New OIG Guidance Publishes on Permissive Exclusions from Federal Health Care Program Participation May Interest Nurses

Miles Indest HeadshotBy Miles Indest, J.D./M.B.A candidate at Tulane University: Law Clerk, The Health Law Firm

On April 20, 2016, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released updated non-binding criteria that disclosed when a company or individual can be barred from participating in Medicare, Medicaid, and other federal health care programs.

The OIG has permissive authority to exclude a person or company from participation in federal health care programs for engaging in certain prohibited conduct, such as false claims or kickbacks. The OIG has consistently asserted that there is a presumption in favor of exclusion. The new guidance updates the OIG’s position by stating that its presumption in favor of exclusion is rebuttable in certain situations. Importantly, the OIG guidance outlines those situations and the risk factors that trigger an exercise of its permissive authority.

Four Factors May Affect OIG’s Decision to Exclude an Individual or Entity.

In its release, the OIG outlined four non-binding factors that signal a compliance risk and can affect its decision to pursue an exclusion: (1) the nature and circumstances of the prohibited conduct; (2) the conduct during the Government’s investigation; (3) any significant ameliorative efforts; and (4) the history of compliance.

First, the OIG will evaluate the nature and circumstances of the bad actor’s conduct. For instance, conduct that causes physical, mental, or financial harm to others increases compliance risk, thereby increasing the likelihood that the OIG will pursue an exclusion. Similar to the Department of Justice’s heightened focus on individual accountability, the OIG stressed that it will scrutinize an individual’s role in planning or leading unlawful conduct, which increases compliance risk.

Second, the OIG will assess the bad actor’s conduct during the Government’s investigation. If that person obstructed or impeded the investigation of the unlawful conduct, then the OIG will be more likely to pursue an exclusion. Notably, the OIG stated that a prompt response to a subpoena is “expected” and will not favorably affect the risk assessment.

Third, the OIG will weigh the bad actor’s ameliorative or remedial steps taken after the prohibited conduct occurred. For example, an entity that takes disciplinary action against individuals responsible or the conduct will lower its compliance risk. Similarly, individuals that receive new training or retain a mentor to improve their health care practice will face a lower risk of exclusion.

Finally, the OIG will focus on the bad actor’s history of compliance with the OIG. Importantly, the existence of a compliance program will not affect the risk assessment— likely another “expected” requirement of health care organizations. In contrast, the absence of a compliance program will increase compliance risk and the likelihood that the OIG will pursue an exclusion.

The OIG update ultimately reflects the government’s increased expectations of compliance programs and heightened scrutiny of individual wrongdoing. As federal agencies continue to prioritize the prosecution of fraud and abuse, health care organizations and practitioners would be wise to proactively address these concerns internally.

Contact Health Law Attorneys Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program and Assisting in Reinstatement Applications.

The attorneys of The Health Law Firm have experience in dealing with the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

About the Author: Miles Indest, J.D./M.B.A. candidate, will graduate in May 2016 from Tulane University Law School and the Freeman School of Business. He has served three years as a member of Tulane Law Review, and currently serves as the Writing Skills Chair of Tulane Moot Court.

Sources:

“Criteria for Implementing Section 1128(b)(7) Exclusion Authority.” U.S. Department of Health and Human Services Office of Inspector General. (2016). Web.

Dani Kass. “HHS Watchdog Lays Out New Grounds For Exclusion List.” Law360. (2016). Web.

KeyWords: Health law, Office of Inspector General, exclusion list, defense lawyer, exclusion, OIG, OIG exclusion list, Florida defense attorney, reinstatement, application for reinstatement, OIG hearing,Medicare exclusion, Medicare reinstatement, Removal from List of Excluded Individuals and Entities, LEIE, Florida defense lawyer, defense attorney, The Health Law Firm

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 2016 The Health Law Firm. All rights reserved.

Increased Florida ARNP Prescriptive Authority to Include Controlled Substances

00034_RT8By Joanne Kenna, R.N., J.D., The Health Law Firm
Under new law passed just this month, Advanced Registered Nurse Practitioners (ARNPs) in Florida will be able to prescribe controlled substances beginning January 1, 2017. This increased prescriptive power will be permitted under the supervision and protocol requirements that already exist for ARNPs, and will require that the ARNPs register as controlled substance prescribers (i.e., hold a valid federal controlled substance registry number). ARNPs who are controlled substance prescribers also must indicate this on their practitioner profiles.

There will be some restrictions, limitations and requirements:

• Only ARNPs who have graduated from a program leading to a master’s or doctoral degree in a nursing clinical specialty area with training in specialized practitioner skills will be eligible to prescribe controlled substances.

• ARNPs will only be allowed to issue prescriptions for Schedule II controlled substances for a period limited to a 7-day supply. However, psychiatric ARNPs will not be limited to this 7-day supply limitation when prescribing Schedule II psychiatric drugs.

• A joint committee, composed of three (3) ARNP members, three (3) physician (any combination of M.D. or D.O.) members, and a doctor of pharmacy member, will establish a formulary of controlled substances that an ARNP will not be allowed to prescribe, or will be allowed to prescribe only for specific uses, or in limited quantity, or only if the ARNP has certain specialty certification. The initial formulary recommended by the committee is to be adopted by the Board of Nursing by no later than October 31, 2016.

