Exclusion from Medicare and Medicaid can have devastating consequences for doctors, nurses, pharmacists, and other healthcare professionals. Exclusion results in the inability to submit claims to federal healthcare programs. It also means that you cannot work for any healthcare providers that accept payment from such programs. In addition, many private insurance companies, providers, and suppliers will not do business with an excluded professional. Unfortunately, too many medical professionals and their lawyers do not think about exclusion and its career-destroying potential until it is too late. When faced with a billing dispute or a fraud investigation, they tend to focus exclusively on avoiding criminal charges or reducing the financial exposure. Even if they avoid criminal charges, however, they still may face exclusion from Medicare, Medicaid, and other federal healthcare programs. Under federal law, there are two types of exclusion: mandatory and permissive. Mandatory exclusions: The Office of Inspector General (OIG) at the Department of Health and Human Services (HHS) must exclude individuals and entities from participation in all federal health care programs if they are convicted of certain criminal offenses. The types of criminal offenses that result in mandatory exclusion from Medicare and Medicaid are:
Permissive exclusions: The OIG may, but is not required to exclude individuals and entities that engage in other conduct, including conduct that does not involve Medicare or Medicaid. For example, a misdemeanor conviction for submitting false claims to a private insurance company may result in exclusion from federal healthcare programs. Even defaulting on student loans may result in exclusion. The grounds for permissive exclusion include:
If you are facing a dispute over claims submitted to Medicare, Medicaid, or even a private insurance company, then you should consult with an experienced Medicare and Medicaid fraud attorney who understands all the implications, including the possibility of exclusion and the potential impacts on your professional license. To arrange a free and confidential consultation, call John Howley, Esq. at (212) 601-2728 or click here to reach our offices via email. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules.
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A jury has found that Tuomey Healthcare System in Sumter, S.C., violated the Stark Law by paying doctors in ways that rewarded them financially for referring patients to the hospital. The jury found that more than 20,000 Medicare claims were tainted by the illegal compensation arrangements. The hospital was accused of offering doctors lucrative part-time contracts that paid above fair market value and were not commercially reasonable. The contracts contained “non-compete” provisions requiring that the doctors perform their outpatient procedures at the hospital. The doctors who accepted the contracts were paid an annual base salary plus a “productivity bonus,” which varied based on how much the hospital earned from outpatient procedures. The trial focused on dueling experts: The hospital had an appraiser’s opinion that its compensation arrangements with the physicians were consistent with fair market value; the government’s expert disagreed. The jury agreed with the government’s expert. The hospital faces up to $357 million in potential False Claims Act liabilities. Federal law requires repayment of all of the money paid under illegal Medicare claims, and the False Claims Act allows an award of up to three times the amount of total damages, plus as much as $11,000 per claim. The government’s lawsuit was commenced by a whistleblower, Dr. Michael Drakeford, under the qui tam provisions of the False Claims Act. Dr. Drakeford filed his whistleblower lawsuit after he declined to enter into one of the agreements that the hospital was offering. The whistleblower reward in this case will be between 15% and 25% of the amount collected by the government. Even if the hospital avoids treble damages and penalties by settling the case, the whistleblower reward could be in the range of $7 million to $10 million. If you have evidence that a hospital, nursing home, or other healthcare facility has agreed to pay physicians in return for referrals, then you should consult with an experienced whistleblower attorney immediately. You may be entitled to a whistleblower reward. John Howley, Esq. is an experienced Medicare and Medicaid fraud whistleblower attorney. Call our office today at (212) 601-2728 or click here to arrange a free and confidential consultation. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules. |
John Howley, Esq.
350 Fifth Avenue 59FL New York, NY 10118 (212) 601-2728 |