By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
The North Carolina Department of Health and Human Services (DHHS) announced on July 25, 2012, in a press release, that it investigated 75 cases for potential Medicaid billing fraud. The DHHS has already referred 35 cases totaling $21 million to the special Medicaid Investigations Unit of the North Carolina Attorney General’s office.
Investigators Used Data Analytics Software to Detect Questionable Billing Practices.
Using data analytics software from IBM, the DHHS reviewed 75 cases that showed, what it calls: “questionable billing practices by Medicaid outpatient behavioral health providers.”
The software program can allegedly detect billing behaviors that suggest fraud and can point to other related providers that may be abusing the Medicaid program. North Carolina is the first state to use the IBM software to track down Medicaid fraud.
Thirteen of the referred Medicaid providers were in Wake County, four in Durham, three in Robeson and two each in New Hanover and Franklin counties. The following counties each had one provider referred: Pitt, Orange, Onslow, Nash, Martin, Johnston, Iredell, Guilford, Granville, Franklin, Forsyth and Cumberland.
To see the full press release from the North Carolina DHHS, click here.
The Investigation Continues, More Referrals Could Be Coming.
The healthcare practices were not listed by name, because they have been referred for a criminal investigation. If criminal charges are filed, the names of those being investigated would then be public record.
More referrals could be forthcoming if DHHS finds more suspicious billings.
Responding to a Medicaid Audit.
Should you find yourself, your facility, or your health practice the subject of a Medicaid audit by your state Medicaid agency or audit contractor, there are a few things you should know.
The most important thing is that just because you are being audited, it does not mean that you or your business has done anything wrong. State and federal governments conduct audits for many different reasons. Typical ones include: special audits of high-fraud geographic areas, auditing of particular billing codes, randomly selected provider auditing, and complaints of possible fraud.
Click here to see a complete list of steps you should take in order to compile and provide a set of records that will best serve to help you avoid any liability at the conclusion of the audit process.
Don't Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Audits Now.
The lawyers of The Health Law Firm routinely represent physicians and other healthcare professionals in Medicare and Medicaid investigations, audits and recovery actions. They also represent physicians and health professionals in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.
Our attorneys have represented Medicaid providers in cases in North Carolina, South Carolina, Michigan, Florida, Mississippi and New York, among other states.
Our attorneys can represent healthcare providers in Medicare and Medicaid investigations, audits and administrative hearings in other states and jurisdictions as permitted by the rules governing attorneys in those jurisdictions.
Call now at (407) 331-6620 or (850) 439-1001 or visit our website www.TheHealthLawFirm.com.
Pearson, Chrissy. “Almost Three Dozen Medicaid Cases Referred to Law Enforcement.” North Carolina Department of Health and Human Services. (July 25, 2012). Press Release From: http://www.ncdhhs.gov/pressrel/2012/2012-07-25_medicaid_cases_referred.htm
DeBruyn, Jason. “DHHS investigating dozens of alleged billing fraud cases.” Triangle Business Journal. (July 26, 2012). From: http://www.bizjournals.com/triangle/news/2012/07/26/dhhs-investigating-dozens-of-alleged.html
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.
Tag Words: Medicaid, Medicaid fraud, Medicaid Fraud Control Unit (MFCU), Medicaid audits, administrative hearing, North Carolina Medicaid, Medicaid provider, Medicaid contract, Florida Medicaid, South Carolina Medicaid, Georgia Medicaid, termination of Medicare billing privileges, Department of Health and Human Services, DHHS, Centers for Medicaid & Medicaid Services (CMS), request for reconsideration, physicians, medical groups, medical practices, fraud prevention, Medicaid revocation, Medicaid termination, special agents