Florida is Serious in Combating PIP Fraud: Don’t Land Yourself in Prison

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

An Orlando health clinic owner and one other person were recently arrested on charges of defrauding multiple insurance companies and payers, according to the Florida Division of Insurance Fraud. Dr. Troy Godsey of Spine Health Solutions, P.A., allegedly provided treatments to”patients” involved in auto accidents. Three insurance companies received a $300,000 bill for reimbursements under the “patients'” personal injury protection (PIP) auto insurance. The companies reportedly paid out $100,000 before realizing it was a scam.

Godsey Operated Under the Pretense That He Was the Sole Owner of the Clinic.

Although Godsey, a licensed chiropractor, was allegedly the sole owner of the clinic, it was employee Renata Berriel Deazevedo, a non-licensed individual, who carried out the daily operations of the business. According to the Florida Department of Financial Services, Godsey was previously granted an exemption from clinic licensing requirements with the Agency for Health Care Administration. This reportedly allowed him to run the PIP fraud scheme without having to obtain a separate health care clinic license that would make the practice subject to periodic inspections. This further violated Florida’s PIP insurance laws.

It seems Godsey was attempting to create a “straw ownership” to avoid the proper licensing of his clinic. In accordance with Florida law requirements, it should have been licensed under the Florida Health Care Clinic Licensure Act (HCCLA). To operate a clinic in violation of the HCCLA is a felony. Furthermore, every day of operation is a different felony charge. In addition, all medical bills that an illegal clinic issues are void.

To learn more about health care clinic licensing, read one of our past blogs here.

Facing Prison for Half a Century.

Godsey’s and Deazevedo’s felony charges include operating an unlicensed health care clinic and filing false and fraudulent insurance claims. These charges carry with them penalties in excess of 50 years prison time. If convicted, the pair are faced with spending more than half a century behind bars. For most individuals, this would equate to a life sentence behind bars.

Who’s Your Boss?

Physicians, especially dentists, chiropractors, and optometrists, should always be extremely wary about working for a clinic or medical group owned in any part by someone who is not a licensed health professional. If it is owned in any part, even one percent (1%) by a person or business entity that is not a Florida licenced health professional, it may be operating illegally. This includes someone licensed in another state or who has a suspended or revoked license in Florida. Dentists, optometrists and chiropractors have even more restrictions placed on their practices than other health professionals in Florida and most other states.

Florida specifically prohibits the corporate practice of dentistry. The key provision in Florida law that establishes this is Section 466.028, Florida Statutes, but the Florida Board of Dentistry has adopted administrative rules on this topic as well.

Physicians who are “partners,” “shareholders” or “co-owners” with unlicensed personnel need to ensure they are in full compliance with the HCCLA and all other applicable Florida laws and regulations. Consult with an experienced health lawyer before making an expensive mistake. To see another blog I wrote on these issues, click here.

The Effect of the New Legislation: Know the Law and Be Sure to Follow It.

Several health care clinics wholly owned by licensed practitioners, were once allowed exemptions from licensing requirements of their facilities per Section 400.9905 (4)(G) of Florida Statutes. However, if these clinics wish to collect on PIP benefits, they will no longer be eligible to maintain their exempt status. For more on this matter, see previous blog post here.

The new PIP legislation is still under fire and it is likely it will undergo additional revisions. Due to its’ ever-changing nature, a licensed dentist or other licensed practitioner needs to stay up-to-date on Florida law requirements to avoid becoming entangled in illegal activity. It’s not enough to assume your employer is following the law.

What may have started off as blissful ignorance or an honest mistake, can quickly catapult into a significant consequence. Consulting with an experienced health attorney will keep your license safe and keep at bay unwanted prison time.

Comments?

Have you ever been a victim or suspect of a PIP scam? Please leave any thoughtful comments below.

Contact Experienced Health Law Attorneys.