• The legislature has designated that the formulary must restrict the prescribing of psychiatric mental health controlled substances for children younger than 18 years of age to ARNPs who also are psychiatric nurses (i.e., a master’s or doctoral degree in psychiatric nursing and two (2) years of post-master’s degree clinical experience under the supervision of a physician).

• ARNPs who prescribe controlled substances will be required to complete three (3) hours of continuing education in the safe and effective prescribing of controlled drug prescribing as part of their biennial nursing licensure continuing education requirement.

• ARNPs will not be permitted to prescribe controlled substances in pain management clinics.

Also, ARNPs will be held accountable and subject to disciplinary action by the Board of Nursing if they fail to meet the generally accepted standards of practice for the prescribing of controlled substances and document the requisite medical record information to demonstrate the standards have been met. This would include, but not be restricted to, the necessity of a medical history and physical examination; sufficient justification for the use of a controlled substance; discussion with the patient, surrogate or guardian of the risks benefits of the controlled substance use, including the risks of abuse, addiction and physical dependence; and discussion of the proper administration of the controlled substance.

In addition to ARNPs, the legislature has similarly increased the prescriptive authority for physician assistants (PAs).

Contact Health Law Attorneys Experienced in Representing Nurses.

The Health Law Firm’s attorneys routinely represent nurses in Department of Health (DOH) investigations, in appearances before the Board of Nursing in licensing matters and in many other legal matters. We represent nurses across the U.S., and throughout Florida.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

About the Author: Joanne Kenna is a nurse-attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

KeyWords: Ordering of controlled substances, Prescribing controlled substances, Florida increased prescriptive authority, Florida ARNPs, CRNAs and PAs, HB 1241 Ordering, Florida Association of Nurse Anesthetists (FANA), American Association of Nurse Anesthetists (AANA), Florida Board of Nursing, Florida legislation, legal counsel for Nurses, nursing defense lawyer, health care attorney, health law defense attorney, historic legislation, health care law, nurse attorney, nurse lawyer, nurse representation, The Health Law Firm
“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 2016 The Health Law Firm. All rights reserved.

Amendment to Florida Law, HB-1241, Expands Authority of ARNPs and PAs to Order Controlled Substances

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On March 11, 2016, a number of health care-related bills made their way through the Florida Legislature, including a bill that will amend the existing laws applicable to Florida Advanced Registered Nurse Practitioners (ARNPs) and Physician Assistants (PAs). The Florida Legislature passed a measure that expanded existing Florida law on the ordering of controlled prescriptions by ARNPs and PAs.

HB 1241-Ordering.

HB 1241 makes it clear that ARNPs and PAs can order medications, including controlled substances for administration to patients in hospitals, ambulatory surgery centers and nursing homes. Medical Associations, such as Florida Association of Nurse Anesthetists (FANA), have long been fighting for this measure and quickly supported the legislation.

To view HB 1241 and the amendments, click here.

To learn more on the regulations on ARNPs and PAs scope of practice, click here to read one of my prior blogs.

This bill will now be forwarded to the governor, Rick Scott, for signature. It is not a law until it is signed by the governor, who may still decide to veto it.

Contact Health Law Attorneys Experienced in Representing Nurses.

The Health Law Firm’s attorneys routinely represent registered nurses, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, midwives and licensed practical nurses in Department of Health (DOH) investigations, in appearances before the Board of Nursing in licensing matters and in many other legal matters. We represent nurses across the U.S., and throughout Florida.

To contact The Health Law Firm, please call (407) 331-6620 or visit our website at www.TheHealthLawFirm.com.

Sources:

Ammann, Phil. “Health Care Bills Advance in Legislature.” Florida Politics. (March 12, 2016). Web.

“Historic Legislation Passes-Controlled Substance Prescriptive Authority For All Florida ARNPs Including CRNAs.” FANA. (March 11, 2016). Web.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Florida Legislature, ordering of controlled substances, Florida ARNPs , CRNAs and PAs, HB 1241Ordering, Florida Association of Nurse Anesthetists (FANA), American Association of Nurse Anesthetists (AANA), legal counsel for Nurses, nursing defense lawyer, health care attorney, health law defense attorney, historic legislation, health care law, nurse attorney, nurse lawyer, nurse representation, The Health Law Firm

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 2016 The Health Law Firm. All rights reserved.

Big News For Nurses: Historic Legislation (HB 423) Passes Allowing ARNPs to Prescribe Controlled Substances

IndestBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On March 11, 2016, the Florida Legislature approved a measure that would expand the drug prescribing powers of all Advanced Registered Nurse Practitioners (ARNPs) and Certified Registered Nurse Anesthetists (CRNAs), and also including Physician Assistants (PAs), to authorizing them to prescribe controlled substances. This decision comes as big news as medical associations such as Florida Association of Nurse Anesthetists (FANA) and the American Association of Nurse Anesthetists (AANA) have been battling for this right for many years.

HB 423 – ARNP/PA Controlled Substance Prescribing.

This HB 423 allows ARNPs and PAs to prescribe controlled substances under existing supervision and protocol requirements, as well as subject to a formulary to be developed by a committee made up of ARNPs, Medical Doctors (MDs) and a pharmacist. The formulary does not apply to controlled substances ordered by a CRNA for pre-anesthetic, anesthetic or post-anesthetic recovery purposes.

