Articles Posted in Medicare Fraud

QuackbustersandtheShockTroopsofMedicalMcCarthyism-e1664472813118This is the second post in a series related to the Pretrial Diversion Program in Georgia.  The first post provided an overview of the Pretrial Diversion Programs in Georgia and the potential impact on a successful participant’s criminal record.  This post focuses on how successful completion may impact a participant’s responses to questions relating to the offense on employment, licensing, and credentialing applications.  If you have questions regarding this blog post or need counsel relating to your professional responsibilities after an arrest or conviction, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@littlehealthlaw.com. You may also learn more about our law firm by visiting www.littlehealthlaw.com.

For clients who have been arrested and charged with an offense, the concern is how to answer offense-related questions on questionnaires while participating in and after completing a pretrial diversion program. Continue reading ›

ny-medicare-fraud-img-e1664218102664Our healthcare and business law firm works with many providers and other professionals who have been arrested and charged with misdemeanors.  Our clients will, of course, hire criminal defense counsel to handle the criminal proceedings but professionals generally hire our firm navigate the professional consequences of an arrest.  Many of our clients are first time offenders who are presented with the option of participating in a pretrial diversion program.  Whether to participate in such a program should be discussed with criminal defense counsel.  This is the first blog post of two on this subject, and it focuses on providing an overview of the Pretrial Diversion Programs in Georgia and the potential impact on a successful participant’s criminal record.  The second post will focus on how successful completion may impact a participant’s professional responsibilities thereafter responding to questions relating to the offense on employment, licensing, and credentialing applications.  If you have questions regarding this blog post or need counsel relating to your professional responsibilities after an arrest or conviction, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@littlehealthlaw.com. You may also learn more about our law firm by visiting www.littlehealthlaw.com.

Eligible Offenders

Pretrial diversion programs are authorized under O.C.G.A. § 15-18-80.  Thereunder, “the prosecuting attorneys for each judicial circuit . . . shall be authorized to create and administer a Pretrial Intervention and Diversion Program.”  Each county may have different guidelines on who is eligible for a Pretrial Diversion Program and different requirements for successful completion. Continue reading ›

iStock_000033418316_Medium-e1626470315777Many of our healthcare and business law firm’s clients periodically face audits by insurance companies or governmental organizations, usually through a contractor.  Audits can be unnerving times for a practice to go through.  This blog post outlines 3 tips for handling an insurance audit.  The Centers for Medicaid and Medicare recently published that the flexibilities allowed during COVID-19 will soon end and practices should ensure compliant safety and billing practices.  As a result of this change after two and half years, practices may see increased audits.  If you have questions regarding this blog post or need counsel navigating an audit, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@littlehealthlaw.com. You may also learn more about our law firm by visiting www.littlehealthlaw.com.

  1. Take it Seriously at the Initial Record Request (and Not Just When They Ask for Repayment).

Many practices call us after the auditor requests repayment.  Almost always, the process starts before then with the auditor initiating an investigation by requesting additional records and information.  After the repayment is requested, however, there is an uphill battle to argue on behalf of your practice that no or less repayment is warranted.  The best chance that your practice has of both reducing any requested overpayment and persuading the auditor not to expand its investigation to more patients or a larger time period is during the response to the initial request for records and documentation.

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223220955_d39c2ebad0_b-e1642805878743Many of our healthcare and business law firm’s clients are in the business of renting expensive medical equipment for use by medical practices.  Generally, these arrangements raise compliance questions under the Physician Self-Referral Act, referred to as Stark Law, and the Anti-Kickback Statute (“AKS”).  Should a regulator find an arrangement violates either law, the consequences are severe.  The perhaps unfortunate truth is that rarely can a sincere and analytical attorney tell you with confidence that an arrangement does or does not violate either law.  The analysis usually places an arrangement on a scale of low to high risk of noncompliance.  To assist in understanding whether an arrangement complies with Stark Law and AKS, the rules provide specific exceptions and safe harbors, respectively.  Both Stark Law’s exceptions and AKS’s safe harbors outline ways in which an equipment rental agreement may satisfy the protections.  One question that frequently arises with our clients is whether they can structure an equipment rental agreement to have a per-use (often called a “per-click”) payment term, wherein there is no set monthly amount but, rather, the lessee pays the lessor a predetermined amount for each time the equipment is used.

In this blog post, we outline the basic rules for equipment rental agreements under AKS and whether per-click payment terms satisfy AKS’s Equipment Rental safe harbor. Continue reading ›

iStock_000033418316_Medium-e1626470315777Many of our healthcare and business law firm’s clients are in the business of renting expensive medical equipment for use by medical practices.  Generally, these arrangements raise compliance questions under the Physician Self-Referral Act, referred to as Stark Law, and the Anti-Kickback Statute (“AKS”).  Should a regulator find an arrangement violates either law, the consequences are severe.  The perhaps unfortunate truth is that rarely can a sincere and analytical attorney tell you with confidence that an arrangement does or does not violate either law.  The analysis usually places an arrangement on a scale of low to high risk of noncompliance.  To assist in understanding whether an arrangement complies with Stark Law and AKS, the rules provide specific exceptions and safe harbors, respectively.  Both Stark Law’s exceptions AKS’s safe harbors outline ways in which an equipment rental agreement may satisfy the protections.  One question that frequently arises with our clients is whether they can structure an equipment rental agreement to have a per-use (often called a “per-click”) payment term, wherein there is no set monthly amount but, rather, the lessee pays the lessor a predetermined amount for each time the equipment is used.

