Health Facility Entitled to Attorney's Fees Against AHCA in Defending Medicaid Overpayment Case

Monday, July 6, 2015
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The following is a summary of a recent administrative hearing case on an issue relevant to health law, decided by the Florida Division of Administrative Hearings (DOAH).

Via three Final Audit Reports dated July 10, 2013, AHCA advised the Chrysalis Center that it had overbilled the Medicaid program by $284,535.83 for community mental health services.  The Chrysalis Center responded on August 23, 2013, by asserting in a letter that one of AHCA's program analysts had previously determined that the vast majority of the services at issue were reimbursable by Medicaid.  Nevertheless, AHCA transmitted the three files to DOAH.  

OUTCOME: The ALJ's Recommended Order concluded that the overpayments proved by AHCA were less than 1% of the cumulative amounts identified in the Final Audit Reports.  In the course of doing so, the ALJ characterized AHCA's transmittal of the case files to DOAH as a "rejection" of the program analyst's determination.  Accordingly, the ALJ sua sponte determined (in a portion of the Recommended Order that was characterized as a "Final Order") that the Chrysalis Center was entitled to an award of attorneys' fees under Section 57.105(1)(a), Florida Statutes, because AHCA "knew or should have known from the outset that it lacked necessary material facts to support its claim."  The AHCA advocate filed several exceptions to the ALJ's findings of fact regarding the overpayments claimed in the Final Audit Reports, but AHCA rejected those exceptions and rendered a Final Order on September 2, 2014, requiring the Chrysalis Center to only repay $5,232.54 in Medicaid overpayments. 

Separately, on June 30, 2014, AHCA appealed the ALJ's determination that the Chrysalis Center was entitled to an award of attorneys' fees.  However, the First District Court of Appeal dismissed the appeal because the "Final Order" was not truly final, having only determined entitlement to fees without also determining the amount of fees.  The case remains pending at DOAH under the same case number (14-0136MPI) for entry of a final order determining the amount of fees to which the ALJ previously determined Chrysalis Center is entitled.

AHCA v. The Chrysalis Center, Inc., DOAH Case No.14 - 0136MPI (Rec. Order June 3, 2014), AHCA Case No. 14-757-FOF-MDO (Final Order Sept. 2, 2014).

The case summary above was originally published in the Administrative Law Section Newsletter,  Vol. 34, No. 2 (Dec. 2014), a publication of The Administrative Law Section of the Florida Bar.

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

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Healthcare Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), the FBI, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS). Often other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies participate. Don't wait until it's too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health law attorney familiar with medical billing and audits today.  Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.
The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.
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As a health care entity owner, have you ever received a Medicaid overpayment demand? What did you do? 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.  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: medical groups, Medicaid, Medicaid program, Medicaid defense attorney, Medicaid overpayment, Medicaid overpayment demands, Medicaid audit, Medicaid audit appeal, administrative hearing, informal hearing, exclusion from Medicaid, revocation, professional license, licensure issues, health law attorney , health law lawyer, Florida health law attorney, Florida health law lawyer, defense attorney, defense lawyer, Florida Medicaid attorney, Florida Medicaid lawyer, Florida Division of Administrative Hearings, DOAH, American Health Care Association, AHCA, The Health Law Firm reviews

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