HB 423 Limitations.

Prescriptions for Schedule II controlled substances are limited to a 7-day supply, with an exception for psychiatric medications. Additionally, psychiatric medications for patients under 18 years of age may only be prescribed by a psychiatric nurse.

This bill also allows the AANA to conduct continuing education classes required by this bill. Medical Associations such as FANA strongly support this historic piece of legislation, which took more than two decades to pass the Florida Legislature.

Click here to view HB 423.

To learn more, read one of my past blogs on this topic here.

This bill will now be forwarded to the governor, Rick Scott, for signature. It is not a law until it is signed by the governor, who may still decide to veto it.

Contact Health Law Attorneys Experienced in Representing Nurses.

The Health Law Firm’s attorneys routinely represent registered nurses, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, midwives and licensed practical nurses in Department of Health (DOH) investigations, in appearances before the Board of Nursing in licensing matters and in many other legal matters. We represent nurses across the U.S., and throughout Florida.

To contact The Health Law Firm, please call (407) 331-6620 or visit our website at www.TheHealthLawFirm.com.
Sources:

“Historic Legislation Passes-Controlled Substance Prescriptive Authority For All Florida ARNPs Including CRNAs.” FANA. (March 11, 2016). Web.

“Series Of Health Care Bills Poised To Pass House.” Health News Florida. (March 12, 2016). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Florida Legislature, controlled substance prescriptive authority, Florida ARNPs , CRNAs and PAs, HB 423, ARNP/PA Controlled Substance Prescribing, Florida Association of Nurse Anesthetists (FANA), American Association of Nurse Anesthetists (AANA), legal counsel for Nurses, nursing defense lawyer, health care attorney, health law defense attorney, historic legislation, health care law, nurse attorney, nurse lawyer, nurse representation, The Health Law Firm

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 2016 The Health Law Firm. All rights reserved.

FTC Again Addresses State Legislators to Reconsider the Impact of State Regulations on APRNs’ Scope of Practice

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Two weeks ago, the Federal Trade Commission (FTC) submitted written comments on the competitive impact of a legislative proposal to modify the supervision requirements imposed on Advanced Practice Registered Nurses (APRNs), sometimes called Advanced Registered Nurse Practitioners (ARNPs), Advanced Nurse Practitioners (ANPs) or Advanced Practice Nurses (APNs). The proposal in West Virginia, would permit some APRNs, under limited conditions, to write prescriptions without a formal agreement with a supervising physician. The proposal would also place the regulation of certain APRNs under authority of the West Virginia Board of Medicine of Osteopathic Medicine.

The Second Time the FTC Has Made Comments.

In 2014, the FTC issued a paper titled, “Policy Perspectives: Competitions and the Regulation of Advanced Practice Registered Nurses,” in which it advocated for the expansion of APRN scope of practice. APRNs, also known as nurse practitioners, are registered nurses who have been both educated and received specialized training beyond the requirements for a registered nurse. The FTC’s paper in 2014, contended that expanding the scope of practice would create more competition, helping to control costs, improve quality, promote innovation and expand access to care.

To read more about the FTC’s paper in 2014, click here.

The FTC’s Involvement.

The FTC has repeatedly voiced its opinion and recognized “the critical importance of patient health and safety, and [] defer[s] to state legislators to determine the best balance of policy priorities and to define the appropriate scope of practice for APRNs and other health care providers.” However, the FTC cautioned that the modifications in the proposal “could benefit patients, as it would permit a route to independent prescribing, at least for some APRNs under certain conditions,” it still “raises significant competitive concerns.

Limitations on Health Practitioners Result in Antitrust Scrutiny as Artificial Restraint on Trade.

Such limitations on what different health care practitioners are allowed to do or prohibited form doing by state licensure boards has fallen under scrutiny by the antitrust regulators lately. Often regulators believe that restrictions on what capable, trained professionals are allowed to do is nothing but an artificial restraint on trade, where one professional that may have more clout is attempting to keep the other profession(s) off of its “turf.” This is especially true when there appears to be no other valid reason to do so.

In the light of antitrust suits being filed across the nation against boards of dentistry and other licensure boards, many state boards and regulatory authorities are “running scared.” In Florida, for example, the Board of Medicine, Board of Dentistry, Board of Nursing, Board of Physical Therapy and other professional licensing boards have recently received legal instruction on how to avoid such charges being made against them. Additionally legislation has recently passed in the Florida Legislature to allow Advance Registered Nurse Practitioners (ARNPs) in Florida to write prescriptions for controlled substances for the first time ever.

In Hill v Florida Department of Health, our attorneys won a rule challenge/non-rule policy case against the Florida State Department of Health over information it promulgated stating that nurses were prohibited form administering Botox. See Shelley Kay Hill, R.N. v. Department of Health, Board of Nursing, Fla. Div. Admin Hrng. Case No. 14-4511RU (Final Order dated Mar. 10, 2015). Click here to read more.

To read a prior blog that I wrote on FTC vs. North Carolina Board of Dental Examiners case, click here.

The Health Law Firm Attorneys Represent Clients in Restraint of Trade, Scope of Practice and Other Related Legal Matters.

