“King” of Nursing Home Fraud

Philip Esformes, once titled the “King” of Medicare fraud was sentenced to 20 years in prison last year by a federal judge in Miami.  The estimated amount involved in his fraud was 1.3 billion Medicaid/Medicare dollars.  It was called the largest single criminal healthcare fraud case ever brought.

President Trump, through his press secretary, noted that Esformes “has been devoted to prayer and repentance” while in prison and is in declining health.  Esformes is 52 years of age.

President Trump commuted Esformes’ sentence.

As part of the indictment, it was charged that kickbacks were exchanged between Esformes and corrupt medical professionals, with high-end escorts flown to Orlando and chauffeured in limousines for liaisons with Esformes at the Ritz Carlton Hotel.  Esformes drove a $1.6 million Ferrari Aperta and it was alleged that he used $300,000 of the stolen proceeds to bribe the head men’s basketball coach at University of Pennsylvania to admit Esformes’ son.  The coach at the University of Pennsylvania pled guilty to money laundering and testified against Esformes at the Miami trial.  A jury convicted Esformes of paying bribes, money laundering and other crimes.  At the time of his sentencing Esformes said “there is no one to blame but myself.”

Price Clarity

Beginning January 1, 2021, hospitals and other healthcare providers are required to provide clear and transparent pricing for their services and procedures.  Looking at various hospital responses and attempts to comply with this law, indicates that it will be some time before there is accurate and easily accessible price information for many healthcare consumers.

Some hospitals are requiring you to provide your name, insurance policy and other information to them in an email type format where the hospital will then respond to you to tell you what your magic price will be.

Other hospitals are providing immediate online estimates of price once you specify your location and your insurance coverage.While this is a beginning, it is not nearly the end.The new rules were designed to require the hospitals to disclose openly and clearly their pricing.Hiding behind screens and information demand for giving limited slices of particular prices probably will not suffice.In other words, how can you comparison shop pricing when the hospital websites are not consistent in presentation or content?

Tell the Police?

HIPAA’s privacy rule continues to generate questions from healthcare providers regarding when they can disclose protected health information (PHI) to law enforcement.  PHI disclosure may be made:

1. To comply with a Court ordered subpoena, warrant or summons;
2. To respond to an administrative subpoena or investigative demand by a law enforcement official.  This response requires the request to be accompanied by a written statement from the requesting party that the information requested is relevant and material, specific and limited in scope, and that identified information cannot be reused;
3. PHI used to identify or locate suspect or fugitive, missing person or material witness.  In this case, you must limit your disclosures to name, address, date and place of birth, SSN, blood type and RH factor, type of injury, date and time of treatment, date and time of death if applicable and a description of distinguishing physical marks or characteristics; and
4. To respond about a victim of a crime if the victim agrees.  Where the victim is a child abuse victim or adult abuse victim, there are other rules that apply regarding reporting to law enforcement officials.

“An Excellent Start”

United Healthcare (UHC) reported $2.2 Billion in profit for the fourth quarter of 2020 which means its full year 2020 earnings are $15.4 Billion.

UHC expects to bring in $227 Billion in revenue for 2021.

Cigna announced that it earned $4.1 Billion in profit for the fourth quarter of 2020 and for the full year $8.5 Billion in profit (an increase from the $5.1 Billion for 2019).

Interesting information for those providers who face continuing efforts from some healthcare insurers to continually drive down payments to physicians, practices and hospitals. 

This newsletter is edited by Paul Wallace of Jones • Wallace, LLC, a member of 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.