By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
Due to a rise in fraud across the system, the Florida Attorney General (AG), through the Medicaid Fraud Control Unit (MFCU), is directing its focus toward Medicaid targeted case management (TCM) services. TCM services were established to help children with documented mental health conditions access medical, social, educational, and other support services. To qualify for these services, a child must meet specific and stringent criteria.
Eligibility Criteria for Children’s Mental Health TCM Services:
1. Must be enrolled in a Department of Children and Families (DCF) children’s mental health target population (birth through 17 years);
2. Has a mental health disability (i.e., serious emotional disturbance) that requires advocacy for and coordination of services to maintain or improve level of functioning;
3. Requires services to assist in attaining self-sufficiency and satisfaction in the living, learning, work, and social environments of choice;
4. Lacks a natural support system for accessing needed medical, social, educational, and other services;
5. Requires ongoing assistance to access or maintain needed care consistently within the service delivery system;
6. Has a mental health disability (i.e., serious emotional disturbance) that, based upon professional judgment, will last for a minimum of one year;
7. Is in out-of-home mental health placement or at documented risk of out-of-home mental health treatment placement; and
8. Is not receiving duplicate case management services from another provider.
Unfortunately, many of the children TCM providers assist and bill Medicaid for do not meet these criteria. In addition, the Medicaid program’s lack of oversight has led to numerous improper and fraudulent payments to TCM providers.
Florida TCM Fraud Cases.
Improper and fraudulent payments often arise when TCM providers bill for services that were never performed and pay kickbacks for client referrals.
The Florida AG reported that the owners of Destiny TCM Corporation in Central Florida were arrested for $27,000 in Medicaid fraud. They allegedly billed Medicaid for non-existent case management services and bribed individuals to obtain Medicaid recipient numbers.
Similarly, owners of Kingdom Builders Ministries in Lake County faced arrest for allegedly defrauding Florida Medicaid out of $80,000. They reportedly instructed employees to bill for entire families when only one member received services and to charge for unauthorized expenses. Records also show that they received payments for services supposedly provided to children without documented mental health conditions and continued to invoice after terminating services.
Tips for Responding to a Medicaid Fraud Control Unit Investigative Subpoena.
The MFCU has identified instances of improper payments and has started a thorough investigation of TCM providers. The MFCU is responsible for investigating and prosecuting healthcare providers suspected of defrauding the state’s Medicaid program. When the unit opens a case against a provider, the first step is typically to issue an investigative subpoena to obtain specific patient records. It’s important to note that the MFCU only becomes involved when there is a suspicion of criminal fraud; this is not a routine audit.
Defend Yourself from Fraud Charges.
Individuals in situations like this have sought our counsel before and after facing criminal convictions for fraud and related offenses. In many cases, we are convinced of their innocence. Yet, those under Medicaid or Medicare fraud audits often fail to grasp the severity of their circumstances or neglect to hire top-quality legal representation.
If you are accused of Medicare or Medicaid fraud, recognize that your freedom and career are on the line. You must be prepared to sell your possessions, borrow funds, and hire the best criminal defense attorney who specializes in these cases.
Winning your case means retaining your professional license and the chance to rebuild your life. Losing, however, can result in years of prison, loss of your license, exclusion from Medicare, and a felony conviction that could derail your future. This is a critical situation, and you must be willing to make significant sacrifices to protect your future and avoid a conviction. Act decisively; your life depends on it.
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. Regularly, Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints. Don’t wait until it’s too late. If you are concerned about any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today.
The Health Law Firm’s attorneys routinely represent speech therapists, occupational therapists, vocational therapists, therapy groups, physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs). They also represent 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 toll-free (888) 331-6620-1001 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 Avenue, Suite 1000., Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.
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