The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, denials and demands for repayment from insurance companies, inspections and audits involving the Drug Enforcement Administration (DEA), Federal Bureau of Investigation (FBI), Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Chief Financial Officer’s Press Office. “Orlando PIP Clinic Owner Arrested for Defrauding Insurance Companies of More Than $100,000.” (June 25, 2015). From http://www.myfloridacfo.com/sitePages/newsroom/pressRelease.aspx?id=4520

Health News Florida Staff. “Chiropractor Caught In PIP Scam.” (June 29, 2015). Health News Florida. From http://health.wusf.usf.edu/post/chiropractor-caught-pip-clinic-scam

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: PIP fraud, PIP claims, licensed dentist, health care clinic owners, health fraud defense lawyer, Agency for Health Care Administration, Health Care Clinic Licensure Act, health care clinic attorney, litigation over ownership of clinic, corporate practice of medicine, health fraud defense attorney, false claims lawyer, insurance fraud, Florida Division of Insurance Fraud, health law firm, The Health Law Firm, fraudulent claims, false claims attorney, health care fraud, health care clinic attorney

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2015 The Health Law firm. All rights reserved.

Florida Law Prohibits Optometrists from Practicing with Non-Licensed Corporations or Individuals

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Florida , unlike many other states, does not prohibit the corporate practice of medicine. This lack of prohibition, allows for a licensed physician or other health care provider to practice medicine as an employee or contractor of a corporation or other business entity owned and operated by a non-physician. This principle has been exhibited in a number of court cases and several declaratory statements issued by The Florida Board of Medicine.

However, this rule does not extend to optometrists, who are expressly prohibited by Florida law from practicing with non-licensed corporations or individuals.

Florida Statutes, Section 463.014(1)(a) and (b), state in pertinent part:

“No corporation, lay body, organization, or individual other than a licensed practitioner shall engage in the practice of optometry through the means of engaging the services, upon a salary, commission, or other means or inducement, of any person licensed to practice optometry in this state.” And–

“No licensed practitioner shall engage in the practice of optometry with any corporation, organization, group, or lay individual.”

Not Prohibited by Florida Law for the Practice of Optometry.

However, the statutes do not prohibit an optometrist from practicing under the following circumstances:

(1) “…with a multi-disciplinary group of licensed health care professionals, the primary objective of which is the diagnosis and treatment of the human body”;

(2) “…from employing, or from forming partnerships or professional associations with, licensed practitioners licensed in this state or with other licensed health care professionals, the primary objective of whom is the diagnosis and treatment of the human body”; and

(3) to practice “in or on the premises of a commercial or mercantile establishment.” Fla. Stat. §463.014(1)(a), (b), and (c) (2015).

Additionally, corporations or other business entities can employ licensed practitioners to provide optometry services to employees of the corporation or business and their immediate family members. This rule only applies so long as such services provided are incidental to the primary objective and business of the corporation or organization. This section is not to be construed as the authorization for employment of a licensed practitioner by a non-licensed corporation established primarily for such services as optometry. Fla. Stat. §463.014(2) (2015).

The Importance of Advertising.

While it is important to advertise your business to maintain traffic flow and profits, that’s not exactly the objective being discussed here. Rather, Florida law and the Florida Board of Optometry has specific requirements for advertising that must clearly distinguish between professional and lay practice.

“Advertising goods or services in a manner which is fraudulent, false, deceptive, or misleading in form or content” is grounds for disciplinary action by the Board, per Florida Statutes, Section 463.016(1)(f) (2015).

Florida law further prohibits licensed practitioners from:

(1) “…practic[ing] under practice identification names, trade names, or service names, unless any dissemination of information by the practitioner to consumers contains the name under which the practitioner is licensed or that of the professional association in which the practitioner participates. Any advertisement or other dissemination of information to consumers may contain factual information as to the geographic location of licensed practitioners or of the availability of optometric services”; and

(2) “…adopt[ing] and publish[ing] or caus[ing] to be published any practice identification name, trade name, or service name which is, contains, or is intended to serve as an affirmation of the quality or competitive value of the optometric services provided at the identified practice.” Fla. Stat. §463.014(1)(d) and (e) (2015).

