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December 16, 2021

UPDATE 2.4.13.3 Involuntary Disenrollment DEPARTMENT OF JUSTICE CRIMINAL DIVISION MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone: (225) 326-6210 Fax: (225) 326-6295

Richard R. Vath, MD

United States Federal Agencies warn to prosecute opportunistic acts of process by discrimination or exploitation of Coronavirus pandemic, retaliation under federal protection ...


DEPARTMENT OF JUSTICE CRIMINAL DIVISION MEDICAID FRAUD CONTROL UNIT 

Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 

Telephone: (225) 326-6210 Fax: (225) 326-6295 

Attorney General Jeff Landry

PREVENTION & PROSECUTION OF MEDICAID FRAUD.

  1. 2.4.13.3 Involuntary Disenrollment Requested by the MCO

    2.4.13.3.1 The Contractor may request involuntary disenrollment of an enrollee if the enrollee’s utilization of services constitutes fraud, waste, and/or abuse. In such case the Contractor shall report the event to LDH and MFCU.

    2.4.13.3.2 The Contractor shall submit disenrollment requests to the enrollment broker, in a format and manner to be determined by LDH.

    2.4.13.3.3 The Contractor shall ensure that involuntary disenrollment documents are maintained in an identifiable enrollee record.

    2.4.13.3.4 The Contractor shall not request disenrollment because of an adverse change in physical or mental health status or because of the enrollee’s health diagnosis, utilization of medical services, diminished mental capacity, pre- existing medical condition, refusal of medical care or diagnostic testing, attempt to exercise his/her rights under the Contractor’s grievance system, or attempt to exercise her/her right to change, for cause, the primary care provider that he/she has chosen or been assigned. Further, the Contractor shall not request disenrollment because of an enrollee’s uncooperative or disruptive behavior resulting from his or her special needs, except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to either this particular enrollee or other enrollees.

    [42 C.F.R. §438.56(b)(2)]

    2.4.13.3.5 The Contractor shall not request disenrollment for reasons other than those stated in this Contract. In accordance with 42 C.F.R. §438.56(b)(3), LDH shall ensure that the Contractor is not requesting disenrollment for other reasons by reviewing and rendering decisions on all Disenrollment Request Forms submitted to the enrollment broker.

    2.4.13.3.6 All disenrollment requests shall be reviewed on a case-by-case basis and are subject to the sole discretion of LDH or its designee (enrollment broker). All decisions are final and not subject to the dispute resolution process by the Contractor.

    2.4.13.3.7 When the Contractor’s request for involuntary disenrollment is approved by LDH, the Contractor shall notify the enrollee in writing of the requested disenrollment.

    2.4.13.3.7.1 The reason for the disenrollment;

    2.4.13.3.7.2 The effective date;

    2.4.13.3.7.3 An instruction that the enrollee choose a new MCO; and

    2.4.13.3.7.4 A statement that if the enrollee disagrees with the decision to disenroll, the enrollee has a right to submit a request for a State Fair Hearing.

    2.4.13.3.8 Until the enrollee is disenrolled by the enrollment broker, the Contractor shall continue to be responsible for the provision of all MCO covered services to the enrollee.

    2.4.13.4 Disenrollment Effective Date

    2.4.13.4.1 The effective date of disenrollment shall be no later than the first day of the second month following the calendar month the request for disenrollment is filed.

    2.4.13.4.2 If LDH or its designee fails to make a disenrollment determination by the first day of the second month following the month in which the request for disenrollment is filed, the disenrollment is deemed approved.

    2.4.13.4.3 LDH, the Contractor, and the enrollment broker shall reconcile enrollment/disenrollment issues at the end of each month utilizing an agreed upon procedure.

    2.4.14 Enrollment and Disenrollment Updates

    2.4.14.1 LDH’s enrollment broker shall notify each MCO at specified times each month of the Medicaid beneficiaries that are enrolled, re-enrolled, or disenrolled from their MCO for the following month. The MCO shall receive this notification through the ASC X12N 834 Benefit Enrollment and Maintenance electronic transaction, or in instances of corrections to closed segments, the MCO shall receive this notification through a manual correction processing file.

    2.4.14.2 LDH shall use its best efforts to ensure that the Contractor receives timely and accurate enrollment and disenrollment information. In the event of discrepancies or irreconcilable differences between LDH and the Contractor regarding enrollment, disenrollment and/or termination, LDH’s decision is final.

     

    Plan goals  2.8.4 Continuity of Care for Pharmacy Services

     

    2.8.4.1

     

    The Contractor shall submit for approval, a transition of care program that ensures enrollees can continue treatment of maintenance medications for at least sixty (60) calendar days after enrollment into the MCO or switching from one plan to another. The Contractor shall continue any treatment of antidepressants and antipsychotics for at least ninety (90) calendar days after enrollment into the Contractor’s plan.

    Additionally, an enrollee that is, at the time of enrollment into the MCO, receiving a prescription drug that is not on the PDL shall be permitted to continue to receive that prescription drug if medically necessary for at least sixty (60) calendar days.
    2.6.2.3.3.2 Enrollees experiencing a disparate level of social needs such as housing, food insecurity, physical safety, and transportation ...


    2.4.15 Updates

    The enrollment broker shall make available to the Contractor daily via electronic media (ASC X12N 834 Benefit Enrollment and Maintenance transaction) updates on beneficiaries newly enrolled into the MCO in the format specified in the MCO Manual. The Contractor shall have written policies and procedures for receiving these updates, incorporating them into its management information system and ensuring this information is available to their providers. Policies and procedures shall be available during readiness reviews. In instances of corrections or updates to closed segments, the Contractor shall receive data through a weekly manual correction processing file.

    2.4.16 Reconciliation

    2.4.16.1 Enrollment The Contractor is responsible for monthly and quarterly reconciliation of the membership list of enrollments and disenrollments received from the enrollment broker against its internal records. The Contractor shall provide written notification to the enrollment broker of any data inconsistencies within ten (10) calendar days of receipt of the monthly and quarterly reconciliation data file.

    The State, including LDH, Louisiana Office of the Attorney General Medicaid Fraud Control Unit (MFCU), and the Louisiana Legislative Auditor (LLA), and the federal government, including, CMS, HHS Inspector General, and the General Accounting Office or their designees, have the right to audit, evaluate, and inspect any records or systems that pertain to any activities performed or amounts payable under this Contract at any time




    Medicaid Fraud Control Unit 11
    EXCLUSIONS

    An excluded individual cannot work, in any
    capacity, for any federally-funded health care
    provider. This includes (but is not limited to)
    doctor, nursing home, hospital, and PCS/home
    care agency.

    If an excluded individual is employed by a
    federally-funded provider, both the
    employee and the employer could face State
    and Federal penalties ($10,000 or more.)

