Allegations of Bad Faith, Fraud and Antitrust Violations by Moda Health - A Whistleblower Complaint
Mentor Research Institute, 501c3
October 10, 2024
A Discussion Paper
SUMMARY
This complaint is presented for discussion by Mentor Research Institute on behalf of the Independent Mental Health Practices Alliance (IMHPA) (and 128 similar provider groups) who have been offered unfair and arguably fraudulent contracts by Moda Health. The health plan stated that provider groups prefer to maintain confidentiality; however, this preference is not clearly justified, as the risk of harm increases by not identifying the affected parties. These contracts, presented to providers in a deceptive and misleading manner, were designed to give Moda an unfair competitive advantage in securing contracts with mental and behavioral health care providers, the Oregon Education Benefits Board (OEBB), the Public Employee Benefits Board (PEBB), and Oregon Health & Science University (OHSU). Moda Health’s contracting process is unfair and creates an unfair competitive advantage over other health plans. We believe the Oregon Health Authority has a fiduciary responsibility to investigate Moda Health’s contracting behavior, which reveals evidence of bad faith contracting, fraud, and antitrust violations because it involves taxpayers’ dollars. Our analysis reveals that Moda’s contracting for mental and behavioral health services has a probable to almost certain moderate to catastrophic impact on stakeholders that include individual patients, purchasers, taxpayers, and mental and behavioral health providers.
Assessing Stakeholder Impact: How Moda Health’s Contracting Practices Undermine Providers, Patients, and Public Health
The Moda contract and negotiation was evaluated using a standard practice used by certified internal auditors. This involves an evaluation of the contract value, objectives, risks-impacting objective (RIO), a risk control matric (RCM), controls, a residual risk analysis (RRA), key performance indicators (KPI), and a bubble map (a.k.a., heatmap). The bubble map is visual representation of our analysis.
The Figure 1. graphic titled "Healthplan X Top Risk Review Heatmap" illustrates the risk landscape for Moda Health using a bubble map to display the relationship between the likelihood and significance of various risks. The Y-axis represents the likelihood of risks occurring, ranging from "Rare" at the bottom to "Almost Certain" at the top, while the X-axis represents the significance of risks, from "Insignificant" on the left to "Catastrophic" on the right. The heatmap uses color coding to indicate the level of concern: green for low risk, yellow for moderate risk, orange for high risk, and red for critical risk.
Figure 1.
The risks identified include short-term thinking and patient overutilization, both located in the yellow zone, indicating moderate risk with high likelihood but moderate impact. Asymmetric information is positioned in the red zone, indicating a critical risk with high likelihood and more than moderate negative impact. Patient under-utilization is found in the orange zone, suggesting a high risk with probable likelihood and more than moderate negative impact. Other risks such as non-agreement on measures and metrics, failure to align value/incentives, provider overtreatment, and inability to reconcile agreements are also placed in the yellow and orange zones, indicating varying degrees of moderate to high risk. Low-risk areas, such as data ownership and financial risk, are positioned in the yellow zone, indicating moderate risks that can significantly impact objectives.
The graphic highlights that the high-risk areas, indicated by yellow, orange, and red zones, need additional controls as they are likely to lead to failure. Effective controls (i.e., risk management strategies) are essential to mitigate these critical issues and ensure the viability of value-based payment contracts. Viable contracts should design controls that keep risks within the green zone, thereby minimizing potential negative impacts on objectives.
The bubble map depicted in Figure 1 also illustrates how Moda Health’s contracting practices are structured in a way that disproportionately benefits the health plan while placing significant burdens on other stakeholders, including providers, patients, and public and the purchasers. It highlights the unbalanced distribution of risks and rewards in these value-based contracts, making it probable to almost certain that Moda’s approach favors its own financial gain at the expense of providers’ costs, risk tolerance and patients’ access to care.
Overall, Figure 1 reinforces the core concern that Moda Health’s contracts are designed to shift risks onto providers while securing hidden financial benefits for the health plan. It visually communicates that these practices harm the very stakeholders that value-based contracts are supposed to support; providers who strive to deliver quality care, patients seeking access to services, and public entities responsible for stewarding taxpayer funds.
