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Losing your medical license is distressing for anyone in the healthcare industry. A state medical board can suspend or revoke a physician’s license after wrongdoing or negligence. It’s possible to reinstate your medical license with time and hard work, and at Norman Spencer Law Group, we have a skilled team of licensed attorneys that can help you through the process. We can walk you through every step you need to complete so you can return to practicing medicine in due time.

Reinstating a Suspended License

Reinstating a medical license depends upon the severity of your case and the state where you acquired it. It also depends on whether or not the license in question was suspended or revoked since both cases have differing procedures surrounding reinstatement. A license reactivation form must be submitted in medical license suspension cases. Completing this form also requires filing other forms, such as proof of ongoing medical requirements, drug abuse reporting requirements, child abuse reporting protocols, etc. You will also need to fill out a National Practitioner Data Bank (NPDB) query and provide a curriculum vitae spanning the previous ten years of employment. You must also apply for professional liability insurance, which includes state-mandated minimum coverage amounts.

Depending on the state, there will be specifications about how to submit the form. Some states allow electronic submission, while others only accept it through mail or direct delivery. The state medical board also usually requires clinical skill evaluations and mandatory training programs, especially if a long time has passed after a license suspension. On top of these requirements, the board can also apply tailor-made requirements based on your case, which must follow the letter. The board can delay the form or reactivation until your suspension ends or all of your retraining is completed. Reactivation fees vary by state, and the process takes six months to a few years.

Reinstating a Revoked License

If you need to reinstate your medical license because it was revoked, things become a little more complicated with severe penalties to overcome. It is still possible, however. Before you can apply to reinstate a revoked license, there is a mandatory three-year waiting period. After the three-year mark, you must file for a Petition of Reinstatement. To file the petition properly, you must include at least two letters of support from licensed physicians who support your reinstatement and a written narrative explaining that you have been rehabilitated and why you deserve a second chance. 

After filing the petition, you will have a hearing before an Administrative Law Judge (ALJ). The state medical board attorney will file a Statement of Issues that opposes your reinstatement. The ALJ will hear evidence during the hearing and send a proposed decision to the state medical board. The board has 100 days to accept, change, or deny the decision, though you can appeal.

Showing the board that you have been rehabilitated, retrained, or have learned from your previous mistakes is paramount when filing a Petition of Reinstatement. Any proof of this can make a difference, and letters from supervisors, other physicians, former patients, family members, and friends all count. Also include documents showing that court mandates have been met, mental health provider testimony, certificates of education or rehabilitation, or proof of community service. Much like a suspended license, there are fees involved with reinstating a revoked license, which differ by state. These tend to be more expensive, as a revoked license takes more time to deal with, and the entire ordeal can last several years beyond the mandatory three-year waiting period.

How Our Attorneys Can Help Reinstate Your Medical License

Regardless of whether your license was suspended or revoked, your first order of business before starting reinstatement should be to contact an attorney. This one act can make all of the proceeding steps that much easier. An attorney can help gather all the required documentation for a reactivation application of a Petition of Reinstatement. An attorney can also help you keep track of the critical dates, witnesses, and supplementary documentation and walk you through any board requirements.

A lawyer becomes even more critical if you get a hearing before the state medical board or an ALJ. The hearing is the most crucial step of reinstatement, and having a qualified professional at your side to represent you is vital. Our professional license defense attorneys at Norman Spencer Law Group are very familiar with the particulars of license reinstatement. Do not wait to contact us if you are trying to reinstate your license. We can discuss your case with a free consultation over the phone, via Zoom, email, or even in person.

Medicaid fraud and abuse are some of the most severe allegations a business can face, and the federal government has taken a firm stance on fighting such cases. More than ever, proofing your business against potential fraud and abuse allegations is a good idea. If you are worried about your company’s ability to defend a fraud allegation or just want to cover your bases, Norman Spencer Law Group can help. Our team of attorneys has handled a wide range of healthcare cases, including Medicaid fraud defense and consultation. 

What is Medicaid Fraud and Abuse?

Before going into how to safeguard your business from Medicaid fraud, it is important to know what kind of actions constitute fraud and abuse. Fraud is any intentional deception intended to cause unauthorized benefit, and abuse is any practice inconsistent with proper fiscal and medical business practices. 