    To see if a prospective employee is excluded—
    go to the following U. S. Department of Heath
    and Human Services, Office of the Inspector
    General, website:

    http://exclusions.oig.hhs.gov/

    and to the Louisiana Department of Health
    and Hospitals’ Adverse Actions website:

    https://adverseactions.dhh.la.gov

    10 Louisiana Department of Justice
    Cruelty to Persons with Infirmities La. R.S. 14:93.3 Exploitation of Persons with Infirmities La. R.S. 93.4 False Imprisonment La. R.S. 14:46 False statements concerning employment in a nursing or health care facility La. R.S. 14:126.3 Filing or maintaining false public records La. R.S. 14:133 Forgery La. R.S. 14:72 Identity Theft La. R.S. 14:67.16 Medicaid Fraud La. R.S. 14:70.1 Obstruction of Justice La. R.S. 14:130.1 Unauthorized Participation in Medical Assistance Programs La. R.S. 14:126.3.1
    Perpetration or Attempted Perpetration of certain crimes of violence against a victim sixty-five years of age or older La. R.S. 14:50.2 Simple Battery La. R.S. 14:35 Simple Battery of Persons with Infirmities La. R.S. 14:35.2 Sexual Battery of Persons with Infirmities La. R.S. 14:93.5 Theft La. R.S. 14:67     Theft of the assets of an aged person or disabled person La. R.S. 14:67.21
    REPORTING SUSPECTED
    FRAUD AND ABUSE Duty to Make Complaints La. R.S. 40:2009.20 Non- Retaliation by health care provider La. R.S. 40:2009.17


    To view complete statutes, please visit the
    Louisiana State Legislature’s website:
    www.legis.state.la.us
    Statutes Related to Abuse and Medicaid Fraud


    Medicaid Fraud Control Unit 3

    As your Attorney General, I am committed to ensuring the Louisiana Department of Justice serves all of our State’s people – especially the elderly and the poor. Medicaid fraud and nursing home abuse are unlawful and immoral acts that our office will vigorously investigate and prosecute. We have compiled this booklet to help educate the citizens of Louisiana on who is a Medicaid provider, what are fraud and abuse as they relate to the Medicaid program, what are the legal responsibilities of reporting suspected Medicaid fraud and abuse, and what are the consequences of committing fraud or abuse. I hope this brochure is helpful to you. If you have questions or would like more information, please visit www.AGJeffLandry.com or call our Medicaid Fraud Control Unit at 888-799-6885. I am here to serve you and do all that I can to make Louisiana an even better place to live, work, and raise a family. Sincerely, Jeff Landry

    A Message from the Attorney General

    Jeff Landry


    4 Louisiana Department of Justice
    Since 1978, Louisiana’s Medicaid Fraud Control Unit
    (MFCU) has been recognized as a national leader in the
    investigation and prosecution of Medicaid fraud and
    nursing home abuse. In that time, the Louisiana MFCU has
    c o n v i c t e d h u n d r e d s o f i n d i v i d u a l s f o r
    program violations and recovered millions of tax dollars.

    The MFCU has twice been
    recognized as the top-
    r a te d u n i t i n th e
    nation by the United
    States Department of
    Health and Human Ser-
    vices, Office of the In-
    spector General.

    The mission of the MFCU is
    to aggressively combat
    the fleecing of taxpayers
    by fraudulent heath care
    providers. Furthermore,
    the MFCU seeks to protect
    our most vulnerable citizens—the elderly and mentally
    disabled– and vigorously prosecute criminals who prey
    on them.
    LOUISIANA MEDICAID FRAUD CONTROL UNIT


    Medicaid Fraud Control Unit 9
    Write reports.
    Memories fade. Reports should be written to ensure
    details of incidents are not forgotten months later.

    Be Specific.
    Who, what, when, where, and why. Document all
    details about the incident.

    Be clear, precise, and complete.
    Details, details, details. Provide as many specific
    facts as possible. Where was the person struck and
    how? What services were billed for and not
    rendered? For whom and on what dates?

    Get supporting evidence.
    If visible signs of abuse are present, take
    photographs. If fraudulent claims are suspected of
    being submitted, document details supporting
    suspicion.

    CONSEQUENCES OF COMMITTING
    FRAUD OR ABUSE
    Immediate termination
    Loss of certification (CNA, LPN, RN)
    Arrest and prosecution
    Severe criminal penalties and fines
    Exclusion from working for any federally-funded
    healthcare provider for a minimum of five years

    2.5.1.9 The Contractor shall provide a mechanism to reduce inappropriate and duplicative use of healthcare services, including but not limited to potentially preventable hospital emergency departments visits and inpatient readmissions

    PART 2: CONTRACTOR RESPONSIBILITIES

    Compliance

    2.1.1 The Contractor shall comply, to the satisfaction of LDH, with:

     

    • (1) all requirements set forth in this Contract;

     

    • (2) all provisions of state and federal laws, regulations, rules, the State Plan, and waivers applicable to managed care; and

    • (3) the MCO Manual.

    2.1.2 The Contractor shall comply with federal statutes and regulations governing managed care, including, but not limited to, all applicable provisions of

    42 U.S.C. § 1396u-2 and 42 C.F.R. Part 438

     

     

    2.1.3 The Contractor shall cooperate with LDH, CMS, the External Quality Review Organization, the University of Louisiana at Monroe’s Office of Outcomes Research and Evaluation, and any other LDH contractors related to the evaluation and monitoring of this Contract, the Contractor, or the Louisiana Medicaid managed care program.
    2.1.4 Neither the Contractor nor any material subcontractor shall, for the duration of the Contract, have any interest that will conflict, as determined by LDH, with the performance of services under the Contract, or that may be otherwise anti-competitive. Without limiting the generality of the foregoing, LDH requires that neither the Contractor nor any material subcontractor have any financial, legal, contractual or other business interest in any entity performing MCO enrollment functions for LDH, the enrollment broker and subcontractor(s), if any.

    2.1.5 The Contractor shall comply with all court-ordered requirements, including but not limited to, United States v. State of Louisiana (DOJ Agreement- Case-3:18-cv-00608) and Chisholm v. Gee (Case 2:97-cv-03274) in the manner determined by LDH.

    2.1.6 The Contractor shall establish and maintain interdepartmental structures and processes to support the operation and management of this Contract in a manner that fosters integration of physical and behavioral health service provision. The provision of all services shall be based on prevailing clinical knowledge and the study of data on the efficacy of treatment, when such data is available.

     

    2.1.7 The Contractor shall notify LDH in writing when there has been a significant change in its operations. The written notification shall include the details of the change and an assurance that it will not impact the ability of the Contractor to comply with the requirements of this Contract.

     

    2.1.8 The Contractor shall comply with all of the reporting requirements established by this Contract and in accordance with the MCO Manual.