Bad Faith, Misleading, Deceptive and Fraudulent Contracting Process
Moda Health has offered contracts to IMHPA and 128 (reportedly) other provider groups that contain intentionally vague and ambiguous terms. Key performance indicators (KPIs), risk adjustment methods, and payment calculations are not clearly defined, leaving providers unable to understand or analyze the risks and requirements necessary to meet contractual obligations. Moda Health retains unilateral control over the incentive calculation, and how risk scores are calculated, preventing providers from participating in this process and verifying the accuracy of Moda’s analysis. Moda stated they are “making it up” as they go to explain why they were not forthright about the upside benefit to Moda. At the time, the upside benefit to Moda (House Bill 4069) explained why the information shared was asymmetric and why the contract is nonsensical to providers. The design of HB 4069 was a reasonable explanation of why Moda’s contract has contractual voids and policy gaps to such an extent that the contract is, on the surface, “to good to be true” and make no sense. We believe it is probable to almost certain that the Moda contract was a “bait and switch” which apportions a hidden risk on providers so that Moda would have an advantage to win contracts supported by HB 4069 funding. This is unfair to providers and other health plans.
Using ambiguous contract language, withholding crucial information, and refusing to collaborate with providers, Moda Health manipulated provider reimbursements to create a false image of value, while at the same time increasing Moda’s financial returns from public contracts funded by taxpayer dollars. This deceptive, and probably fraudulent practice, not only harms providers but also undermines the integrity and ethical foundation of public health contracts with OEBB, PEBB, and OHSU, paid for with taxpayer dollars.
Unfair Competitive Advantage
Moda Health’s fraudulent contract terms give Moda an unfair competitive advantage over other health plans in securing public contracts. By offering contracts that (1) appear to be more cost-effective than those of their competitors, and (2) appear to have the support of providers, Moda is presenting itself as better lower-cost option to purchasers. Moda’s misleading image of efficiency and provider support are generated through deceptive contracts are not transparent, apportion the downside risk to providers, allocate the upside benefit to Moda, and will almost certainly undermine providers’ willingness to support this contract over time. The contract was offered in bad faith and as a take-it or-leave contract (i.e. contract of adhesion).
Additionally, Moda Health’s refusal to disclose critical information - such as the identities of other providers involved in risk-sharing agreements - creates an environment where providers cannot (1) collaborate, (2) create efficiencies, or (3) evaluate the fairness of the terms. This isolation of providers allows Moda to control the contract process, suppress competition, and distort the market for public contracts.
Impact on Smaller Provider Groups
IMHPA and 128 provider groups were reportedly offered new Moda contracts in 2023 and 2024. Many of these groups are unfairly impacted because they lack the legal and financial resources to fully analyze and negotiate the terms. Moda Health offered IMHPA a contract of adhesion which was not transparent and was negotiated with asymmetric information creating an unfair advantage over IMHPA. Some of these 128 groups are perhaps smaller than IMHPA. Unlike IMHPA, they do not have access to the necessary resources or legal expertise to recognize and understand the risks embedded in a “bad faith” contract, nor are they fully informed of the administrative infrastructure which can be required to meet the compliance demands imposed by Moda Health. Some groups may be comfortable with their level of participation, but it was not fair that Moda has not been forthcoming about information that may have made them even more uncomfortable. For example, HB 4069 “died” in the ways and means committee in the 2024 legislative short session. Before that, Moda’s potential upside risk was an important and identifiable factor when negotiating a risk share agreement that was not disclosed and should have been disclosed to providers because the contract IS conceivably a risk share.
Manipulation of Public Healthcare Contracts
Moda Health’s contracting practices extend beyond providers to harm the public healthcare system itself. By manipulating risk scores and offering deceptive reimbursement rates, Moda can divert public funds intended to improve patient care into its own profits. This deception probably to almost certainly is intended to misuse taxpayer money. Were this to happen, more likely than not, this will degrade the quality of care available to public employees and students. It almost certainly undermines the state’s efforts to create a sustainable and equitable healthcare system through the OEBB, PEBB, and OHSU contracts.
Furthermore, Moda Health’s ill-defined contracts may lead to the creation of “phantom networks,” where providers are listed as part of the health plan’s network despite being unable, reluctant or unwilling to accept new patients. Moda requires providers to give 6 months’ notice, to not terminate patients, and to refer patients in-network. Ironically, providers must sign these contracts or else risk even greater financial instability, while at the same time providers must wait and see what will be added to the contract over time. Moda’s contract misleads patients and public entities unnecessarily into believing they have broader stability and access to care than is feasible.
Legal and Ethical Concerns
Moda Health’s contracting practices raise serious legal and ethical issues. By offering contracts Moda knows are misleading, deceptive and designed to benefit itself at the expense of providers, the health plan is engaging in bad faith contracting. Moda’s manipulation of contract terms, risk scores, and reimbursement rates appears to violate both state and federal laws governing fair competition, monopolistic progressions, contract transparency, and their fiduciary responsibilities when using public funds.
