December 2012 Khouri Law wins landmark Medicare over payment case determination case for physician. Nationwide implications for healthcare providers. More news to come soon.
Khouri Law is proud to be acknowledged as one of the top healthcare law firms in the country, to read the full article, click here.
Michael J. Khouri was recently quoted in The Wall Street Journal in an article titled “Chasing Fraud, Then Chasing Cash “. Click Here to read the full article.
Attorneys experienced in RAC audit defense can ensure that a healthcare provider’s rights are protected while also guiding the provider through a successful audit process. The Centers for Medicare/Medicaid Services (CMS) utilize the services of Recovery Audit Contractors (RACs) to detect and correct overpayments resulting from non-compliant medical claims submitted by physicians and other healthcare providers. In a 3-year time span, RACs have identified and modified more than $1.03 billion in payments to healthcare providers. Almost 100% of this amount were funds collected from providers for overpayments.
RAC audit defense counsel is an essential asset once a healthcare provider has been informed that they will be subject to a RAC audit. In a report titled Doctors, health care executives accused of Medicare fraud published by CNN on June 24, 2009, one can establish that the Obama Administration is devoted to effectively identifying Medicare fraud, recovering those funds, and reducing fraud that effects the American taxpayer. The majority of healthcare providers are consistently adhering to the ever-changing documentation requirements set by the CMS. However, some have submitted non-compliant medical claims which result in improper payments. An attorney experienced with RAC audit defense can articulate the pearls of proper documentation that will reduce the chances of an RAC audit. In the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Congress authorized CMS to pay RACs on a contingency basis. This entitles RACs to a percentage of the monies that they identify and recover from improper medical claims. Incentivizing RACs to identify as many possible improper payments naturally increases the likelihood that a healthcare provider will be audited.
An RAC audit defense attorney can advise a healthcare provider as to the proper steps to take from the outset of the audit process. It is essential for a healthcare provider to comply with every request from the RAC. Non-compliance with requests may have negative financial and/or legal consequences. Ensure that you are knowledgeable about CMS’s current documentation requirements. Equally important is to be knowledgeable about your rights. An RAC audit defense attorney is ready to provide you with the proper information to do this.
In 2010, president Obama issued an Executive Order designed to reduce waste, payment errors, fraudulent practices, and abuses within government programs. It mandated that federal agencies perform studies twice a year as a means of identifying and reducing potential vulnerabilities in areas of the system where there was suspected to be a greater likelihood of mistakes or abuse.
In the wake of this announcement, chiropractors across the nation began receiving Medicare audit notices with requests for patient records targeted for verification. If you have been a recipient of one of these letters, it is critical that you begin to prepare to respond immediately, and obtaining the services of an experienced RAC Audit Lawyer can make the process much smoother and less stressful.
The studies are part of the Comprehensive Error Rate Testing (CERT) program of The Centers for Medicare & Medicaid Services (CMS), and where chiropractic care is concerned they focus on examining the practices of chiropractors known to have filed for the same Medicare beneficiary multiple claims during a designated sample time period. This is where an RAC Audit Lawyer can assist you with organizing and preparing an adequate defense that support and clarifies your actions.
The primary aspect of the chiropractic services study involves examining patient records back one full year from the date of service. Since Medicare pays only for treatment deemed to be medically necessary, any continuing care received where further improvement was not expected, would be considered maintenance care and not covered by Medicare.
For each case, CMS will decide whether or not the services for which Medicare was billed qualified as acute medically necessary chiropractic care, and if not the claims will be denied and CMS will demand reimbursement for any overpayments. As this can equate to a substantial sum, it is another reason to contact an RAC Audit Lawyer who specializes in recovery audits and representing and protecting your interests.
Dr. Tom Neela, a professional medical auditor, advises chiropractors who have received audit letters to promptly reply to the records request even if the documentation is not in perfect order. Failure to respond within 30 days can result in an automatic denial of claims, charges of fraud, or other violations. So don’t put off complying with the audit. Instead, contact an RAC Audit Lawyer who can provide assistance and answer all of your questions.
Once the assessment is complete, you will want to review your practice to avoid future audits or a repeat of any errors that might have been identified. An RAC Audit Lawyer will be happy to evaluate your current situation to advise you as to what measures you should take to ensure you’ll be ready and in compliance if ever audited again.
Claims submitted to Medicare, Medicaid, State Workers Compensation Commissions and other federal healthcare insurers by physicians in the pain management specialty are under increased scrutiny. Pain management physicians have been advised about the significance of submitting compliant medical claims.
