Exposing Healthplan Deceptions: How and Why Provider Groups Could Take a Stand

A Discussion Paper about a Hypothetical

In what will be a dash to secure better paying contracts, providers may not be aware or may be turning a blind eye to ethical business and clinical standards, potentially supporting deceptive contracting practices. In a troubling scenario unfolding in the healthcare sector, a conscientious provider group has discovered that a Healthplan’s contract is ill-defined, misleading, deceptive, and misrepresents its value and stability. Despite their good faith efforts to raise these concerns and the associated risk, the Healthplan has shown defensive interest in understanding the issues, and seemingly is turning a "blind eye" to protect itself. To complicate matters further, other provider groups, should be warned about these concerns. If provider groups are warned and they also turn a blind eye to contract, and choose to sign the contract, hypothetically they could be complicit. If the Healthplan is not paid with taxpayer dollars, the Purchasers will have a problem with the Healthplan. This might be an employer or an individual. If the Purchaser is using Taxpayer dollars, the Purchaser will have a problems with the State of Oregon and the Federal Government. If the contract involves Oregon taxpayer money, the problems are between the the Healthplan and State of Oregon.

This article delves into the actions and implications for the Healthplan, the provider group raising the concerns that will not sign a contract, and the providers who do not investigate the warnings and sign the contract.

Healthplan Transparency

A Healthplan’s refusal to fully understand and acknowledge a provider group’s concerns, suggests an intent to mislead the purchasers and the provider that needs to sign the contract but cannot for legal, ethical and moral reasons. By ignoring the warnings and continuing with a misleading contract, the Healthplan might be engaging willful or unwilfully in fraud. They might even be engaged in violating Antitrust Laws. Their actions may be willfully negligent, if they intentionally avoid addressing potential harm, thus protecting themselves at the expense of transparency with ethical provider groups. Additionally, the Healthplan’s actions could be seen as anticompetitive, if they are misrepresenting the quality and value of the contract to gain an unfair advantage over other Healthplans. These problems are compounded if provider group contracts are not negotiated with good faith and fair dealings. If the contract is a fee-for-service contract, the Healthplan may offer a “contract of adhesion” (take-it-or-leave-it) if the contract is not unconscionable, do-able, and does not involve risk-sharing with other groups or the Healthplan. If the contract requires providers to take a chance they will fail to meet performance requirements, the Healthplan must collaborate so that Provider groups can accurately evaluate the risk and make an informed decision. Healthplans have legal obligation to negotiate a contact in good faith and with fair dealing. They should not hide facts that could cause harm to providers. Potential harm might be to the providers reputation, well-being, or financial ability to operate responsibly and effectively. If the Provider group’s economic survival or ability to compete is put at risk by a Healthplan, the Healthplan must be transparent about any risk a provider practices need to understand. If a Healthplan offers an incentive based on performance and sharing risk with the Healthplan and or other provider groups, the Healthplan must be transparent and forthcoming. This is crucial if the Healthplan is paid with taxpayer dollars.

Provider Group Raising Concerns

The provider group raising concerns to the Healthplan has acted ethically and responsibly by not signing the contract and continuing to discuss matters with the Healthplan. They do not wish to risk harm or be involved in a deceptive contract, which demonstrates their commitment to ethical practice and patient care. Their good faith efforts and documented communication would mitigate their culpability and show their intent to uphold standards of transparency and honesty. This group would stands out for its dedication to ethical practices, aiming to protect their patients and the integrity of the healthcare system. At the same time it is a Provider’s responsibility not to look the other way and to protect the public and other providers.

Providers Who Turn a Blind Eye

In contrast, another provider group, despite being warned about the issues with the contract, chooses to turn a blind eye and sign the contract. This behavior can be classified as willful negligence because they are intentionally ignoring the potential for harm and the deceptive nature of the contract. By signing without investigating further, they are complicit in supporting the Healthplan's deceptive practices, which could have legal and ethical implications. Their actions contribute to the broader issue of deception and unfair advantage, potentially exposing themselves to significant legal and ethical repercussions.

