Chicago and Downstate Medicare and Medicaid Compliance Lawyer

Attorneys Assisting With IDHFS Audits and Enforcement Throughout Illinois

Many doctors, pharmacists, and other healthcare providers offer services to people who receive health insurance coverage through Medicare or Medicaid. In order to do so, a provider must receive an authorization from the Illinois Department of Health and Family Services (IDHFS). To ensure that providers are meeting the terms of these contracts, IDHFS regularly conducts audits, and it may take enforcement actions, including contract termination, peer review, or exclusion from providing services to Medicare/Medicaid patients.

If you need to determine your rights in an IDHFS audit, or if you are facing IDHFS exclusion, the attorneys of Williams & Nickl, LLC can provide you with legal representation and help you protect your ability to practice medicine. Fred and Edward have over 55 years of combined legal experience, and we have assisted more than 3,000 clients in cases involving professional licensing and insurance contracts.

Medicare/Medicaid Compliance Issues

An IDHFS audit may uncover a variety of issues that could result in enforcement, including:

• Fraud, which occurs when a provider attempts to obtain money or benefits through false pretenses. Fraud may include billing for services that were not actually provided or altering medical records or claim forms in order to receive higher payments.
• Waste, which involves the misuse of resources or other practices that cause unnecessary costs to the Medicare or Medicaid programs. Waste may include performing excessive or unnecessary medical tests or prescribing medications in amounts that are not necessary to treat a patient’s condition.
• Abuse, which occurs when a provider receives payment from Medicare or Medicaid that they are not entitled to receive. Abuse typically involves actions committed without the intentional misrepresentation of information by a provider, such as unintentionally billing for services that were not medically necessary, or accidentally billing for brand name drugs when generic drugs were dispensed.
• Failure to provide records, payment information, or other data to IDHFS when requested.
• Failure to provide medically necessary services to a patient covered under an IDHFS authorization.
• Noncompliance with HIPAA regulations regarding the privacy of patient information.

Any issues which could result in discipline to a person’s medical license may also affect Medicare/Medicaid compliance. If the Illinois Department of Financial and Professional Regulation (IDFPR) is investigating a complaint against a doctor, IDHFS may also perform an audit or conduct a peer review, and disciplinary action by the IDFPR may also result in IDHFS exclusion. In these cases, it is important to work with an attorney who is experienced in defending against discipline to professional licenses and addressing IDHFS compliance issues.

We have worked with clients to address a wide variety of compliance and disciplinary issues, and we have a record of success in defending against license discipline and termination of insurance contracts. In one case, we worked with a surgeon who was facing discipline for multiple issues, including failing to properly maintain patient records. We successfully appealed negative actions by third-party insurers to terminate the surgeon’s contracts, and we also assisted in restoring the surgeon’s medical license to unencumbered status.

Contact an Illinois IDHFS Audit Lawyer

If you are being audited by IDHFS, you will want to be sure to take steps to protect your contract and your ability to provide services to patients. At Williams & Nickl, LLC, we can work with you to respond to requests from IDHFS and address any irregularities in your records or other issues that may result in enforcement. We can also help you understand how these issues may affect your medical license, and we can work with you to address potential disciplinary action by the IDFPR or the Illinois Medical Board.

Before responding to any requests from IDHFS or the IDFPR, you should consult with our attorneys to determine your legal options. We will provide you with a one-hour consultation at no cost to you, and we will advise you on the most prudent steps you can take to defend your license and avoid an IDHFS exclusion. Contact our office today at 312-335-9470 to learn more about how we can help.