    2.4.12.1.3 The Contractor shall not discriminate against enrollees on the basis of their health history, health status, need for health care services or adverse change in health status; or on the basis of age, religious belief, sex, gender, sexual orientation, gender identity, or disability.

     

    Further, the Contractor shall not use any policy or practice that has the effect of discriminating on the basis of age, religious belief, race, color, national origin, sex, sexual orientation, gender identity, or disability.

    This applies to enrollment, re-enrollment or disenrollment from the MCO.

    The Contractor shall be subject to monetary penalties and other sanctions if it is determined by LDH that the MCO has requested disenrollment for any of these prohibited reasons.

    2.3.7.5.1

    This right exists for ten (10) years from the termination of this Contract for the Contractor and any material subcontractors or from the date of completion of any audit, whichever is later; provided, however that if any of the entities above determine that there is a reasonable possibility of fraud or similar risk, they may audit, evaluate, and inspect at any time;
    2.3.7.5.2
    The Contractor and any material subcontractors shall make their premises, facilities, equipment, records, and systems available for the purposes of any audit, evaluation, or inspection described immediately above;

    2.3.7.5.3

    The Contractor and any material subcontractors shall retain, as applicable, enrollee grievance and appeal records in 42 C.F.R. §438.416, base data in 42 C.F.R. §438.5(c), MLR reports in 42 C.F.R. §438.8(k), and the data, information, and documentation specified in 42 C.F.R. §438.604, 438.606, 438.608, and 438.610 for a period of no less than ten (10) years; and

     

    2.3.7.5.4

    The Contractor shall monitor any material subcontractor’s performance on an ongoing basis and perform a formal review annually. At a minimum, the annual review shall include any performance concerns identified by LDH. If any deficiencies or areas for improvement are identified, the Contractor shall require the material subcontractor to take corrective action. The Contractor shall provide LDH with a copy of the annual review and any corrective action plans developed as a result. If there are corrective active plans put in place, the Contractor shall provide ongoing updates to LDH on the material subcontractor’s activities to improve the performance pursuant to the corrective action plan.

     

    2.3.7.6

    Upon notifying any material subcontractor, or upon being notified by such material subcontractor, of the intention to terminate such subcontract, the Contractor shall notify LDH in writing no later than the same day as such notification, and shall otherwise support any necessary enrollee transition or related activities as described in the Continuity of Care section and elsewhere in this Contract.

     

    2.3.7.7

     

    The Contractor shall require that all Material Subcontracts stipulate that Louisiana law, without regard to its conflict of laws provisions, will prevail if there is a conflict between the state law where the material subcontractor is based and Louisiana law.

     

    2.3.7.8

    Notwithstanding any relationship the Contractor may have with a subcontractor, including material subcontractors, the Contractor shall maintain ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of this Contract. No subcontractor will operate to relieve the Contractor of its legal responsibilities under the Contract.

    2.4.12.1.4

    The Contractor shall comply with all federal and state statutes and rules governing direct reimbursement to Medicaid enrollees for payments made by them for medical services and supplies delivered during a period of retroactive eligibility.

     


     

    2.3.3.4 The Behavioral Health Medical Director shall be a physician with a current, unencumbered Louisiana-license as a physician, board-certified in psychiatry with at least three (3) years of training in a medical specialty.

     

    The Behavioral Health Medical Director shall be devoted full-time (minimum forty (40) hours weekly) to the Contractor’s operations to ensure timely medical decisions, including after-hours consultation, as needed. During periods when the Behavioral Health Medical Director is not available, the Contractor shall have physician staff available to provide competent medical direction. The Behavioral Health Medical Director shall serve exclusively in this position and may not also function in an executive capacity for another insurance product. The Behavioral Health Medical Director shall share responsibility for the management of the behavioral health services delivery system with the Behavioral Health Coordinator, and shall be actively involved in all major clinical and quality management components of the behavioral health services of the MCO. The Behavioral Health Medical Director shall meet regularly with the Medical Director. The Behavioral Health Medical Director’s responsibilities shall include, but not be limited to, the following:

     

    2.3.3.4.1 Oversee, monitor, and assist with the management of psychopharmacology pharmacy benefits manager (PBM) activities, including the establishment of prior authorization, clinical appropriateness of use, and step therapy requirements for the use of stimulants and antipsychotics for all enrollees under age 18;

    2.3.3.4.2 Provide clinical case management consultations and clinical guidance for contracted primary care physicians (PCPs) treating behavioral health-related concerns not requiring referral to behavioral health specialists;

     

    2.3.3.4.3 Develop comprehensive care programs for the management of youth and adult behavioral health concerns typically treated by PCPs, such as ADHD and depression;

     

    2.3.3.4.4 Develop targeted education and training for MCO PCPs to screen for mental health and substance use disorders using evidence-based tools (e.g., AUDIT- C, PHQ-9 and GAD-7), perform diagnostic assessments, provide counseling and prescribe pharmacotherapy when indicated, and build collaborative care models in their practices;

     

    2.3.3.4.5

     

    Coordinate with the Medical Director to integrate the administration and management of behavioral and physical health services;

     

    42 C.F.R. §438.608(a)(1)(ii)

    2.3.4 Additional Required Staff

     

    2.3.4.1 The Contractor shall have sufficient number of qualified staff with sufficient experience and expertise to meet both physical health services and behavioral health services responsibilities, and shall provide dedicated staff where necessary to meet this obligation including all required timeframes and geographic coverage outlined in this Contract.

     

    2.3.4.2 The Contractor shall comply with additional staffing requirements included in the MCO Manual. Mental Health Parity

     

    2.3.11.1.1

     

    The Contractor must comply with parity requirements for aggregate lifetime or annual dollar limits on mental health or substance use disorder benefits, including prescription drugs as specified in

     

    42 C.F.R. §438.905.

     

    2.3.11.1.2

     

    All financial requirements or treatment limitations, including non-quantitative treatment limitations (NQTL), to mental health or substance use disorder benefits shall not be more restrictive than the predominant financial requirement or treatment limitation applied to substantially all medical/surgical benefits, in accordance with

     

    42 C.F.R. §438.910

    Financial requirements cannot accumulate separately for medical/surgical benefits and mental health/SUD benefits.

     

    2.3.11.2

     

    The Contractor shall develop and maintain internal controls to ensure mental health parity. The Contractor’s utilization practices such as prior authorization, standards for medical necessity determination, and network policy, procedures, and practices shall comply with the federal regulations referenced above.

     

    2.3.11.2.1

     

    The Contractor shall conduct an initial parity analysis as part of its readiness review process and at other times as directed by LDH, based on benefit classifications for parity as defined by LDH.

     

    If an enrollee is provided mental health or substance use disorder benefits in any classification of benefits, mental health and substance use disorder benefits must be provided to the enrollee in every classification in which medical/surgical benefits are provided.

