Texas Medicaid Settlement Raises Questions Among Health Care Providers

Tuesday, April 8, 2014
By Lenis L. Archer, J.D., M.P.H., The Health Law Firm and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On March 17, 2014, Carousel Pediatrics in Austin, Texas, agreed to pay the state a $3.75 million settlement, after an investigation by the Texas Health and Humans Services Commission Office of Inspector General (OIG) allegedly found a number of billing errors.  According to a press release, the Texas OIG alleged the pediatric office charged for higher levels of care than were supported by patients' charts and double-billed for certain services.

Click here to read the press release from the Texas OIG.

According to the Texas OIG, Carousel provides primary care for more than 25,000 Texas children, a majority of whom are Medicaid patients. This settlement is not sitting well with many health care providers who treat the Lone Star State's poorest patients. Texas Medicaid providers are now questioning the Texas OIG's process for distinguishing health care fraud from human error. The settlement also comes at a time when the number of Texas physicians opting not to participate in the Medicaid program is at an all time high.

How the Texas OIG Determined Billing Errors By Carousel.

According to the Texas OIG, after its investigation it determined that Carousel demonstrated a quality of care similar to other Medicaid providers, but the pediatric office overbilled the state for its services. Carousel's attorney stated that the office may have made billing errors, but they were not intentional. The Texas OIG maintains that health care providers billing Medicaid should read every regulation and assume someone will review every document submitted with great attention to detail. The settlement agreement calls for an initial payment of nearly $614,000, followed by monthly payments until Carousel reimburses the state the full amount.

Texas OIG Too Aggressive?

In a New York Times article about the settlement, the Texas Medical Association criticizes the OIG's aggressive tactics. In addition to initiating investigations and requesting records, the Texas OIG can suspend payments to providers and seek restitution if credible evidence of fraud is found. Together these tactics can cost a health care practice in both time and money, sometimes to the point that the practice must shut down.

According to the article, the number of Texas physicians accepting Medicaid dropped to just 31 percent in 2012, and continues to drop. The Texas Medical Association predicts this settlement will convince other providers considering participating in the Medicaid program to decline.

To read more from The New York Times article, click here.

Many Providers Do Not Mean to Intentionally Commit Fraud.

We have been consulted by many individuals, both before and after receiving criminal convictions for fraud or related offenses. In many instances, we are convinced that the provider is actually not guilty of fraud. However, in many cases those subject to Medicaid or Medicare fraud audits and investigations refuse to acknowledge the seriousness of the matter or they decide not to spend the money required for an experienced attorney to defend them.

It's important to note that the fees collected by government agencies fighting fraud is going up. With more money being recovered, you can expect these agencies to continue their aggressive investigations on Medicare and Medicaid providers throughout the country.

If you are accused of Medicare or Medicaid fraud, realize that you are in the fight of your life. Your liberty, life and profession are at stake. You need to hire the best criminal defense attorney available with experience in defending fraud cases to represent you.

If you win and are acquitted, you may still have a professional license and can start over. However, if you lose, you could be sentenced to years of prison time. You will lose your license. You will be excluded from Medicare and Medicaid. You will be a convicted felon. You will have no credentials and no way of starting over successfully. Do not delude yourself. This is extremely serious. Be prepared to give up whatever you have if you can avoid a conviction.

By Taking Medicaid, a Healthcare Provider is Subjecting Itself to the Government's Whim and Scrutiny.

An associate of the firm who happened to also be a health law attorney once said, "If you eat at the government's trough you may one day be slaughtered like a pig."By this he meant, if you did not want to subject yourself to government regulation, scrutiny and caprice, don't sign up to be a Medicaid provider.

Unfortunately, the government holds the upper hand in such cases as it can threaten to bring criminal fraud charges in order to leverage a large monetary settlement. This would be the crime of extortion if a private individual or organization did it; but no such law applies to the government.

A reasonable remedy against such audits is to insure one's practice. Insurance can be purchased that covers all of the legal expenses of a defense of such a case, even through trial. At least in this manner the legal expenses of defending oneself won't bankrupt the provider.

Another way of avoiding such a situation is to have a good internal compliance program, monitored by an experienced outside consultant. If your personnel are well trained and your program is effective, such problems cab be avoided from the outset. At the very least, having a good compliance program is considered in mitigation to reduce possible fines and penalties.

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 Health Care 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  about possible violations and would like a confidential consultation, contact a qualified health 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. To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.


Have you ever considered not participating in the Medicaid program? Do you think the drop in providers accepting Medicaid patients is common, not just in Texas, but the entire country? Please leave any thoughtful comments below.


Goodman, Stephanie. "OIG Reaches $3.75 Million Settlement with Carousel." Texas Health and Human Services Commission. (March 17, 2014). From: http://www.hhsc.state.tx.us/news/release/2014/031714-Carousel-Settlement.shtml

Aaronson, Becca. "Settlement in Medicaid Fraud Case Worries Health Providers." The New York Times. (March 27, 2014). From: http://nyti.ms/1gJpvQx

About the Authors: Lenis L. Archer is as attorney with 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 Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

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 providers, Texas Medicaid providers, health care fraud, over billing, billing error, double billing, Texas Medicaid, Texas Medicaid fraud, pediatrics, physician, doctor, Medicaid billing, Texas Health and Humans Services Commission Office of Inspector General, OIG, Texas OIG, Medicaid settlement, suspended payments, Medicaid audit, withholding payments, suspicious billing patterns, defense attorney, defense lawyer, Medicaid defense attorney, Medicaid defense lawyer, health law firm, The Health Law Firm

"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.
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