Fighting a Medicare or Medicaid Revocation

 Posted on October 15, 2021 in Professional License Defense

In today’s litigious society, doctors often have to worry about medical malpractice claims. The high cost of malpractice insurance to protect a physician and their practice is one of the factors that drives the high cost of healthcare. Although focused on malpractice concerns, worrying about accusations for Medicare or Medicaid fraud is not something that a physician usually concerns themselves with, yet these accusations occur much more often than you may realize.

Medicare Fraud Accusations

The False Claims Act was enacted to protect these programs from the filing of false claims. A physician can be accused of fraud for false claims if the Office of Inspector General (OIG) feels that physician knew or should have known the claims were not valid. Under this law, a physician can be held legally liable even if they had no idea their office was submitting fraudulent claims with Medicare or Medicaid. If the OIG finds the physician guilty, that physician can receive a fine of $11,000 for every incorrect or fraudulent item billed to the government.

Incorrect coding is also another reason why the OIG may accuse a doctor of Medicaid fraud. If the incorrect code results in a larger amount of reimbursement than what the actual charge should have been, the OIG could deem this act an abuse of the program.

There are other billing and coding issues that can result in accusations of fraud:

• Billing Medicaid or Medicare separately for services that are covered by a different fee.

• Billing for a provider who is not allowed to participate in Medicaid or Medicare

• Billing for services that the doctor never provided.

• Billing for services that were medically unnecessary.

• Billing for services that were conducted by an unqualified or unsupervised employee.

Appealing a Medicaid Revocation

If a physician is ultimately barred from participating in federal insurance programs, they do have the right to appeal that decision. If the revocation occurred because the OIG found there were deficiencies that can be corrected, the physician is allowed to submit a plan that details the corrective actions they will take to eliminate those deficiencies. Keep in mind that the OIG sets stringent requirements and deadlines for this submission and there must be proof of compliance included in the request.

If the revocation was a result of fraud or other wrongdoing by an employee or other individual associated with the practice, terminating any relationship with that individual and submitting proof of that termination within 30 days is required for a request of reconsideration.

If a revocation reconsideration is not successful, the next step for appealing is a hearing with an administrative law judge (ALJ). If the ALJ does not reverse the revocation, the physician has 60 days to file an appeal with the Departmental Appeals Board (DAB).

Contact a U.S. Provider Enrollment Defense Lawyer

During each one of the above steps – whether the initial accusations of fraud, all the way to an appeal with the DAB, having a skilled and experienced Illinois provider enrollment defense attorney right by your side is critical for any chance of success. This appeal process is a complex one and having an attorney who understands how to navigate through it, as well as what is required to successfully appeal, makes all the difference. Call The Law Offices of Joseph J. Bogdan, Inc. at 630-310-1267 to schedule a free and confidential consultation.

Sources:

https://oig.hhs.gov/

https://www.dol.gov/agencies/oalj/about/ALJMISSN