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healthcare defense fraud investigations targeting federally qualified health centers lawyers3 Jul 2020

In the United States healthcare system, federally qualified health centers play an integral role. These facilities are healthcare providers that are based in communities and do not get funds from the Health Resources and Services Administration or HRSA, which is an agency within the Department of Health and Human Services or DHHS.

What are Federally Qualified Health Centers?

These organizations are generally found in underserved areas to provide primary medical services to individuals who would not otherwise have access to such care. As a result, federally qualified health centers must meet certain strict requirements, including providing care to people on a sliding fee scale based on their ability to pay. Facilities must also have a governing board that includes their very own patients. Obviously, due to the purpose of these facilities, they also participate in Medicaid and Medicare programs. As such, they receive reimbursements per the prospective payment system or PPS, detailed in the Affordable Care Act. Facilities eligible for funding through the HRSA, Medicaid and Medicare include the following:

• Community health centers
• Healthcare for the homeless
• Health centers for residents of public housing
• Migrant health centers

Generally speaking, there are around 1,400 federally qualified health centers across the country. These facilities provide primary care services to over 28 million people, including routine physicals and screenings, diagnosis and treatment of injuries and illnesses, counseling and issuing referrals for s. They also receive funds from the federal government to help fight the opioid crisis and the spread of HIV.

Why do Federally Qualified Health Centers Get Investigated?

Although federally qualified health centers play such an important role in the healthcare system and society, there are times when they can get in trouble and be investigated. Certain mistakes are very common and can lead to a facility becoming the target of a fraud investigation. They include the following:

Patient or treatment misclassification: Misclassification of a patient or treatment is highly suspicious and is reported as potential fraud when spotted. Although federally qualified health centers see high volumes of new patients each year, if the numbers are unusually high, it can be seen as Medicare billing fraud.
Billing non-compliance: Federally qualified health centers undergo stringent billing requirements, which means if there are too many billing errors, it can be seen as not a genuine mistake but fraud. Investigations can look for a number of issues, including: billing for services offered by doctors that aren’t associated with the facility, failure to provide face to face consultations, not meeting billing requirements for home-bound patients, billing for services not qualified to be necessary and improper use of medical billing code G0466 (new patient) instead of G0467 (established patient) and code G0469 (mental health, new patient) instead of G0470 (mental health, established patient).
Improperly using 340B drug pricing program: Registration is required for using the 340B drug pricing program and all requirements must be strictly followed. An investigation can ensue if it is misused through improperly obtaining discounted medications, improperly diverting those medications or if other issues arise involving discounted medications.
Non-adherence to the program’s compliance manual: Federally qualified health centers must adhere to the program’s compliance manual by doing the following: provide high quality comprehensive primary health care, provide services even if a patient cannot pay and charge based on a sliding fee scale, develop systems that are centered around the patient that offer integrated care based on each patient’s needs and maintain operations while developing and using their own procedures as well in compliance with the program’s requirements and federal state and local laws and regulations.
Failing an operational site visit: Facilities are subject to various operational site visits by the HRSA to ensure that everything is in compliance. Sometimes, these visits may reveal potential acts of fraud, leading to an investigation.
Improper referral relationships with other providers: If a facility is found to have an improper relationship with another healthcare provider, it is a violation of the Anti-Kickback Statute and Stark Law.

There are numerous adverse consequences that can come as a result of an investigation for any of these scenarios. A federally qualified health center that is under investigation needs a strong healthcare defense fraud attorney’s representation.

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