Podcast

Allegations of Underpaid Debt Lands Big Healthcare Players in Whistleblower Hell – Podcast

When physicians think about allegations of kickbacks in the context of large insurers, it’s generally related to how a carrier’s internal “claims cops” have alleged that some physician or other provider engaged in a kickback scheme, obviating the payor’s need to pay claims, or, even worse, supporting their demand for repayment.

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Medical Group Minute | Videocast

Allegations of Underpaid Debt Lands Big Healthcare Players in Whistleblower Hell – Medical Group Minute

When physicians think about allegations of kickbacks in the context of large insurers, it’s generally related to how a carrier’s internal “claims cops” have alleged that some physician or other provider engaged in a kickback scheme, obviating the payor’s need to pay claims, or, even worse, supporting their demand for repayment.

Comment or contact me if you’d like to discuss this post.

Mark F. Weiss

www.weisspc.com

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Compliance

Allegations of Underpaid Debt Lands Big Healthcare Players in Whistleblower Hell

When physicians think about allegations of kickbacks in the context of large insurers, it’s generally related to how a carrier’s internal “claims cops” have alleged that some physician or other provider engaged in a kickback scheme, obviating the payor’s need to pay claims, or, even worse, supporting their demand for repayment.

In what some physicians might view as karmic or even dark comedic payback, a federal False Claims Act case against Humana, the nation’s third largest health insurance company, as well as against Roche Diagnostics Corporation and its affiliate Roche Diabetics Care, Inc., is moving toward trial.

The whistleblower lawsuit was filed by Crystal Derrick, a former Roche employee, who also alleges that Roche fired her in retaliation for raising concerns about the lawfulness of the underlying scheme.

In encapsulated form, Ms. Derrick alleges that Roche gave a kickback to Humana in order to keep its diabetes testing products on (and to keep their competitors off) Humana’s formularies for Medicare Advantage and other federally funded plans. The alleged form of the kickback? Dismissing millions of dollars of debt that Humana owed to Roche.

Just as schadenfreude can be satisfying to the psyche, indirect benefit, even deeply buried, can satisfy the remuneration requirement under the federal Anti-Kickback statute, which prohibits all remuneration, in whatever form, directly or indirectly, to induce referrals of federally funded healthcare program patients.

What will happen to Humana and Roche is yet to be seen.

While you’re waiting for the result, see what risk may exist in your own dealings.

Is hidden remuneration (cash, discounts, write-offs, contract rights, and so on) lurking in the shadows?

Comment or contact me if you’d like to discuss this post.

Mark F. Weiss

www.weisspc.com

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Manage Your Practice

Sexual Harassment is in the News. Make Sure Your Group’s or Facility’s Name Isn’t Included.

From Harvey Weinstein to Al Franken to, now, a well known physician at Fenway Community Health Center, the Boston institution known for its pioneering care for LGBT patients, allegations of sexual harassment and bullying are surfacing on what seems to be a daily basis.

Even if the allegations aren’t aimed at you, they pose significant challenges for your medical group, facility, or organization.

Take the Fenway Community Health Center situation, for example. Last week, the Boston Globe initially reported that the health center’s CEO, Dr. Stephen L. Boswell, resigned, after 20 years in the position, under pressure from the board of directors. Then, the paper reported that Fenway’s board chairman, Robert Hale, was out, too.

The events center around years of sexual harassment allegations against Dr. Harvey J. Makadon. Makadon had allegedly sexually harassed at least three male co-workers and had “yelled at and belittled” male and female staff members. Dr. Makadon denies the allegations. He’s said to have resigned from the facility.

The Globe uncovered the fact that Fenway engaged legal counsel twice over the last four years relating to allegations against Makadon. In connection with the second instance, the CEO apparently ignored the law firm’s advice to terminate Makadon and didn’t report the matter to the board. The Globe also reports that the CEO didn’t tell the board about a $75,000 settlement paid to a former employee in connection with the allegations.

What’s your entity’s policy on harassment? Does it have one?

What action do you take to investigate?

Who conducts the investigation?

What rights do both the accuser and the accused have?

What steps do you take if the allegations are found to be true?

An investigation gone bad, or bad decisions made during and after a proper investigation, have an impact far beyond that on the accuser and the alleged. The easiest way to keep your name and that of your organization out of the press is not to do things that would get it in there in the first place.

For help on policies, investigations, and staying out of the press, comment or contact me if you’d like to discuss this post.

Mark F. Weiss

www.weisspc.com

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