IPA diligence and persistence is critical to being optimally contracted with the insurers. The challenge is to communicate effectively to the managed care companies that Physician Direct Access, the IPA of value, is to be compensated at the top of the market rate.
Today, PDA received notice that Aetna would prepare a new agreement that reflects plan recognition, inclusion, and new payment levels. The upward adjustment was hard-won by PDA leadership. Special recognition is due Tim Paquette, Chief Finance and Administration Officer. Material contribution also was made by Dwight A. Lee M.D., Chairman and by Daniel S. Karin M.D., Medical Director. This is another milestone event in the re-positioning of PDA and its efforts on behalf of the independent practitioner.
Ecosystem is a portmanteau word – that is, a word made by banging and slamming two other words together. Companies such as Apple, Cisco, Proctor & Gamble, and Johnson & Johnson refer to themselves as a delicately balanced, self supporting economic model that functions as a self-contained system. Apple is an amazing example of this balanced, coordinated system. As a person uses his IPhone applications to find where his car is parked, the IPod may be playing his favorite tunes, and the IPad is actually a convenient portable computer. When a single “Clicker” controls the new Apple TV and the other “synced” Apple components, the full value of the “I” ecosystem is clear. Everything is connected. Everything is seamless.
The concept of an ecosystem is very different from either the matrix management or direct line approach to managing a business to its goals. For example, the Flagship Network ecosystem operates like a dome over six zip codes surrounding Lake Ray Hubbard. This system is powered by Lake Pointe Health Network and by committed community physicians. Other important outpatient services and practitioners are also linked as interconnected aspects of the ecosystem. The businesses insured under the Flagship umbrella are the beneficiaries the ecosystem. They will realize improvement in their work forces’ health and wellness resulting in cost savings and higher productivity.
With the American worker motivated to buy into a better life style and the medical care providers equally involved, there are other necessary ecosystem catalysts. First must come biometrics testing and feedback from the company physician. Then installation of an innovative wellness program and involvement by Flagship “benefits consultants” is necessary to craft the optimum plan design for the client/employer. This is a physician-led action that delivers custom plans for the prospective client. More ecosystem balance and substance is then added by the Third Party Administrator (TPA) with its actuarial skills, stop-loss coverages and reporting capability. Like a thermostat, the TPA monitors the entire plan construction, the projected costs of delivery and when operational…the monthly plan performance, premiums, etc. The TPA’s insight into aggregate biotech scores and actual claims also brings the Flagship “Transitional Care & Disease Management Program” into play. So, the ecosystem can deal with solutions for past, current and projected needs of a working population. These are the major components of the Flagship ecosystem. It is a new concept for the delivery of healthcare. The small business and its employees become an integral part of the Flagship Healthcare ecosystem.
Business and science are learning that it takes coordinated resources to produce a community-based healthcare solution. The secret is in the power of a tightly knit, concerned community versus a linear pre-formed plan contrived by a distant insurance giant. Granted, the large insurers may have great ability and financial resources, but the community based ecosystem is very attuned to the needs and opportunities of the local economy.
The Flagship Network is soon to roll-out in its first market. There are two more markets waiting in the Dallas area. This is a very exciting business, filled with opportunity for physicians, for employers, and for their employees.
If a person has information showing that a healthcare provider has committed fraud on a government healthcare program such as Medicare or Medicaid, then they may be able to bring a qui tam lawsuit under the federal False Claims Act or similar state laws. Through the qui tam lawsuit, the person would help the government recover money that has been paid as a result of fraudulent claims. Federal and state governments have recovered billions of dollars as a result of information provided by qui tam whistleblowers about fraud committed by hospitals, nursing homes, pharmaceutical companies, DME suppliers, and physician practices. As a reward for blowing the whistle, a witness could receive a share of the government’s recovery. A whistleblower who brings a successful qui tam lawsuit will receive between 15% and 30% of the amount that the government recovers. The legal profession is ready and eager to “assist” in such endeavors.
Types of Healthcare Fraud Covered By the False Claims Act
Healthcare providers who submit claims to the Medicare or Medicaid system must provide various types of information and maintain certain specified records in order to legally claim reimbursement. If a provider submits a claim for payment to which it is not entitled or falsifies the documentation supporting the claim, then the provider may be violating the False Claims Act. Some common forms of Medicare and Medicaid fraud include the following:
- Charging For Services Or Supplies Not Provided
- Upcoding and Unbundling
- Falsifying or Failing to Maintain Records
- Off-Label Marketing By Pharmaceutical Or Medical Device Companies
- Unlawful Kickbacks or Financial Arrangements
- Cost Report Fraud
PDA’s Medical Director is available to confidentially discuss any issues that relate to questionable invitations to generate additional revenues. This consultative service is perhaps just the first and preliminary action in many steps for the practitioner to insure that a proposal for new revenues is appropriate.