If you feel that those rights have been abused in any way, you need to speak to an experienced attorney. The hospitals, clinics and physicians who work with you should be forthcoming about your Medicaid or Medicare benefits. If they are not, you may want to seek legal advice.
Have your Medicare card or Medicare Number and the claim or MSN ready. Contacting the Office of the Inspector General. Visit tips.oig.hhs.gov or call 1-800-HHS-TIPS (1-800-447-8477). TTY users can call 1-800-377-4950.
Beneficiaries commit fraud when they… Let someone use their Medicare card to get medical care, supplies or equipment. Sell their Medicare number to someone who bills Medicare for services not received. Provide their Medicare number in exchange for money or a free gift.
The following are the most common areas of healthcare fraud of which you should be aware:#5 – Kickback Schemes. ... #4 – Medically Unnecessary Services. ... #3 – Failure to Properly Charge Medicare and Medicaid Patients for Prescriptions. ... #2 – Allowing Nurses and Staff to Perform Examinations. ... #1 – Upcoding.More items...•
Government agencies, including the U.S. Department of Justice (DOJ), the U.S. Department of Health & Human Services (HHS), the HHS Office of Inspector General (OIG), and the Centers for Medicare and Medicaid Services (CMS), enforce these laws.
Some red flags to watch out for include providers that:Offer services “for free” in exchange for your Medicare card number or offer “free” consultations for Medicare patients.Pressure you into buying higher-priced services.Charge Medicare for services or equipment you have not received or aren't entitled to.More items...
The False Claims Act, 31 U.S.C. §§ 3729, provides that anyone who violates the law “is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, . . . plus 3 times the amount of damages.” But how does that apply in practice?
The Stark Law applies only to referrals from physicians and certain itemized services to be paid by Medicare and Medicaid. The Anti-Kickback Statute applies to any referral regarding any expenditure that any federal government healthcare program will pay for.
Liability under the federal False Claims Act occurs when a defendant (1) knowingly presents (or causes to be presented) a false or fraudulent claim for payment; (2) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; (3) conspires with others to ...
The length of time you have to file an appeal depends on the nature of your case. If you received an unfavorable audit determination from a ZPIC or...
Here, too, the answer depends on the type of situation with which you are dealing. If you are facing recoupment demands or denial of payments from...
While you do not need to hire a lawyer for your appeal (in other words, there is no legal requirement to retain new appellate representation), it w...
This is an important question. From a purely legal perspective, if you lose your Medicare appeal, you have two options: (i) you can accept the deci...
This, too, is a question that raises both legal and practical considerations. While a successful audit appeal can lead directly to a favorable fina...
These are the five stages of appeal for an unfavorable ZPIC or RAC Medicare audit determination: 1. Redetermination Redetermination is the first st...
In addition to the considerations discussed above regarding retaining your trial attorney or hiring new appellate counsel for your Medicare fraud a...
Protecting against fraud allegations requires taking proper proactive measures. Often, conduct that might give rise to fraud allegations or other regulatory compliance issues arises simply because of poor training and billing practices, inefficient workflows, lack of written policy manuals, and other inefficiencies.
Medicare fraud can be committed in a variety of ways, many of which do not strike as immediately insidious and intentional as the term “fraud” might imply. Sometimes, such fraud can occur simply as a result of poor billing practices–for example, untrained employees using the wrong billing codes or being improperly trained about bundling codes.
The goal of a Medicare fraud attorney is to stop investigations and prosecutions from taking place. However, sometimes fraud does occur, or at least practices are unearthed that appear potentially fraudulent.
For help with matters involving healthcare fraud allegations, healthcare regulatory compliance, auditing, employment disputes, mergers and acquisitions, business disputes, licensing, or any other California healthcare law matters, contact the Law Offices of Art Kalantar in Los Angeles or California statewide at 310-773-0001.
Medical devices are similar to drugs in that the FDA only approves them for limited uses. Medical device companies, like pharmaceutical companies, often try to increase their revenues by marketing their devices for off-label uses, which often include kickbacks to doctors.
These false claims arise from the violation of Medicaid rules requiring pharmaceutical manufacturers to give the government the lowest price of any purchaser. Ways that pharmaceutical manufacturers commit fraud include concealing the actual best price or by pricing deals between pharmaceutical companies and favored customers, such as chain drug stores.
Medicare and some Medicaid programs determine how much it will reimburse pharmacies based on a drug’s Average Wholesale Price (AWP), which it gets from the pharmaceutical manufacturer. By fraudulently inflating the price so Medicare and Medicaid over-reimburse for a drug, a pharmaceutical manufacturer can “market the spread,” i.e., promote the difference to a pharmacy. That pharmacy now has a financial incentive to dispense that drug versus its competitors. This is a violation of the Anti-Kickback Statute and should be discussed with a healthcare fraud attorney.
Pharmacies sometimes dispense a generic drug in place of the brand name drug on the patient’s prescription to get a better reimbursement rate from the government. Billing government healthcare programs for these substituted drugs can violate the False Claims Act.
One of the most common False Claims Act violations, this occurs when the facility or provider fraudulently bills the government using incorrect billing codes that result in a higher reimbursement than the correct billing code. For example, a surgeon who performs a simple procedure but bills for an expensive, complicated surgery; a dentist who pulls one tooth but bills for three; a hospital that submits a false diagnosis that pays more; or an ambulance company bills a routine transport as emergency services.