Additionally, Moda Health’s actions may violate antitrust laws by restricting competition among providers and creating barriers to entry for new or smaller provider groups. Moda’s dominant market position allows it to suppress competition and secure public contracts through deceptive and manipulative practices.
The allegations outlined in the Complaint filed with the Oregon Health Authority (OHA) suggest significant discrepancies between Moda Health's stated Code of Conduct and its actual contracting and negotiation practices. An comparative analysis of the Moda Health’s Contract was conducted using specific allegations with the corresponding sections of the Moda Health Code of Conduct, alongside broader implications for providers, patients, and public trust (see Appendix 1).
For more information see:
Moda Health Code of Conduct
https://www.modahealth.com/pdfs/comp/code_of_conduct.pdf
Reportable Concerns
The allegations of fraud and antitrust violations by Moda Health, as uncovered by Mentor Research Institute (MRI), working with Independent Mental Health Practices Alliance (IMHPA), revealed systemic issues in the way Moda Health structured its contracts with mental and behavioral health providers. These practices, if designed to manipulate financial outcomes in favor of the health plan, undermines both the integrity of value-based payment (VBP) systems and fair competition. The following is a more detailed breakdown of the issues involved.
Lack of Transparency
Transparency is a cornerstone of ethical contracting, especially in complex value-based models where payment is tied to performance metrics. Moda Health is accused of deliberately withholding crucial information from providers, creating significant information asymmetry. Key issues include:
Opaque Incentive Calculations: Providers were not given access to the formulas or data Moda Health used to calculate financial incentives. This opacity left providers unable to understand how their performance was evaluated, what data was being used, or how incentives were being determined. Without this knowledge, providers couldn't make informed decisions about how to meet performance targets or assess the fairness of the contract.
Concealed Risk Adjustment Methods: In value-based payment systems, risk adjustment scores play a vital role in determining reimbursement rates. Higher-risk patients generally lead to higher reimbursements. Moda Health’s refusal to allow providers to participate in or even review the risk adjustment process suggests manipulation of these scores for its own financial gain. By keeping this process hidden, Moda Health could inflate its reimbursement from state and federal funds without delivering corresponding improvements in care.
Isolation of Provider Groups: Another key concern was the health plan’s refusal to disclose the identities of other providers sharing risk in the value-based contracts. This practice hindered collaboration among providers, which is crucial for achieving shared goals in risk-sharing arrangements. By keeping providers siloed, Moda Health prevented them from comparing performance outcomes, risk calculations, or identifying patterns of inequitable treatment.
This lack of transparency created a one-sided contract where the providers were left in the dark, unable to assess risks or determine if the performance targets were achievable, while Moda Health is able to manipulate outcomes to its advantage.
Misleading Contracts and Unfair Terms
Moda Health is alleged to have structured its contracts in a way that misled providers, forcing them into agreements without clear understanding of the risks or requirements involved. These contracts are referred to as "contracts of adhesion"—standardized contracts presented on a take-it-or-leave-it basis, which offer no room for negotiation. Specific issues include:
Vague and Ill-Defined Terms: The contracts were deliberately ambiguous, with vague definitions of key performance indicators (KPIs), baselines, and targets. Providers were not given clear information on how their performance would be measured, what metrics were essential, or how success would be determined. This lack of specificity made it easy for Moda Health to manipulate outcomes post-contract by introducing new, unforeseen requirements or targets.
"Bait and Switch" Practices: Moda Health is accused of engaging in "bait and switch" tactics. Initially, the contracts appeared to offer lucrative incentives, enticing providers to sign up. However, once they committed, the health plan allegedly altered the terms, increasing the burden of compliance or introducing new performance requirements that were not part of the original agreement. Providers will almost certainly be compelled to meet changing, difficult or impossible targets, or face penalties and reduced reimbursements.
False Profit Leader: Moda Health used a deceptive tactic known as a "false profit leader." They offered what seems to be a profitable contract, with incentives tied to participation in measurement-based care (MBC) or outcome-informed care (OIC). However, the real costs of compliance (e.g., investments in technology, staff, or administrative overhead) were not offered. The contract promised profit, but it ultimately leaves providers facing financial loss once hidden requirements surface.
This manipulation placed providers in a precarious position, where they will either attempt to “game” the contract - minimizing care or avoiding complex patients to meet arbitrary targets - or exit the value-based payment (VBP) system altogether, leaving fewer options for patients.