The attorneys of The Health Law Firm provide advice and representation concerning antitrust law, trade regulation, restraint of trade issues, and regarding deceptive and unfair trade practices. We routinely provide advice and analysis of proposed business ventures that include the foregoing. We have represented both plaintiffs and defendants in state court litigation and in federal court litigation in such matters. We prepare requests for OIG Advisory Opinions, CMS Advisory Opinions and Petitions for Declaratory Statements to state agencies. We also prepare detailed Legal Opinion Letters on complex health care business transactions for proposed business ventures, mergers acquisitions, financing, etc.

The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (ALFs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Source:

Lomax, Dionne. “FTC Again Urges Consideration of Competitive Impact on State Regulation of APRNs.” Health Law & Policy Matters – Mintz Leven. (February 17, 2016). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Advanced Practice Registered Nurses (APRNs), Federal Trade Commission (FTC), scope of practice, Advanced Registered Nurse Practitioners (ARNPs), Advanced Nurse Practitioners (ANPs), Advanced Practice Nurses (APNs), Restraint of Trade, antitrust law, trade regulation, OIG Advisory Opinions, CMS Advisory Opinions, Petitions for Declaratory Statements to state agencies, health care lawyer, health law defense attorney, health law, The Health Law Firm

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 2016 The Health Law Firm. All rights reserved.

State Nursing Boards to Give Greater Scrutiny to License Applications Watching for Fraud: Part One: Reciprocity and Fraudulent Applications

IndestBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health

This will be a two-part blog series focusing on increased scrutiny given to license applications by state nursing boards following the suspension or revocation of 13 nursing licenses due to alleged fraud.

The first part will discuss the incident that initiated the heightened inquiry expected from state nursing boards, as well as the reciprocity process in licensing.  The second part will discuss how these new and more extensive investigations will affect nurses and their employers.

A Case of Fraud.

Nurses seeking licensure by reciprocity should expect their applications to receive increased scrutiny by the licensing board based upon the recent events in Massachusetts.  The State of Massachusetts Board of Registration in Nursing recently discovered more than a dozen nursing licenses it issued were obtained by fraud.  The licenses were obtained by submitting fraudulent documents showing the individuals were licensed as nurses in other states. The Board revoked or suspended the licenses of those individuals and Massachusetts health regulators launched a statewide review of some 21,000 professional licenses for fake credentials.  All of the fraudulent applications sought licensure in Massachusetts through reciprocity provisions in the state’s law.

Click here to read more details on the story.

Licensure by Reciprocity.

Most states offer licensure by reciprocity to nurses and other health care professionals that are licensed in other jurisdictions.  Reciprocity broadly defined is a mutual exchange of privileges.  In the matter of professional licensing, it is a provision that allows for a license from one state to be recognized as valid in another.  Licensure by reciprocity allows a health care provider to forgo retaking examinations when seeking a license in a new jurisdiction.  The normal process for licensure by reciprocity is for the board staff or an outside contractor to review the applications, verify the information and then make recommendations to the board.  The board then acts upon the recommendations.

Forged Documents and Failed Verifications.

The 13 nurses alleged of fraud are said to have taken advantage of the reciprocity provision in Massachusetts.  The investigation in Massachusetts revealed that four of the applications were submitted with forged documents purportedly from the Hawaii Board of Nursing.  Additionally, six others had forged documents claiming the applicants were licenced in Alabama and in Oklahoma.  The applications for licensure bore several similarities including signatures by improper officials for the states in which the applicants were allegedly licensed.  It appears the process of vetting these candidates failed in the verification of the credentials.

The Massachusetts Board engaged Professional Credential Services of Nashville, as an outside contractor to review the applications and verify information submitted before professional licensing was extended by the state.  Professional Credential Services is a contractor for numerous boards and those boards are also reviewing the applications previously processed by the company.

Not the First Time.

The Massachusetts Board is not the first state board to discover numerous licenses were issued based upon fraudulent information.  Several years ago, the Florida Board of Massage Therapy discovered that a corrupt employee of a legitimate college with a legitimate massage therapy program had been taking cash payments from applicants and forging transcripts used to obtain massage therapy licenses.  Some of the applicants actually had the required education and training necessary to become licensed, but the corrupt employee embezzled their payments without submitting their paperwork through the college.

The investigation in Florida eventually led to the corrupt employee, in part due to facts common to all cases.  The fraudulent licenses discovered in Massachusetts also have some common elements that could indicate a single individual or a small group of individuals is responsible for all the fraudulent claims.  To read about the massage therapy fraud case in Florida, click here to read our past blog.

Comments?

Do you think nurses and other health care professionals should have to retake examinations when seeking a license in a new jurisdiction?  Please leave any thoughtful comments below.

Source:

Lazar, Kay and Freyer, Felice J.  “State finds license fraud by 13 nurses.”  The Boston Globe: 13 Sept. 2015.  Web.  25 Jan. 2016.

Contact Health Law Attorneys Experienced in Representing Nurses.

The Health Law Firm’s attorneys routinely represent registered nurses, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, midwives and licensed practical nurses in Department of Health (DOH) investigations, in appearances before the Board of Nursing in licensing matters and in many other legal matters. We represent nurses across the U.S., and throughout Florida.