These practices result in unnecessary costs for the Medicaid program, cause reimbursements for unneeded medical services, or fail to meet recognized healthcare standards. Several groups can commit fraud and abuse, including: 

• Managed Care Organizations 
• Contractors and Subcontractors
• Healthcare Providers
• State Employees
• Medicaid Beneficiaries and Managed Care Enrollee   

There are also many ways that Medicaid fraud and abuse can be committed. These include:

• Billing for unprovided services
• Misusing medical codes 
• Billing for unneeded services
• Charging for exessive or unneeded medical supplies 
• Billing for appointments that patients fail to keep

Medicaid Fraud Defense – Laws to Know

On top of the types of fraud and abuse your organization could face, there are many laws that must be followed. Federal and state laws cover Medicaid fraud, but the most important federal laws include:

The False Claims Act (FCA): The FCA is a federal law that protects the government from being overcharged or charged for inferior goods and services. No actual intent to defraud the government is required to trigger an FCA claim. Acting in a way that proves knowledge of a false claim or working with deliberate ignorance is enough.

Anti-Kickback Statute: This federal law makes it a crime to knowingly and willfully pay or receive remuneration – directly or indirectly – to cause or benefit from patient referrals. This also applies to any business involving items and services that federal healthcare programs can reimburse.

Stark Laws: Stark laws, also known as physician self-referral laws, are federal laws that forbid a physician from referring a patient to Medicare or Medicaid reimbursable services via a group through which the physician or the physician’s immediate family members are associated.

Criminal Healthcare Fraud Statute: A federal law forbids going through with or attempting a scheme to interfere with the delivery or payment of healthcare benefits and services. This includes attempts to defraud a healthcare benefit program or deceitfully obtain money owned by any healthcare benefit program.

Exclusion Statute: This federal law allows the Office of Inspector General (OIG) to exclude any healthcare provider from healthcare benefit programs for committing Medicaid fraud, abusing or neglecting patients, or felony convictions surrounding healthcare laws. This statute can also be triggered by any of the above regulations, misdemeanor charges, license suspensions, or revocation. 

Civil Monetary Penalties Law (CMPL): This federal law allows the OIG to charge damages and sometimes exclude a provider from a national healthcare benefits program. Different penalties can be imposed based on the types of violations, up to a maximum of three times the amount claimed for a service. Much like the Exclusion Statute, the above laws can trigger this penalty. 

Steps to Properly Defend Your Business

The first step to protecting your business from Medicaid fraud allegations is to ensure you and your employees are aware of all the types of fraud that apply. Knowing what groups can be involved and how they might commit fraud or abuse is essential. Another crucial step is to be aware of the major federal laws that deal with Medicaid fraud and abuse. Updating your business on federal and state legislation can make a difference in borderline cases. 

Finally, knowing a healthcare attorney with Medicaid fraud defense experience goes a long way. Building this relationship is vital since a lawyer can help prevent you from being caught in the middle of a fraud case in the first place. A Medicaid fraud attorney can also help look at your business’s financials, claims, and employee records to ensure nothing is amiss. Your lawyer will be ready to defend you if something does come up.

Norman Spencer Law Group has a dedicated team of healthcare fraud and abuse lawyers with the expertise you can count on. If you have questions about protecting your business, want to consult with an expert, or find yourself in the middle of a Medicaid fraud allegation, call us. We can set up a free consultation over the phone, via ZOOM, email, or in person.

The federal government has several tools to root out fraud in the healthcare industry, and a big one is the ability to audit a healthcare provider. This happens through federal contractors, state agencies, or even private auditors, and Medicaid is one of the most significant areas that the government focuses on. Finding yourself on the other end of a Medicaid audit can be intimidating, but it is not the end. Several procedures can let you get through such an audit with minimal damage, and having a lawyer who is well-versed in these matters can make it even easier. If you are dealing with a Medicaid audit, the Norman Spencer Law Group has you covered.

Steps in the Appeal Process

While there are many different types of audits that you might face, there are five steps to the appeals process.

Redetermination: This is the first step of appealing a Medicaid audit. Requesting a redetermination must be done within 120 days of receiving the initial determination from the Centers for Medicare and Medicaid Services. Remember that the auditor can start recouping alleged overpayments while an appeal is in the process unless the request is filed within 30 days of the initial determination. Filing a redetermination early is always preferable. 

Reconsideration: This is the second step of an appeal and is handled by a Qualified Independent Contractor (QIC). A request for reconsideration is filed within 180 days of receiving the CMS redetermination decision, and contractors can begin recoupments within 60 days of the notice. All evidence of an appeal is submitted at this stage since no new evidence will be allowed in the later stages of the appeal.

Administrative Law Judge: A hearing before an Administrative Law Judge is the third step in the appeals process. The request for a hearing must be filed within 60 days of receiving the reconsideration decision. Unlike the first two steps, a hearing request must also meet a certain amount of controversy, which changes annually. Multiple claims can be grouped to meet this amount. 

