Healthcare Liability Lawyer

Medicare and Medicaid Exclusions, Payor Audits, and Related Enforcement Actions

At Lype, Dest & Smith Lawyers, our healthcare attorneys regularly defend clients in actions involving alleged Medicare and Medicaid fraud, over-billing, waste, and other improper billing practices. These are high-stakes cases where a negative finding can lead to recoupment, civil penalties, exclusion from Medicare/Medicaid, and even criminal prosecution. These outcomes can be devastating to a healthcare provider’s bottom line and threaten their ability to continue operating.

Texas physicians, pharmacies, dentists, and other healthcare providers receiving any kind of government-supported reimbursement face constant scrutiny from a panoply of state and federal agencies and subcontractors. These include the Centers for Medicare & Medicaid Services, the federal Office of Inspector General, Qlarant, Novitas, the FBI, and state and federal law enforcement. These agencies and private contractors aggressively investigate potential fraud, waste, and overutilization.

Investigations usually focus heavily on the provider’s records and confirming whether they support their billed services. For example, a pharmacy might be asked to produce years of wholesale purchase records so the OIG can verify whether it had sufficient drug stock to support filed reimbursement claims. Similarly, a physician practice could be asked to produce a set of patient charts so that they can be examined for possible upcoding or improper bundle billing. A psychologist that conducts child assessments paid for by the State of Texas might need to provide a detailed appointment calendar to confirm they have stayed within the daily maximum hour limits for billing.

 

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Founding Attorney

Once the agency concludes their preliminary investigation, they may demand repayment of any alleged improper reimbursement with possible additional penalties. The agency could also seek to terminate the provider’s continued participation in Medicare, Medicaid, and other government payor programs.

In a worst-case scenario, the government entity could move to exclude the provider from Medicare or Medicaid. This can be a death sentence to the provider’s continued economic viability and employment opportunities. Most insurers, managed care organizations, hospitals, and other healthcare entities view exclusion from Medicare or Medicaid as a significant red flag. Exclusion will frequently lead to termination of the provider’s other contracts and serve as a bar in future applications. Excluded providers can find themselves unable to work in any setting that isn’t purely cash based.

Darrin Dest

Darrin’s practices primarily in the areas of administrative and health care law, with a focus on the representation of professionals in front of their licensing boards and credentialing bodies. Darrin formerly worked for the Texas Medical Board and currently defends licensees.

Years of experience: 15 years
Bar numbers: 24065146
Location: Austin, TX

If you or your business is the subject of an audit or investigation by the OIG, CMS, Qlarant, Novitas, or other government agency or subcontractor, contact the attorneys at Lype, Dest & Smith for a consultation. The early involvement of legal counsel is crucial. While investigations will often begin with what seems to be a benign request for records, the stakes can be high. The prompt involvement of an attorney can often prevent or limit a provider’s exposure to potentially high repayment amounts and the threat of exclusion. Moreover, legal representation is not viewed by these agencies as an admission of guilt or a sign the provider has something to hide. The agencies will have their own attorneys assigned to the case and are used to working through defense counsel.

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A thorough and experienced lawyer. We are grateful to have Dan and his staff helped us with our case, dealing with Texas Medical Board. Dan is honest, experienced and very thorough. He was supportive throughout the proceedings. His caring and calm nature has made us feel at ease during the whole process. His office staff was professional and responsive. Dan responded to our phone calls and emails promptly. We wholeheartedly recommend Dan and his firm without any reservation.

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Our Practice Areas

Texas Medical Board Defense
Physician peer review and credentialing
Nursing Peer Review
Texas Pharmacy Board Defense
Texas Board of Nursing Defense
Texas Dental Board Defense
Texas Board of Law Examiners Defense
Medicare and Medicaid Exclusions, Payor Audits, and Related Enforcement Actions
DEA Defense
Professional License Defense
BHEC Defense