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| Dear Friend,
When is it improper to bill for a case?
OK, it’s a softball question: When is it improper to bill for a case?
The answer: When the patient didn’t need the procedure in the first place.
If everyone were as smart as you, but not smarter because maybe that’s the problem, we’d have no False Claims Act settlements like the one recently entered into by Aarti D. Pandya, M.D., and her medical group, Aarti D. Pandya, M.D. P.C. (“Pandya Practice Group” or the “Practice”). Note that the settlement is of civil, not criminal claims, and that it resolves allegations only, there having been no determination of liability.
The settlement in the amount of approximately $1,850,000 arose as a result of a False Claims Act case, commonly referred to as a whistleblower lawsuit, initially brought by Laura Dildine, a former Pandya Practice Group employee. The suit centered around allegations that Dr. Pandya and her Practice:
Knowingly submitted false claims to federal healthcare programs for medically unnecessary cataract extraction surgeries and YAG laser capsulotomies.
That Dr. Pandya performed these procedures on patients that did not qualify for the procedure under accepted standards of medical practice and, in some cases, caused injury to her patients.
That Dr. Pandya falsely diagnosed patients with glaucoma to justify unnecessary diagnostic testing and treatment that was billed to Medicare.
That many of the diagnostic tests that Dr. Pandya ordered were not properly performed, were performed on a broken machine, or were not interpreted in the medical record, as required by Medicare.
Here are some general observations on cases of this type, all valuable takeaways for you:
False Claims Act settlements, being civil, not criminal, cases, generally resolve only the civil allegations. Any potential criminal liability remains unresolved.
Depending on the type of allegations in a False Claims Act case, the underlying facts might trigger prosecution for a wide range of criminal activity, from federal healthcare fraud to state law crimes such as battery.
Additionally, the allegations underlying a False Claims Act case might support state medical board action.
Remember, False Claims Act cases often arise from whistleblowers within the medical practice or healthcare organization. I’m not suggesting a support group for fraudsters “victimized” by their own staff; rather, I’m simply pointing out that anyone engaged in what appears to be fraudulent activity has to be worried about more than payors and “the police”, they have to be worried about those on their own payroll, too.
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| | Wednesday - Audit Medical Group and Physician-Owned Facility Deals in Light of Tomorrow (and Today) - Medical Group Minute
Watch the video here, or just keep reading below for a slightly polished transcript:
It was June when I saw it. The boarded-up stores of Main Street, paved red with bricks and lost hope. As I’ve written before (for example, here) and as you’ve undoubtedly witnessed, medical care is shifting from a hospital and, in many cases, physician office, model to a consumer model. Walk-in clinics in markets and drug stores. Apps bringing nurse practitioners or physicians to one’s door. iPhones as diagnostic equipment. Yet many medical group governing documents and physician-owned facility agreements contain provisions that are inflexible and destined to be breached (or deemed unenforceable) in light of change. Or, worse, destined to strap down your ability to thrive or even to function. For example, depending on the entity and its purpose, scheduling provisions, restrictive covenants, and compensation models may be out of tune or stretched to the point of soon being so. Consider a provision that allows a group to determine at which hospital facility a provider will be scheduled during a calendar month, when you now want to schedule her to work at Mark’s Pharmacy or at Mark’s house. Audit and update your strategies, structures and documents not simply in light of compliance and control, but in terms of focus, flexibility and the future. No one knows exactly where the road to the future is heading, but the signs indicate that it’s away from where things have been. Do you want to go along for the ride? Oh, yeah, about Main Street. The highway had bypassed the town. |
| | | Listen to the podcast here, or just keep reading for the transcript.
A magic show is about misdirection: that which is seen and that which isn’t seen. Just like the title of the essay by Frédéric Bastiat, the early 19th Century French political economist, but in a slightly different direction.
Bastiat’s point was that governments legislate to correct a problem (and then bask in the glory of having taken action) but never truly consider what problems they create when they enact the legislation to correct the problem. In other words, they act based on what is seen (the initial “problem” and the easily seen “solution”) but do not pause to consider the potential damage that their action will later cause.
For example, in the United States we had the Great Society movement — Lyndon B. Johnson — supposedly to help the poor. One of the prime programs was public housing, which, in actuality, deserves significant blame for having created an almost permanent underclass which is dependent upon public housing and other government programs.
The Great Society programs and the slice of help that they provided to then current beneficiaries was “that which is seen.” Unfortunately, the negative impacts, the “that which isn’t seen,” were never taken into account and never even considered.
It part, we can blame this on the short lifespan of term of office. “I’ll be out of office and retired in the Bahamas before the shit hits the fan.” In part we can blame this on the immunity from liability for negligence that we’ve given politicians and bureaucrats: I’ve heard, but can’t find any proof, that the Romans made bridge builders live under their bridges for a period of time, the ultimate test of quality planning and construction. We don’t impose any risk at all on politicians who impose harebrained schemes on us.
But, in large part, the problem is one of thinking, and it pervades industry and child rearing ("Okay, little Johnny, you can have another ice cream cone, just be in bed by 7:30 . . .") and decision making of all sorts, including that within medical groups.
There are many methods by which a medical group can make decisions. Some are clearly ill advised and others far more likely to generate good results, or, at a minimum, results that can quickly be corrected.
But any decision making method must be governed by a decision making process: what is considered in making the decision?
To drive the maximum chance of success, both in terms of advancement and in terms of managing against risk, the process must incorporate not only a view to what will be achieved by the decision, but also a view as to what deleterious impact the decision itself might bring, perhaps not immediately, but bring just the same. Think plus and minus. Think positive and negative. Think that which is seen and that which isn’t seen.
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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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