To contact The Health Law Firm, please call (407) 331-6620 or visit our website at www.TheHealthLawFirm.com.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida area.  http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: Board of Nursing, Discipline, Board of Nursing attorney, Board of Nursing case, Board of Nursing lawyer, Board of Nursing representation, Florida Board of Nursing, Massachusetts Board of Registration in Nursing, Professional Credential Services, Florida Board of Massage Therapy, fraudulent credentials, fraudulent licenses, fraudulent applications, health law firm, licensed practical nurses, medical licensing board, licensure by reciprocity, nurse, nurse attorney, nurse lawyer, nurse midwives and nurse practitioners, nurse representation, The Health Law Firm

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2016 The Health Law Firm. All rights reserved.

Terminated Nurse Whistleblowers Retaliation Claims Reinstated

indest1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Husband and wife, Ronald and Ramona Young, were terminated from their nursing jobs with CHS Middle East LLC (CHS), following reports made by the couple regarding alleged violations of the company’s contract with the United States government.  The couple alleged that CHS was using expired medications, employing improperly trained and inadequate staff, and lacking protocols and guidelines.  The pair filed a retaliation suit against the health care contractor (operating a U.S. Department of State outpost in Iraq) claiming that they engaged in protected activity under the False Claims Act (FCA) for blowing the whistle about such violations.

CHS contended in its motion for summary judgment that the Youngs’ conduct was not protected whistleblower activity because the couple did not assert allegations of false claims submissions by the company.  Furthermore, CHS maintained that the contractor fired the Youngs due to “loud, accusatory and even threatening” behavior aimed at CHS management and fellow co-workers.  The company concludes the Youngs were terminated “for very good cause.”

To read the motion in opposition filed with the court by the Youngs, click here.

This is the couple’s second go at the suit.  The first attempt resulted in the case’s dismissal in 2013.  However, the U.S. Fourth Circuit Court of Appeals reinstated it in 2015, with a finding that quality-of-care concerns fall under the protections offered by a recent ruling expanding FCA liability.

To read the Fourth Circuit’s full opinion, click here.

The Case That Changed the Rules.

The claims asserted by the Youngs seem to mirror allegations of FCA violations raised in United States ex rel. Badr v. Triple Canopy, Inc., Nos. 13-2190, 13-2191 (4th Cir. Jan. 8, 2015).  In that case, the Fourth Circuit implemented the doctrine of implied certification under the FCA to determine liability.

Fourth Circuit Judge Dennis W. Shedd stated, “While we have guarded against turning what is essentially a breach of contract into an FCA violation, we have also continued to recognize that the FCA is ‘intended to protect the treasury against the claims of unscrupulous contractors, and it must be construed in that light.'”  Id. (quoting United States ex rel. Owens v. First Kuwaiti General Trading & Contracting Co., 612 F.3d 724, 734 (4th Cir.2010).  Furthermore, “to satisfy this goal, courts have recognized that ‘a claim for payment is false when it rests on a false representation of compliance with an applicable contractual term.”  Id. (quoting United States v. Sci. Applications Int’l Corp., 626 F.3d 1257, 1266 (D.C.Cir.2010) (SAIC ).

In other words, the doctrine treats a claim submitted by a contractor as an implicit representation that the contractor has accordingly complied with any relevant contract terms, laws or regulations.  If the contractor knows it is in noncompliance with contractual terms, a submission for a claim renders a false representation in determining FCA liability.

To read the full opinion of the Fourth Circuit in United States ex rel. Badr v. Triple Canopy, Inc., Nos. 13-2190, 13-2191 (4th Cir. Jan. 8, 2015), click here.

In determining that implicit false statements may constitute fraud under the FCA, even in the absence of the explicit condition of payment, the Fourth Circuit further concluded that an employee raising concerns of implicit false statements may likewise constitute protected whistleblower activity.

Not All U.S. Courts of Appeals Are Embracing the Doctrine.

The U.S. Seventh Circuit Court of Appeals more recently rejected the notion of the implied certification doctrine in United States v. Sanford-Brown, Limited, No. 14-2506 (7th Cir. June 8, 2015).  In that case, Brent M. Nelson, former Director of Education of Sanford-Brown College (SBC), contended that the defendants agreed to comply with all Title IV regulations by entering into a Program Participation Agreement (PPA) with the U.S. Secretary of Education.  Nelson argued that due to this agreement of compliance, SBC fraudulently used Title IV benefits when they made, or caused students to make or use, applications for federal subsidies with the knowledge that they were not in compliance with Title IV restrictions.

On the flip side, SBC argued that in order to satisfy the “knowingly” component under the FCA, Nelson must offer proof of SBC’s intention to defraud the government out of subsidies upon the execution of the PPA.  The Seventh Circuit relied on its prior decision in United States ex rel. Main v. Oakland City Univ., 426 F.3d 914 (7th Cir. 2005), where it concluded that “a PPA entered into by an institution qualified as a false record under the FCA where the promises of future compliance it contained were false when the parties entered into the agreement.”  Id. at 916.

However, in Nelson’s case the Seventh Circuit did not embrace the implied certification theory, finding that Nelson failed to present any evidence to prove that SBC entered into the PPA in bad faith.  The Seventh Circuit is less liberal in its interpretation of the doctrine stating, “fraud requires more than a breach of promise: fraud entails making a false representation, such as a statement that the speaker will do something it plans not to do.”