Medicare Appeals Council: A Medicare Appeals Council review is the fourth step to appealing an audit. A request for this review must be filed with the court within 60 days of receiving the Administrative Law Judge hearing receipt. It must also meet controversial requirements that change annually. The provider has to explain why it disagrees with the Administrative Law Judge. This step does not involve a hearing, though you can request an oral argument.

Federal District Court: The final step of the appeals process is a review in a Federal District Court. Much like the previous step, this request has to be filed within 60 days of receiving the Medicare Appeals Council decision. This request also requires a certain amount of controversy, which changes annually.

These steps are the general structure that a Medicaid appeals process follows, but every state has its regulations and administrative procedures. In many states, there is the option of opting for an informal resolution or a settlement. 

Attorneys and Medicaid Audit Appeals  

Appealing a Medicaid audit can be lengthy, with numerous federal and state regulations. Having an experienced attorney from the moment an audit notice is received can make a difference. A Medicaid appeals attorney can help gather all the documents needed for all five steps of the appeals process. They can help you stay on top of the deadlines for all of the different steps when requesting further appeals. Also, they can prepare you for a hearing, plan your defense, and even help you reach an informal settlement if the appeal gets that far. If the case continues, they can defend you in Federal District Court.

At Norman Spencer Law Group, we have a team of attorneys that is very familiar with Medicaid audits and appeals. We know how demanding a Medicaid audit can be. If you have received an audit notice, do not wait to contact us. We can set up a free consultation via phone, ZOOM, email, or in person.

The U.S. government has become more active in cracking down on healthcare in recent years, and dental practice fraud is no exception. Dental spending is expected to reach over $203 billion, and fraud will likely cost the industry $6 billion. With the threat of federal and state action looming over the dental industry, it is essential to be aware of fraud and what could trigger an investigation.

Familiarizing yourself with the different types of dental fraud and knowing how to defend against allegations is crucial in this new regulatory landscape. Often, an attorney that has experience with dental fraud investigations is handy when creating a defense for your practice. Norman Spencer Law Group has precisely the sort of experience you can count on in these matters.

Common Types of Dental Practice Fraud Cases

The American Dental Association defines dental fraud as any crime where someone gets insurance money for false claims, inflating the costs of services, or charging for services not provided. There are many types of fraud, but they involve intention, deceit, and unlawful gain.

A few of the most likely types of fraud are:

• Upcoding or inflating prices on services
• Medicaid and Medicare fraud 
• Kickbacks for patient referrals 
• Intentionally or accidentally keeping government payments
• Pressing for excessive or unneeded dental procedures   
• Misrepresenting non-covered procedures
• Unlicensed individuals performing dental procedures
• Misrepresenting the provider of a dental service

Patients, as well as providers, can commit dental fraud such as:

• Using a fake ID, another person’s ID, or multiple IDs to get benefits
• Requesting that a dentist misreport dates to alter calendar year maximums or limits
• Misrepresenting available dental coverage or asking a dentist to do so

While most fraud cases require intent, a few accidental cases can lead to investigations as well. For example, accidentally coding wrong, listing a different dentist than the one who performed a procedure, or misrepresenting a date for service can lead to a fraud investigation.

Many of the cases listed above can lead to either a federal or third-party audit into your practice, which can bring criminal and civil charges. The penalties can range from jail time, hefty civil fines, loss of your dental license, and exclusion from federal healthcare programs. There is also reputational damage to consider as well. 

Ways to Fight Fraud

Luckily, you can do a few things to reduce dental fraud and help insulate yourself from an investigation. Here are a few ways to guard your practice against fraud allegations:

• Make sure to layout payment details for services before rendering them. Go over fees for covered and non-covered options so that patients know what their options are and how much they owe
• Try to create distance from patients that do not pay on time or do not make any effort to pay for services rendered 
• Make sure that you have a detailed fraud policy in place, and have all of your employees read it
• Split up tasks related to processing payments among multiple employees 
• Review all claims your practice submits as you are responsible for any claim that comes out of your practice
• Check profit and loss records for your dental practice regularly to make sure everything adds up

There are also outside organizations that can make defending against fraud easier. You can hire an auditing agency to go through your financials to ensure there are no questionable billing practices. Internal audits are also an excellent in-house option to check up on the health of your practice.

Why Choose a Dental Practice Fraud Attorney

One of the best things you can do as a dentist or dental healthcare worker is get in touch with a qualified attorney. No matter what kind of situation you may be facing, a lawyer is indispensable. If you need help fraud-proofing your practice, a lawyer can help set up your third-party audits through lawyer-client confidentiality. A lawyer can also help you create a comprehensive anti-fraud policy for your practice.

