Medicaid | The Health Law Firm Blog

You Must Challenge Overpayment Demands from Medicare and Medicaid Audits

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

We have recently received numerous communications from health care professionals, including physicians, physical therapists, occupational therapists, mental health counselors, durable medical equipment (DME) providers, assisted living facilities (ALFs), group homes, and psychologists, who have been placed on prepayment review after failing to challenge Medicare or Medicaid audit results. The problem is that these providers, once placed on prepayment review, have their payments held up for many months and are often forced out of business. Sometimes it appears that this may actually be the goal of the auditing contractor or agency.

What Happens on Prepayment Review.

Failing […]

By The Health Law Firm|2024-03-14T10:00:45-04:00June 1, 2018|Appeal, In the Know, Medicaid, Medicaid audit, Medicare, Medicare Audit, The Health Law Firm Blog|

Physician Argues Definition of “Peer” at Formal Administrative Hearing

FACTS: The Agency for Health Care Administration (“AHCA”) is responsible for administering Florida’s Medicaid program and conducting investigations and audits of paid claims to ascertain if Medicaid providers have been overpaid. With regard to investigations of physicians, section 409.9131, Florida Statutes, provides that AHCA must have a “peer” evaluate Medicaid claims before the initiation of formal proceedings by AHCA to recover overpayments. Section 409.9131(2)(c) defines a “peer” as “a Florida licensed physician who is, to the maximum extent possible, of the same specialty or subspecialty, licensed under the same chapter, and in active practice.” Section “109.9131(2)(a) deems a physician to be in “active practice” if he or she has “regularly provided […]

By The Health Law Firm|2024-03-14T10:00:58-04:00June 1, 2018|Administrative law, Agency for Health Care Administration, Appeal, Health Care Industry, Medicaid, Medicaid audit, Medicaid Fraud, The Health Law Firm Blog|

A New Year Means New Audits and Site Visits for Assisted Living Facilities – Protect Yourself Now

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

For Assisted Living Facilities (ALFs) in Florida, it’s time to do a little brushing up on your compliance material.

Beginning in January 2015, the Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), Bureau of Medicaid Program Integrity (MPI), will conduct site visits to determine compliance with the Florida Medicaid Provider General Handbook and the Assistive Care Services Coverage and Limitations Handbook. This is just one of several initiatives aimed at ALFs to curtail fraud, waste, and abuse in the Florida Medicaid program.

Be Prepared.

The goal of a site visit is to determine if providers […]

By The Health Law Firm|2024-03-14T10:00:58-04:00June 1, 2018|Assisted Living Facilities, Medicaid, Medicaid audit, Office of Inspector General, The Health Law Firm Blog|

Internal Medicine Specialists Should Be Aware of Impending Medicare Audits

Coming to a medical practice near you. . . It’s scary, it’s horrible, and it could cost you a lot of money!

It’s the dreaded Comprehensive Error Rate Testing (CERT) audit.

The Horror! The Horror!

First Coast Service Options, the Medicare contractor for Florida, announced a new prepayment audit program that will impact Internal Medicine Specialists. The prepayment program is focused on Initial and Subsequent Hospital Evaluation and Management Services, CPT Codes 99223 and 99233. The program is being launched due to the high CERT error rate associated with these codes.

The audits will start on October 21, 2014.

What is the CERT Program?

CMS created the CERT program to measure the paid claims error rate […]

By The Health Law Firm|2024-03-14T10:00:58-04:00June 1, 2018|CERT, Comprehensive Error Rate Testing, Internal Medicine, Medicaid, Medicaid audit, Medicaid Fraud Control Unit, Medicaid managed care, Medicare, Medicare Audit, Medicare Fraud, The Health Law Firm Blog|

CMS in the Hot Seat for Lax Oversight of Medicaid Managed Care Organizations

By Lenis L. Archer, J.D., M.P.H., The Health Law Firm

For years, each state has kept an eye on its own Medicaid managed care plans, while the Centers for Medicare and Medicaid Services (CMS) is required to monitor how well each individual state is doing. However, a recent Government Accountability Office (GAO) report claims CMS is sleeping on the job. The report, released on June 20, 2014, stresses the need for more federal oversight of these plans.