An RAC Audit Attorney can articulate the pearls of submitting compliant medical claims. Submitting non-compliant medical claims to Medicare, Medicaid, State Workers Compensation Commissions, or other federal healthcare insurer can lead to substantial legal consequences. Charges that a physician can face include federal healthcare fraud, wire fraud, mail fraud, unlawful distribution of a controlled substance, and making false statements. Each carry individual sentences. A RAC Audit Attorney can provide essential tips on proper documentation to ensure compliance with federal healthcare claims.
Texas pain management physician, Dr. Anthony Valdez, was recently indicted on fraudulent claims submitted to Medicare, Medicaid, Texas Workers Compensation Commission and Tricare. The 99-count indictment alleges that Dr. Valdez fraudulently billed an estimated $41 million. Dr. Valdez has pain management clinics in El Paso and San Antonio. A RAC Audit Attorney is knowledgeable about federal healthcare billing audits and can provide valuable information to the pain management physician.
These alleged charges carry lengthy sentences which would be served in a federal prison. If convicted of the alleged wire fraud charge, Dr. Valdez faces up to 20 years for each count. He faces 10 years for the healthcare fraud charge. Making false statements could result in a 5 year sentence. A RAC Audit Attorney can describe the particular billing practices that would result in each of these charges. Today, pain affects people of all ages and economic status. Naturally, this increases the volume and diversity of medical claims submitted by pain management physicians. The pain management physician inherently prescribes a larger volume of narcotic pain medication because of the particular ailments that he/she treats. Collectively, these factors attract closer scrutiny by federal healthcare billing auditors.
A RAC Audit Attorney can guide the pain management physician through the many intricacies of today’s federal healthcare billing system, and provide insight on how to avoid being subjected to an audit or represent the pain management physician if an audit is conducted.
A 2010 ruling has revealed that Tuomey Healthcare violated the Stark Law when it provided large rewards to physicians that referred their patients to medical facilities owned by Tuomey. The U.S. government took up the role of plaintiff for the case at the behest of Dr. Michael Drakeford and a Stark Law attorney he consulted, following several physicians working under Tuomey were referring patients to the Tuomey Outpatient Surgery Center in exchange for financial kickbacks.
The Stark Law details that physicians cannot self-refer patients for other procedures and tests, and the law also maintains that referral to another medical facility where the doctor has a financial interest would be a violation as well. Since Tuomey was giving these physicians business, and the referred patients underwent treatment that was higher than the normal market value, the court found Tuomey guilty of a Stark Law violation, although jurors held that the False Claims Act was not violated. The False Claims Act is reserved for businesses that fraudulently bill the government for goods or services, so billing the government through Medicaid and Medicare claims could have meant that Tuomey had committed a crime of this nature, as well.
While the jury did not believe Tuomey Healthcare had broken the law under the False Claims Act, they did rule that the government would receive damages for actions that fell under the Stark Law. One Stark Law attorney said that the government was originally seeking $277.5 million from Tuomey for violations of both laws, but that they would still seek a large amount of damage compensation based on the ruling.
In cases where a patient or health care professional believes that a physician may have had a vested interest in referring people for treatment, consulting a Stark Law attorney is always the best option. A specialized Stark Law attorney will be able to inform the person if the rights of patients may have been violated if their physician recommended another treatment or doctor out of self-interest, or if the government had been fraudulently billed as a result of these actions. Additionally, a Stark Law attorney can inform the individual if they are entitled to a portion of any damages awarded from the case in order to protect them from potential consequences of whistleblowing.
Recently, Ronald A. McFarland agreed that he would plead guilty to a charge of embezzlement. McFarland was the head of Medical Alliance Partners LLC and Verimed Services Inc, two companies that are based out of State colleges. McFarland was charged with embezzling a total of $2.46 million of health insurance reimbursements. The reimbursements came from cancer treatment centers.
On Thursday, February 24th, 2011, the Williamsport US Attorney’s Office submitted a plea agreement charging the fifty three year old citizen of Bellefonte with embezzlement. He makes a good example of why experts in the industry recommend a medical billing lawyer.
The companies that he presided over provided billing services to Oaktree Cancer Care Inc and Rosewood Cancer Care Inc, companies which ran out of East Liverpool, Ohio and Pittsburgh respectively. Both were radiation treatment centers for cancer patients.
The documents filed by the US Attorney’s Office state that McFarland transferred a total of $2.46 million to bank accounts that were under his control. Verimed, a company under his control, was supposed to make records of checks sent to it, and forward the checks to the cancer treatment centers. The documents claim that McFarland attempted to hide the embezzlement by entering false information into records, something which a medical billing lawyer would have advised against to be sure.
As a part of the plea agreement, McFarland will be required to pay a restitution of $2.46 million, a cost far lower that would have been needed for a medical billing lawyer.
The investigation began in Fall of 2010 when a state police fire marshal from Indiana County filed a warrant for McFarland’s credit report. The warrant was filed because the owners of Oaktree and Rosewood lost their home to a fire that occurred the night before they were scheduled to meet with McFarland to talk about issues regarding their accounts. A medical billing lawyer may have been able to prevent this issue.