     

    2.3.11.2.2

    The Contractor shall cover, in addition to State Plan required services, any service necessary for compliance with the requirements for parity in mental health and substance use disorder benefits based on parity analysis. As directed by LDH as part of ongoing parity review, the Contractor may be required to cover or change services necessary for compliance including type and amount, duration and scope of services and change policy or operational procedures in order to achieve and maintain compliance with parity requirements. 

     

    2.3.11.2.3 The Contractor shall ensure enrollees receive a notice of adverse benefit determination per

     

    42 C.F.R. §438.915(b) and other sections of this Contract which extend notice requirements beyond denials. The Contractor shall make available in hard copy upon request at no cost to the requestor and available on the Contractor’s website, the criteria for medical necessity determinations for mental health and substance use disorder benefits to any enrollee, potential enrollee or provider per

     

    42 C.F.R. §438.236(c) and 438.915(a).

     

    2.3.11.3 The Contractor shall require that all providers and all subcontractors take such actions as are necessary to ensure compliance with mental health parity requirements.

     

    To the extent that the Contractor delegates oversight responsibilities for behavioral health services to a material subcontractor, the Contractor shall require that the material subcontractor complies with provisions of this Contract relating to mental health parity. The compliance and review shall be in conjunction with parity analysis on the medical/surgical benefit administration.

     

    The Contractor shall require mental health parity disclosure on provider enrollment forms as mandated by LDH.

    at any time the State moves to a single delivery system and any remaining benefits from FFS are completely provided through managed care, it shall be the responsibility of the Contractor to review mental health and substance user disorder and medical/surgical benefits and conduct the complete parity analysis to ensure the full scope of services available to all enrollees of the Contractor complies with the requirements set forth in 42 C.F.R. Part 438, Subpart K.

    2.3.11.4
    The Contractor shall provide LDH and its designees, which may include auditors and inspectors, with access to Contractor service locations, facilities, or installations, including any and all records and files produced, electronic and hardcopy. Access described in this section shall be for the purpose of examining, auditing, or investigating mental health parity.

     

    2.3.11.5
    The Contractor shall comply with all other applicable state and federal laws and regulations relating to mental health parity. Population Health and Social Determinants of Health.

     

    The Contractor shall utilize a defined population health approach aligned with the Louisiana Medicaid Managed Care Quality Strategy.

     

    A population health approach seeks to maintain and improve the health status of the entire population through prevention, while systematically identifying sub-populations with complex needs and implementing strategies to improve status and reduce health inequities among sub-populations.

     

    The Contractor’s population health approach shall engage enrollees across the entire care continuum, promote and incentivize healthy behaviors and disease self-management, address priority social determinants of health (SDOH), which include housing, food insecurity, physical safety, and transportation, integrate care management, and advance evidence-based practices.

     

    As part of the population health approach, the Contractor shall evaluate the entire enrollee population, make prevention and wellness programs available to all enrollees, and identify specific enrollees for specific programs based on health needs assessments, data analysis and risk stratification, enrollee self-referral, and provider referral. The Contractor’s population health approach shall be data-driven and built on an understanding of social, economic, familial, cultural, and physical environmental factors and how these relate to the distribution of health conditions, health-related behaviors, and health outcomes among different geographic locations and enrollee groups (e.g., socioeconomic, racial/ethnic, or age) in Louisiana.

     

    2.6.1 Population Health Strategic Plan

     

    2.6.1.1 The Contractor shall develop a Population Health Strategic Plan aligned with the Louisiana Medicaid Managed Care Quality Strategy and submit it to LDH by March 1, 2020.
    health needs assessments and findings from different regions across the state, including but not limited to those conducted by the Office of Public Health (OPH), a plan for how the Contractor shall work with community-based organizations and/or OPH to address at least one

     

    (1) specific initiative, regionally or statewide, to improve the overall health of enrollees in the community and address discrete health inequities and a description of how it will identify and measure the impact of targeted interventions in addressing discrete health inequities experienced by different sub-populations of enrollees.

     

    2.6.1.3

     

    The Contractor shall be responsible for implementing its Population Health Strategic Plan, and shall provide updates to LDH on its implementation during regular Contractor performance reviews and an annual report of its progress on meeting Population Health Strategic

  1. DEPARTMENT OF JUSTICE CRIMINAL DIVISION MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone: (225) 326-6210 Fax: (225) 326-6295 Attorney General Jeff Landry PREVENTION & PROSECUTION OF RECIPIENT ABUSE and MEDICAID FRAUD

  2. MEDICAID FRAUD CONTROL UNIT • Is defined as ….‘a single identifiable entity of state government, annually certified by the Secretary of the US Department of Health and Human Services, that conducts a statewide program for • The investigation and prosecution of health care providers that defraud the Medicaid program. • Review complaints of abuse and neglect of nursing home residents and also may investigate complaints of misappropriation of patient funds in these facilities • Investigating fraud in the administration of the program’

  3. MEDICAID FRAUD CONTROL UNIT MEDICAID FRAUD CONTROL UNIT • Federal law requires each state to have an MFCU or provide a waiver to the Secretary of HHS • 50 states and the District of Columbia have MFCU’s • 43 MFCU’s are in the Office of Attorney General • 7 are in other state agencies such as State Police • MFCU must be independent of the state agency • No Medicaid agency has the authority to review Unit activities • No state Medicaid agency funds go to MFCU or vice versa • Every state Medicaid agency is required to have a formal agreement with the Unit that outlines each agency’s responsibilities and duties to one another

  4. MEDICAID FRAUD CONTROL UNIT MEDICAID FRAUD CONTROL UNIT • Staffed by Investigators, Auditors and Prosecutors • One or more attorneys with experience in the investigation and prosecution of civil or criminal fraud • Senior investigators with substantial experience in commercial or financial investigations • One or more experienced auditors capable of reviewing financial records • MUST work Medicaid matters exclusively

  5. MEDICAID FRAUD CONTROL UNIT LOUISIANA MEDICAID FRAUD CONTROL UNIT Established in 1978 • Staffed by: • Director • Chief Investigator • Supervisory Investigators • Forensic Nurse Investigators • Forensic Auditors • Forensic Computer Analysts • Prosecutors • Investigators • Support Staff • Total - 63 staff

  1. LOUISIANA MEDICAID FRAUD CONTROL UNIT LOUISIANA MEDICAID FRAUD CONTROL UNIT Federal Fiscal Year 2015 Statistics • 426 investigations • 356 fraud • 70 abuse and neglect • 91 indictments/charges • 84 fraud • 7 abuse and neglect • 73 convictions • 66 fraud • 7 abuse and neglect • 25 civil judgements and settlements Recovered $17,905,243.00 $5,072,526.00 criminal $12,832,717.00 civil

  2. What is Abuse? Abuse Can Be: • PHYSICAL • Hitting, slapping, pinching, punching • MENTAL • Threatening, scaring, intimidating • EMOTIONAL • Yelling, making cry • SEXUAL • Any inappropriate contact • FINANCIAL • Misuse of finances or resources

  3. In Louisiana, all these forms of abuse--whether physical, sexual, financial, or mental--are considered crimes, and any person who commits abuse can be prosecuted.