To read the full opinion of the Seventh Circuit in United States v. Sanford-Brown, Limited, No. 14-2506 (7th Cir. June 8, 2015), click here.

Comments?

What are your thoughts on the implied certification doctrine?  Do you think FCA liability and whistleblower protections should extend to implicit false statements?

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims.  We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.  We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

To contact The Health Law Firm, please call (407) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

United States ex rel. Badr v. Triple Canopy, Inc., Nos. 13-2190, 13-2191 (4th Cir. Jan. 8, 2015).

United States v. Sanford-Brown, Limited, No. 14-2506 (7th Cir. June 8, 2015).

Young et al. v. CHS Middle East LLC, No. 13-2342 (4th Cir. May 27, 2015).

Fischler, Jacob.  “Nurses Say Whistleblowing Activity at Iraq Base Protected.”  Law360.  Portfolio Media Inc.: 8 Jan. 2016.  Web.  11 Jan. 2016.

Overley, Jeff.  “Nurses’ Whistleblowing Protected Under FCA, 4th Circ. Says.”  Law360.  Portfolio Media Inc.: 27 May 2015.  Web.  11 Jan. 2016.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida area.  www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Florida health attorney, qui tam lawyer, health law attorney, Florida health lawyer, The Health Law Firm, health law defense lawyer, health care fraud attorney, whistleblower attorney, False Claims Act (FCA) defense lawyer, FCA attorney, government health care fraud, health fraud and abuse allegations, health fraud attorney, FCA legal representation, relator attorney, qui tam attorney, relief from retaliation by employer, legal representation for retaliatory claims, FCA retaliation, wrongful termination attorney, FCA employee investigation, implied certification doctrine, implicit false statements theory, government health contractor attorney, noncompliance with contractual terms, Title IV restrictions attorney, FCA liability determination, employee protected activity under FCA

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2016 The Health Law Firm. All rights reserved.

Nonprofit Teaching Hospital Agrees to Pay $850,000 in HIPAA Settlement

indest1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Massachusetts-based Lahey Clinical Hospital Inc. (Lahey) recently entered into a settlement agreement with the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) to resolve potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules.  The HHS press office announced on November 25, 2015, that Lahey agreed to pay $850,000 and to adopt an extensive action plan to correct deficiencies in its HIPAA compliance program as a part of a Resolution Agreement.

To read the full Resolution Agreement, click here.

Lahey is a nonprofit teaching hospital affiliated with Tufts Medical School.  It is a covered entity per Section 160.103, 45 Code of Federal Regulations, and thereby required to comply with HIPAA rules.  The medical center provides primary and specialty care to hundreds of thousands of patients each year.

In 2011, Lahey notified HHS that an unencrypted laptop used in connection with a computerized tomography (CT) scanner had been stolen from an unlocked treatment room during overnight hours.  The laptop hard drive contained certain unsecured electronic protected health information (ePHI) of approximately 599 patients.  The OCR notified Lahey of its investigation regarding Lahey’s compliance with HIPAA by way of letter dated November 9, 2011.

To read the full press release issued by HHS on November 25, 2015, click here.

OCR’s Investigation into Lahey’s Conduct.

The OCR claimed that its investigation uncovered Lahey’s widespread non-compliance with HIPAA rules.  Per the terms of the Resolution Agreement, no admission or adjudication of guilt has been determined by Lahey or HHS.  However, the OCR reported to Lahey that its investigation indicated the following potential HIPAA violations:

(1)    Failure to conduct a thorough risk analysis of all of its ePHI as part of its security management process (section 164.308(a)(1)(ii)(A), 45 Code of Federal Regulations (C.F.R.));

(2)    Failure to implement reasonable and appropriate physical safeguards for a workstation that accessed ePHI to restrict access to authorized users only (section 164.310(c), 45 C.F.R.);

(3)    With respect to the workstation, failure to implement and maintain policies and procedures that govern the receipt and removal of hardware and electronic media that contain ePHI, including the movement of these items within its facility (section 164.310(d)(1), 45 C.F.R.);

(4)    Failure to assign a unique user name for identifying and tracking user identity with respect to the workstation at issue (section 164.312(a)(2)(i), 45 C.F.R.);

(5)    Failure to implement a mechanism to record and examine activity at the workstation at issue (section 164.312(b), 45 C.F.R.); and

(6)    Impermissible disclosure of the ePHI of 599 patients for a purpose not permitted by the Privacy Rule (section 164.502(a), 45 C.F.R.).

The Implementation of a Corrective Action Plan.

Lahey agreed to enter into a Corrective Action Plan (CAP) with HHS as a part of the settlement.  In accordance with the CAP, Lahey has agreed to certain action obligations to be completed within specific time frames.  Lahey is expected to fully and timely comply with all provisions contained in the CAP.  Should Lahey breach any of the provisions contained in the CAP, it is offered a limited amount of time to correct the breach in order to avoid civil monetary penalties (CMP) pursuant to section 160.312(a)(3)(i) and (ii), 45 C.F.R.

For more information on penalties resulting from failure to comply with HIPAA, click here read one of my previous blogs.

HIPAA is a Tricky Situation.  

