Holland & Hart Healthcare Law Blog

Ill. Jury Hits Amerigroup With $144 Million Managed Care Fraud Verdict.

An Illinois jury today entered judgment in favor of a Qui Tam whistleblower, Cleveland Taylor, against Amerigroup Illinois, Inc.today. The judgment of $48 Million following weeks of trial will be trebled under the Federal False Claims Act and the Illinois Whistleblower Reward & Protection Act. Mr. Taylor, a former Amerigroup employee, stands to gain a $21 Million to $36 Million dollar share of the verdict if it is upheld and collectible.  Amerigroup has announced that it will appeal.  Mr. Taylor supported by the Justice Department and the Illinois Attorney General, asserted that Amerigroup consciously discriminated against and discouraged pregnant women  in their late pregnancies from signing up with Amerigroup, which makes its money by providing managed care to Medicaid recipients in Illinois and other states.

OIG BLESSES DENTAL PPO PAYMENT TO MARKETING FIRM FOR SIGNING UP FEDERAL EMPLOYEES HEALTH PLAN

Did it ever occur to you that a Preferred Provider Organization might run afoul of the federal anti-kickback statute by paying for the services of a marketing firm on the basis of PMPM (per member per month)?  On October 13, 2006 the OIG posted advisory opinion No. 06 17.  The dental network (the “Network”) contracted with a marketing firm for services.  The marketing firm introduced a third party administrator (“TPA”) to the network.  The marketing TPA made the network available to one of its clients, a Federal employee health benefits plan.  Most of the beneficiaries in the Federal employee health benefit plan do not qualify for federal healthcare benefits programs, although some do.

LOOSE LIPS IN OR: PENNSYLVANIA FEDERAL DISTRICT COURT PERMITS DEFAMATION SUIT AGAINST TELLAR SURGEON TO PROCEED.

A Federal District Court for the Middle District of Pennsylvania dismissed multiple claims against Pinnacle Health Hospitals, Inc. (“Pinnacle”) and a number of physicians which arose out of the peer review of Dr. Ayadeji O. Bakare, M.D., but permitted a defamation action against Dr. Barry B. Moore, M.D. and his employer, Pinnacle to proceed.

In Bakare, M.D. v. Pinnacle Health Hospitals, Inc. et al., Civil Action 1:03-cv-1098 (Aug. 24, 2006), Dr. Bakare, a board certified OB/Gyn physician, sought recovery of damages based upon claims of anti-trust violations, breach of contract, interference and defamation arising out of his precautionary suspension from the Pinnacle medical staff and an adverse recommendation from the Medical Executive Committee that his medical staff privileges be revoked.  Pinnacle lifted Dr. Bakare’s suspension shortly after it was imposed following  an agreement worked out between the parties to limit the scope of Dr. Bakare’s practice pending the investigation.  The adverse recommendation as to his privileges was reinforced by an independent outside review by a physician recommended by the Academy of Obstetrics and Gynecology (“ACOG”).

Michigan Supreme Court Jetisons Judicial Non-Intervention Doctrine in Review of Private Hospital Staffing Decisions.

Judges have long been reluctant to intervene in private hospital staffing decisions.  They are frequently uncomfortable in second guessing hospital decisions regarding the qualifications and competency of physicians.  In the case of public hospitals they have had little choice.  Public facilities are public actors and staffing decisions raise constitutional and civil rights issues.  In June of this year the Michigan Supreme Court specifically rejected the judicial non-intervention doctrine in private hospital disputes previously adopted by the Michigan Court of Appeals in a line of cases.  In Feyz, M.D. v. Mercy Memorial Hospital et al., 719 N.W.2d 1 (Mich. 2006), the court determined that the judicially created “doctrine of non-intervention” was at odds with the Michigan peer review immunity statute.