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| Dear Friend,
Fraud and stupid excuses.
“My dog ate my homework,” said Billy.
Sobbing, Sally said, “my grandma died, so I didn’t have time to write the paper.”
Maybe those excuses worked in fourth grade, and maybe Samirkumar J. Shah, M.D. should have tried them, but the one he went with, “I can’t show up at my sentencing for health care fraud because my doctor says I need to rest at home following a Covid vaccine reaction,” didn’t impress United States District Judge David S. Cercone.
The Background
Dr. Shah, a cardiologist, was convicted in June 2019 of two counts of health care fraud resulting from his submission of fraudulent claims to private insurance plans covered by Highmark Blue Cross Blue Shield and UPMC Health Plan, to managed Medicaid plans issued by Gateway Health Plan, as well as to Medicare, all in connection with outpatient external counterpulsation, also referred to as “ECP” treatment.
Payors cover ECP only for patients who suffer from disabling angina, and only when a physician supervises the treatment.
Yet Shah advertised ECP as the fountain of youth and claimed that it made patients younger and smarter. He offered the treatment for a range of ailments other than disabling angina, including, among others, obesity, high blood pressure, low blood pressure, and erectile dysfunction.
To support false claims, he instructed employees at his more than 18 locations to indicate on billing sheets that every patient had disabling angina. In many cases, neither he nor any other physician was present at the location when treatments were performed.
As if billing for medically unnecessary and unsupervised ECP treatments weren’t enough, Shah also double-billed insurers by billing for both a “bundled” ECP code, which accounted for and included payment for various incidental procedures, and then separately submitting claims for the same included procedures.
In addition, Shah routinely submitted fabricated patient files and made false statements concerning his practice, his patient population, his record-keeping, and his compliance with applicable coverage guidelines.
Time, or Not, to Pay the Piper
Between his June 2019 conviction and July 2021, Shah remained free, awaiting sentencing. Yes, the wheels of justice turn slowly, but eventually even that bus reaches its destination.
Facing a July 14, 2021, sentencing, Shah’s attorney made a motion that same day to continue the inevitable based on the claim that Shah’s doctor told him he needed six weeks bed rest due to an allergic reaction to the Covid vaccine.
Likely to no one’s surprise, the motion was denied and when Shah still didn’t show up for sentencing, the judge issued an order for his arrest. He remained in jail until August 5, 2021, when he was sentenced to 78 months of imprisonment followed by three years of supervised release as well as ordered to pay restitution of over $1.2 million to the victimized payors, in addition to forfeiting another $500,000.
Some Lessons
In addition to the serious slice of schadenfreude sprouting from the Shah story, you’d be well advised to note that most physicians engaging in billing fraud do so on a smaller scale than the industrial-sized health care fraud overseen by Shah. However, it’s just as illegal.
Billing for unnecessary tests and procedures, even on a small scale, is particularly egregious because of the risk inherent to the victim patients, let alone the financial fraud on payors.
Shah went down because of what appears to be an initial investigation by the Pennsylvania Attorney General’s Medicaid Fraud Control Unit. Often, physicians engaging in such scams are tripped up by someone within their office or at an outsourced billing and collection service who becomes a whistleblower, whether in the context of a false claims act lawsuit which then triggers a criminal investigation, or as an anonymous “tipster.”
If you can’t do the time, don’t do the crime.
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| | | Business Life in the Time of Coronavirus Mini-Series
The coronavirus crisis caused a short term economic crisis for many medical groups. Our mini-series shows you the way out. Plus, many of the concepts discussed are applicable during both good times and bad.
[If you haven't already seen them, follow this link to watch our entire series.] |
| | Watch Tuesday's video here, or just keep reading below for a revised, more polished transcript:
The news is filled with a new surge of Covid. In California, things appear to be masking up again, perhaps locking down again, as more and more people become infected, whether it comes with as serious a set of consequences, whether as deadly as before, remains to be seen.
What is certain is that there’s another wave of fear moving across many medical groups and facilities.
In all probability, you weren’t prepared for the first wave of Covid and what it did to your business, your practice. But now there's some time to take the lessons that you perhaps unfortunately learned from that experience and apply them to your business.
Right now money is cheap; interest rates are still basically at a five-thousand-year low. Think about borrowing now, don’t wait for there to be loan assistance programs. Think about increasing your credit lines, just in case you need them.
Second, if you haven’t done it already, think about what you can do with some of your employees. Can you put them on flex arrangements, so that you aren’t in essence stuck with massive payrolls if work slows down again?
Think also about the opportunities.
If other groups and facilities are running scared and suffer a significant drop in their revenue, what opportunities does that present for you to expand? That could mean taking their opportunities away from them, or buying them and thus their opportunities.
Be sure you are thinking on both ends of the field: think defense and offense. They’re both at play with another wave of Covid.
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| | How to Deploy the Secret Sauce of Opportunistic Strategy
Webinar On Demand
They say that COVID-19 has changed the world, creating the "new normal." Many of your colleagues and many hospital administrators are running scared.
Others, leaders like you, know that crisis means opportunity.
Let me provide you with the strategic tools and insights that you need in order to seize opportunities, whether they’re in the context of your current business relationships, the expansion of your business activities, or the creation of new ventures.
You will learn:
•Defense as a defective default: It’s necessary, but not sufficient.
•Exploiting weakness: Drop the guilt and identify opportunity.
•Flat line negotiation is fatal: Understand its myths and limitations.
•Negotiation reality: Learn to identify and deploy on multiple planes to affect the outcome.
•Maneuver: Harness the power of maneuver, both in overall strategy and in specific negotiation strategy.
Others see a crisis and freeze in fear. Learn how to see the opportunities and obtain the tools to increase your odds of obtaining them.