An optometrist, in advertising his or her practice, should be wise not to give the appearance of being associated or affiliated with another business entity or individual which or whom itself is not a licensed practitioner.

Make Sure the Contract Protects Your Interests.

A licensed practitioner should review both the statutory law and the latest rules of the Board of Optometry before entering into any business arrangement for the provision of optometry services that includes any unlicensed person or entity.

Identifying one’s activity or practice in a manner which represents to the public that the person is a licensed practitioner or certified optometrist, when the person has not been licensed or certified per Florida law requirements, constitutes a misdemeanor. Furthermore, practicing or attempting to practice optometry without a valid license is punishable as a felony in this state.

Finally, the Florida Board of Optometry, through its rule-making authority, has enacted rather stringent requirements to separate professional optometry from control by others. For example, the Board of Optometry has implemented a rule to require that Optometrists’ contractual agreements may not limit their independent professional judgment.

Therefore, an optometrist should always have such contractual agreements reviewed in advance by his or her own experienced health attorney as a fundamental safeguard. The optometrist entering into any such contract must make sure he or she complies fully with the law.

To read one of our past blogs with more information regarding this subject, click here.

Contact Health Law Attorneys Experienced in Representing Optometrists.

The attorneys of The Health Law Firm provide legal representation to optometrists in Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations, contract matters, business law matters, business litigation and other types of investigations of health professionals and providers.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Optometrist attorney, Optometry lawyer, Opthamology lawyer, Opthalmologist attorney, Licensed Practitioner, Non-Licensed, Florida Law, Florida Statutes, Lay Practice, Board of Optometry, Florida Board of Medicine, Health Attorney, Disciplinary Action, The Health Law Firm, medical license defense attorney, Optometry license defense lawyer, Board of Medicine complaint defense, Board of Optometry Defense Lawyer

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2015 The Health Law Firm. All rights reserved.

Say Whatttt? Defamation in Florida

TTP Headshot SmBy Thu T. Pham, O.D., J.D., The Health Law Firm.

Defamation is defined as any intentional false statement that harms a person’s reputation. It encompasses both written (libel) and spoken (slander) statements. Depending on the nature of the offense, it can lead to both civil and/or criminal sanctions. But when has defamation actually been committed? Successfully proving defamation can be difficult and convoluted.

Defamation Is Not…

Let’s start by stating what defamation is NOT. Speaking one’s mind, or voicing a negative opinion, is not defamation. The Constitution protects our freedom of speech. So, for example, to say that someone has a very un-agreeable disposition, is tacky, or even bad breath, is not defamation. We are all entitled to our opinions.
So What is Defamation?

Defamation has been committed when someone knowingly makes a false accusation. For example, falsely accusing an ex-employee of committing theft in order to gain the upper hand in an unemployment hearing would be considered defamation. There are 3 elements that must be demonstrated in order to prove defamation. One, the statement made was false, the statement caused harm, and the statement was made without adequate research as to its credibility. For a celebrity or public official, to prove defamation, they must also prove there was malicious intent behind the statement.
Situations Where You May Recover Damages Without Proving Actual Damages.

There are times when a statement is so heinous and despicable in nature that actual damages need not be proven. This is known as “defamtion per se.” Such statements include but are not limited to accusations of immoral acts, criminal activity, having a sexually transmitted infection, or having a characteristic that is incompatible with the proper exercise of one’s trade or profession. Punitive damages may be awarded in these instances as a way to punish the libeller.
Defenses In a Defamation Suit.

There are special protections afforded to members of the media, government workers, politicians, and public figures, providing them certain defenses in a defamation lawsuit.