  4. Common signs of abuse include the following: (1) Bruises, cuts, welts, discoloration; (2) Dehydration and/or malnourishment without illness-related causes; (3) Fear, agitation, withdrawal, or depression; (4) Weight loss or other physical changes. Observe the patients under your care!!

  5. FACTORS CONTRIBUTING TO PATIENT ABUSE ABUSE JOB FRUSTRATION HIGH STRESS LOW WAGES STAFF PERSONAL PROBLEMS LOW STAFF RATIO LACK OF EMPATHY FOR ELDERLY INADEQUATE STAFF SUPERVISION MORE SEVERELY ILL RESIDENTS HIGH STAFF TURNOVER ABUSIVE OR BELLIGERENT PATIENTS LACK OF SKILLS TRAINING CULTURAL DIFFERENCES

  6. TOOLS OF THE TRADE, PART I: LOUISIANA LAWS GOVERNING PATIENT ABUSE

  7. False Imprisonment La R.S. 46 The intentional confinement or detention of another, without his consent and without proper legal authority. Fined not more than two hundred dollars and or imprisoned for not more than six months

  8. Criminal AbandonmentLa. R.S. 79.1 • Intentional abandonment • Aged (65 or older) or disabled person by paid caregiver • 1 year in jail and/or $1000 fine *This statute allows us to prosecute caregivers even when no injury occurs to the infirmed or disabled person

  9. Simple BatteryLa. R.S. 14:35 Simple battery is a battery committed without the consent of the victim Fined not more than five hundred dollars and/or imprisoned for not more than six months BRUISE

  10. Simple Battery of the Infirm La. R.S. 14:35.2 Battery committed upon Infirm Disabled Aged 6 months in jail and/or $500 fine

  11. Cruelty to the InfirmLa. R.S. 14:93.3 The intentional or criminally negligent mistreatment or neglect By any person, including a caregiver Whereby unjustifiable pain, malnourishment, or suffering is caused To the infirmed, a disabled adult, or an aged person

  12. Cruelty to the InfirmLa. R.S. 14:93.3 10 years in jail and/or $10,000 fine

  13. Sexual Battery of the InfirmLa R.S. 14:93.5 Engaging in sexual touching of genitals or anus Victim cannot resist due to advanced age or mental or physical infirmity 10 years in jail and/or $10,000 fine

  14. SIMPLE FORCIBLE AGGRAVATED RAPE HOMICIDE • NEGLIGENT • MANSLAUGHTER • MURDER

  15. The court in its discretion may sentence, in addition to any other penalty provided by law, any person who is convicted of a crime of violence or of an attempt to commit any of the crimes as defined in R.S. 14:2(B) with the exception of first degree murder (R.S. 14:30), second degree murder (R.S. 14:30.1), aggravated assault (R.S. 14:37), aggravated rape (R.S. 14:42) and aggravated kidnapping (R.S. 14:44), to an additional three years' imprisonment when the victim of such crime is sixty-five years of age or older at the time the crime is committed. Perpetration or attempted perpetration of certain crimes of violence against a victim sixty-five years of age or olderLA R.S. 14:50.2

  16. TheftLa R.S. 14:67 A. Theft is the misappropriation or taking of anything of value which belongs to another, either without the consent of the other to the misappropriation or taking, or by means of fraudulent conduct, practices, or representations. An intent to deprive the other permanently of whatever may be the subject of the misappropriation or taking is essential

  17. Property kept by the elderly may have little economic value…. But that property is likely to have a great personal value to the owner.

  18. Exploitation of the Infirmed La. R.S. 93.4 Expenditure, Use, or Diminution of Assets or Property Of Disabled Adult, Infirmed or Aged Person OR Misuse of Infirmed Persons Power of Attorney 10 years in jail or $10,000 fine

  19. Identity TheftLa. R.S. 14:67.16 (a) Social security number (b) Driver's license number (c) Checking account number (d) Savings account number (e) Credit card number (f) Debit card number (g) Electronic identification number (h) Digital signatures (i) Birth certificate (j) Date of birth (k) Mother's maiden name (l) Armed forces identification number (m) Government issued identification number (n) Financial institution account number Personal identifying information shall include, but not be limited to, an individual's:

  20. Identity Theft La. R.S. 14:67.16 • Intentional Use, Possession or Transfer • With fraudulent intent • Personal identifying information of another to obtain anything of value • Up to 10 years in jail pending and amount

  21. Theft of the Assets of An Aged or Disabled PersonLa. R.S. 14:67.21 • Intentional Use, Consumption, or Conversion of Aged or Disabled Person’s Assets • For benefit of another OR • Misuse of Power of Attorney of Aged or Disabled Person • For benefit of another • Up to 10 years in jail and/or $10000 fine • Offender can be ordered to pay full restitution

  22. TOOLS OF THE TRADE II LOUISIANA LAWS REGULATING CAREGIVERS

  23. Duty to Make Complaints La. R.S. 40:2009.20 ANY Caregiver (this means YOU) Having knowledge that consumers physical or mental health Has been or will be affected by abuse MUST report to local law enforcement, DHH or MFCU within 24 hours 2 months in jail or $500 fine

  24. Non- Retaliation by Health Care Provider LA. R.S. 40:2009.17 No discriminatory or retaliatory action shall be taken by any health care provider or government agency against any person or client by whom or for whom any communication was made to the department or unit, provided the communication is made in good faith for the purpose of aiding the office or unit to carry out its responsibilities. Any person who knowingly or willfully violates the provisions of this Section shall be guilty of a misdemeanor and upon conviction punished by a fine of not less than one hundred dollars nor more than five hundred dollars.

  25. Filing or Maintaining False Public Records La. R.S. 14.133

  1. A.

 

  1. Filing false public records is the filing or depositing for record in any public office or with any public official, or the maintaining as required by law, regulation, or rule, with knowledge of its falsity, of any of the following:

 

  1. (1) Any forged document. (2) Any wrongfully altered document. (3) Any document containing a false statement or false representation of a material fact.

 

  1. C. Whoever commits the crime of filing false public records shall be imprisoned for not more than five years with or without hard labor or shall be fined not more than five thousand dollars, or both.

