- A closer assessment of the recent Medicare risk adjustment fraud lawsuits initiated by Fernandez.
- Keith Fernandez is the second whistleblower who says he is about to expose large-scale fraud has been an unfair cost to the American tax payer.
Keith Fernandez- the second whistleblower of the Medicare Adjustment Risk Fraud lawsuits that have been recently filed against Anthem’s Subsidiaries and Physician Partners LLC, is a Harvard College graduate with an extensive background in Corporate Finance. Having worked in a plethora of eminent firms such as KKR and Bank of America, Fernandez moved on to start his own chain of businesses with his father- including National Diagnostic Solutions.
Insights On The Alleged Medicare Fraud:
In September 2015, Keith Fernandez- the aforementioned CEO of National Diagnostic Solutions (NDS), formed a contract with a management service organization that served over 20,000 Medicare Advantage patients (called Physician Partners LLC) to provide ultrasounds screening exams to the corporation’s Medicare patients in Florida. (It should be noted that PPL, Optimum Healthcare and Freedom Health are all affiliated corporations and in fact, have ownership that overlaps.)
Following their initial introductory talks, Fernandez’s National Diagnostic Solutions was hired by PPL and shortly began performing rare ultrasound screening exams ‘of the lower arteries of the legs and echocardiograms’ to PPL’s prolific patients for a ‘flat’ fee of $ USD 70 per screening. Over the next two months, NDS conducted over 1,748 screening exams for the patients of PPL.
However, the relator (Fernandez) soon allegedly discovered the troubling fact that PPL was routinely and consistently engaging in Medicare Adjustment Fraud by Fraudulently forging their primary care physicians prescriptions for both the leg and cardiac screening scans. Essentially, instead of having scripts being generated as a direct result of their physicians, PPL was using its own form of communications to manipulate its patients- imploring them to call a ‘toll-free’ phone number to enquire about their next steps.
In the call, the patients were directed to a PPL call center (instead of their physician’s office), where the center’s staff were directly instructed (via a written and recorded script), to tell the patients that for the sake of their health, they could not afford to refuse the tests. As Fernandez found out, there were in fact no medically-approved reasons that would make it reasonable to necessitate the need of such heavy radiology exams; contrarily, these tests were ordered for the direct ‘benefit’ of the Anthem Subsidiaries (Freedom Health & Optimum Health), as well as PPL- the alleged ‘main culprit’ whose actions have placed the aforementioned Anthem Subsidiaries shareholders in severe risk.
This makes sense, especially when considering the fact that echocardiograms are never really ordered by primary care physicians, with even specialised cardiologists referring to them only upon ‘ a precipitating examination and medical necessity’. According to Fernandez and the relative material evidence provided by Public Citizen- a consumer advocacy group with a membership exceeding 300,00 individuals around the U.S., the aforementioned tests were undoubtedly solely ordered to ‘increase the risk score’ of PPL’s Medicare Advantage and consequently enhance the government’s reimbursement payments from Medicare to PPL.
A Final Take: Examining the Damages
The damages of the aforementioned alleged Medicare Fraud on the U.S. Government have been estimated by the CEO of National Diagnostic Solutions and aforementioned whistleblower, Keith Fernandez. According to Fernandez, a rough estimation of the 1,000 false ultrasounds screening claims that were undertaken during NDS’s direct affiliation with PPL- in conjunction with the increased monthly capitation payments involved, yields an astounding net of over $ 6,000,000 per year in Medicare reimbursement.
However, as pointed out, NDS was not the only corporation that conducted screening tests for PPL, with ‘HealthFair’ administering tests to over 12,00 patients. Consequently, the final estimate of the aforementioned Medicare Risk Adjustment fraud is allegedly well over $ USD 70,000,000 in damages to the U.S. Government, and consequently should prompt prolific consideration in relation to: a) how such a widespread fraud on the U.S. government went unnoticed, and b) how this fraud went on to continue for a plethora of years following the first ‘whistleblowing’ event conducted by Darren Sewel.
As illustrated by the above graph, the U.S.’s Health spending is significantly higher per person in relation to other OECD countries- such as Switzerland, Germany and Japan, whilst at the same time maintaining a significantly lower life expectancy. Fernandez (and other critiques of the Anthem Subsidiaries’ aforementioned fraudulent conduct) have pointed out that the exacerbative effect of such extensive and nation-wide fraud should not be underestimated, and perhaps is widely at fault for the illustrated deficit in spending in comparison to other OECD countries.
