Responding to a Medicaid Audit: Important Tips You Should Know

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), Bureau of Medicaid Program Integrity, is the Florida agency responsible for routine audits of Medicaid health care providers. Each state has a similar state agency, though it may have a different name.  The agency’s job is to ensure that the Medicaid Program was properly billed for services. Health care professionals receiving large payments from Medicaid or who practice in areas that typically see the most abuse or fraudulent billings, are the ones most likely to be audited.  These include pediatricians, Ob/Gyns, family practice physicians and pediatric dentists.

A different state agency that may also conduct Medicaid audits is the state Medicaid Fraud Control Unit (MFCU).  However, by definition, the MFCU is investigating allegations that there is substantial fraud going on.  You should know that if you are contacted by the MFCU, this is a very serious matter.  This is not a routine audit.
However, on the “routine” audits conducted by the Medica agency, the Medicaid audit usually requests information in a questionnaire that the medical practice is required to complete. Additionally, copies of medical records (including x-rays and other diagnostic studies) on the list of Medicaid patients selected for the audit.

If AHCA (or the state Medicaid agency) 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.

 

General Practice Tips:
There are various 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 into 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.

To learn more about the Medicaid audit process and how The Health Law Firm can assist you, click here to watch our short video blog.

Don’t Wait Until It’s Too Late, 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.
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.

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 Medicaid audits, Medicaid audit defense attorney, health care fraud defense attorney, health care fraud investigation defense attorney, legal representation for health care fraud investigation, legal representation for health care fraud, Medicaid fraud defense attorney, legal representation for Medicaid fraud, legal representation for fraudulent billing, legal representation for submitting false claims to the government, legal representation for overbilling, health care fraud attorney, The Health Law Firm, reviews of The Health Law Firm attorneys, reviews of The Health Law Firm
“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 © 2017 The Health Law Firm. All rights reserved.

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East Texas Lab Agrees to Pay $3.75 Million to Settle False Claims Suit

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On December 14, 2016, owners of an East Texas clinical laboratory who overcharged Medicare for falsified driving mileage bills have agreed to pay the U.S. government $3.75 million to settle a whistle blower’s False Claims Act (FCA) lawsuit. The suit was brought by a former employee, the U.S. attorney’s office announced.

Submitting False Claims.

Texas-based Elite Lab Services LLC (Elite) and its owners, Gerard and Suzanne Dengler, reportedly settled claims brought under the False Claims Act (FCA) by plaintiff Karen Malcolm. The Denglers admitted that from approximately 2010 to 2014 they submitted inflated employee mileage claims to Medicare and billed the government health agency knowing it does not pay for mileage claims in excess of actual miles driven.

According to court documents, the defendants employed phlebotomists who traveled around East Texas to collect blood samples and transport those samples back to Elite for lab services. For several years, the defendants at Elite knowingly submitted or caused to be submitted inflated mileage calculations beyond the actual distances driven by the employees.

The Whistle Blower.

In 2014, the whistle blower Malcolm, filed the suit alleging that Elite had defrauded Medicare. She claimed that she approached the Denglers in the spring of that year to voice concerns about the billing practices, but the issue was not corrected. She then resigned from the company as a result. The U.S. Attorney’s Office revealed that the government intervened in the suit for purposes of the settlement.

In an agreed final judgment, the parties said that the defendants relinquished and waived all right and title to more than $2.5 million in cash held in a collection of several financial accounts and sales of real property that they owned to satisfy the settlement in the instant case.

As a result of the deal, Malcolm will receive a 21 percent share of the recovery, totaling $787,500, authorities said.

Medicare and Medicaid fraud cases brought on by whistleblowers are unfortunately becoming more common. To read about the serious repercussions of cases like this, click here to read one of my prior blogs.

Contact an Experienced Health Law Attorney to Assist in Whistleblower/Qui Tam Cases.

If you have knowledge of false claims being filed against Medicare, Medicaid, TRICARE/CHAMPUS or any other type of government program, please contact us, and we will be happy to assist you. Our law firm represents health professionals and health care organizations almost exclusively. Yet, we have been involved in a number of whistle blower/qui tam cases, in which we represent the person who files the claim, as well as in defending them in certain cases.

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

Sources:

Wolf, Alex. “East Texas Lab Pays $3.75M For Falsified Medicare Billing.” Law360. (December 14, 2016). Web.