  2. MEDICAID FRAUDLa. R.S. 70.1 • Intent to defraud the state through any medical assistance program • Presents for allowance or payment any false or fraudulent claim • Knowingly submits false information for the purpose of obtaining greater compensation than to which entitled • Knowingly submits false information for the purpose of obtaining authorization for furnishing services • Imprisoned with or without hard labor for not more than five years • May be fined no more than $20,000 • Both

  3. Forgery La R.S. 72 To forge with intent to defraud, any signature to, or any part of, any writing purporting to have legal efficacy. Can be theft from residents by forging checks Can be false documentation of medical records

  1. Penalty include 10 years jail time and five thousand dollar fine, per occurrence

  2. INVESTIGATIVE CRIMES When witnesses are threatened… When evidence is destroyed… When documents are altered…

  3. Obstruction of Justice La. R.S. 14:130.1 Tampering with evidence Threatening witnesses Retaliating against witnesses Up to 40 years in jail AND $100,000 fine


  5. REPORTING ABUSE and/or FRAUD

  6. Document Complaints/Instances WRITE REPORTS BE SPECIFIC BE CLEAR AND PRECISE BE COMPLETE SUPPORTING EVIDENCE


  8. Consequences of Committing Fraud and/or Abuse Immediate Termination Arrest and Prosecution Severe criminal penalties, including jail time and fines Loss of certification (LPN’s, RN’s, CNA’s, etc.) Exclusion from any healthcare provider/entity accepting state/federal insurance (Medicare/Medicaid/Tri-Care)

  9. Type name and search

  10. Unauthorized Participation in Medical Assistance ProgramsLA R.S. 14:126.3.1. • When the person has been excluded by any state or federal agency and knowingly: • Seeks, obtains, or maintains employment with a provider. • Seeks, obtains, or maintains employment as a provider. • Seeks, obtains, or retains any monies or payments derived in whole or in part from any state or federal medical assistance funds while excluded from participation in any state or federal medical assistance program. • Seeks, obtains, or maintains a contract with a provider. • Shares in the proceeds from a provider or participates in the ownership or management of a provider.

  11. Unauthorized Participation in Medical Assistance ProgramsLA R.S. 14:126.3.1. Imprisoned for not more than six months or fined not more than one thousand dollars, or both, when the state or federal exclusion is based on an underlying criminal conviction defined by Louisiana law as a misdemeanor, or when the exclusion is based on any reason other than a criminal conviction.

  12. TO REPORT FRAUD or ABUSE, CONTACT: Louisiana Attorney General Office Medicaid Fraud Control Unit 225-326-6210, M-F 8am – 5pm 888-799-6885, 24 hours a day 225-326-6295, fax 24 hours a day

2011 Louisiana Laws
Revised Statutes
TITLE 40 — Public health and safety
RS 40:1300.88 — Denial, modification, suspension, or termination of services; appeal procedure; judicial review

Universal Citation: LA Rev Stat § 40:1300.88

§1300.88. Denial, modification, suspension, or termination of services; appeal procedure; judicial review

A. The medical center, for cause, may deny the application of or modify, suspend, or terminate services to an applicant for or recipient of services after notice and opportunity for a hearing.

B. Any person who is aggrieved by a decision of the medical center with regard to a request for the provision of services may appeal such decision within thirty days. Such appeal shall be conducted in accordance with the Administrative Procedure Act and shall be subject to judicial review.

C. The provisions of this Section shall not apply if program services are restricted to conform to budgetary limitations that require the medical center to adopt service priorities regarding types of services to be furnished or classes of eligible persons.

Acts 1995, No. 951, §1; Acts 1997, No. 557, §1, eff. July 1, 1997.

 The secretary of the Department of Health and Hospitals is authorized to promulgate rules and regulations in accordance with the Administrative Procedure Act to provide for the administration of the fund.

Acts 1997, No. 1390, §1; Acts 1999, No. 1311, §1; Acts 2001, No. 391, §1; Acts 2001, No. 1185, §4, eff. July 1, 2001; Acts 2003, No. 201, §1; Acts 2008, No. 785, §1, eff. July 7, 2008.

 

C. The department shall adopt rules and regulations in accordance with the Administrative Procedure Act to provide for notice to the facility of any violation, for an informal reconsideration process, and for an appeal procedure including judicial review. Such appeal shall be suspensive. The facility shall have the right to a devolutive appeal.

D. The facility shall furnish, with an appeal, a bond in the minimum amount of one and one-half times the amount of the fine imposed by the department. The bond furnished shall provide in substance that it is furnished as security that the facility will prosecute its appeal, that any judgment against it, including court costs, will be paid or satisfied from the amount furnished, or that otherwise the surety is liable for the amount assessed against the facility. The appeal shall be heard in a summary proceeding which shall be given precedence over other pending matters.

E. The department may institute all necessary civil action to collect fines imposed and not timely appealed. No facility may claim imposed fines or interest as reimbursable costs, nor increase charges to residents or clients as a result of such fines or interest. Interest shall begin to accrue at the current judicial rate on the day following the date on which any fines become due and payable.

2011 Louisiana Laws
Revised Statutes
TITLE 40 — Public health and safety
RS

2011 Louisiana Laws
Revised Statutes
TITLE 40 — Public health and safety
RS 40:2009.17 — Retaliation by health care provider


Universal Citation: LA Rev Stat § 40:2009.17

§2009.17. Retaliation by health care provider

No discriminatory or retaliatory action shall be taken by any health care provider or government agency against any person or client by whom or for whom any communication was made to the department or unit, provided the communication is made in good faith for the purpose of aiding the office or unit to carry out its responsibilities. Any person who knowingly or willfully violates the provisions of this Section shall be guilty of a misdemeanor and upon conviction punished by a fine of not less than one hundred dollars nor more than five hundred dollars.

Added by Acts 1978, No. 687, §2; Acts 1990, No. 859, §1; Acts 1997, No. 1002, §1.

— Retaliation by health care provider


Universal Citation: LA Rev Stat § 40:2009.17

§2009.17. Retaliation by health care provider

No discriminatory or retaliatory action shall be taken by any health care provider or government agency against any person or client by whom or for whom any communication was made to the department or unit, provided the communication is made in good faith for the purpose of aiding the office or unit to carry out its responsibilities. Any person who knowingly or willfully violates the provisions of this Section shall be guilty of a misdemeanor and upon conviction punished by a fine of not less than one hundred dollars nor more than five hundred dollars.

Added by Acts 1978, No. 687, §2; Acts 1990, No. 859, §1; Acts 1997, No. 1002, §1.

