Tag: claim

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