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| Dear Friend,
Healthcare billing scams.
With thousands of employees and many hundreds of vendors, it wasn’t difficult to see how the scam went on for close to 20 years before the bars slammed shut behind her.
No, it wasn’t a healthcare business, more on that in a moment, but it was a scam older than double entry accounting. A long time and well trusted accounts payable supervisor of the manufacturing business had set up a slew of phony vendors, each of which generated a regular stream of phony invoices, each of which was paid by the business, the dollars ending up in the employee’s bank-account.
Although that was more than 40 years ago, I have no reason to believe that similar scams haven’t been run every day since then.
Take Josh Maywalt for example.
Maywalt, of Tampa, Florida, worked as a medical biller at a billing services provider. Among his duties, he was assigned to a particular client physician’s account. As a result, he had access to the practice’s financial, provider, and patient information. For anyone who didn’t skip immediately to this paragraph, you can see where this is going.
Maywalt wrongfully accessed patient information and utilized the physician’s name and identification number to submit false and fraudulent claims to a Florida Medicaid HMO for services purportedly rendered by the physician but not actually performed. In order to obtain the resulting cash, Maywalt altered the “pay to” information on the claims so that payments were directed to bank accounts that he controlled.
To add a little extra insult to injury, and probably to hide the snail trail of fraud, Maywalt didn’t file federal income tax returns for 2017 and 2018. He did file a return for 2019, but substantially understated his income by reporting only his employment wages, not the substantial amount of money he was depositing into his bank accounts as a result of his fraudulent activities.
Maywalt’s short criminal career ended abruptly when he pleaded guilty on December 1, 2021, to healthcare fraud, aggravated identity theft, filing a false income tax return, and failing to file income tax returns.
On June 2, 2022, he was sentenced to five years and five months in federal prison and was also ordered to forfeit $2,257,029.86 and real property located at 5346 Northdale Boulevard in Tampa, which are traceable to proceeds of his crimes.
For physicians as well as for those running facilities, and in fact for the owner of any business of any sort, the moral of the story is to exercise tremendous diligence and implement operational checks and balances in connection with the presentation, and in some cases, payment, of invoices.
But there is a special twist here, especially for medical practitioners: In many cases, fraudsters construct their fake claim scams such that proceeds are directed into the practice’s account and then back out to the criminal via various means. Once those payments flow through your account, it raises the very serious question as to whether you participated in the scam.
The sick thrill of being able to take your medical license away provides ample fuel for an unscrupulous prosecutor to name you as a codefendant; in fact, he or she might even allow the actual criminal to flip and testify against you.
To discuss what you need to do to protect yourself, contact me. |
| | | 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 version:
What do custom bike frames have to do with the success of your medical practice, especially if it’s a large group?
Remember studying the Industrial Revolution in high school? In particular, there was a shift in manufacturing from the “guild” system, in which craftsmen created one-off products one at a time, to industrialization and factories, in which products are mass produced.
The benefit, of course, for society in general is that items that were expensive and in short supply because they were made one at a time were now made en masse. Prices went down, availability went way up.
In some cases, quality stayed the same. But in many cases, depending on the item, quality suffered.
Today there’s a rebirth of sorts in the bespoke world, from bespoke tailoring to bespoke shoes. To a slightly lesser degree of customization, there's also made-to-measure and made-to-order, in which an item is not completely made just for the customer, but is custom fitted or custom produced on a one-off basis.
I saw a story in The Wall Street Journal focused on a bike manufacturer producing uber high-priced bikes - we’re talking about frames that sell for thousands and thousands of dollars. While a lot of the business has shifted to carbon fiber, which can be mass-manufactured, the subject of the WSJ article creates custom titanium frames which sell for, at a minimum, almost $5,000. Each frame is made just for the rider who was willing to spend the five, six, or seven thousand dollars just for the frame, let alone the rest of the bike.
What does that have to do with medicine and medical practice, especially with a large group?