With the rise of the use of technological devices for personal and professional purposes, HIPAA violations are now resulting from seemingly innocent behavior that actually constitutes a breach.  It is important to be aware of what all HIPAA encompasses and how to safeguard yourself and your workplace from blindly falling into its snare.  Click here to read an informative and eye-opening blog post by The Sentinel Watch regarding various HIPAA perils for health care professionals that aren’t so obvious.

HHS recently issued a HIPAA fact sheet to assist health care professionals and organizations.  To review the document providing a basic overview of HIPAA’s rules and your responsibilities as a licensed health care professional, click here.

For even more information on HIPAA basics and the implementation of safeguards, read one of my previous blog posts here.

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other health care providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

For more information about HIPAA violations, or corrective action plans , please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620.

Sources:

HHS Press Office.  “HIPAA Settlement Reinforces Lessons for Users of Medical Devices.”  Press Release.  U.S. Department of Health & Human Services: 25 Nov. 2015.  Web.  3 Dec. 2015.

Resolution Agreement, 1-2, Nov. 19, 2015.

Appendix A: Corrective Action Plan, 2 & 6, Nov. 19, 2015.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Health Insurance Portability and Accountability Act (HIPAA), HIPAA, HIPAA compliance, data security, protected health information (PHI), electronic protected health information (ePHI), Patient privacy, U.S. Department of Health and Human Services (HHS), Office of Civil Rights (OCR), patient rights, HIPAA compliance audit, HIPAA violation, penalties for HIPAA violation, criminal penalties for HIPAA violation, civil penalties for HIPAA violation, civil monetary penalties for HIPAA breach, HIPAA compliance, privacy, defense attorney, HIPAA defense lawyer, health care professional attorney, HIPAA defense attorney, HIPAA violation help, HIPAA attorney, HIPAA lawyer, compliance plans, health law firm, The Health Law

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2015 The Health Law Firm. All rights reserved.

Florida Federal Court Upholds False Claims Act Retaliation Claim Against Northside Hospital and HCA, Inc. Health System

5 Indest-2008-2By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

In a recent decision, the United States District Court for the Middle District of Florida refused to dismiss a second amended complaint for a False Claims Act (FCA) Retaliation Action. The Florida federal court found that the second amended complaint filed in the case adequately stated protected conduct the former employee engaged in as an effort to prevent and stop further FCA violations by the alleged offending hospital. Therefore, it properly stated a cause of action.

The Facts of the Case.

Brenda Farnsworth, former Vice President of Quality and Risk Management for Northside Hospital, was placed on administrative leave for alleged insubordination in February of 2012. A whistleblower action by Farnsworth against the hospital and its parent company, HCA, Inc., quickly followed, but the government did not intervene.

Farnsworth dismissed her original complaint and filed a second claim, this time an FCA retaliation claim per Section 3760(h), 31 United States Code. The Court dismissed that claim without prejudice, however, due to Farnsworth’s failure to properly demonstrate any specific protected conduct she engaged in as an effort to prevent or stop the alleged FCA violations.

To see the full Order of the court dated May 29, 2015, click here.

Requirements for Filing a Successful Claim.

A showing of protected conduct (in furtherance of an FCA enforcement action by way of a whistleblower lawsuit) in an effort to prevent or remedy fraudulent activity is necessary in order to successfully file an FCA claim. Specific actions of internal reporting or other alternative means to a lawsuit need to be outlined in the complaint.

Dismissing an action without prejudice allows the Plaintiff the opportunity to remedy the defect in the complaint and re-file the claim.

The Third Time’s a Charm.

Farnsworth filed her second amended complaint and the defense again moved to dismiss it. However, this time the court found that Farnsworth had satisfactorily corrected the errors in her retaliation claim to meet the standards set forth for filing a claim under the FCA.

Click here to view the Second Amended Complaint.

Farnsworth alleged defendants were billing Medicare and Medicaid for treatments not performed by attending physicians, falsifying medical records for services ordered by a physician on suspension, double billing for unauthorized medical research, and billing for tests and treatments that were not medically necessary.

For more information on the allegations raised, click here to read about the case at its’ commencement in 2013.

Furthermore, Farnsworth detailed instances in which she internally reported the alleged fraudulent activity to specific members of management within Northside Hospital and HCA. Such internal reports constituted a showing of an effort to stop the illegal activity and prevent further violations to satisfy the requirements for an FCA claim.

Therefore, the court denied the alleged defendants’ motion to dismiss as to HCA, Inc. and Northside Hospital.

To read more on the court’s full decision of September 8, 2015, upholding the Second Amended Complaint, click here.

The Purpose of the False Claims Act and Relief from Retaliation.

The FCA has become the government’s main line of defense against health care fraud and abuse. The FCA allows any employee with knowledge of fraudulent activity to bring a civil suit against an employer in the name of the government.

Furthermore, the government protects such employees from any retaliation by the employer for reporting alleged health care fraud and abuse. Section 3730(h)(1), 31 United States Code states:

“Any employee, contractor, or agent shall be entitled to all relief necessary to make that employee, contractor, or agent whole, if that employee, contractor, or agent is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment because of lawful acts done by the employee, contractor, agent or associated others in furtherance of an action under this section or other efforts to stop 1 or more violations of this subchapter.”

