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Friday, September 28, 2018

Hospital Chain Will Pay Over $260 Million to Resolve False Billing and Kickback Allegations; One Subsidiary Agrees to Plead Guilty

“It is critically important to all of us that the patients’ interest drive the physicians’ decisions on care,” said U.S. Attorney Lydon. This is a lofty statement, but it is not entirely true for healthcare in America. Rather, three parties exercise co-fiduciary obligations to the patients. Those co-fiduciary parties are: 1) The health insurer 2) The healthcare organization 3) The physician For instance, your physician may refer you to the best orthopedic surgeon in the area, one with excellent outcomes and quality records relative to her peers, yet, your health insurer may state that surgeon is out-of-network. Your copayment to use that surgeon may be prohibitive, so you utilize another surgeon who is in-network but has lesser clinical outcomes. An additional example: you may come to the ER with meningitis and need an urgent lumbar puncture to diagnose a severe brain infection, but the hospital did not maintain inventory on the relevant procedural kit. A fiduciary is someone who is entrusted to provide you with advice deemed in your best interest. Whether you take that advice or not is your decision. For instance, as a fiduciary, your financial adviser may advise you not to spend every monthly paycheck at the casinos. If you, nevertheless, hit the casinos frequently and don't meet your other financial obligations in life, that fiduciary has done her job of providing you advise she judged was in your best interest. The days of your physician being a wild west gunslinger who is the sole effector of all that is good and best for your care has been a bygone era for 35 years now and counting. Co-fiduciaries have to work collaboratively to effect such care. The first step is to acknowledge this relationship exists, then we can have a meaningful conversation on how to better serve you the patient. While the above commentary is not the major subject matter of the posted article, I thought I would call out this element contained in that news release. Another element worthy of discussion is that of "inducement of physician referrals." Do you know when the US government itself engaged in the largest ever inducement of physician referrals?
from Rajesh Harrykissoon, MD

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