Letters: Partnerships aren't the silver bullet in healthcare

The editorial “Off the hook for fraud and abuse” incorrectly suggests that recent U.S. Department of Justice actions help white-collar criminals, when in fact DOJ policy reduces unwarranted fraud investigations that will free up resources to pursue real cases.

I’m a CPA/management consultant with over 45 years of healthcare industry experience. I’ve represented hospitals and other providers as an expert witness in civil and criminal healthcare fraud cases.

Fraud investigations create a substantial burden on providers to dispute. Suspension of cash flow can result in bankruptcy before having any chance at defense. Accordingly, a tightening up over such audits is welcome news for providers. The editorial mentions a data analytics firm that had 11 cases dismissed by the DOJ. This was proper. Data fluctuation may be an “indicator” of a problem; but it is not “evidence” of anything. A whistleblower must have firsthand knowledge of facts that evidence a fraud or abuse transaction occurred. Analytics fail that test and rightfully should not be a basis for investigation.

Additionally, challenges to medical necessity frequently arise from differences in interpretation over the extent of clinical documentation. These cases become “he said, she said” disputes that are often settled without proof of wrongdoing. In too many cases, auditors apply outdated standards, inapplicable regulations, or fail to consider local coverage decisions that allow departures from standard published guidance. Whistleblowers frequently don’t have an in-depth understanding of the rules and overstate claims of fraud and abuse.

The editorial also suggested that the Supreme Court decision regarding disproportionate-share hospital payments was used by DOJ to either dismiss or fail to pursue additional fraud cases because the CMS issued an internal memorandum to acquiesce to such a decision. First, Supreme Court decisions are law and must be followed. Second, this case involved the failure by the CMS to provide adequate notice and comment on guidance. Accordingly, the guidance was unenforceable.

Lance Loria
Managing director
Loria Associates
Montgomery, Texas

The article covering Modern Healthcare’s CEO Power Panel survey highlights a new reality for how health systems are approaching business efficiency and growth. But what the article and survey fail to address is how this transition away from mergers to partnerships must include considerations of independent physicians in the communities they serve and the inevitable transition to value-based care.

Experts in the piece touch upon the need for a better continuum of care, and independent physicians—especially primary-care providers—are the linchpin in that continuum. If health system partnerships overlook these critical players, partnerships can risk further alienating providers who are the center of a patient’s long-term care.

In addition, claims that healthcare doesn’t pay for value are shortsighted. The shift to value-based care is accelerating. Health systems can expect an ever-increasing level of their business tied to value-based agreements. If the partnerships health systems enter into now are not prepared for that reality, patient outcomes and business performance will suffer.

Ultimately, the progress away from traditional mergers to more adaptable, customized partnerships signals novel thinking and thoughtful planning embraced by innovative health systems. But these partnerships must have a long-term view that makes room for other players in the community as the industry evolves.

Mark Foulke
Executive vice president, transformational value-based care
Privia Health