— Public health and safety
RS 40:2009.13 — Health care provider complaints; procedure; immunity

Universal Citation: LA Rev Stat § 40:2009.13

§2009.13. Health care provider complaints; procedure; immunity

A. The provisions of R.S. 40:2009.13 through 2009.20, excluding R.S. 40:2009.18, shall apply to all licensed health care providers and all federally participating health care providers who operate in the state of Louisiana, provided the provisions of these Sections shall not prevent the institution of judicial action. For purposes of said Sections, "licensed health care provider" or "health care provider" means an institution or distinct part of an institution, facility, or agency licensed by the department or certified for participation in either or both of the Medicaid or Medicare programs to provide health care services. "Health care providers" include but are in no way limited to hospitals, nursing facilities, skilled nursing facilities, home health agencies, ambulatory surgical centers, providers of outpatient physical therapy and/or speech pathology services, comprehensive outpatient rehabilitation facilities, hospices, or suppliers of services, including but not limited to independent laboratories, suppliers of portable X-ray services, and end-stage renal disease treatment facilities.

B. Any person who has knowledge that a state law, minimum standard, rule, regulation, plan of correction promulgated by the department, or any federal certification rule pertaining to a health care provider has been violated, or who otherwise has knowledge that a consumer has not been receiving care and treatment to which he is entitled under state or federal laws, may submit a report regarding such matter to the department. The report may be submitted to the department in writing, by telephone, or by personal visit.

C. The office designated by the secretary shall have responsibility to assure that all reports are referred to the Medicaid fraud control unit or processed in accordance with this Section and R.S. 40:2009.14 through 2009.20.

D. If the report involves an alleged violation of criminal law, the department shall refer the reports to the Medicaid fraud control unit of the attorney general's office.

E. Any person, other than the person alleged to be responsible for the violation, who in good faith submits a report pursuant to this Section shall have immunity from any civil liability that otherwise might be incurred or imposed because of such report. Such immunity shall extend to participation in any judicial proceeding resulting from the complaint.

F.(1) If the report involves an alleged violation by an individual of laws governing professional licensure as provided in Title 37 of the Louisiana Revised Statutes of 1950 or rules and regulations promulgated pursuant to a professional practice act, the department shall refer the report to the appropriate professional licensing board.

(2) If the ensuing investigation results in determination that an individual may have violated laws pertaining to the individual's licensure as a health care professional, such investigation results shall be referred to the appropriate licensing board.

Added by Acts 1978, No. 687, §2, eff. July 12, 1978. Acts 1983, No. 98, §1; Acts 1997, No. 1002, §1; Acts 1999, No. 1109, §1.

— Public health and safety
RS 40:2009.14 — Procedure for investigation by the office; confidentiality of reports


Universal Citation: LA Rev Stat § 40:2009.14

§2009.14. Procedure for investigation by the office; confidentiality of reports

A.(1) The office of the department assigned to investigate the report shall review the report and determine whether there are reasonable grounds for an investigation. No report shall be investigated if in the office's judgment it is not made in good faith, is outdated, or is trivial, or if the report is not within the investigating authority of the office. The office may further determine whether to consider a report as a complaint or as an allegation of noncompliance.

(2) If the office determines that grounds for an investigation do not exist, it shall notify the complainant of its decision and the reasons therefor within fifteen work days after receipt of such complaint.

(3) As used in this Section:

(a) An "allegation of noncompliance" is an allegation that an event has occurred or is occurring that has the potential for causing no more than minimal harm to a consumer or consumers.

(b) A "complaint" is an allegation that an event has occurred or is occurring and has the potential for causing more than minimal harm to a consumer or consumers.

(c) An "outdated report" is a report pertaining to an incident that occurred one hundred twenty or more days prior to its being reported to the office.

(d) A "trivial report" is a report of an allegation that an incident has occurred to a consumer or consumers that causes no physical or emotional harm and has no potential for causing harm to the consumer or consumers.

(e) "Minimal harm"
is an incident that causes no serious temporary or permanent physical or emotional damage and does not materially interfere with the consumer's activities of daily living.

(4)(a) If the office determines that grounds for an investigation of a report as a complaint exist, the office shall investigate the complaint within thirty days of receipt of the report submitted under R.S. 40:2009.13(B).

(b) If the office determines that grounds for an investigation of a report as an allegation of noncompliance exist, the office shall investigate the allegation of noncompliance by telephone, provider report, or at the time of the next scheduled visit to the provider's facility.

(5) Results of any investigation of a complaint shall be communicated in writing to the administrative officer of the facility and the complainant within thirty working days of completion of the investigation.

B.(1) The nature of the complaint or allegation shall be furnished to the provider no earlier than at the commencement of the investigation of the complaint or allegation of noncompliance.

(2) When the nature of the complaint or allegation is furnished to the health care provider, it shall not identify the complainant or the consumer unless the individual has consented to the disclosure either in writing or in a documented telephone conversation with an employee of the department. If disclosure is considered essential to the investigation or if the investigation results in a judicial proceeding, the complainant shall be given the opportunity to withdraw the complaint.

Added by Acts 1978, No. 687, §2, eff. July 12, 1978. Acts 1997, No. 1002, §1.

 — Public health and safety
RS 40:2009.15 — Investigation report

Universal Citation: LA Rev Stat § 40:2009.15

§2009.15. Investigation report

 

A. The report of the investigation by the department shall state whether any state licensing law, or any minimum standard, rule, regulation, or plan of correction of the Department of Health and Hospitals, or any federal certification rule affecting the health care provider, or any standard relating to the health, safety, care, or treatment of consumers has been violated. If such violation is found to exist, the appropriate departmental staff shall promptly provide notice to the secretary or his designee of such violation. The secretary or his designee shall take appropriate action as authorized by Subsection B of this Section. Results of the investigation, including any notification of violations or deficiencies as provided in Subsection C of this Section, shall be sent by certified mail or hand delivered to the complainant and to the health care provider.

B. Upon receipt of such notice of violation from the department, the secretary shall consider:

(1) For violation of a federal certification rule or standard, appropriate action to terminate the health care provider's participation in the Medicaid program, the Medicare program, or both.

(2) For any violation which jeopardizes the health or safety of the consumer or consumers, appropriate steps to revoke the license pursuant to the authority granted under the licensing law for that type of health care provider.

(3) For any identified violations, imposing a sanction against the health care provider as authorized by law.

C.(1) If deficient practices are identified, the department shall notify the health care provider of the violation, list the rules or laws violated, and solicit a plan of correction from the health care provider.

(2) A health care provider which is required to correct identified violations may submit a written request to the department for informal reconsideration regarding the validity of the violations of the law or rule specified in the notice. This request must be received by the department within ten days of the health care provider's receipt of the notice. The complainant shall also be afforded an opportunity to request an informal reconsideration of the findings. Such a request must be made within thirty days of the complainant's receipt of the results of the investigation. The department shall schedule the requested informal reconsideration in a timely manner.

(3) The time periods specified in this Subsection shall commence with receipt by the health care provider of the notice specifying the corrective actions to be taken.

Added by Acts 1978, No. 687, §2; Acts 1990, No. 859, §1; Acts 1997, No. 1002, §§1, 2.