For medical doctors, optometrists, nurses, dentists, hospitals, and nursing homes that are not afforded such protections, their only defense would be “substantial truth.” This means that the statement does not have to be entirely true as long as the “gist” of the statement is true.
If You Have a Valid Defamation Action, Don’t Delay!

If you feel that you’ve been defamed, do not wait to contact an experienced attorney. In Florida, the statute of limitations for a defamation action is two years. If a claim is not brought forth in this time period, it is forfeited.
Comments?

Before this blog, did you fully understand defamation? Please leave any thoughtful comments below.
Contact Health Law Attorneys Experienced in the Representation of Health Professionals and Providers.

The attorneys of The Health Law Firm provide legal representation to physicians, nurses, nurse practitioners, CRNAs, pain management doctors, dentists, optometrists, pharmacists, psychologists and other health providers.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.
About the Author: Dr. Thu T. Pham represents physicians, dentists, nurses, optometrists, and other health care providers. Her practice includes health law, nursing law, employment law, defense of Medicare and Medicaid audits, and investigations, administrative proceedings and the defense of professional licenses and prepares appeals of administrative law cases. Dr. Pham is also an active doctor of optometry.

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2014 The Health Law Firm. All rights reserved.

Vision Service Plan Audits: An Eye-Opening Experience for the Unprepared

TTP Headshot SmBy Thu T. Pham, O.D., J.D., The Health Law Firm

Unannounced guests dropping by can be a stressful experience for a surprised host. Many would agree that the worst unannounced visitor of all, dreaded more than the in-laws, is the auditor. This “guest” is looking to scrutinize your office policies, patient records, and billing files to uncover and prove allegations worthy of disciplinary action. Optometrists and ophthalmologists have very different audit experiences in comparison to other types of healthcare professionals. Third party payers, typically Vision Service Plan (VSP), perform the audits of vision care practices. Warning: These third party payers have recently increased the frequency of such audits. Below is everything you need to know.

Types of VSP Audits.

Like most healthcare audits, the objective of VSP audits is to identify lapses in strict compliance of industry rules and regulations in areas such as billing, filing, and general business practices. However, unlike Medicare audits that take place only when there is a suspected issue or violation, VSP commonly performs routine audits to ensure quality control. Eventually VSP reviews each doctor about once every five years as required by the National Committee for Quality Assurance Standards. VSP rules change frequently without warning, so it’s critical to stay up to date on the latest compliance rules.

VSP audits can take place in two very distinct formats. The most common audit previously noted above is the routine quality control audit. A practitioner will be asked to send in a small number of randomly selected patient files. These files will be reviewed by the VSP Quality Control Unit that will issue a report of the audit results. If issues are noted in the audit, the results may include a corrective action plan identifying the necessary corrections required. These audits can be expected time to time for all practicing optometrists and ophthalmologists.

The second type of VSP audit is typically ordered when major patterns of inconsistency are noted in an initial quality control audit. A “targeted audit” is performed by the VSP Special Investigations Unit (SIU) and is almost always unannounced. The SIU investigator will show up at an office and request on average 30 to 50 records. These records are not randomly selected, but rather, are related to one or more areas of interest. These audits are conducted to prove violations when it is already believed, by VSP, that rules are being broken.

How to Avoid Negative Audit Results.

A targeted audit can be triggered by a multitude of red flags. Disgruntled employees who make a claim or a patient complaint can lead to a surprise in-office visit from a VSP auditor. In addition, many questionable billing patterns noted by an auditor during a routine quality control audit can spark curiosity for further investigation. Billing for services and products at a rate higher than surrounding area doctors, or at a rate higher than you traditionally have charged, are both red flags. Billing for a comprehensive eye exam and a routine exam on or near the same date will also stick out as potential fraud.

Auditors, in both a quality control audit and targeted audit, focus their scrutiny on the history, examinations, and medical decision-making parts of a patient record. For a doctor, it is beneficial to clearly and completely record the reason for a patient’s visit, their symptoms, and past health history.