With the implementation of the Affordable Care Act (ACA), the Medicaid program is expected to expand significantly. Most of the new beneficiaries enrolled in managed care are covered almost entirely by federal […]

By The Health Law Firm|2024-03-14T10:00:57-04:00June 1, 2018|Department of Health and Human Services, GAO, Government Accountability Office, Health Care Industry, HHS, In the Know, In the News, MCO, Medicaid, Medicaid managed care, Medicare, The Health Law Firm Blog|

Florida Attorney General Targets Targeted Case Management Fraud

By Christopher E. Brown, J.D., The Health Law Firm

Due to increased fraud throughout the system, the Florida Attorney General (AG), through the Medicaid Fraud Control Unit (MFCU), is focusing its attention on Medicaid targeted case management (TCM) services.

TCM services were created to assist children with documented mental health conditions in gaining access to medical, social, educational, and other support services. To be eligible for such services a child must meet very strict criteria.

Eligibility Criteria for Children’s Mental Health TCM Services:

1. Must be enrolled in a Department of Children and Families (DCF) children’s mental health target population (birth through 17 years);
2. Has a mental health disability (i.e., serious emotional disturbance) that […]

By The Health Law Firm|2024-03-14T10:00:56-04:00June 1, 2018|Medicaid, Medicaid Fraud Control Unit, The Health Law Firm Blog|

OIG Audit Finds Federal Database of Terminated Medicaid Providers Needs Improvement

By Lenis L. Archer, J.D., M.P.H., The Health Law Firm

The Affordable Care Act (ACA) requires the Centers for Medicare and Medicaid Services (CMS) to establish a process for sharing information about terminated Medicaid providers. The federal database, called Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS), is designed to prevent terminated health care providers from billing another state’s program. However, an audit by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), released in March 2014, states the MCSIS is not working as intended.

The MCSIS is supposed to collect data from every state Medicaid program on providers that were terminated […]

By The Health Law Firm|2024-03-14T10:00:56-04:00June 1, 2018|Department of Health, Health Care Industry, MCSIS, Medicaid, Medicaid audit, Our Firm, The Health Law Firm Blog|

AHCA Expert Not Allowed to “Use His Discretion” in Deciding Claims Were Improper in Medicaid Appeal Hearing

FACTS: The Agency for Health Care Administration’s (“AHCA”) Office of Medicaid Program Integrity audited Dr. Rao, an authorized provider of Medicaid services, for claims between July 1, 2007, and June 30, 2009, and found him to be in violation of certain Medicaid provider policies. AHCA prepared a Final Audit Letter on June 1, 2011, notifying Dr. Rao that he had been overpaid by the Medicaid program by $110,712.09 for services provided during the audit period. Dr. Rao’s administrative hearing challenging AHCA’s overpayment determination was pending before DOAH. On August 17, 2012, Dr. Rao filed an unadopted rule challenge, alleging that AHCA’s overpayment determination was based on unadopted rules regarding the medical necessity of long-term monitored electroencephalograms (LTM EEGs).

OUTCOME: […]

By The Health Law Firm|2024-03-14T10:00:55-04:00June 1, 2018|Administrative law, Assisted Living Facilities, Medicaid, Medicaid audit, The Health Law Firm Blog|

Adventist Health System Settles Whistleblower Lawsuit

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

On December 18, 2013, Adventist Health System/Sunbelt Inc., the parent company of Orlando-based Florida Hospital, settled a whistleblower lawsuit, according to court documents. The whistleblower lawsuit, filed in 2010, stated that seven Adventist hospitals in Florida overbilled the federal government between 1995 and 2009, allegedly resulting in tens of millions of dollars in false claims, according to an article in the Orlando Sentinel and other sources.

Click here to read the Order of Dismissal.

Previous reports from the Orlando Sentinel stated that the lawsuit could have damages of more than $100 million, but […]

By The Health Law Firm|2024-03-14T10:00:53-04:00June 1, 2018|False Claims Act, Medicaid, Medicare, qui tam, The Health Law Firm Blog, Whistleblower|

Florida Nursing Home Owner Arrested for Alleged $395,000 Medicaid Fraud Scheme

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

A Miami-Dade nursing home owner was arrested for allegedly committing $395,000 worth of Medicaid fraud. The Florida Attorney General (AG) accused the nursing home owner of using the billing names of non-existent businesses to submit fraudulent invoices. The fake invoices were then allegedly paid with Medicaid funds. The nursing home owner was arrested on October 17, 2013, by the AG’s Medicaid Fraud Control Unit (MFCU) and the Miami-Dade Police Department.

To read the press release from the AG, click here.

Nursing Home Owner Allegedly Pocketed Medicaid Money.

According to the AG, the nursing home […]

By The Health Law Firm|2024-03-14T10:00:52-04:00June 1, 2018|Medicaid, Medicaid audit, The Health Law Firm Blog|