Manipulation of Risk Adjustment Scores
In value-based payment models, risk and risk adjustment scores are designed to reflect the complexity of a provider's patient population (i.e., care-mix severity). Risk adjustment scores ensure that providers caring for higher-risk patients (who require more intensive care) are adequately compensated. Moda Health, however, is alleged to have manipulated these risk scores in several ways:
Controlling the Risk Adjustment Process: Moda Health is accused of passively preventing providers from submitting their own risk scores or participating in defining the risk adjustment process. By controlling this process substantially, Moda Health has positioned itself to underreport the severity of patient population and sub-populations, thereby apportion to providers a greater downside risk while apportioning a greater upside benefit to itself from state and federal payers.
Skewing Financial Incentives: By assuming low risk scores for high-risk population, Moda Health justifies paying providers less, while still collecting higher reimbursement from government programs based on inflated risk projections. Providers will be forced to serve fewer high-risk population patients or to shorten the duration of treatment to maintain financial stability. This tactic will almost certainly reap financial benefits for the health plan while leaving providers underpaid for the resource demands and the actual complexity of care they deliver.
Non-Collaborative Approach: The refusal of Moda Health to be transparent, accountable, and collaborate with providers in establishing accurate baselines and reasonable and sensible patient risk scores, demonstrates Moda intent to control financial outcomes. This use of asymmetric information is evidence of bad faith. Shared and transparent baselines are essential for fair risk-sharing arrangements, and Moda Health’s unilateral control over this process provides evidence of violating the essential principles of value-based contracting.
Unfair Competitive Practices and Antitrust Violations
The behaviors exhibited by Moda Health raise serious concerns regarding antitrust violations. Key issues include:
Restricting Provider Competition: By imposing opaque and misleading contracts, Moda Health effectively restricted competition among providers. Independent and smaller providers were placed at a significant disadvantage, as they lacked the resources to analyze the complex contract terms or challenge the health plan’s practices. This limited the ability of new providers to enter the market, reinforcing Moda Health’s market dominance.
Creating Phantom Networks: The isolation of providers, combined with the use of ambiguous contract terms, led to the creation of “phantom networks.” In these cases, Moda Health would list providers as part of its network, even though those providers may be unable or unwilling to take on new patients due to burdensome contract requirements. This practice will almost certainly misled patients and employers into believing they had broader access to care than was available.
Market Foreclosure: Moda Health’s refusal to disclose critical information and engage in fair negotiations effectively forecloses the market to new entrants. Smaller provider practices are unable to compete, while larger groups with greater resources could potentially compete or "game" the system. This exclusionary tactic distorted competition, limiting patient choice and harming the quality of care.
These practices may violate the Sherman Antitrust Act, which prohibits actions that may restrict trade or create monopolistic control over a market. By manipulating contracts and suppressing competition, Moda Health could be engaging in anticompetitive behavior that harms both providers and patients.
Consequences for Providers and Public Health
The fallout from Moda Health’s practices is significant, affecting both providers and the broader public health system:
Erosion of Trust: Providers who signed these contracts will almost certainly become disillusioned when they realize the terms were not what they initially appeared to be. The lack of clear communication, hidden financial risks, and inability to collaborate with other providers is damaging trust in the health plan and in the broader value-based payment system.
Reduced Quality of Care: When financial incentives are tied to opaque or unachievable metrics, providers are incentivized to cut corners, avoid high-risk patients, or focus on gaming the system rather than delivering quality care. This ultimately leads to poorer outcomes for patients, as providers focus more on meeting arbitrary financial targets than addressing the actual health needs of their patients.
Financial Losses and Provider Burnout: The hidden costs associated with Moda Health’s contracts - such as the need to invest in new technologies, hire additional staff, or spend time on administrative compliance - led to financial strain for providers. Providers as whole will almost certainly find themselves working harder for less money. Some will opt out of a so-called value-based system altogether, limiting patient access to care.
Systematic Waste of Taxpayer Dollars: Moda Health’s manipulation of risk adjustment scores and opaque contract terms position Moda to misuse of public funds. By inflating its reimbursements initially, which are designed to decline, will underpay providers. There is evidence that Moda is, almost certainly, diverting taxpayer dollars away from improving patient care and toward its own financial bottom line.