The Health Law Firm is highly experienced in assisting health care employees with whistleblower, qui tam, and retaliation claims under the FCA.

To learn more on whistleblower/qui tam cases, read our two-part blog. Click here for part one and click here for part two.

Editor’s Comments:

Brenda Farnsworth, the plaintiff in this case, had been the hospital’s Vice President of Quality and Risk Management. When she did the correct thing, to protect patients, it is alleged that she was retaliated against. Physicians, nurses and hospital employees should always do the right thing. When superiors refuse to take action or, worse, retaliate against you, blow the whistle!

Comments?

Do you have knowledge of or have you ever suspected health care fraud or abuse in your workplace? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

American Health Lawyers Association. “U.S. Court in Florida Refuses to Dismiss FCA Retaliation Action Against Health System.” Fraud and Compliance: AHLA. 25 Sept. 2015. Web. 28 Sept. 2015.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

Keywords: False Claims Act defense attorney, retaliation defense attorney, health care fraud defense lawyer, anti-fraud attorney, Medicare and Medicaid attorney, fraudulent practices in health care, whistleblowers lawyer, FCA violations, fraud detection, qui tam lawyer, health attorney, defense attorney, The Health Law Firm, health law firm, fraud investigations, fraudulent Medicare billing, federal health care program fraud, illegal Medicare and Medicaid billing practices, relief from retaliation, False Claims Act (FCA) Retaliation Action, retaliation claims defense lawyer

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“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2015 The Health Law Firm. All rights reserved.

Detroit Medical Center Agrees to Pay $42M to End Long-Running Antitrust Suit

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A month before trial was set to begin, Detroit Medical Center (DMC) agreed to pay $42 million to end a nine-year antitrust class action lawsuit. The suit was brought by nurses accusing eight Detroit area hospitals of conspiring to keep their wages low, violating antitrust laws from 2002-2006. The DMC was the last remaining defendant in a 2006 class-action lawsuit before Chief U.S. District Judge Gerald Rosen. To read a blog I wrote on another health care antitrust case, click here.

A copy of the class action complaint that was filed in the U.S. District Court for the Eastern District of Michigan can be found here.


Last Man Standing.

The nurses have alleged the DMC and seven other Detroit area hospitals “participated in an unlawful conspiracy to depress wages for Registered Nurses and/or to unlawfully exchange wage information in violation of Section 1 of the Sherman Antitrust Act.” For more information on antitrust laws, visit the “Areas of Practice” page on our website. The seven other hospitals involved in the suit settled with the nurses for a combined $48 million. DMC is expected to pay $42 million into a combined settlement fund, bringing total compensation in the case to $90 million. To view the class settlement agreement in this case, click here.

“It’s Not What It Looks Like.”

DMC had planned to take the case to trial in a month, but instead veered off course and decided to settle instead. “The settlement is not an admission of liability but rather a business decision to bring the matter to a resolution. We remain committed to our nurses and value the hard work and dedication of all our hospital staff,” DMC counsel released in a statement defending their decision. For more information, visit their website by clicking here.

Comments?

Do you think the settlement amount of $42 million was fair? Have you ever experienced a situation where antitrust laws were broken? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced With Antitrust Laws and Trade Regulation.

The Health Law Firm has attorneys who practice in the area of antitrust law and trade regulation. We have defended a hospital in federal court against allegations of violations of the antitrust laws, we routinely provide advice and opinion letters on antitrust and trade regulation matters, we have represented plaintiffs in law suits alleging anticompetitive behavior and violations of state and federal antitrust laws.

The attorneys of The Health Law Firm provide advice and representation concerning antitrust law, trade regulation, restraint of trade issues, and regarding deceptive and unfair trade practices. We have represented both plaintiffs and defendants in state court litigation and in federal court litigation in such matters.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Kang, Peter. “Detroit Hospital to Pay $42M to End Nurse Wage-Fixing Suit.” Law360. (September 11, 2015). From: http://www.law360.com/health/articles/702135?nl_pk=68a34a8e-1544-489d-9b84-bbd4587b4d64&utm_source=newsletter&utm_medium=email&utm_campaign=health

Cwiek, Sarah. “Detroit Medical center agrees to settle with nurses, end long-running antitrust lawsuit.” Michigan Radio. (September 14, 2015). From: http://michiganradio.org/post/detroit-medical-center-agrees-settle-nurses-end-long-running-antitrust-lawsuit#stream/0

Halcom, Chad. “DMC expects to settle nurse wage class-action lawsuit for $42 million.” Crain’s Detroit Business. (September 14, 2015). From:
http://www.crainsdetroit.com/article/20150914/NEWS/150919922/dmc-expects-to-settle-nurse-wage-class-action-lawsuit-for-42-million

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Antitrust laws, violating antitrust laws, anticompetitive conduct, Sherman Act, price fixing, wage fixing, trade regulation law, Federal Trade Commission, FTC, Detroit Medical Center, DMC, Michigan Antitrust Reform Act, unfair competition laws, deceptive and unfair trade practices, restraints on trade or business, defense attorney, defense lawyer, health care law, health law attorney, wage dispute, wage settlement, settlement agreement, health care law, health law attorney

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“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2015 The Health Law firm. All rights reserved.