  1. Physicians Health Program

    Physicians often find themselves caring for others continuously, many times sacrificing their own wants and/or needs. However, physicians also need assistance at times and we want you to know that it is ok to ask for help, to not be able to solve every problem, overcome every obstacle or combat every illness by yourself.  Help is available.  It is the primary role of the Physicians' Health Foundation of Louisiana (PFHL) Physicians Health Program (PHP) to offer assistance to physicians who may be suffering from difficulties such as substance use issues, depression, anxiety, etc., in addition to a host of physical ailments and maladaptive behavioral patterns. The PHFL PHP also supports physicians who are in our program with their applications for hospital privileges, health plan network enrollment, malpractice insurance, disability insurance, and medical licensure.

    Of noteworthy importance, the assistance offered by the PHFL PHP is confidential. For example, any physician who is experiencing a problem with substance use for which they have not been adequately treated or monitored, can access the PHFL PHP without any obligation on the part of the PHFL PHP to notify the Louisiana State Board of Medical Examiners (LSBME). There are some circumstances which the PHFL PHP is mandated to report to the LSBME. The PHFL PHP is obligated to inform when it receives information indicating a physician has diverted prescription drugs for trade or sale, information of a physician acting inappropriately with a patient (boundary violation), or a relapse. However, in all cases, the LSBME and the PHFL PHP mutually support early detection and treatment of physicians.

    If you or someone you know could use the assistance of the PHFL PHP, please do not hesitate to contact us at 888-743-5747.


 Our Lady of the Lake to Welcome 71 New Medical Residents

  • CONTACT:Kathleen Crapanzano 
  • EMAIL:kcrap1@lsuhsc.edu 
  • PHONE:225-757-4210 
  • FAX:225-757-4230

03/19/2021

Today, Our Lady of the Lake celebrated the 71 new residents coming to Baton Rouge this summer to begin their specialty training as part of the next stage of their medical education. The residents matched today filled all available residency slots at Our Lady of the Lake. The annual Match Day is a celebratory day when academic medical centers and medical students around the country learn which residents were matched to different graduate medical education programs nationwide.

  • Our Lady of the Lake Pediatric Residency

  • LSU-Our Lady of the Lake Psychiatry Residency

  • LSU Emergency Medicine Residency

  • LSU Internal Medicine Residency

  • LSU Surgery Residency

  • LSU Ear, Nose and Throat Residency

  • Our Lady of the Lake Psychology Clinical Internship


Our Lady of the Lake also trains more than 1,600 learners on its campuses each year including students studying nursing, pharmacy, physician assistant studies, among others.
About Our Lady of the Lake
Our Lady of the Lake is a not-for-profit healthcare ministry based in Baton Rouge, Louisiana with more than 7,500 employees committed to serving the Capital Region and building a healthy community through excellence in patient care and education. With an 800-bed Regional Medical Center, a dedicated Children’s Hospital, a 78-bed hospital in Gonzales, Louisiana, two freestanding emergency rooms, and a 500+ provider Physician Group, Our Lady of the Lake provides comprehensive healthcare services for common to complex conditions. Our Lady of the Lake Regional Medical Center is a primary teaching site for graduate medical education programs and is recognized in the areas of heart and vascular, trauma and emergency care, stroke, cancer care, minimally-invasive procedures and more. Our Lady of the Lake is part of the Franciscan Missionaries of Our Lady Health System.
About Our Lady of the Lake Physician Group
With more than 450 healthcare providers throughout more than 70 locations, Our Lady of the Lake Physician Group is one of the area’s largest physician networks. In addition to primary care, this experienced group of doctors specializes in diagnosis and treatment of a broad range of illnesses and complex medical problems.

Franciscan Missionaries of Our Lady Health System Names Richard R. Vath, MD, President and CEO


Baton Rouge, Louisiana, June 17, 2019 (GLOBE NEWSWIRE)

The Franciscan Missionaries of Our Lady Health System announced today that Richard R. Vath, MD, has been named president and CEO. Vath has served as interim-president and CEO since March 2019.

“We are pleased to announce Dr. Richard Vath’s appointment as our health system’s president and CEO,” said Sister Barbara Arceneaux, Regional Minister, Franciscan Missionaries of Our Lady.
“Character in the face of adversity is often a true test of leadership. I will always be grateful for Dr. Vath’s willingness to quickly step into an interim role as our health system leader earlier this spring. He is an advocate for Catholic healthcare and the unique opportunities we have to be the face of Christ to each person, especially those most in need. Dr. Vath is a man of deep faith and continues to bring the vision and strength of service to his role that we believe are essential for long-term stability and strength.”

Vath graduated from Louisiana State University School of Medicine, New Orleans in 1977, completed his Internal Medicine Residency at the University of Alabama, Birmingham in 1980 and his Pulmonary/Critical Care Fellowship at UAB in 1983.

The Chief Executive Officer (CEO) shall provide overall direction for this Contract, develop strategies, formulate policies, and oversee operations to ensure goals are met. The CEO shall be a full-time position (minimum forty (40) hours weekly) based in Louisiana. The CEO shall serve exclusively in this position and may not function in an executive capacity for another insurance product. The CEO shall be the primary contact for LDH regarding all issues and shall coordinate with other key personnel to fulfill the requirements of the Contract. The CEO shall attend all CEO designated meetings in person.

2.3.3.2

The Chief Operating Officer (COO) shall manage day-to-day operations of multiple levels of staff and multiple functions/departments across the MCO to meet the performance requirements of the Contract. The COO shall be accountable to the CEO for operational results and may be designated to serve as the primary point-of- contact for all MCO operational issues. The COO shall be a full-time position (minimum forty (40) hours weekly) based in Louisiana. The COO may not function in an executive capacity for another insurance product. The COO shall attend meetings in person, when requested.

 

2.3.3.3 The Medical Director/Chief Medical Officer (CMO) shall be a physician with a current, unencumbered license through the Louisiana State Board of Medical Examiners.

 

The Medical Director shall have at least three (3) years of training in a medical specialty and five (5) years of experience post-training providing clinical services. The physician shall have achieved board certification in his or her specialty.

 

The Medical Director shall be located in Louisiana and shall be involved in all major clinical and quality management components of the MCO’s activities.

 

The Medical Director shall be devoted full-time (minimum forty (40) hours weekly) to the Contractor’s operations and shall be responsible for ensuring timely medical decisions, including after-hours consultation, as needed.

 

During periods when the Medical Director is not available, the Contractor shall have physician staff available to provide competent medical direction. The Medical Director shall serve exclusively in this position and may not function in an executive capacity for another insurance product.

 

The Medical Director shall be responsible for:

 

2.3.3.3.1 Development, implementation and medical interpretation of clinical policies and procedures, including, but not limited to, service authorization, claims review, discharge planning, credentialing and referral management, Page 50 of 347 utilization management and medical review included in the MCO Grievance System;


 


 

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