In this blog post, we outline the basis rules for equipment rental agreements under Stark Law and whether per-click payment terms may satisfy Stark Law’s Rental of Equipment exception.  Our next post will analyze the same question under AKS.  If you have questions regarding this blog post or wish to evaluate the risks in your equipment lease arrangement, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@littlehealthlaw.com. You may also learn more about our law firm by visiting www.littlehealthlaw.com.

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About 20% of United States tax dollars are spent on heathcare.  Naturally, reducing improper payments has been a priority of CMS. Thus, all medical practice managers and healthcare providers should be aware of CMS’s process of contracting with Uniform Program Integrity Contractors (UPIC’s), private entities hired by CMS Health-Audit-300x200to audit providers suspected of fraud. UPIC contracts combine Zone Program Integrity Contractors (ZPIC’s) and Medicaid Integrity Contractors (MIC’s) to coordinate Medicare and Medicaid auditing. UPIC’s focus primarily on Medicare claims, and seek to distinguish between provider billing errors or fraud.

UPIC Audit Lawyers

Our business and healthcare law firm follows legal trends in the healthcare industry.  UPIC’s are private sector organizations that review Medicare claims in order to assist the government in recovering overpayments to healthcare providers.  UPIC audits are often generated through data analysis or by review of consumer complaints and most often target specific healthcare providers. UPIC’s conduct screening, medical reviews, and investigations, while also implementing remedies and collaborating with state and local governments to ensure compliance with payment guidelines. UPIC’s are organized regionally, with Georgia and South Carolina falling in District 4 and managed by Safeguard Services.  In recent years, home health agencies, DME companies, therapy clinics, and laboratories have been targets for fraud investigations through extensive audits.

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In a landmark federal False Claims Act case closely watched for many years by hospice administrators, other healthcare providers and legal experts, last week the Department of Justice (DOJ) entered a joint dismissal in settlement of the case against AseraCare Inc., a national hospice provider company.  The settlement marks an effective win for the defendants, in that the government agreed to accept repayment of $1 million, reduced from its initial demand of more than $200 million. https://www.businesswire.com/news/home/20200227005767/en/

Georgia-based Healthcare Reimbursement and Compliance Attorneys

Allegations in the case were brought initially between 2008 – 2010 by several former employees of AseraCare and the Department of Justice, alleging that AseraCare had submitted false claims to Medicare for patients who were arguably not terminally ill, and thus ineligible for hospice benefits, placing pressure on employees to enroll more patients using questionable recruitment practices – including targeting near-death patients so that length of stay numbers were kept low.

medical-doctor-1314902-mAs technology improves the ability for providers to communicate, existing healthcare laws will continue to be put to the test. Now, a new call for care coordination is driving quality improvement initiatives for physicians and hospitals. In 2018, U.S. Department of Health and Human Services (HHS) launched its initiative “Regulatory Sprint to Coordinated Care,” to facilitate value-based healthcare and promote effective communication strategies between physicians. The Regulatory Sprint seeks to increase a patient’s ability to understand their treatment plan, promote coordination between providers, establish incentives for providers to coordinate efficient care, and encourage information-sharing between providers and facilities.

Healthcare Fraud and Abuse Lawyers

The initiative highlights the importance of removing the barriers created by four federal healthcare laws: the Physician Self-Referral Law; the Federal Anti-Kickback Statute; the Health Insurance Portability and Accountability Act (HIPAA); and substance-disorder treatment rules stemming from 42 CFR Part 2. Previously, critics have claimed that the monetary penalty provisions within the statutes prevent providers from being able to adequately coordinate care. In response, HHS has proposed Stark Law and Anti-Kickback reforms.

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1066058_patrol_hat_too1Healthcare fraud attributable to nurses, hospitals, pharmacists, equipment providers and doctors, contributes to the high cost of medical care. For this and other reasons, fraud continues to be a hot topic in the healthcare industry. Recently, there have been numerous headlines regarding Medicare, Medicaid, and private insurance company investigations of providers for improper billing practices. Accusations stem from both whistleblowers and audits, making it difficult for providers to hide behind fraudulent billing practices. With numerous investigations in the spotlight in recent months, providers should be alert and act to ensure that they are compliant with the law.

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medical-doctor-1314903-mLegislation controlling self-referrals has created a complex road map that can leave doctors with questions regarding their ability to use business agreements to promote lab work and advanced imaging technology for their patients. For physicians, the rules and regulations of self-referrals for imaging can create headaches and lead to fines.

Georgia Physician Self-Referral and Fraud and Abuse Lawyers

Physician self-referrals may create conflicts of interest and can potentially result in violations of federal or state law. Previously, providers only had to worry about referrals for patients with federal insurance plans. However, the new legislative trend is expanding their liability. Physicians recently have been prosecuted for kickbacks involving patients with commercial insurance plans as well. If a physician’s referral is determined to be guided by profit and not the patient’s best interest, that referral could be violating the law.

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