Pharmaceutical manufacturers or distributors often try to give doctors a reason to prescribe their drugs besides the doctor’s medical judgment. One of the many ways they do so is by giving kickbacks to doctors like lavish vacations, meals, and so-called “consulting fees,” where the pharmaceutical companies pay the doctors to “consult” about their products.
Examples of this type of False Claims Act violation are a doctor billing for cancer treatments for a patient who does not have cancer; a facility admitting patients who do not meet admission criteria; or a pain management doctor who over-prescribes procedures and medications.
From a purely legal perspective, if you lose your Medicare appeal, you have two options: (i) you can accept the decision, or (ii) you can continue to appeal until you have exhausted your rights at all levels of the appellate process. There are five levels of appeal for ZPIC and RAC audit determinations; there are various levels of appeal in civil enforcement matters depending on where your case starts; and, there are two levels of appeal – the U.S. Circuit Courts of Appeal and the U.S. Supreme Court – for criminal convictions in federal district court.
However, in order to avoid recoupment liability, you must file within 30 days. In both instances, the clock starts running from the date you receive a demand for payment.
In civil and criminal cases, there are some additional factors to consider. While your trial attorney will undoubtedly be intimately familiar with the happenings at trial, he or she may not have experience at the appellate level. Federal trials and appeals are entirely different propositions, and a savvy trial lawyer will not necessarily have the skillset required to pursue a successful appeal. In addition, in order to determine whether you have grounds to assert ineffective assistance of counsel (which is a Constitutional claim under the Sixth Amendment), you will need to seek unbiased advice from an appellate attorney.
Medicare audit determinations, impositions of civil monetary penalties (CMPs), and criminal Medicare fraud convictions are all subject to appeal. In this article, the healthcare fraud defense attorneys of Oberheiden, P.C. answer common questions about Medicare fraud appeals.
The hospitals, clinics and physicians who work with you should be forthcoming about your Medicaid or Medicare benefits. If they are not, you may want to seek legal advice.
If you have been denied such coverage, the best thing to do is to consult with a lawyer who specializes in Medicare and Medicaid law. Simply accepting a denial on a claim may not be a smart course of action. Many times, you do have legal recourse.
Although Medicaid and Medicare are run by the United States government, individuals do have rights under law. If you feel that those rights have been abused in any way, you need to speak to an experienced attorney.
Medicare And Medicaid. The Medicare and Medicaid system in the United States can be tremendously confusing. When you are denied Medicaid benefits or otherwise have problems with a social welfare program, it can feel like you are all alone.
Medicare is the federal health insurance program for people who are age 65 or older. Almost all seniors are enrolled in Medicare, which pays for outpatient visits, hospital stays, prescription drugs, and much more. There are four different parts of Medicare, and each part covers a different aspect of health care.
Medicare Part C is the least-used type of Medicare coverage. It is a type of health plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits. If you have Medicare Part C, often called a Medicare Advantage Plan, most Medicare services are covered through the plan instead of Medicare Parts A and B. ...
There are four separate parts to Medicaid, and each one covers a different aspect of medical care. Most people are enrolled in Part A and Part B, but it is important to learn about all four parts of Medicare to determine which coverage you might need.
An attorney can help defend you against these claims and reach an ideal conclusion for your circumstances. If you would like to learn more about Medicare or if you need the assistance of an attorney to help you navigate the Medicare process, contact Alperin Law today to schedule your consultation.
If you or a loved one needs long-term care in a nursing home or assisted living facility, you may want to consider Medicaid instead. Medicaid is a federal needs-based program administered by the states that provides coverage for people who need long-term care.
If unknown people start calling you and claiming they’re affiliated with the lawyer, make sure to double-check. Do your research and analyze everyone calling or emailing you. Check out their email, phone number, law firm and more. Make sure the information adds up. Usually scammers act aggressive and pushy when they’re trying to get your money. If your lawyer is not demanding any money, you’re in the clear.
The term attorney scams is used to denote the ways and means by which a lawyer uses his or her knowledge in law, in order to deceive the clients for the purpose of amassing money. These acts constitute a direct violation of the ethical standards and professional code of lawyers.
Last, but probably the most important thing to do to avoid being scammed is to ask for second opinion. Never settle for the opinion of just one lawyer and immediately hire his services. It would be better to look for another lawyer who offers free consultation fee regarding the merits of one’s case. A good lawyer never promises victory but only guarantees to uphold justice. A comparison of the lawyers’ opinions will help the client to distinguish a lawyer with genuine intentions from the scamming one.
Tip: If the lawyer has a change of tone and starts acting nervous when they’re around you, they might be out to get you. Most frequent lawyers can tell if you’re not easily convinced and they’ll let go after some pressure. Don’t fall prey to aggression tactics and always trust your instinct when you’re dealing with lawyers.
If you notice your lawyer acting differently, ask them what prompted the behavioral change. If you’re contacted by people you don’t know offering you services, they might be legitimate or they might be out to scam you. You will find out if you ask them questions.
Being direct doesn’t only mean telling you the facts. It also means they have integrity. If the lawyer is only telling you things you want to hear, you should replace them.
The first step is to research the credentials of the lawyer representing you. You want to know that the lawyer is licensed and has experience dealing with cases similar to yours. Ask them how many cases they’ve won. Ask about the amount of times they’ve taken their cases to trial. Ask them how many years they’ve worked as a lawyer. Question their qualifications. You want to know the lawyer representing you will give the best chance to win in the court of law.