Verify that you have recorded any and all tests and exams that were performed during the appointment. Auditors will argue that if you didn’t write it down, it didn’t happen. From our experience, the most poorly documented section of a patient’s record is the medical decision at the conclusion of an exam. It is very crucial to provide detailed statements in addition to a final diagnosis. This will show the auditor you gave sufficient consideration during the exam to conclude a diagnosis. The more documentation you have, the more defensible those records are in an audit. The number one reason an audit may have a negative outcome is due to missing or insufficient documentation.

The Auditor is Knocking at the Door. Now What?

During an audit, the single most important action you can take is to agreeably provide the auditor with ALL complete records related to their requests. The less you argue and defend yourself, the better. A common mistake doctors make during a VSP audit is not providing copies of all relevant information. Relevant information includes any and all information you have on a patient related to the services and materials provided. Do not make assumptions when it comes to what information the auditor needs. Give them copies of everything you have.

If you cannot locate necessary files required for the investigation, ask the auditor for a time extension and put this permission in writing. Do your best to locate these missing files. Patient charts you cannot find during an unannounced audit will be considered over billed. Also, ask the auditor for a copy of the list of patient records that were audited. Keeping track of what you provided the auditor is also important in legally protecting yourself.

The Aftermath of an Audit: What to Expect.

The results of your audit will be mailed to you in a letter. The letter will either give you notice that VSP is terminating your Network Provider Agreement, order that you pay restitution, or both. You may be offered a Consent Decree or a Corrective Action Plan. The Corrective Action Plan is self explanatory: you must agree to immediately cease the actions alleged in the audit. In a Consent Decree, you will receive a probationary time period in which VSP may decide to terminate you or not. In this time frame, you are also eligible for additional audits billable to you.

The letter will also explain the process of appealing the audit’s findings under the “Fair Hearing Plan.” You will only have 30 days to file an appeal. During the process, should your letter claim restitution payments, VSP will immediately start withholding all funds owed to you and apply it to the claimed restitution.

An appeal will be conducted through an administrative peer-review hearing before the VSP Quality Control Panel. Records of the audit will be reviewed once again, and you will have the opportunity to provide evidence and your own records in support of your defense. The board, consisting of three doctors selected by VSP, has the authority to overrule the initial ruling. They may revise the restitution owed, repeal the termination, or initiate another form of disciplinary punishment. It is extremely difficult to convince this panel for an appeal. Should you lose an appeal, you still may seek arbitration or legal action in court.

Ideally, it is best to have an attorney familiar with you and your business available before any audit is initiated. An experienced health law attorney armed with knowledge of industry laws can be critical in successfully surviving the audit process. Any negative VSP action is typically reported to the National Practitioner Data Bank (NPDB) and will remain on your professional file for life. You may also be reported to the Board of Optometry which can lead to disciplinary action against your license. Securing a health law attorney who is familiar with the process is invaluable when considering the potential harm a negative VSP audit can cause.

Comments?

Have you ever had experience with a VSP audit? Please leave any thoughtful comments below.

 

Contact Health Law Attorneys Experienced in Handling VSP Audits, Investigations and other Legal Proceedings.

The Health Law Firm’s attorneys routinely represent ophthalmologists, optometrists or other health professionals in VSP investigations, audits and recovery actions. We also represent optometrists, ophthalmologists and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the DEA, Department of Health (DOH) and other law enforcement agencies.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

About the Author: Thu T. Pham, O.D., J.D., is an attorney with The Health Law Firm, which has a national practice. It’s main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2014 The Health Law Firm. All rights reserved.

 

Florida Ophthalmologist Blinded by Greed-Accused of $7 Million in Medicare Fraud

1 Indest-2008-1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

An Orlando ophthalmologist is accused of performing unnecessary laser-eye surgeries on numerous patients and submitting $7 million in false claims to Medicare. The eye doctor was indicted on April 24, 2014, on 20 counts of Medicare fraud by a federal grand jury in Jacksonville, according to the Orlando Sentinel. If convicted, the ophthalmologist could face life in prison.