Requested Action
To prevent bad faith, fraud, and antitrust violations, provider and stakeholders need the definition in health plan contracts that describe: (1) transparent shared values, objectives, controls, and key performance indicators, (2) tests of design and effectiveness, (3) definitions that can be used across all health plans in Oregon, (4) whistle blower protections for contracted providers, (5) resolving legislative voids and regulatory gaps to ensure investigations of bad faith contracts, fraud and antitrust violation, and (6) plain understandable contract language. Given the severity of these allegations, we respectfully request that the Oregon Health Authority take the following actions:
Investigate Moda Health’s Contracting Practices: We ask for a thorough investigation into Moda Health’s offering of fraudulent contracts to IMHPA and 128 provider groups, with a focus on the manipulation of risk scores, deceptive contract terms, and bad faith contracting. Lack of transparency and take-it-or-leave-it contracting has no place in value-based payment contracts.
Evaluate Potential Antitrust Violations: We request an evaluation of whether Moda Health’s practices violate Oregon’s antitrust laws, including its impact on competition, market foreclosure, and the isolation of providers while using opaque risk-sharing agreements.
Ensure Public Accountability: Given that Moda Health is using taxpayer funds through contracts with OEBB, PEBB, and OHSU, we ask the Attorney General’s office to ensure that these public resources are being used appropriately and not diverted into fraudulent schemes using providers to win contracts and to increase their market share by creating an unfair advantage over other health plans.
Provide Remedies for Affected Providers: We ask that the Attorney General’s office consider ways to provide legal and financial remedies for the disadvantaged providers affected by Moda Health’s fraudulent practices, including compensation for financial losses and legal assistance for those seeking to exit these contracts.
Support Legislation: Create Definitions, Secure online Reporting System, and OHA Monitoring for Evidence of bath Faith Contracting, Fraud and Antitrust Violations
Moda Health’s contracting practices present serious threats booth to providers and the public health system in Oregon. We urge the Office of the Attorney General to take immediate action to investigate these practices, enforce the anti-fraud and antitrust laws, and protect the integrity of public healthcare contracts. Thank you for your attention to this critical matter.
Legal and Regulatory Considerations for Investigating Moda Health’s Contracting Practices
An investigation into Moda Health’s contracting practices would likely consider several state and federal laws and regulations to determine whether Moda engaged in fraudulent practices, violated antitrust laws, or breached fair contracting requirements.
Relevant and Related Laws and Regulations
The Sherman Antitrust Act (1890) prohibits monopolistic practices, restraint of trade, and actions that restrict competition. An investigation would examine whether Moda’s actions to manipulate contract terms and restrict provider collaboration provide evidence that Moda violated these provisions.
The Clayton Antitrust Act (1914) addresses anti-competitive practices not covered by the Sherman Act, including price discrimination and exclusive dealing contracts that might be designed to limit competition or create barriers to entry. An investigation would examine whether Moda’s contracting practices violated these provisions.
The Federal Trade Commission (FTC) Act (1914) prohibits unfair or deceptive acts or practices in commerce. This could be applicable if Moda’s contracts are found to be misleading or exploitative, causing harm to providers and consumers.
The False Claims Act (FCA) applies if Moda’s manipulation of reimbursement rates results in inflated claims for federal or state healthcare funds. The FCA allows whistleblowers to file qui tam lawsuits if they have evidence of fraudulent claims submitted to government programs like Medicaid or Medicare.
The Health Insurance Portability and Accountability Act (HIPAA) includes provisions for fraud and abuse prevention, particularly if health plans are manipulating data or reimbursement models in ways that could misrepresent the nature of care being delivered.
The Oregon Antitrust Act mirrors many federal protections but is tailored to local business practices. These laws would apply if Moda’s contracting practices unfairly limit competition within the Oregon healthcare market, create barriers for smaller providers, or constitute collusion with other market participants.
The Oregon Unlawful Trade Practices Act (UTPA) prohibits businesses from engaging in “unconscionable tactics” when contracting with consumers or businesses. Moda’s “bait and switch” tactics and contracts of adhesion could be scrutinized under this law, particularly if providers can demonstrate that they were misled or coerced into unfair agreements.
The Whistleblower Protection Act (WPA) protects federal employees and contractors from retaliation for reporting fraud, abuse, or violations of law. Oregon’s state laws offer similar protections. If Moda’s actions discourage or retaliate against providers contracted and paid with federal dollars attempting to report unethical practices, they could be in violation of these protections. (Oregon law, in effect, protects consumers and employees of health plan, not contracted providers who are paid with private sector funds)
Instructive and Potentially Relevant Laws and Regulations
The Patient Protection and Affordable Care Act (ACA) includes specific whistleblower protections and regulations regarding transparency in healthcare contracting, particularly where federal funds are involved. An investigation would consider whether Moda’s failure to disclose risk-sharing and incentive terms violates these regulations.
