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Month: June 2018

Healthcare fraud action highlights ongoing problem

The sweep of healthcare fraud cases announced by the Justice Department is sweeping and vast. Over $2 billion in fraud was identified by 600 defendants charged across the nation, defrauding health insurance for opiods that were re-sold as well as general services.

A stunning $350 million of that fraud comes from South Florida alone. Those charged come from all over the state, too. Prosecutors make it clear that this is only the tip of the iceberg, however, and there is much more that they have not yet uncovered.

The enforcement operation

It appears to be the largest operation ever undertaken against healthcare fraud. The press often highlights the abuse of Medicaid reimbursements, but private insurance companies were caught up in it as well.

Like much of the fraud today, it involved a vast network of doctors, clinics, patients, and services all working together. It even connected the opiods obtained with false prescriptions to a drug cartel that is traffic in them.

Much is South Florida based

Fully 20% of the defendants ensnared are from South Florida. In the Tampa area alone, 13 defendants including four doctors have been charged. The network of fraud reached out all across the nation but was clearly centered here.

The $350 million in fraud in South Florida came from nearly every aspect of the healthcare industry, too. All insurers in the state have probably been defrauded, at least in part, by this operation. And officials are stressing that this is only what is known at this time, there is likely to be more.

What can be done?

Fraud that is identified by the Justice Department can be recovered. It takes experience in insurance fraud to navigate a case like this, especially when the operation is so vast and criminal charges are involved. More importantly, there may be evidence in the criminal trial which highlights other fraud not currently charged.

Insurance fraud is so common in South Florida that vigorously pursuing it is critical for any insurer. A legal team with a proven track record pursuing every case to full recovery can make a large difference in the bottom line for any insurer operating in Florida.

Over-payments: getting the advantage for the insurer

Overpayments to providers by insurers happen all the time. It’s not a matter of fraud but the complexities of the system. Medical providers rarely have fixed tables of cost for any given services and the actual price for any given treatment is often negotiable.

Insurers have a disadvantage in this system. The position is made even weaker by Florida law. The only way to regain the advantage, when necessary, is to be prepared for civil litigation.

The law in Florida

Insurance payments to providers are covered in Florida statute 627.6131, Payment of claims. The exact dates and methods for all claims are spelled out in great detail. Section (6)(a) covers overpayments discovered as part of a review or audit and not related to fraud.

1. All claims for overpayment must be submitted to a provider within 30 months after the health insurer’s payment of the claim. A provider must pay, deny, or contest the health insurer’s claim for overpayment within 40 days after the receipt of the claim. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.

This establishes the procedures and the clock for payments. Further, in section 3 it is made clear that insurers cannot take any action on their own including reducing payment for other services as part of an overpayment claim.

What this means

If a provider simply ignores the overpayment request, it can be enforced after 140 days. But it often takes the threat of civil action in order to have that reimbursement occur.

It is often in the best interests of any provider to simply deny the overpayment as a matter of course. This leaves them in the even stronger position, given that it is not legal to reduce any payments to the provider. There is no recourse for hte insurer other than to threaten to sue.

How to proceed

For this reason, all situations involving overpayment have to be considered on the basis of how the information will be presented at trial. The providers must believe that the overpayment is going to proceed to trial before they will take it seriously, based on their strong position under the law.

That is why any collection action against a provider must be undertaken with a law firm experienced in handling collection and refunds from providers. There is simply no alternative, given the position insurers are in under Florida law.