If you are facing allegations of fraud or even a legal investigation, getting in contact with a lawyer is essential. A professional healthcare fraud attorney can help you understand the allegations you are facing. They will help you gather the documents to defend your practice, prepare you and your employees for any meetings with investigators, and help you build a case for court if needed.

At Norman Spencer Law Group, we pride ourselves on our team of healthcare defense lawyers. Our attorneys have experience with various healthcare-related cases, including dental fraud defense. If you are facing allegations against your practice, are under investigation, or just need help to draft a fraud policy, call us now. We can set up a free consultation over the phone, through email, via ZOOM, or even in person.

Compliance is one of the most important aspects of working in the healthcare industry. The network of complicated federal and state laws involved with maintaining compliance can be a hassle to keep up with, but it cannot be overlooked. Everyone involved in healthcare should know how compliance audit benefits and regulations affect the workplace since the rules constantly shift and carry heavy consequences if broken. 

Fortunately, compliance issues do not have to be more complicated than they already are. The compliance process can be easily managed with the help of experienced attorneys at every step. Norman Spencer Law Group has you covered for any of your compliance needs or questions.

Factors Affecting Compliance Audit Benefits

While healthcare compliance might seem straightforward at first, there are several elements you need to remember. For example, hospitals are not the only organizations responsible for maintaining compliance. Primary care providers, dentists, dermatologists, radiologists, ophthalmologists, and physical therapy centers must be on top of compliance laws. 

Mental health providers, pharmacies, drug manufacturers, and medical equipment manufacturers are not exempt. Even IT specialists who work in healthcare or have healthcare-related clients need to be aware of compliance regulations. No matter how you fit into the healthcare industry, compliance laws are never far off. 

Other factors go into compliance laws. The size of your organization and the number of employees determine the types of compliance laws you must follow. The location also matters since different state and local laws can apply on top of federal ones. The number and complexity of business transactions and the types of services or products offered also affect compliance. Take these into consideration when a compliance audit is considered.

Types of Compliance Audits  

There is no single type of compliance audit. Internal audits focus on an organization’s policies, while compliance audits focus on adherence. Different types of compliance audits can affect your organization. Here are a few audit types that may come up:

HIPAA Audits: Any organization or company that handles or transfers patient data is subject to HIPAA and its audits. This includes healthcare providers, insurance companies, and clearinghouses. This type of audit looks at how patient information is stored, handled, and protected.

SOX Audits: The Sarbanes-Oxley Act (SOX) covers accurate corporate disclosures. A SOX audit looks at data protection, management of electronic records, executive accountability, and internal controls management. Because of the wide range this audit covers, IT and financing sectors in healthcare are often affected.

PCI Audit: Payment Card Industry (PCI) audits involve any organization or company that processes payment cards, including healthcare industries. PCI audits make sure credit card data is appropriately handled, shore up security gaps, ensure no sensitive credit card or social security data is stored, and address any risks to customer cards.

SOC 2 Audits: SOC 2 audits apply to any organization that stores customer or patient information on the cloud. They look at data security, confidentiality, privacy, data availability, and processing integrity. SOC 2 audits also come in type 1 and type 2. Type 1 audits look at a vendor’s security systems and make sure they are well-designed. Type 2 audits look at how effective a vendor’s operating system is.

ISO Audit: The International Organization of Standardization (ISO) handles standards for multiple industries to align their business practices worldwide. ISO guidelines can allow an organization to become ISO compliant or even reach ISO accreditation, and ISO compliance certification takes a longer audit process.

GDPR Audit: The General Data Protection plan is a law that covers citizens of the European Union and affects any organization that handles info related to EU citizens. American healthcare companies are no exception. This audit makes sure that EU citizen data is used with consent, is made anonymous, is safely handled when crossing borders, and has a protection officer overseeing it. 

These audits have standards that need to be followed to be fully compliant. Some, like the SOC and ISO audits, are voluntary but can increase the reputation of any organization that takes the time to go through them. Like HIPAA, SOX, PCI, and GDPR, other compliance laws are mandatory and can carry severe penalties if ignored. You need to make sure that your organization is aware of the different types of standards it could be subjected to. 

How to Determine Your Compliance Audit Benefits

If your business has decided to undergo compliance voluntarily or face a compliance audit from an outside agency, your first order of business should be to contact a healthcare law attorney with experience in compliance regulations. Attorneys can help with planning out compliance protocols, setting up an audit, walking employees through compliance training, or defending you in court if a situation goes that far. 