“Tyler lab, owners to pay $3.75 million for filing false Medicare claims.” Longview Business Journal. (December 14, 2016). Web.

“East Texas lab company, owners to pay $3.75M for false Medicare claims.” KLTV-ABC. (December 14, 2016). Web.

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

KeyWords: False Claims Act (FCA) attorney, legal representation for submitting false claims to the government, defense attorney, Medicare false claims defense lawyer, allegations of false billing, Medicare and Medicare fraud investigation defense attorney, consumer reports of false claims, Medicare audit defense lawyer, health care fraud defense attorney, whistle blower attorney, qui tam defense lawyer, legal representation for whistle blower suits, reviews of The Health Law Firm attorneys, The Health Law Firm reviews, qui tam relator’s attorney, qui tam defense attorney, Florida whistle blower case, Virginia Whistle blower case, Colorado whistle blower case, Louisianan Whistle blower case, complex healthcare litigation attorney
“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.



DOJ Releases 2016 False Claims Act Recovery Statistics: Third Highest Annual Recovery Ever

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On December 14, 2016, the U. S. Department of Justice (DOJ) released its annual False Claims Act (FCA) recovery statistics. It revealed that the DOJ obtained more than $4.7 billion in settlements and judgments from civil cases involving fraud and false claims against the government in fiscal year 2016. What this indicates to me is that, if all of these cases had been brought by individual relators, those relators could have shared in as much as $1.41 billion as their personal reward for the relator’s part of the recoveries. A whistle blower can receive up to 30 percent of the amount warded to the government, plus all attorney’s fees and costs, for bringing a successful False Claims Act case.

The Third Highest Annual Recovery.

Based on these statistics, 2016 took its place as the third highest annual recovery since the FCA was established in the 1800s. The fiscal year average jumps to nearly $4 billion since fiscal year 2009, and the total recovery during that period to $31.3 billion.

“Congress amended the False Claims Act 30 years ago to give the government a more effective tool against false and fraudulent claims against federal programs,” said Mizer. “An astonishing 60 percent of those recoveries were obtained in the last eight years. The beneficiaries of these efforts include veterans, the elderly, and low-income families who are insured by federal health care programs; families and students who are able to afford homes and go to college thanks to federally insured loans; and all of us who are protected by the government’s investment in national security and defense. In short, Americans across the country are healthier, enjoy a better quality of life, and are safer because of our continuing success in protecting taxpayer funds from misuse.”

Fraud in the Health Care Industry.

The DOJ recovered $19.3 billion in health care fraud claims from January 2009 to the end of fiscal year 2016. Additionally, 57 percent of the health care fraud dollars recovered in the 30 years since the 1986 amendments to FCA claims. Most of the false claims actions are filed under those whistle blower, or qui tam, provisions. Whistle blowers filed 702 qui tam suits in fiscal year 2016, and the DOJ recovered $2.9 billion in these and earlier filed suits in 2016. The government awarded the whistle blowers a total of $519 million during the same time period.

Click here to read the DOJ’s press release in full.

These DOJ fraud recoveries restore valuable assets to federally funded programs such as Medicare, Medicaid, and TRICARE, the health care program for service members and their families.

To read more on the importance of preventing health care fraud, click here to read one of my prior blogs.

If you find yourself at the center on an audit or investigation for health care fraud, don’t wait until it’s too late. Contact an experienced health law attorney. To find out how The Health Law Firm can help you, click here.

Contact Health Law Attorneys Experienced with FCA, Qui Tam or Whistle Blower Cases.

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

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

Richardson, Kalie. “DOJ Announces $4.7 billion in False Claims Act Collections – $2.5 billion in Health Care Alone.” AHLA Weekly. (December 15, 2016). Web.