Federal and state false advertising and consumer protection laws, such as the Lanham Act and Oregon’s Unlawful Trade Practices Act, could be relevant if Moda misrepresented the terms of its contracts to gain a competitive advantage or provided misleading information to providers.
The Oregon Health Authority Regulations oversee health plans and public health contracts, setting standards for transparency, fairness, and ethical conduct. Moda’s practices might violate these regulations if it is found that they engaged in bad faith contracting or created barriers to care for underserved populations.
Federal and state fraud statutes, such as the Mail and Wire Fraud Statutes, could apply if Moda used electronic communications (e.g., emails, phone calls) to further fraudulent schemes. Any deliberate attempt to deceive providers about the nature of contractual terms, reimbursement rates, or risk-sharing arrangements could also be prosecuted under state-level criminal fraud statutes.
Oregon’s Public Contracting Code governs transparency, fairness, and integrity in public procurement processes. Moda’s contracts with public entities like OEBB, PEBB, and OHSU may fall under these standards, particularly if there is evidence of manipulating public funds.
By leveraging these laws and regulations, an investigation would have multiple avenues to scrutinize Moda’s actions. If these practices are proven to violate these laws, Moda could face substantial penalties, mandated corrective actions, and potential loss of public contracts.
What Does “Too Big to Fail” Mean?
The economic term "too big to fail" refers to a situation where a business, typically a financial institution, has grown so large and interconnected within the economy that its failure would have catastrophic consequences for the broader financial system. This could lead to widespread economic disruption, potentially triggering a financial crisis. Consequently, these institutions may receive government bailouts or other forms of support during times of distress to prevent their collapse.
The concept gained prominence during the 2008 financial crisis, when major banks and financial firms like Lehman Brothers, AIG, and others were deemed too systemically important to be allowed to fail without significant negative repercussions. In response, some of these institutions received government intervention to stabilize the economy.
Key characteristics of "too big to fail" institutions include:
Size: These entities are typically among the largest in their sector.
Interconnectedness: Their operations are deeply entwined with other financial institutions, markets, and sectors.
Systemic Risk: Their failure could lead to a domino effect, impacting many other institutions and potentially leading to a broader economic collapse.
As a result, governments often feel compelled to support these institutions, fearing that allowing them to fail would be costlier than a bailout. However, this also leads to moral hazard, where firms might take on excessive risks, believing they will be rescued if things go wrong.
Potential Impact of Complaint on Trajectory of Value-Based Care
The purpose of this complaint is NOT to punish Moda but rather to create guardrails that would prevent what is described in this complaint. A proposed bill that directly addresses the contracting practices highlighted in a whistleblower report could indeed influence Moda to take corrective actions. Legislative action should include comprehensive measures such as standardized contract definitions, whistleblower protections, transparency requirements, and reporting with independent oversight provisions. Ideally legislation should compel health plans to avoid misconduct in the following detailed ways:
Mandatory Transparency in Contracts
Legislation should require clear and standardized definitions for key contractual terms, such as risk-sharing, incentive calculations, and key performance indicators (KPIs). This provision would reduce Moda’s ability to use vague or ambiguous language that allows them to manipulate reimbursement and risk scores. By setting legislative standards, Moda would be forced to ensure all their contracts comply with these new requirements, thereby curtailing the practices currently described as "misleading" and "deceptive."
Mandatory Whistleblower Protections in Contracts
Including whistleblower protections in Legislation would make it safer for contracted providers to report unethical practices without fear of retaliation. This could lead to increased accountability, as providers might feel more empowered to share information that exposes unfair or fraudulent practices. With stronger whistleblower mechanisms, Moda would likely face more scrutiny and be pressured to preemptively address internal issues rather than risk being reported.
Independent Oversight and Auditing
If Legislation mandates independent oversight of value-based contracts, Moda would be subject to regular audits and reviews by an external body or an independent internal body. This provision would reduce the likelihood of Moda engaging in practices such as ill-informed policy, unfair risk adjustments, or withholding critical information from providers. The presence of independent oversight could also deter Moda from implementing opaque contracting practices, knowing that any misalignment would be investigated by an independent party.
Market Consequences and Legal Accountability
A Legislative emphasis on fair competition and ethical contracting could have serious market consequences for Moda if it fails to comply. Should the bill become law, Moda’s ability to secure public contracts could be jeopardized if they are found violating the new standards. This potential risk would incentivize Moda to realign their contracting strategies to adhere to the new regulations, thereby avoiding penalties, loss of contracts, or legal repercussions.
