Medicaid audit | The Health Law Firm Blog

Be Prepared for a Medicaid Audit Request

By Lance O. Leider, J.D., M.P.A., LL.M., Board Certified by the Florida Bar in Health Law

Florida healthcare providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. The reason is that Florida has become synonymous with healthcare fraud. As a result, auditing and subsequent overpayment demands are some very real possibilities.

Should you find yourself, your facility, or your health practice the subject of a Medicaid audit by your state Medicaid agency or audit contractor, there are a few things you should know.

The most important thing is that just because you are being audited, it does not mean that […]

By The Health Law Firm|2024-03-14T10:00:33-04:00June 1, 2018|Medicaid, Medicaid 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|

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|

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|

Medicaid Fraud Control Unit Arrests Three Florida Women for Allegedly Bilking Medicaid Out of $27,000

By Lance Leider, J.D., The Health Law Firm

Three Central Florida women were arrested by the Attorney General’s (AG) Medicaid Fraud Control Unit (MFCU) on July 18, 2013, for allegedly defrauding Medicaid out of $27,000. According to the AG, the owner and two managers of Destiny TCM Corporation are accused of billing Medicaid for services never rendered and also bribing people in order to obtain their Medicaid recipient numbers.

To read the press release from the AG’s office, click here.

Violated Medicaid Fraud Kickback Statute.

An article in the Orlando Sentinel states that the Destiny TCM Corporation was supposed to provide targeted case-management services and link Medicaid recipients with mental health service […]

By The Health Law Firm|2024-03-14T10:00:50-04:00June 1, 2018|Medicaid, Medicaid audit, The Health Law Firm Blog|

Cardiologists Face Higher Scrutiny by CMS

By Lance O. Leider, J.D., The Health Law Firm

As the U.S. population ages and heart disease continues to be a leading cause of health issues, cardiologists and cardiology practices are finding themselves billing Medicare for more and more visits and procedures.

Along with that increase in reimbursement from Medicare comes an increase in scrutiny. According to the Centers for Medicare and Medicaid Services (CMS), more than sixteen percent (16%) of total Medicare spending in 2010, was for cardiovascular care.

Some experts predict that this number will increase as cardiologists continue to adopt state-of-the-art technology and procedural techniques when treating their patients.

All of this means that whistleblowers, Recovery Audit Contractor (RAC) auditors, […]

By The Health Law Firm|2024-03-14T10:00:50-04:00June 1, 2018|Medicaid audit, Medicare Audit, The Health Law Firm Blog|

Speech Therapist Arrested for Billing Medicaid $500,000 for Work at Florida Day Care Centers While Living in Illinois

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

A speech therapist was arrested on March 29, 2013, for allegedly billing Medicaid more than $500,000 for services that she did not provide, according to the Florida Office of the Attorney General (AG). The speech therapist now faces charges of Medicaid fraud and grand larceny.

Click here to read the press release from the AG.

Billed Medicaid for Services Provided in Florida, While Living in Illinois.

According to an article in The Palm Beach Post, authorities began investigating the speech therapist when they received a tip that she was overbilling for services provided. During the investigation […]

By The Health Law Firm|2024-03-14T10:00:47-04:00June 1, 2018|Medicaid, Medicaid audit, The Health Law Firm Blog|