Accusations of Medicaid/care Fraud Run Rampant in SC: There Are Legal Remedies!
As if South Carolina didn’t have enough issues with the recent flooding, let’s throw in some allegations of Medicaid fraud against the health care providers. I’m imagining a provider under water, trying to defend themselves against fraud allegations, while treading water. It’s not a pretty picture.
Flash floods happen fast, as those in SC can attest.
So, too, do the consequences of allegations.
Shakespeare is no stranger to false accusations. In Othello, Othello is convinced that his wife is unfaithful, yet she was virtuous. In Much Ado About Nothing, Claudio believes Hero to be unfaithful and slanders her until her death. Interestingly, neither Othello and Claudio came to their respective opinions on their own. Both had a persuader. Both had a tempter. Both had someone else whisper the allegations of unfaithfulness in their ears and both chose to believe the accusation with no independent investigation. So too are accusations of Medicaid/care fraud so easily accepted without independent investigation.
With the inception of the Affordable Care Act (ACA), We have seen a sharp uptick on accusations of credible allegations of fraud. See blog for the definition of credible allegation of fraud.
The threshold for credible allegation of fraud incredibly low. A mere accusation from a disgruntled employee, a mere indicia of credibility, and/or even a computer data mining program can incite an allegation of fraud. Hero was, most likely, committing Medicare/acid fraud too.
The consequences of being accused of fraud is catastrophic for a health care provider regardless whether the accusation is accurate. You are guilty before proving your innocence! Your reimbursements are immediately suspended! Your entire livelihood is immediately crumbled! You are forced to terminate staff! Assets can be seized, preventing you even the ability to hire an attorney to defend yourself!
I have seen providers be accused of credible allegations of fraud and the devastation that follows. In New Mexico. In North Carolina. See documentary. Many NC providers serve SC’s population as well. The Medicaid reimbursement rates are higher in SC.
Obviously, The ACA is nationwide, federal law. Hence, the increase in allegations/accusations of health care fraud is nationwide.
Recently, South Carolina health care providers have been on the chopping block. Othello and Claudio are in the house of Gamecocks!
South Carolina’s single state agency, DHHS, required Medicaid recipients to get a 2nd prior approval before receiving health care services for “rehabilitative behavioral health” services, such as behavioral health care services for substance abuse and mental illness (could you imagine the burden if this were required here in NC?).
Then, last year, SC DHHS eliminated such 2nd prior approval requirement.
With fewer regulations and red tape in which to maneuver, SC saw a drastic uptick of behavioral health care services. Othello and Claudio said, “Fraud! More services with only one prior approval must be prima fracie fraud!”
Hence, behavioral health care providers in SC are getting investigated. But, mind you, during investigations reimbursements are suspended. You say, “Well, Knicole, how will these health care provider agencies afford to defend themselves without getting paid?” “Good question,” I say. “They cannot unless they have a stack of cash on hand for this exact reason.”
“What should these providers do?” You ask.
Hire an attorney and seek an injunction lifting the suspension of payments during the investigation.
Turn a Shakespearean tragedy into a comedy! Toss in a dingy!
Judges have lifted the suspensions. Read the case excerpt below:
As you can read in the above-referenced case, despite 42 455.23(a) mandating a suspension of payments upon credible allegations of fraud, this Judge found that the state failed to carefully weigh the evidence before suspending all payments.
There are legal remedies!!
Posted on October 13, 2015, in "Single State Agency", Administrative Remedies, Affordable Care Act, Appeal Rights, Behavioral health, Credible Allegations of Fraud, Criminal Medicaid Fraud, Division of Medical Assistance, Due process, Federal Government, Federal Law, Fraud, Health Care Providers and Services, Injunctions, Knicole Emanuel, Lawsuit, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Advocate, Medicaid Appeals, Medicaid Attorney, Medicaid Audits, Medicaid Fraud, Medicaid Providers, Medicaid Reimbursements, Medicare, Medicare and Medicaid Provider Audits, Medicare Appeal Process, Medicare Attorney, Medicare Audits, Mental Health, NC, NC DHHS, North Carolina, Obamacare, Preliminary Injunctions, Provider Appeals of Adverse Decisions for Medicare and Medicaid, Provider Medicaid Contracts, Regulatory Audits, Suspension of Medicaid Payments, Timely Payments, TRO and tagged 42 CFR 455.23, ACA, Behavioral health, Centers for Medicare and Medicaid Services, Credible Allegations of Fraud, Division of Medical Assistance, DMA, Gordon & Rees, Health care provider, Injunctions, Legal Remedies for Health Care Providers, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Attorney; Medicaid Lawyer; Medicare Attorney Medicare Lawyer, Medicaid Payment Suspension, Medicaid recipients, Medicaid Services, Mental health, NC DHHS, New Mexico, New Mexico Behavioral Health Providers, North Carolina, postpayment review; Suspension of Medicaid reimbursements, Preliminary Injunction, SC DHHS, South Carolina, South Carolina Medicaid, Suspension of Medicaid Payments. Bookmark the permalink. 2 Comments.
Your article appears to be defending providers if so you have never worked for one. Since privatization of behavioral health services this is common. They push staff to produce revenue at any cost hence people will lie about the services provided. The system is broke for consumers and for honest providers. Staff are treated very badly by these agencies. Anyone should report fraud the only way this will stop.
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Mary Mary,
Thanks for your comment! You are correct in that this blog post is in defense of providers. I have actually worked for thousands of providers as legal counsel. More often than not, in my experience, the accusations of fraud are baseless. Perhaps there are nit picky documentation errors, but not fraud. Yet the consequence of an accusation of fraud can put a company out of business. I agree that it is imperative to disclose fraud when present, but not to the detriment of honest providers with a disgruntled employee. Due process is a necessity. We don’t throw people in jail without a trial. Nor should we destroy a company, people’s careers, and recipients’ access to providers without due process. I am sorry that, perhaps, you have had a bad experience. I wish you the best.