Medicine has become more factory-like with the aggregation of practices into large practices and the introduction of outside money, that is, private equity and publicly held money, into aggregating medical groups.
In many cases, the previously existing relationships have suffered, whether we're talking about provider to patient relationships or group to facility relationships.
I’m not suggesting the solution to this is to go back to a complete craftsman model where practices break up and all we have are solo physicians treating patients one at a time, the “concierge” practice model. I believe that works on a small scale for those willing to pay for it, but it doesn’t work on a large scale.
Instead, consider the impact of the made-to-measure or the semi-custom model where patients and relationships are treated in a way that transforms not just the delivery of a service or the delivery of an experience, but the delivery of an experience within the setting of a much larger business that creates a true sort of transformation for the patient.
Think of the distinction between a large internal medicine group which has a lobby that looks like the DMV, which gives patients numbers and calls them out loud, and another large practice in which the front stage, the image portrayed to the patients, is one of actual customization and care. Think how those latter practices thrive in a very different way. The relationship is on a much higher level.
This sort of "made-to-measure" relationship also plays out between a hospital-based group and a facility.
Think about how you can customize or semi-customize your relationships. |
| | 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 - Why Contract Termination Provisions Are Like Highway Exits - Medical Group Minute
Watch the video here, or just keep reading below for a slightly polished transcript:
Over the weekend, I took a road trip out to the middle of nowhere. Once in a while, you'll see a sign that says, “No Services Next 32 Miles,” and what do you know, there isn’t even an exit for 32 miles.
That's not unlike the term of a contract. It runs for the three or five years, or whatever -- that's the stated term of the contract.
On the other hand, you’re driving on some road, and suddenly there's a detour, forcing you to exit. That’s like a termination provision in a contract.
It might have been you who decided to detour because there’s a rest stop (you terminated the contract), or it might have been that the road ahead is actually blocked (the other party exercised the termination provision).
Exits of that sort, of the contractual sort, can be two kinds: either an exit as a result of a breach (which should be with the right to cure), or a “without cause” type of exit.
Of course, "without cause" exits cut two ways. One is that you want out of the contract early, so you exercise it. But, the other is that your contracting partner wants you out of the deal and they want you out quickly.
Just remember, the correct and complete way of analyzing the true term of any agreement isn’t simply to look at the 32 mile stretch, that is, the three or five year stated term.
Instead, it's to take into account how quickly you could be forced to exit or how quickly you could force the other side to exit the deal.
You can brag all you want to your partners that you pulled one over on the hospital CEO when you talked her into that five-year exclusive contract. Just don’t mention the 60 days without cause termination provision, because that's the true term of the deal. |
| | | Listen to the podcast here, or just keep reading for the transcript.
Even though a federal court struck the U.S. Department of Health & Human Services’ No Surprises Act (“NSA”) regulations as pertain to the process for arbitrating disputes between payors and out-of-network providers, the law and the remaining implementing regulations remain in effect.
Although much of the attention has been placed, for good reason, on the operative billing-related restrictions imposed by the NSA, the technical notice requirements require immediate attention.
In particular, the regulations require that patients be given a notice of rights and, should they so request, a good faith estimate of charges.
For facility-based groups, the hospital or facility will almost always (but not completely) be charged with providing notice to patients and responding to requests from uninsured and self-pay patients for good faith estimates of charges. But the obligation to provide the notice and estimate does not obviate the need for all medical practices to provide required website notice, nor does it, unless you want to give up financial control, obviate the need to coordinate how the charges for your services will be estimated by the hospital or ASC.
Despite the fact that much of this can be offloaded to the facility, it’s wise for all facility-based providers (and required of all office-based providers) to include notice on the practice’s website. Although HHS has provided a form of notice, the use of which demonstrates a good faith effort to comply, it must be customized to incorporate applicable state law. Print copy notices must be made available and (in nearly all cases) posted.
Although the law has been in effect as of January 2022, the government is exercising discretion as to enforcement of the good faith estimate requirement. The better approach, though, is to address these issues ASAP. |
| | | 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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