Act or whistle blower suit. We work with physicians, nurses and other professionals to investigate, document and file such cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding and other services that assist us in such matters. We have represented number of doctors and other licensed health professionals as relators in bringing qui tam or whistle blower cases. Our attorneys are also available to defend physicians, medical groups and health care providers in qui tam or whistle blower cases.

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

Sources:

Kass, Dani. “Wis. Supermarket Should Face FCA Suit, Pharmacist Says.” Law360. (December 20, 2016). Web.

“Wis. Supermarket Should Face FCA Suit, Pharmacist Says.” Make Me Feed. (December 21, 2016). Web.

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.

KeyWords: False Claims Act (FCA) defense attorney, whistle blower defense attorney, qui tam defense attorney, legal representation for FCA claims, legal representation for qui tam cases, legal representation for whistle blower defense cases, Medicare and Medicaid fraud defense attorney, legal representation for Medicare and Medicaid fraud, legal representation for illegal kickback schemes, health care fraud defense lawyer, health care fraud scheme, legal representation for Medicare and Medicaid fraud investigation, Florida FCA defense attorney, Colorado FCA defense attorney, Kentucky FCA defense attorney, Louisiana FCA defense attorney, District of Columbia FCA defense attorney, Virginia FCA defense attorney, The Health Law Firm reviews, reviews of The Health Law Firm attorneys, complex health care litigation attorney, legal defense of complex health care business disputes, complex litigation defense counsel

“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 © 2016 The Health Law Firm. All rights reserved.