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| Dear Friend,
Even if you can't even spell sinuplasty, understanding the lessons of the January 5, 2022, indictment of Raleigh, North Carolina ENT Anita Louise Jackson, M.D. will make you breathe easier.
Dr. Jackson, who operated Greater Carolina Ear, Nose & Throat, P.A. (“GCENT”) billed Medicare in excess of $46 million from 2014 through 2018 for more than 1,200 balloon sinuplasty procedures on more than 700 patients. Those billings resulted in more than $5.4 million in Medicare payments to GCENT.
Jackson apparently came on the government’s radar (via a program integrity contractor audit) because that volume made Jackson the top Medicare paid provider of balloon sinuplasty in the U.S. even though GCENT was outside of a major metropolitan area.
In the Superseding Indictment made public last week, a federal grand jury indicted Dr. Jackson for:
- Adulteration of Medical Devices in violation of 21 U.S.C. §§ 331(k), 333(a)(1), 333(a)(2), and 351(a)(2)(A).
- Ten counts of Paying Illegal Remunerations in violation of 42 U.S.C. § 1320a-7b(b)(2)(B) [i.e., the federal Anti-Kickback Statute].
- Three counts of Making False Statements Relating to Health Care Benefits, in violation of 18 U.S.C. § 1035(a)(2).
- Two counts of Aggravated Identity Theft, in violation of 18 U.S.C. § 102A(a)(1).
- Three counts of Mail Fraud, in violation of 18 U.S.C. § 1341.
- Conspiracy, in violation of 18 U.S.C. § 371.
Note that an indictment is a series of allegations only. Dr. Jackson has not been convicted of anything and the criminal trial process is just beginning.
However, if convicted, Jackson faces a maximum term of imprisonment of 20 years for Mail Fraud, 10 years for Paying Illegal Remuneration, 5 years for Conspiracy and Making False Statements, and a 2-year mandatory prison sentence for Aggravated Identity Theft consecutive to any other punishment. She also faces fines exceeding $250,000.
The indictment alleges that Dr. Jackson reused, as a routine business practice, no more than 30 strictly “single use” balloon sinuplasty devices to perform the thousand-plus sinuplasty procedures. Although represented to patients as sterile, the indictment alleges that the devices were simply washed with soap, water and some cleaning agents and then air dried in a non-sterile environment before reuse.
The illegal remuneration charge relates to allegations that Dr. Jackson routinely concealed from her Medicare patients the true amount that they were obligated to pay for the procedures, leading them to believe that they either owed nothing or only a small co-payment. The government alleges that she did not collect the patient copayments and ultimately wrote them off without making genuine efforts to collect. That, according to the indictment, resulted in Medicare paying all, or nearly all, of the balloon sinuplasty charges for her Medicare patients, when Medicare was in fact obligated to pay only 80% of the charges.
The indictment alleges that Jackson used cloned medical records, in some cases word for word, and not complete, per patient, medical records, to justify the necessity of the procedures and to document their performance. It also alleges that Jackson acquired patient signatures on various forms after the fact and had an on-staff notary notarize them as of incorrect dates. Additionally, after being directed as a result of audits to repay Medicare more than $1.7 million, Jackson is alleged to have created and supplied false medical records to support an appeal of the audit result.
The Obvious and More Esoteric Lessons For You Even if the Indictment is Hot Air:
- Don’t adulterate devices or other items and then use or supply them as unadulterated.
- Don’t subsequently lie about the bona fides of the devices or items.
- Don’t bill for items that were not provided.
- Don’t routinely write-off Medicare patient balances or even present Medicare patients with false bills that indicate no or a falsely low co-pay.
- Don’t use template, or even worse, cloned medical records to support your claims, even if the services were completely, properly, and ethically performed.
- Don’t falsify records and signatures or the date on which they were obtained.
- Don’t lie to federal auditors.
And, perhaps the most important, don’t set yourself up to go to prison by thinking you are setting the government up to overpay you.
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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:
How can you tell if the deal is real?
Real or fake deal? It's a common problem, one that can come up in any number of circumstances. It could be a negotiation for an exclusive contract, in connection with the acquisition of a facility, or even an employment agreement.
You find a potential deal. You start negotiating but you begin to wonder if it's real. You begin to wonder if you’re really the favored party, or if you're there to put pressure on someone else, the actual favored party. Are you in the “Fool Position” (it might also be called the “rabbit”, someone who’s designed to run to make others chase)?.
Well, there’s no 100% foolproof way of knowing.
But what you can do as you’re negotiating is to keep pushing for the next step, whatever that may be. To ask, “when are we going to meet again?”, or, “when can we receive the information?” Push on those deadlines and work out a method of what happens if deadlines are broken.