Click here to read the entire article from the Orlando Sentinel.

The ophthalmologist’s practices are located in Leesburg and Orlando.

Charges Against the Ophthalmologist.

According to the Orlando Sentinel, the ophthalmologist is accused of falsely diagnosing patients with macular degeneration, a progressive eye disease that can lead to blindness. He allegedly performed laser surgery needlessly and provided unnecessary follow-up care to at least 20 patients. The indictment stated the eye doctor used the laser for treatment at such a low level for the patients that the work had no impact. This scheme allegedly spanned from 2000 until 2011.

And that’s not all. The eye doctor is also accused of falsifying medical records and billing other insurance companies for similar unnecessary procedures.

Records show state health officials suspended the ophthalmologist’s access to collect from Medicare and Medicaid in 2013, after investigating three malpractice complaints against him.

Losing His Luxuries.

As part of the criminal case, federal authorities have filed paperwork to seize the eye doctor’s four homes in Orange County, his Lexus and his Porsche convertible, according to The Florida Times-Union.

To read The Florida Times-Union, click here.

The civil forfeiture of property has become a popular tool for state and federal agencies to combat alleged criminal activity. In Florida, the Florida Contraband Forfeiture Act, Sections 932.701 through 932.706, Florida Statutes permits the government to seize personal property if there is probable cause to believe that property is either an instrumentality or the proceeds of criminal activity.

To read more on how the civil forfeiture of property and money is being used, click here to read a previous blog.

Eye Doctors Seeing Red After Medicare Reimbursement Data Released.

In April 2014, the government released records of Medicare reimbursement payments made to healthcare providers. Ophthalmologists ranked fourth among the highest-grossing Medicare recipients in Florida. To read my previous blog on reasons why ophthalmologists rack up more Medicare bucks, click here.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at http://www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Do you have any personal experience regarding improper billing or false diagnosing? Please leave any thoughtful comments below.

Sources:

Stutzman, Rene. “Orlando Eye Doctor Accused of $7 Million in Medicare Fraud.” Orlando Sentinel. (May 6, 2014). From: http://articles.orlandosentinel.com/2014-05-06/news/os-david-ming-pon-medicare-theft-20140506_1_medicare-fraud-macular-degeneration-laser

Schoellter, Jim. “Judge in Jacksonville Orders Ophthamologist Held in $7m Fraud Case Involving Hundreds of Seniors.” The Florida Times-Union. (May 6, 2014). From: http://members.jacksonville.com/news/crime/2014-05-05/story/judge-jacksonville-orders-ophthamologist-held-7m-fraud-case-involving#ixzz30w2cFtT4

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2014 The Health Law Firm. All rights reserved.

The Health Law Firm Attorneys Often Represent Ophthalmologists and Optometrists in Last Minute Depositions and Hearings

11 Indest-2008-8By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Our attorneys often receive calls from ophthalmologists, optometrists, and other health professionals regarding the possibility of representing them on short notice at a Board of Optometry or Board of Medicine hearing, or at a deposition related to a health care matter.

Call Us If You Need Last Minute Representation.

Many law firms refuse to represent a client at a hearing unless given plenty of preparation time. In a perfect world, we would always prefer to have sufficient time to obtain documents, review files, interview witnesses, conduct research and prepare. But we realize that in certain cases, the alternative is that the client either gets legal representation on little or no advance notice, or has to suffer the consequences of having no legal representation.

Please note, we may refuse some cases, if we believe the case is too complex for us to represent you effectively on such short notice or that any legal representation would be completely futile.

Administrative Proceedings Can be Very Complex.

