That’s My Money

What do you do when Medicaid accuses you of fraud, cuts off your Medicaid payments, and freezes reimbursements for services already rendered?  Let’s say that you were accused by a Medicaid contractor of fraud but later cleared of all charges.  Of course Medicaid would then promptly pay your money, right?

Fifteen behavioral health providers, in 2013, faced allegations that they had committed Medicaid fraud.  When the fifteen providers were cleared of criminal wrongdoing by New Mexico’s Attorney General, they asked for their frozen reimbursement and to be allowed future Medicaid payments.  Now they have accused OptumHealth of avoiding, delaying and refusing to make payments to the now cleared companies.

OptumHealth claims to have placed the $11 million due these companies in a non-interest bearing account.  It is unclear why they would use a non-interest bearing account since this would appear to reduce the ultimate amount paid to the companies.  There appears to be no penalty to OptumHealth for delaying the reimbursements or clearances to the fifteen companies.  The result of all this is a lawsuit by ten behavioral health providers against OptumHealth claiming that it manufactured the claims of fraud in addition to delaying payment.  OptumHealth has requested that the matter be sent to arbitration, obviously preferring that this matter be determined in private.

Question, if a provider commits fraud on Medicaid, the provider can be banned from participation.  Should OptumHealth be barred from contracting as a vendor to Medicaid?

How Much Did Your Insurance Provider CEO Make?

The 2015 compensation numbers are out as a result of filings with various regulatory and reporting agencies.  The Top Five, as reported, are:

1. Cigna CEO David Cordani, $17.3 million;
2. Aetna CEO Mark Bertolini, $17.3 million (tied);
3. United Health CEO Stephen Hemsley, $14.5 million;
4. Anthem CEO Joseph Swedish, $13.6 million; and
5. Humana CEO Bruce Broussard, $10.3 million.

Please remember these numbers do not include the value that could be realized by each of them if they exercised their stock options when due.  These amounts usually do not include the amount of benefit to the CEO from flying the company jet, staying at company apartments, and other non-personal perks.

Real Risk Assessments

When we are asked to assist providers performing risk assessments relating to PHI, or with billing, coding and similar matters, our initial step is often to meet with the client and discuss different levels of risk.

Some risks are day-to-day, common sense, practical decisions:

• The majority of PHI threats and breaches relate to your own employees.  Do you use common sense practices and rules to make sure that unencrypted data is not carried on any device outside the physical walls of your practice or hospital?
• Do you have periodic reviews by a quality IT provider to scan for malware, to review usernames and passwords for adequacy and do you regularly update antivirus protection software?
• Do you relentlessly train and retrain your people to understand why you have PHI rules and the need to comply with security and safety rules?

Let’s Play Hide The Doctor

We previously had written about studies that have found that provider directories for health plans are riddled with errors.  Phone numbers, addresses, doctors included and doctors not included in the plan are the main problems.  Last year federal rules went into effect to start fixing this problem.

The result?  21 Medicare health plans had been warned to fix their serious provider director errors.  These include plans available in Indiana and around the country.  The winner in the worst accuracy category was Piedmont Community Health Plan in Virginia.  But even such large providers as CIGNA seem to find listing the doctors actually available in their plan, and their correct address and phone number to be beyond their capabilities.  Some plans included doctors who had been retired or deceased for years.

The health plans were notified on January 6 that they had 30 days to fix the mistake or face fines or sanctions.  32 other companies, who were not quite as bad as our 21 winning companies, were notified to correct their directories promptly.

This newsletter is edited by Paul Wallace of Jones • Wallace, LLC, a member of the American Bar Association Healthcare Law Section and the American Health Lawyers Association who has been representing physicians and healthcare practices for over 25 years.  Mr. Wallace assists physicians, practices and hospitals in contract items, federal legal compliance, practice entity creation, estate and wealth planning and similar issues.  Please feel free to call if you have any questions on this newsletter or legal matters at (812) 402-1600 or pwallace@joneswallace.com.