In other words, if you don't get back to me by Tuesday, what should I be doing? What would you like me to do? What do you suggest I do?
At some point, if you believe you’re being led on, for example if the other side is supposed to be getting back to you with information, and they don’t, and after you touch base once or twice trying to pull that information from them to get them to move forward, consider the deal dead.
Shut it down.
Look, it's one thing to be played -- to lose a deal. But it's worse to spend tens or hundreds of thousands of dollars all the way to the end, only then to find out it wasn’t real.
Failure to close the deal itself is not the worst outcome; the worst outcome is the failure to close the deal after you’ve put $200,000 and three months into it.
Like the old Turkish saying goes, “No matter how far down the wrong road you’ve gone, go back.”
It’s hard to do, but it’s really the only choice.
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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 - Yes, You Can Build a Health System Without a Hospital - Medical Group Minute
Watch the video here, or just keep reading below for a slightly polished transcript:
Call them mental models, call them viewpoints, the point is the same: the box in which we conceive of what’s possible serves as an artificial barrier that confines our thinking.
I’ve written previously about physician owned ventures that are near replacements for hospitals. Take for example, the post Hospital Becomes Hole In Ground. ASC Takes Up The Slack in which I discuss my concept of the Massive Outpatient Center™: A combination of an ASC, a medical office building, and one or more of a menu of complementary patient care offerings.
If you haven’t read that post, read it now.
I realize though that for some, that description of the very accessible alternative to hospital servitude, and equally accessible route to increased profit, didn’t resonate because its viewpoint focused primarily on the facility as opposed to the function.
So let’s look at the solution from another viewpoint. One that’s equally valuable to those previously stymied as well as to those who already clearly see the implications for their own involvement and investment.
In common healthcare industry parlance, a healthcare system centers around the notion of hospitals, generally, but not always, many hospitals under common ownership, together with their affiliated physicians and other providers.
But with hospitals dying at an increased rate, with healthcare systems, even large systems, merging in an attempt to extend their remaining shelf life, and with technology, pricing advantage, and payer preference all pushing procedures to freestanding (e.g., outpatient) facilities, physicians can replicate the system model . . . without the hospital.
Let’s take a large orthopedic group as an example. [Note that the choice of that specialty is simply an example – the same prescription can potently play out in many practice areas.] Traditionally, the physicians in the group were closely aligned with a hospital. Perhaps the physicians had ownership interests in some ASC, maybe in more than one. Their office practice remained completely separate, certainly in a legal sense, but in a conceptual sense as well.
That model can now be flipped into what is essentially a “hospitalless” healthcare system: the group, whether alone or with investor partners [note that there is so much money available that it is not necessarily the case that outside investors are needed if they are not wanted] reorganizes the structure of their practice relationship and co-locates their office, their ASC, their physical therapy, their imaging facility, and so on.
The goal is to create what is essentially a self-contained center of excellence providing a continuum of orthopedic care for patients. The physicians manage that care from patient intake, through surgery, and through rehabilitation. All through a system of entities, facilities, functions, and processes they own and control.
This fits exactly into the concept of value-based care and this fits exactly into what many large employers seek (just look at what Walmart is doing) in terms of directing their self-insured plan beneficiaries, that is, their employees, to physicians and facilities that provide the most effective care even if it is not the cheapest care.
Just remember the notion of the box that limits your thinking, if you think that this doesn’t apply to you.
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| | | Listen to the podcast here, or just keep reading for the transcript.
Almost every day, the story repeats itself. Another bankrupt or closed or closing hospital. Often the infected facility is rural. But sometimes it's not.
Recently two such stories caught my attention.
The first of the infected hospitals is limping along and about to close. It's located in a rural community. It’s actively looking for proposals from someone who can take it over.
The second is a closed facility. It's issued an RFP, looking for proposals from buyers to, they hope, reopen the place as a hospital (probably a bad idea), or to take it over and convert it another sort of healthcare facility – which is a tremendous idea, if, and it's a big if, the situation is right.
For example, what's the population in the community? What are the demographics? How many physicians are there? How many procedures are those physicians performing? Can those procedures be performed at a surgery center? And so on.
My point is that while the notion that I call The Impending Death of Hospitals (download my complimentary book by that name here) is impacting hospitals of all sizes (certainly small hospitals very hard), some of their physical shells are built out close enough to the specifications for another type of healthcare facility. That makes a conversion a very manageable project, whether it’s a conversion for a single facility or for a multi-facility "medical mall."
If this interests you, start paying attention to the news. You’re going to see a lot more of these types of properties becoming available. Then, let's talk about what's involved its conversion to a facility owned by you.
It’s not a question of how to do it yourself, it’s knowing who can do it for you and with you.
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| | | 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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