The owners, Paul Castro and his wife Marcy Colkitt, lost their home to a fire that reportedly started at a desktop in their home’s basement. At this time, further information about the investigation into the possibility of arson have not been released to the general public.
The investigation into McFarland has ended according to Stephen Collins, a Special Agent working for the the FBI’s State College office. McFarland agreed that he would plead guilty at his next court date. He will receive his sentence at some point in the next few months.
As a part of his sentence, McFarland will receive up to ten years in jail. After serving jail time, he may receive up to three years of supervision, in addition to a fine of $250,000. The fine is separate from the restitution of $2.46 million. All of this might have been prevented by a medical billing lawyer.
Thanks to the work of a diligent Medicaid fraud attorney, four pharmaceutical companies charged with defrauding the state of Wisconsin have agreed to a settlement. The companies in question admitted to adjusting the wholesale prices of their medications in order to obtain fraudulent reimbursements from the state of Wisconsin’s Medicaid program.
The four German-based companies – Boehringer Ingelheim GmbH and three of its affiliates – Ben Venue Laboratories, Inc., Roxane Laboratories, Inc., and Boehringer Ingelheim Roxane Inc. – had been expanding in Wisconsin, Ohio, and other parts of the United States. All were charged by the Medicaid fraud attorney with misrepresenting the costs for prescription pharmaceutical products, thereby reaping undue profits through reimbursement from the Medicaid program. Fraudulently overcharging any government agency or program is a serious offense with severe criminal and fiscal consequences. Although all four companies agreed to settle, none admitted guilt to the charges levied, thereby obviating further inquiry into its criminal liability.
This was part of a larger suit brought by a Medicaid fraud attorney against 36 pharmaceutical companies, accusing them of illegally inflating the costs of their medications. On April 10, 2010, the four companies in question settled with the state of Wisconsin for $7,750,000. This amount includes $7,000,000 in restitution fees to the state and its taxpayers and $750,000 in damages, such as legal fees.
Many other cases brought by the Medicaid fraud attorney have been settled, but there are still several outstanding. Wisconsin Attorney General J.B. Van Hollen, stated that this was a major step in cracking down on instances of Medicaid fraud. He indicated that the result of this case (and other settlements) would act as a deterrent for individuals and companies contemplating committing fraudulent activities.
In cases such as this, the important role of a Medicaid fraud attorney cannot be overstated. This individual was instrumental in initiating an investigation into a large-scale criminal scam. Uncovering the fraudulent activities and prosecuting those responsible saved both the state of Wisconsin and its taxpayers a great deal of money. The impact is all the greater if this makes defrauding the Medicaid system appear less attractive to would-be perpetrators in the future.
Today’s Stark Law Violation Attorney faces the special challenge of transversing the ever-expanding scope of the federal physician self-referral law typically referred to as the Stark Law. Initially passed in 1989, the original purpose of the Stark Law was to clearly identify improper use of self-referred diagnostic services as established by the Centers for Medicare & Medicaid Services, the regulatory institution of the Stark Law. In 1993, the definition of “services” was extended to include a variety of other health services reimbursable through the Medicare program. Under the Stark Law, physicians are forbidden to make referrals for designated health services which may be reimbursed through Medicare to a person or institution with which the physician has a fiduciary relationship. This includes both the entity that presents a claim for service before Medicare as well as the entity that actually performs the service, regardless if another entity bills for the service. The Stark Law Violation Attorney will need the ability to discern the fiduciary relationship between the referring physician and all other parties.
There are several exceptions to the Stark Law physician self-referral ban. The Stark Law Violation Attorney must be able to recognize these exceptions in order to effectively counsel his clients in this era of rapid Stark Law expansion. An example of a Stark Law exception is the In-Office Ancillary Services rule permitting physicians to refer certain services that fall within the spectrum of the physician’s medical practice. In-Office Ancillary Services may include pharmacy, radiology, and physical therapy procedure. The Centers for Medicare & Medicaid Services has proposed that physicians provide full disclosure to their patients regarding the fact that these In-Office Ancillary Services can be obtained by other providers. The proposal states that, as of January 1, 2011, physicians are required to provide a written list of alternate providers for these services. The Stark Law Violation Attorney needs to consider the fact that there may be future limitations to the In-Office Ancillary Services exception. Another exception of which to be mindful is the Whole Hospital exception that permits physicians to have ownership benefits in a hospital providing those benefits are not department specific.
Drakeford v. Toumey Healthcare System, Inc. is a good example of the complex nature of the Stark Law limitations and requirements. The Stark Law Violation Attorney would benefit from being up-to-date regarding the changes and updates in physician self-referral regulations.