Sheppard Mullin Richter & Hampton LLP. “DOJ Releases its 2016 False Claims Act Recovery Statistics.” The National Law Review. (December 15, 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: Florida health law defense attorney, qui tam defense lawyer, legal representation for allegations of health care fraud, legal representation for health care fraud investigations, health care fraud defense attorney, whistle blower attorney, AKS lawyer, Anti-Kickback Statute attorney, False Claims Act defense lawyer, FCA attorney, illegal kickbacks, DOJ settlement attorney, government health care fraud investigation defense attorney, health fraud and abuse allegations, health fraud attorney, FCA legal representation, relator attorney, legal representation for U.S. Department of Justice (DOJ) investigations, DOJ investigation defense attorney, False Claims Act (FCA) defense attorney, legal representation for FCA suit, legal representation for submitting false claims to the government, Medicare and Medicaid fraud defense lawyer, legal representation for Medicare and Medicaid fraud, The Health Law Firm reviews, Reviews of The Health Law Firm attorneys, whistle blower defense attorney, Florida qui tam whistle blower attorney, Colorado qui tam whistle blower lawyer, Louisiana qui tam whistle blower attorney, Kentucky qui tam whistle blower lawyer, Virginia qui tam whistle blower attorney, District of Columbia (D.C.) qui tam whistle blower lawyer, Florida False Claims Act (FCA) and civil monetary penalties attorney, Colorado False Claims Act (FCA) and civil monetary penalties lawyer, Louisiana False Claims Act (FCA) and civil monetary penalties attorney, Kentucky False Claims Act (FCA) and civil monetary penalties lawyer, Virginia False Claims Act (FCA) and civil monetary penalties attorney, District of Columbia (D.C.) False Claims Act (FCA) and civil monetary penalties lawyer
“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.

Forest Labs Agree to Pay $38 Million Settlement to End Whistle Blower’s FCA Suit

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 15, 2016, Forest Laboratories agreed to pay $38 million to resolve a whistle blower’s False Claims Act (FCA) suit involving allegations that it paid kickbacks to doctors who prescribed three of the company’s drugs, the U.S. Department of Justice (DOJ) announced.

The lawsuit contends that Pharmaceuticals Inc. (Forest), targeted physicians who had a high prescription writing potential and large Medicare and Medicaid patient populations. They also allegedly paid those physicians to attend lavish speaking events where the company had the opportunity to give incentives to health care providers to prescribe their products.

The Settlement.

The new deal settles claims that the New York City-based company and its subsidiary, provided money and meals to certain doctors in connection with programs about the drugs Bystolic, Savella and Namenda. According to the DOJ, the scheme took place between the start of 2008 and the end of 2011. Bystolic is a “beta blocker” that’s often used to treat high blood pressure, Savella is used to treat fibromyalgia and Namenda is used to treat dementia.
“Quality and patient safety must be the driving factors in the medical decision making process,” Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services’ Office of Inspector General, said in a statement. “Attempting to sway physicians to deviate from those core values with illegal inducements, as alleged in this lawsuit, debilitates their unbiased medical judgment at the expense of patients and taxpayers.”

 

The Speaker Programs.

The kickback scheme involved speaker programs in which Forest utilized as ways to persuade doctors to prescribe the three drugs. Forest provided payments and food even when the events were canceled, when no licensed health care professionals attended the programs, when the same people attended multiple programs within a short period of time and when the associated meals cost more than Forest generally allowed, the government said.

“Kickback schemes undermine the integrity of medical decisions and increase the costs of health care for everyone,” Principal Deputy Assistant Attorney General Benjamin C. Mizer said in a statement. “Such schemes are particularly of concern when they are designed to influence drug prescriptions, and the Department of Justice will vigorously pursue companies that subvert the law at the public’s expense.”

Of the $38 million that the government was able to recover, state Medicaid programs will get about $2.5 million and the whistle blower in the case is set to receive almost $8 million.
To read about a similar case of kickback schemes involving pharmaceutical companies, click here to read my prior blog.

Contact Health Law Attorneys Experienced with Qui Tam or Whistle blower Cases.

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

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

Sources:

Kennedy, John. “$38M FCA Payout Ends Kickback Suit Against Forest Labs.” Law360. (December 15, 2016). Web.

Tycko & Zavareei LLP. “Forest Laboratories and Forest Pharmaceuticals Inc. Settle Lawsuit Alleging Companies Engaged in Physician Kickback Scheme; Agree to Pay $38 Million.” The National Law Review. (December 19, 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, legal representation for FCA suit, legal representation for submitting false claims to the government, whistle blower defense attorney, qui tam defense attorney, legal representation against whistle blower claims, legal representation for qui tam suits, legal representation for kickback scheme, alleged kickback scheme defense attorney, AKS defense lawyer, Medicare and Medicaid fraud defense lawyer, legal representation for Medicare and Medicaid fraud, legal representation for U.S. Department of Justice investigations, DOJ investigation defense attorney, reviews of The Health Law Firm, The Health Law Firm attorney reviews
“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.