The price to attend is $479. The cost of not attending is astronomical. |
| | | Wednesday - What Are You Dreaming? - Medical Group Minute
Watch the video here, or just keep reading below for a slightly polished transcript:
It's been almost 58 years since Martin Luther King, Jr.'s speech on August 28, 1963, in which he famously stated, "I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin, but by the content of their character. I have a dream today!”
When Rev. King used the term “dream,” he was not speaking of something past, something simply nocturnally ephemeral, but of an active belief, one that will be instantiated, one that will influence action and outcome.
Certainly, the discussions on this blog are at the business level, not that of the civil rights plane. However, even at that level, the business level, the notion of a dream, a belief, an intention, can and does drive action and change the future.
Some might argue that facts are facts and that mindset can’t change them. But what might play out in the uncertain future can’t yet be called facts and mindset drives action that can and does impact the to-become-facts as they unfold for you.
At a recent conference, an instant survey of physician attendants indicated that most believed their incomes will be lower 5 years out.
Will payers attempt to reduce physician reimbursement over the next 5 years? Yes, probably.
Will more physicians become hospital or large group employees over the intervening years and will those employers attempt to ratchet down their compensation? Yes, it’s possible.
But those outcomes are not certain and neither controls total income nor one’s own particular income.
The problem with believing that your own income will be down is that you’re telling yourself to accept it, and accept it you will.
Although thoughts alone won’t change a thing, thoughts influence actions and actions influence outcomes.
How would a baseball team play if the players believed they were going to lose? Poorly; why even try. Would the team play differently if the players knew they were going to win? You bet it would.
It’s your future. You can do what you want.
But if you ask me, why not believe not only that your income will be up 5 years from now, but that it will be up 10 times or more. Either way, believing you’ll be better off or worse off 5 years from now takes the same mental energy. But those beliefs will impact your choices and your actions.
And, as an added bonus, you can employ all those other docs who are setting themselves up to accept less.
It’ll be win-win. Everyone’s expectations will be met. |
| | | | | Listen to the podcast here, or just keep reading for the transcript.
There’s a management saying that what’s measured improves. As a result, managers love to measure things. But measuring does not always indicate value.
Take for example a family of three with total income of $200,000 a year. The parents have another child. Should grandma call the parents to commiserate because the family’s per capita income just dropped from $66,666 to $50,000?
So clearly, you’ve got to be measuring the right thing.
The family comedy described above has a medical group analogy. Groups must distinguish between measuring things which are efficient and measuring things which create a much improved or larger experience for the recipient.
What if you were running a restaurant instead of a medical group. Let’s say you decide to measure and reward on the basis of the time a waiter or waitress takes to picks up food in the kitchen and deliver it to the table. Soon, waiters would be jogging through the joint, tossing plates onto the tables. Slopping the food onto the table with a smirk would still be 99th percentile performance, but the total customer experience would be at rock bottom.
So clearly, some things that measurement says are now “improved” aren’t anything of the sort.
Now back to running a medical group. Take a look at your group’s compensation plan. If you simply measure units produced by your group members–that is, you pay by units only–then you are encouraging fast delivery, not courteous service: tossing the plates, so to speak. On the other hand, if you’ve adopted a fixed compensation system, $X per month as salary, you’ve taken away the incentive to work harder, and you’ve ignored the notion of an incentive for better performance. Of course, that still begs the question, what is better performance?
Correctly formulated, a group compensation plan is not just about encouraging efficiency, it’s about encouraging effective performance in a broad sense. Some of that performance is capable of meaningful objective measurement, but a significant portion is not — but that portion can’t be ignored, it still has to be considered and group members must be cognizant of its impact on their overall compensation. |
| | | Calibrate Your Compass
Read our exclusive RedPaper to guide you through this evolving situation.
The coronavirus crisis caused a short-term economic crisis for many medical groups. Our RedPaper shows you the way out. Plus, many of the concepts discussed are applicable during both good times and bad.
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| | Help Us Help You With Helpful Content
What tailored content would you most like to see during this
time? How can we focus on solutions to your most pressing strategic concerns?
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| | | | We all hear, and most of us say, that the pace of change in healthcare is quickening. That means that the pace of required decision-making is increasing, too. Unless, that is, you want to take the “default” route. That’s the one is which you let someone else make the decisions that impact you; you’re just along for the ride. Of course, playing a bit part in scripting your own future isn’t the smart route to stardom. But despite your own best intentions, perhaps it’s your medical group’s governance structure that’s holding you back.
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| In fact, it’s very likely that the problem is systemic. The Medical Group Governance Matrix introduces a simple four-quadrant diagnostic tool to help you find out. It then shows you how to use that tool to build your better, more profitable future. Get your free copy Free.
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| | | | Whenever you're ready, here are 4 ways I can help you and your business:
1. Download a copy of The Success Prescription. My book, The Success Prescription provides you with a framework for thinking about your success. Download a copy of The Success Prescription here.
2. Be a guest on “Wisdom. Applied. Podcast.” Although most of my podcasts involve me addressing an important point for your success, I’m always looking for guests who’d like to be interviewed about their personal and professional achievements and the lessons learned. Email me if you’re interested in participating.
3. Book me to speak to your group or organization. I’ve spoken at dozens of medical group, healthcare organization, university-sponsored, and private events on many topics such as The Impending Death of Hospitals, the strategic use of OIG Advisory Opinions, medical group governance, and succeeding at negotiations. For more information about a custom presentation for you, drop us a line.
4. If You’re Not Yet a Client, Engage Me to Represent You. If you’re interested in increasing your profit and managing your risk of loss, email me to connect directly. |
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