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What To Do If You Receive A Medicaid Fraud Subpoena In Georgia

medicaid fraudThe Georgia Medicaid Fraud Control Unit (MFCU) investigates and prosecutes fraud and abuse by providers in the Georgia Medicaid program.  One of the first steps MFCU takes when it opens up a case against a provider is often the issuance of an investigative subpoena, requesting specific patient records.

Often the provider has already been looked at by the Georgia Department of Community Health’s Medicaid Program Integrity Unit which handles intake and triage of cases before turning them over to MFCU. In other words, the provider has somehow managed to get on the State’s radar, and it is serious.

Please keep the following in mind if you receive a Medicaid Fraud subpoena:

1. CALL AN EXPERIENCED HEALTHCARE FRAUD ATTORNEY. This is a highly specialized area of the law, and you need someone to represent you that has experience both in defending criminal matters AND in healthcare law. This area of law is like a hybrid car. Just like it takes gas and electric batteries to power a hybrid car, it takes knowledge of criminal and healthcare law to successfully represent a provider facing a Medicaid fraud investigation.

2. Call an attorney BEFORE you respond to the subpoena or talk to an investigator.

3. Remember: the Investigator is NOT your friend. They are doing a job, and their job is find evidence against you. We recently represented a client who was complying with a subpoena from MFCU. Five investigators showed up to get the documents. Since there was no threat of an armed suspect, one can only guess that the use of five investigators to collect documents had to be an intimidation tactic. Likewise, these investigators tried desperately to butter up the employees to get them to talk, and this was with an attorney standing there. Remember: the investigator is NOT your friend.

4. Be Polite and cooperative. If your attorney determines that the subpoena is lawful and enforceable, you have to turn over the documents requested. This can be quite labor- intensive, but you must comply and polite cooperation can only help you in establishing the tone for whatever next steps will be taken.

5. Make copies of every document and electronic file you turnover to MFCU PRIOR to turning them over.

6. DO NOT provide MFCU with anything more than what they have requested in the subpoena- not one document more. And remember, they are only entitled to the records of Medicaid members.

7. Neither you nor your employees are required to speak with the investigator unless individually subpoenaed. Have an attorney present during any interviews.

8. Don’t panic. While a MFCU subpoena should be taken seriously, in Georgia, in 2014, there were 410 Medicaid Fraud Investigations. Of those investigations, only 4 led to indictment.1 The math indicates that MFCU investigates often but indicts with much less frequency.

If you are receive a subpoena from the Georgia Medicaid Fraud Unit, Jeyaram & Associates can help. Contact Kimberly Sheridan at ksheridan@Jeylaw.com or 678.325.3872.

CIS Recoupments Begin – Still Time To Appeal

CIS Recoupment ClaimsThe first Special Remittance Advices (“RA”) pursuant to the Department of Community Health’s CIS Claims Reprocessing were issued this week.  Claims originally processed between November 1, 2010, through June 30, 2012, that billed specific CPT codes are subject to this special reprocessing based on the CMS National Correct Coding Initiative mandated by the Affordable Care Act.

Early reports are that the Special RA’s detailing the voided claims have been several hundred pages long with recoupments reported from $5000 to $100,000.

Some providers have indicated that DCH may be willing to enter into payment plans with providers to space-out the recoupment amount and that the Department may also allow denied claims to be re-billed with the proper CPT modifiers to allow for payment.

Section 202 of DCH’s Part I:  Policies and Procedures Manual requires that claims be received within six (6) months after the month in which service was rendered to be reimbursed unless certain exceptions are met.  It is unclear whether DCH considers the Special Reprocessing as meeting the exception requirements.  If it does not, then providers may be limited to six (6) months for re-billing claims.

If you think the Department’s determination of recoupment is incorrect, you can still appeal the determination as described in Part I of this article. It is extremely important that you satisfy all of the appeal requirements and meet all deadlines.  Failing to do so means that you waive your appeal rights and may not be able to challenge the DCH action.

If you’ve received notice that your practice is subject to the reprocessing recoupment and need help or if you need to appeal DCH’s decisions, Jeyaram & Associates can help. Contact DJ Jeyaram at DJ@Jeylaw.com or 678.325.3872.

Media Coverage for Lawsuit Against the State for Severely Disabled

Class Action Lawsuit Against GeorgiaAdditional media coverage on our class action lawsuit against the state for severely disabled:

http://www.dailyreportonline.com/PubArticleDRO.jsp?id=1202614700896&Class_Action_Seeks_State_Funds_Not_Paid_To_Disabled

http://wabe.org/post/lawsuit-alleges-state-underpaid-providers-who-serve-disabled

http://www.cbsatlanta.com/story/23086886/exclusive-lawsuit-filed-against-state-of-georgia-alleges-funds-withheld-for-disabled

Jeyaram & Associates and Parker, Hudson, Rainer & Dobbs File Class Action Law Suit Against the State

Class Action Law Suit Against GeorgiaJeyaram & Associates and Parker, Hudson, Rainer & Dobbs have filed suit against the state for withholding millions of tax funds earmarked for severely disabled individuals.

Family members representing people with severe disabilities and a group of their health care providers today filed a class action law suit against the Georgia Department of Behavioral Health and Developmental Disabilities and the Georgia Department of Community Health for withholding funds that were designated for the care of those individuals contrary to controlling law.

United Cerebral Palsy of Georgia, Inc., Coastal Center for Developmental Services, Inc., Hope Haven of Northeast Georgia and Creative Community Services, Inc. as well as four families representing nearly 12,000 individuals in the State seek the return of hundreds of millions of dollars that should have been used to care for those individuals since 2008.  The exact amount will be determined at trial.

The families filing suit represent clients who depend on vital services from these healthcare providers every single day. These clients are some of the most vulnerable members of our communities.  Their daily lives have been negatively impacted in real and tangible ways, as have those of their families and caregivers.

“My daughter Tammy wants and needs activity.  Sitting in front of a TV set is counterproductive for her,” says Angela Tulloh of Kennesaw.

Marilyn Harvill worries about the ongoing and future care of her son, 53 year old Matt Windham.  “Matt has severe brain damage and needs 24 hour one-on-one care.  I am worried about the services Matt will receive in the future because I wasn’t given any notice of the cuts.”

None of the families affected was notified by the state of the pending cuts and none was given any recourse.

Additionally, an undetermined number of other individuals requiring new services have been turned away due to the improper budget cuts.

Those organizations filing suit are designated Medicaid providers. The two state agencies being sued have failed to reimburse the plaintiffs for services provided under contract to clients with profound intellectual and developmental disabilities. That has led to severe financial harm to these providers. The state has very specific rules and procedures it must follow before reducing already agreed upon payments to providers and families.  None of those procedures has been followed.

These cuts in Medicaid funds were not tied to the recent economic downturn; rather the funds were allocated by the state legislature and simply not paid in full to the providers and clients who depend on them.

“We have gone through our financial resources to keep serving our existing clients, but we have had to turn away other people with severe developmental, medical and behavioral needs.  I don’t know what happens to those people,” says Sally Buchanan, CEO of Creative Community Services of Norcross.

Curt Harrison, Associate Executive Director of United Cerebral Palsy Georgia and South Carolina, says

“So many people rely on us and we’re doing the best we can.  But development of new services and additional employee training have really suffered.  However, we don’t think it’s morally appropriate to cut services.”

 To view this story on Channel 46: http://www.cbsatlanta.com/story/23086886/exclusive-lawsuit-filed-against-state-of-georgia-alleges-funds-withheld-for-disabled