Protecting Smaller Providers, and Minority Providers, and Encouraging Fair Practices
Legislation could also include provisions that specifically protect smaller provider groups from contracts of adhesion (take-it-or-leave-it agreements) and require full disclosure of all terms and risk-sharing arrangements. This would level the playing field and reduce Moda’s ability to exploit smaller providers, thereby encouraging fairer and more ethical contracting practices across the board.
If passed, legislation could significantly alter Moda’s current trajectory by making it costly for them to continue their current contracting strategies. Given the allegations of bad faith and potential fraud, Moda might proactively change its practices to align with the new legislative requirements to maintain its reputation, secure future contracts, and avoid regulatory sanctions.
Sufficient Evidence to Investigate for Fraud and Antitrust Violations
There is sufficient evidence and reason to investigate Moda Health for conspiracy to commit fraud and violations of antitrust laws, given the documented patterns of deceptive and misleading contracting practices, refusal to disclose risk-sharing terms, and manipulation of reimbursement rates. These actions create an unfair competitive advantage over other health plans and are designed to mislead providers, patients, and public institutions. Such practices, if proven, would constitute violations of both state and federal regulations, particularly those governing fair competition and transparent contracting.
Additionally, the reported lack of transparency and concealment of critical information from 128 small and mid-sized provider groups suggests a deliberate effort to isolate and suppress provider collaboration. This behavior could fall under antitrust violations by restricting competition and creating an environment where Moda controls the entire contracting process to their benefit. If the bill includes stringent auditing and monitoring mechanisms, it could compel Moda to correct these practices and adhere to a more transparent, equitable contracting model.
In essence, the proposed bill would not only address the existing issues but also set a precedent for handling similar cases of antitrust and fraud allegations in healthcare contracting, ensuring that no entity - no matter how large - is above accountability.
Unpacking Value-Based Contracts: The Hidden Risks and Public Concerns Impacting Healthcare Quality and Fairness
The concerns and problems surrounding value-based contracts can be complex, but there are a few key issues that are both easy for the public to understand and resonate with their sense of fairness and the importance of quality care. These issues often directly affect how people perceive healthcare providers' ability to deliver effective care and how patients may be impacted by financial motives:
1. Lack of Transparency
Why It’s Easy to Understand: The public can easily grasp the concept of a lack of transparency because it relates to the idea of trust and honesty. When contracts are not clear, and key details about how providers are paid or evaluated are hidden, it raises questions about fairness and honesty.
Why It Feels Important: People want to know that healthcare providers and organizations are upfront about their intentions and how decisions are made. If the rules of the game aren’t clear, it undermines confidence in the entire system and leads to suspicion about hidden agendas or unfair practices.
2. Misaligned Incentives That Do Not Prioritize Quality Care
Why It’s Easy to Understand: The idea that providers should be paid based on the quality of care they deliver, rather than on cost savings or internal financial targets, is straightforward. The public understands that if a doctor or therapist is rewarded for spending less time or cutting services, this can reduce the quality of care.
Why It Feels Important: People want to believe that their providers are focused on delivering the best care possible, not on cutting corners or making decisions based on financial considerations. When contracts reward cost-cutting rather than patient outcomes, it feels wrong and goes against the idea that healthcare should be centered on what’s best for patients.
3. Manipulation of Performance Metrics
Why It’s Easy to Understand: The idea of changing the rules to make things look better than they are resonates with people because it’s like “moving the goalposts” in any competition. If the way performance is measured is manipulated, it’s easy to see how the results could be misleading.
Why It Feels Important: People want performance metrics to be accurate because they reflect whether their care is effective or not. Manipulated metrics can mean that providers are unfairly penalized or rewarded, which ultimately impacts patient care and public trust in the healthcare system.
4. Contracts That Penalize Providers for Treating High-Need Patients
Why It’s Easy to Understand: This is similar to the idea of punishing teachers for working with students who have greater educational needs. If providers are penalized for serving sicker or more complex patients, it feels intuitively wrong and unfair.
Why It Feels Important: The public wants to know that all patients, including those with complex or severe conditions, have access to quality care. If contracts make it harder for providers to serve high-need patients, it feels like the system is biased against vulnerable people who need the most help.
5. Coercive and “Take-It-Or-Leave-It” Contracts
Why It’s Easy to Understand: People understand when someone is being forced into a bad deal with no room for negotiation. When contracts are presented as non-negotiable, it creates an imbalance of power and feels like coercion.