Some times individuals responding to a disciplinary complaint may be deceived into thinking that they can effectively represent themselves. Laypersons (or nonlawyers) who are not aware of such complex matters as the Administrative Procedure Act, the Rules of Civil Procedure, the Rules of Evidence, the Florida Administrative Code (F.A.C.) Rules which the Board of Medicine or Board of Optometry and the Department of Health (DOH) have enacted, may quickly be perplexed.

The inexperienced individual, or even the inexperienced attorney, in these matters can fall into a number of procedural traps that damage an effective defense. This can be advising the individual to talk to the DOH investigator, filing an unnecessary answer to an Administrative Complaint, forgetting or not knowing that the client’s right to be free of self-incrimination applies in this type of case and many others.

Don’t Risk Damaging Your Defense.

Often you will find that just having an experienced attorney to represent you at a hearing or Board meeting will assist you in avoiding mistakes that damage your case and assist you in preserving your rights for an appeal. In other cases it may even be possible to obtain a change in forum to obtain a better result. For example, many laypersons do not know that if you elect an informal hearing before the Board of Medicine or Board of Optometry, you have waived your right to prove you are innocent by contesting the facts alleged against you.

What few know or think of in the heat of the moment is that you can ask at the informal hearing before the Board of Medicine or Board of Optometry to contest the facts, to prove you are not guilty of the charges, and to have the hearing converted to a formal hearing. A formal hearing will be in front of a neutral Administrative Law Judge (ALJ), and you have many more procedural rights than you have at an informal hearing. We still recommend that you have an experienced health lawyer represent you at a formal hearing.

Professional Liability Insurance is Important, Here’s Why.

If you are a ophthalmologist, optometrist or other health professional who has a professional liability insurance policy, these often provide legal coverage for depositions. This is primarily because the outcome of the deposition may include having you named as a defendant in a professional liability or negligence lawsuit or having disciplinary charges filed against you.

One of the first things you should do if you receive a subpoena or a notice of a deposition is contact your professional liability insurance carrier and see if it will pay for an attorney to represent you. For example, Healthcare Providers Service Organization (HPSO), CPH & Associates and many other malpractice insurance companies provide excellent deposition coverage.

The next step you should take is to call an experienced attorney. Even if you cannot afford to retain the services of the attorney for the actual deposition, a consultation may assist you in properly preparing.

Call An Attorney Experienced in the Representation of Ophthalmologists and Optometrists.

We routinely provide deposition coverage to ophthalmologists, optometrists or other health professionals being deposed in criminal cases, negligence cases, civil cases or disciplinary cases.

The lawyers of The Health Law Firm are experienced in both formal and informal administrative hearings and in representing ophthalmologists, optometrists and other health professionals in investigations and at Board of Medicine or Board of Optometry hearings. Call now or visit our website www.TheHealthLawFirm.com.

Comments?

Have you ever had an informal or formal hearing before the Board of Medicine or Board of Optometry? What was the experience like? Please leave any thoughtful comments below.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Eye Doctors Seeing Red After Medicare Reimbursement Data Released

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

After the government released records of Medicare reimbursement payments made to healthcare providers, upset eye doctors are arguing the accuracy of the data. The Centers for Medicare and Medicaid Services (CMS) recently released the extensive details of such Medicare payments.

According to the New York Times, more than any other specialist, ophthalmologists were the biggest recipients of Medicare reimbursement payouts in 2012. The New York Times article states that 17,000 eye care providers, mostly concentrated in Florida, Texas, California and New York, accounted for seven percent (7%), or $5.6 billion, of all reimbursements in the fiscal year. Despite the data, ophthalmologists are claiming that the numbers released are complete misrepresentations of their actual take-home pay. Eye care physicians argue that the data lacks proper context thus resulting in a false image of fraud and wealth.

To read more on this topic from The New York Times, click here.

Reasons Why Ophthalmologists Rack Up More Medicare Bucks.