At Norman Spencer Law Group, our attorneys are ready to help you with whatever your compliance situation. We have the experience you can depend on whether you need compliance plans or a team to defend you. Do not wait to contact us since it is better to have a relationship with a law firm before any compliance complications arise. We are available over the phone, ZOOM, and we can even meet you in person if need be for a free consultation.

Hospitals, private practices, and other healthcare providers must constantly be aware of many regulations, some of which are subject to change. Even still, there can be weaknesses that a provider has not found yet that could cause severe problems down the road. This is especially true for billing practices and medical claims. An internal healthcare audit is how providers can help spot such weaknesses in their billing plans, reimbursements, and medical claims. 

As the medical field grows and becomes more automated, it subjects providers to new vulnerabilities regarding finances. Medical audits can provide direct benefits and work as a preventative measure to keep a practice running smoothly and efficiently. At Norman Spencer Law Group, our team is highly experienced in all types of healthcare audits. We also offer a free consultation!

The Direct Benefits of a Medical Audit

Audits are a serious undertaking for a medical practice, and the risks can lead to costly setbacks. Whether a provider does an internal audit or hires a third-party agency for an audit, an in-depth review of finances is intelligent and proactive. One of the significant benefits of medical audits is that they can reveal improper billing practices. The amount of bills a provider is likely to deal with is high, increasing the potential for improper billing. A medical audit can identify these practices, including a lack of correct documentation or even fraudulent bills.

Another benefit of medical audits is that they can bring to light coding errors. No matter how good a medical provider is, there is always a chance for claim denials to pile up. These denials often result from coding errors, which we can detect through an audit. Audits help find out-of-date and incorrect codes, allowing us to deal with them before they become a problem.

Medical audits also allow a practice to run smoother by finding out if staff members or departments are prone to specific errors. An audit can show where the mistakes occur and whether or not there is a pattern. This diligence allows hospital staff to identify a potential workflow, communication, or accountability problem. It even extends to a provider’s competitors since an audit can reveal whether error rates are higher than the national average or within industry standards.

Finally, a medical audit can highlight areas where money is mismanaged or lost. If unchecked, these funds can add up to a lot of lost revenue with resolutions that could also become costly. Audits work to keep your medical practice cost-effective in the long run and allow for better allocation of financial resources. An audit can even help find areas of reimbursement deficiencies and correct them.

Internal Healthcare Audit as a Preventative Measure

Outside of providing immediate improvements in the way a practice runs, an audit can also help prevent damaging regulatory action down the line. Since medical audits identify billing and coding errors and stop recurrence, they decrease the federal government’s chances of initiating its own audit.

Repeated errors can look like fraudulent activity to any third party looking at billing data, and sometimes it can be indistinguishable from fraud. Agencies like the Centers for Medicare & Medicaid (CMS), the U.S. Department of Health and Human Services (HSS), and the Office of Inspector General (OIG) employ several contractors that look into healthcare providers and initiate audits to uncover potential fraud. 

While some federal audits are initiated randomly to keep providers honest, high billing and coding error rates can launch a separate investigation. Certain contractors target providers with higher error rates than the national average, and the OIG holds providers liable for prior knowledge of misuse. Potential penalties of a federal audit include:

• Payback demands on claims
• Creating a Corporate Integrity Agreement (CIA) with the OIG
• Requiring the employment of an Independent Review Organization (IRO)
• Exclusion from Medicare, Medicaid, and other federal reimbursement programs
• Potential prosecution under the False Claims Act
• Possible prosecution under state and local laws
• Civil fines
• Criminal penalties

Even if most audits do not lead to severe penalties, the worst-case scenario can damage a medical practice for years to come. A regular schedule for medical audits can help keep the federal agencies and their contracted auditors from launching a targeted investigation into your healthcare business.

How to Prepare for an Internal Healthcare Audit

A yearly audit is considered appropriate to spot any errors and remove harmful patterns before they take root. Experts recommend that a third party does the audit so that a fresh set of eyes can go over familiar documentation and spot the issues.

Another avenue to consider is hiring a healthcare audit attorney. In a planned or random audit, legal counsel can make every aspect of the process easier. An expert can go through the steps to ensure that you don’t expose yourself more than necessary. When faced with an unexpected audit, especially by the government, a lawyer can help defend against any complications. 

Lawyers can even keep internal or third-party audits within the attorney-client privilege or represent a practice during denials or appeals. Since external audits can happen anytime, it is vital to have a prior relationship with a trusted healthcare attorney at the start.

If you are a healthcare provider considering a third-party audit or trying to prepare for an external audit, call the Norman Spencer Law Group. Our healthcare law attorneys are intimately familiar with the medical industry’s demands, including audits, and we can help defend your practice. Call us to schedule a free consultation via phone, ZOOM, email, or in person.