By: Zach Simpson
There have been a rise in cases recently, in which practices that operate under a Health Care Clinic License have been brought under scrutiny by insurance companies trying to recoup funds through any means possible. In an effort to claw back funds insurance companies are beginning to claim that medical directors are failing to meet their statutory obligations under Florida Law which in turn can have serious monetary repercussions. Due to the clinics allegedly failing to meet their statutory obligations the insurance companies are filing suit to recoup any payments made while violating the Health Care Clinic Act obligations, and to stall any future payments due until such cases are heard.
By law, a medical director must be a health care practitioner that holds an active and unencumbered Florida license as a medical physician, osteopathic physician, chiropractic physician, or podiatric physician. The type of services provided at a clinic may dictate who would be able to serve as a clinic’s medical director, because a medical director must be authorized under the law to supervise all services provided at the clinic.
Medical Director Responsibilities
Each clinic that possesses a Health Care Clinic License is required to appoint a medical director who shall agree in writing to accept legal responsibility for the following activities on behalf of the clinic. Pursuant to Fla. Stat. § 400.9935 the medical director shall:
- Have signs identifying the medical director or clinic director posted in a conspicuous location within the clinic already visible to all patients.
- Ensure that all practitioners providing health care services or supplies to patients maintain a current active and unencumber Florida license.
- Review any patient referral contracts or agreements executed by the clinic.
- Ensure that all health care practitioners at the clinic have active appropriate certification or licensure for the level of care being provided.
- Serve as the clinic records owner.
- Ensure compliance with the record keeping, and adverse incident reporting requirements
- Conduct systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful.
In recent months GEICO filed suit against Advanced Diagnostic Group, Radiology Imaging Specialists, CareFirst Imaging (collectively the “Radiology Clinics”), the clinic owners, and the medical directors of each clinic. In the suit GEICO is seeking to recover more than $23,000,000 that they claim the Defendants obtained from submitting thousands of fraudulent no-fault personal injury protection or “PIP” insurance charges. GEICO’s allegations stem from their claim that the clinics violated the operating requirements set forth in the Florida Health Care Clinic Act, and the medical directors failed to meet their statutory requirements which in turn make all claims submitted fraudulent even if the services were actually performed.
Specifically, GEICO alleged that a clinic medical director must and in the case against Advanced Diagnostic Group they did not, “conduct systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful. Upon discovery of an unlawful charge, the medical director or clinic director shall take immediate corrective action.” See Fla. Stat. § 400.9935(1).
Pursuant to the Health Care Clinic Act, “a charge or reimbursement claim made by or on behalf of a clinic that is required to be licensed under this part but that is not so licensed, or that is otherwise operating in violation of this part, regardless of whether a service is rendered or whether the charge or reimbursement claim is paid, is an unlawful charge and is non-compensable and unenforceable.
Therefore, pursuant to the No-Fault Law and the Clinic Act, clinics that operate in violation of the Clinic Act’s medical director or other operating requirements are not entitled to collect PIP
Risks for medical directors and their facilities
There are several inherent risks including legal risks for professional liability, regulatory compliance, and board complaints. Failure of an appointed medical or clinic director to substantially comply with health care clinic responsibilities shall be grounds for the revocation or suspension of the license and assessment of a fine. Health care clinics may be found liable for their medical directors’ failure to fulfill their statutory duties. Therefore, it is essential that any practice operating under the Health Care Clinic Act seek help from a licensed healthcare attorney to ensure their medical director agreements are compliant, and to ensure the medical directors are truly meeting their statutory requirements in place to promote a compliant practice.