“Releasing the data without context will likely lead to inaccuracies, misinterpretations, false conclusions and other unintended consequences,” said Ardis Dee Hoven, M.D., a specialist in internal medicine and infectious diseases, and President of the American Medial Association. This is the argument made by eye doctors claiming the reimbursement data is unfair to them. The basis on which physicians are arguing the data accuracy hinges on the demographics of patients seen and the high cost of prescriptions they require.

With the exception of geriatrics, ophthalmology serves the largest quantity of elderly patients out of all specialities of medicine, according to the Washington Business Journal. Medicare coverage is widely used among this age demographic.

Medicare typically covers corrective procedures for macular degeneration, a common disease in the elderly. Eye physicians are equating the expensive treatment for this degenerative disease to the misleading reimbursement amounts on record with the CMS.

Lucentis is the Food and Drug Administration (FDA) approved drug used in the common procedure to correct macular degeneration. According to The New York Times, in 2012 Lucentis alone accounted for $1 billion in Medicare spending. With vials of the drug costing $2,000 each, physicians argue that it’s easy to see how a Medicare bill can mount up quickly. The majority of eye physicians argue that expenses of the drugs used to perform common procedures go directly to the drug companies, not into their pockets.

Click here to read more from the Washington Business Journal

Eye Drug Expenditures.

Ophthalmologists believe that they are being unfairly targeted by a system that they have no control over. The pressure is now on these physicians to start administering cheaper drugs to their patients. Avastin, an equivalent to Lucentis and produced by the same drug company, has a price tag 40 times cheaper and is reported to work equally as well. Although Avastin has not been approved for eye patients by the FDA, doctors have been saving their patients money by substituting the less expensive drug.

Johnathan Blum, principal deputy director of the CMS stated: “Under the current statutory framework we work under we cannot encourage or require physicians to use lower-cost drugs that are available.” Physicians argue that the profit margins they receive are similar no matter which drug is used in common procedures. They also stress that ultimately, it is the patient who has the final choice when deciding between the high-priced name-brand drug or an unapproved affordable drug.

To read the entire article on Bloomberg News, click here.

Pros and Cons of Publicly Releasing the Data.

The Medicare claims database is considered to be the most extensive source of information on doctors, nurse practitioners (NPs), and physician assistants (PAs) in the United States. Because the Medicare program is financed by taxpayers, many argue that they have the right to access this information. Those advocating the data release claim that the information could guide the general public in selecting physicians of quality and cost-effecting care, according to Modern Healthcare. The publication of this data is also for the purpose of more easily spotting physicians who overcharge Medicare. Insurers also argue that the data will assist in their efforts of demanding low-performing physicians to measure up to set standards.

Click here to read the entire Modern Healthcare article.

Contact Health Law Attorneys Experienced in Representing Optometrists and Ophthalmologists.

The Health Law Firm routinely represents optometrists, ophthalmologists and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the DEA, Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

Do you believe that releasing Medicare reimbursements creates misconceptions about doctors’ spending? As an optometrist or ophthalmologist, do you feel you are being unfairly portrayed by Medicare data? Please leave any thoughtful comments below.

Sources:

Reed, Tina. “7 Questions on Why Ophthalmologists get Reimbursed So Much From Medicare, and Why They Say You Shouldn’t Be Upset About It.” The Washington Business Journal. (April 15, 2014). From: http://bit.ly/1poQvtp

Pollack, Andrew. “Eye Doctors Say Their Profits Are Smaller Than Data Makes Them Look.” The New York Times. (April 9, 2014). From: http://nyti.ms/1m5vZf6

“Medicare database lists top-paid doctors; Fla. ophthalmologist received almost $21 million.” Modern Healthcare. (April 9, 2014). From: http://bit.ly/1nmTnFh

Chen, Caroline and Cortez, Michelle Fay. “Eye Doctors Say Medicare Pay List Unfairly Demonizes Them.” Bloomberg News. (April 11, 2014). From: http://bloom.bg/PXCrY1

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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