Analysis

The Healthplan’s refusal to acknowledge the provider group’s concerns and its deceptive behavior indicate an intent to mislead and gain an unfair advantage, potentially constituting fraud. The Healthplan is primarily culpable for willful negligence by ignoring documented issues and proceeding with the deceptive contract. Additionally, the Healthplan’s actions could be seen as anticompetitive, if they are using a deceptive contract to gain an unfair advantage.

The provider group raising concerns has demonstrated a commitment to ethical practice by addressing issues and choosing not to sign a deceptive contract, thereby protecting themselves and their patients from potential harm. Their documented efforts to communicate issues show they are not complicit in the Healthplan's actions and are actively promoting fairness and transparency.

In contrast, the providers who turn a blind eye to the warnings and sign the contract may be willfully negligent. They fail to exercise due diligence and indirectly support the Healthplan's deceptive practices. Their actions contribute to the broader issue of deception and unfair advantage, potentially exposing themselves to legal and ethical consequences.

Taking Action: Steps to Prevent Fraud and Antitrust Violations

The provider group raising concerns can take further steps to prevent the inappropriate use of taxpayer funds and potential violations of fraud and antitrust laws. Here are some actions they can take:

The provider group should contact their district representative or senator to request an investigation into the Healthplan’s practices. Providing detailed documentation of their concerns, including any correspondence with the Healthplan and evidence of the contract's deceptive nature, is crucial. This step ensures that their concerns are formally acknowledged and can trigger a more thorough examination of the Healthplan's activities.

Request an Investigation

The representative or senator can initiate an investigation into the Healthplan’s practices by involving relevant regulatory and oversight bodies. This could include state insurance departments, the Federal Trade Commission (FTC), and the Department of Justice (DOJ) for potential antitrust violations. An investigation can uncover the full extent of the deceptive practices and hold the Healthplan accountable.

Legislative Action

The provider group can advocate for legislation to prevent similar practices in the future. This might include:

• Strengthening Contract Transparency Requirements: Laws that require Healthplans to clearly define contract terms, reimbursement rates, and the criteria for service authorizations.

• Enhanced Oversight and Accountability: Establishing more robust oversight mechanisms for Healthplans that receive taxpayer funds, ensuring they adhere to ethical standards and do not engage in deceptive practices.

• Protecting Whistleblowers: Providing protections for providers who raise concerns about unethical or deceptive practices, encouraging more transparency and accountability in the industry.

Public Awareness and Advocacy

Raising public awareness about the issue can put additional pressure on the Healthplan and regulators to address the problem. This can be done through media engagement, public statements, and collaborations with professional associations and advocacy groups. Public awareness campaigns can educate other providers and patients about the risks and encourage broader support for ethical practices.

What Representatives or Senators Can Do

Initiate an Investigation

The representative or senator can request a formal investigation by state or federal agencies into the Healthplan’s practices, focusing on potential fraud and antitrust violations. An investigation can hold the Healthplan accountable and ensure that deceptive practices are exposed and addressed.

Propose and Support Legislation

They can draft and support legislation aimed at preventing deceptive practices and ensuring transparency and fairness in contracts involving taxpayer funds. Legislative measures can provide long-term solutions to prevent similar issues from arising in the future.

Hold Hearings

Organizing hearings to gather more information about the issue, bringing in experts, affected providers, and Healthplan representatives to testify, can provide a platform for discussing the problem and developing effective solutions.

Collaborate with Regulatory Agencies

Working closely with agencies like the FTC, DOJ, and state insurance departments to enforce existing laws and regulations and to develop new policies that address the identified issues can ensure comprehensive oversight and accountability.

Conclusion

By taking these steps, the provider group can help ensure that taxpayer funds are used appropriately, and Healthplans are held accountable for their practices. This proactive approach can prevent fraud, protect patients, and promote a fair and transparent healthcare system. The commitment to ethical practices demonstrated by the provider group raising concerns sets a standard for others to follow, emphasizing the importance of due diligence, transparency, and accountability in healthcare contracts.