Why It Feels Important: The public values fairness and equity, and they want to believe that providers are able to negotiate contracts that allow them to deliver the best care possible. If providers are forced into bad agreements, it undermines their ability to focus on patient care and puts them in a position where they may have to compromise quality.
6. Hidden Financial Risks for Providers
Why It’s Easy to Understand: The concept of signing up for something without being told about the risks is easy for anyone to grasp. People know that hidden risks in contracts can lead to unexpected problems and losses, which is unfair and deceptive.
Why It Feels Important: People want to know that providers are in a stable position to deliver care and aren’t being misled into risky financial arrangements that could jeopardize their practice. If providers are destabilized financially, it ultimately impacts patients and their access to services.
7. Incentives That Prioritize Cost Control Over Patient Needs and Outcomes
Why It’s Easy to Understand: The idea that financial incentives could lead providers to prioritize saving money over patient care is straightforward. It’s like a mechanic being paid more to use cheaper parts - everyone understands that this can reduce quality.
Why It Feels Important: The public wants to believe that their health is more important than cost savings. If contracts encourage providers to prioritize financial goals over patient needs, it feels unethical and goes against the core values of healthcare.
These concerns are easy for the public to understand because they tap into basic principles of fairness, trust, and the expectation that healthcare should be focused on patient well-being, not financial gain. When these principles are violated, it resonates with people and feels like a fundamental breach of what healthcare should stand for.
Analysis of Moda Health Code of Conduct and Allegations of Violations
Moda Health Code of Conduct:
https://www.modahealth.com/pdfs/comp/code_of_conduct.pdf
The allegations outlined in the Complaint filed with the Oregon Health Authority (OHA) suggest significant discrepancies between Moda Health's stated Code of Conduct and its actual contracting and negotiation practices. Below is a comparison of specific allegations with the corresponding sections of the Code, alongside broader implications for providers, patients, and public trust.
Shifting Metrics and Retroactive Penalties
Moda Health is accused of implementing a contract with mid-contract changes to performance metrics and with retroactive penalties. These adjustments, described as unpredictable and burdensome, undermine providers’ ability to manage obligations and financial outcomes. According to Moda’s Code of Conduct, the organization pledges to “accurately and honestly represent Moda and may not engage in any activity intended to defraud anyone of money, property, or services.” Retroactive changes appear to violate this principle by introducing financial risks that were not disclosed at the outset. Additionally, the lack of transparent metrics conflicts with the Code’s commitment to transparency and fairness.
Bait-and-Obfuscate Strategy
The complaint highlights a tactic in which Moda initially presents contracts with seemingly acceptable terms which have hidden administrative and performance demands. These undisclosed requirements create significant challenges for providers after the contract has been signed. Moda’s Code emphasizes integrity, stating that all actions should “exhibit a high degree of personal integrity at all times” and “refuse to engage in or tolerate any fraud, misuse, abuse, or waste of resources.” By withholding essential information during contract negotiations, Moda fails to uphold the integrity and honesty required to maintain ethical relationships with providers.
Phantom Networks and Deceptive Representation
Moda is alleged to have listed providers as in-network, even when many of these providers are unlikely to accept new patients. This misrepresentation reportedly misleads public purchasers and skews the competitive healthcare market. Moda’s Code asserts that members have “the right to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care.” Deceptive network practices directly contradict this commitment by depriving patients of reliable access to care and undermining trust in Moda’s network.
Contracts of Adhesion and Asymmetric Negotiations
According to the complaint, Moda employs “take-it-or-leave-it” contracts, leaving providers with no meaningful opportunity to negotiate terms. These contracts disproportionately impact smaller practices, which lack the financial and legal resources to challenge unfavorable conditions. The Code encourages resolving “dissent and discord” and promoting fairness, but asymmetric negotiations reflect an imbalance of power that conflicts with these principles. Moda’s actions may also undermine the Code’s directive for all decisions to be “guided solely by the best interests of Moda,” as equitable provider relationships benefit the broader healthcare system. Moda was avoidant, misleading, abusive and unprofessional during contract discussions.
Retaliation Risks for Reporting Providers
The complaint alleges that Moda does not provide adequate protections for whistleblowers and that providers risk retaliation, including reduced referrals or contract terminations, for raising concerns. This creates a culture of silence that allows unethical practices to persist unchecked. Moda’s Code explicitly promises that there will be “no retribution for asking questions or raising concerns about the Code or for reporting possible improper conduct.” The fear of retaliation reported by providers contradicts Moda’s stated commitment to fostering a safe and open reporting environment.
Financial and Operational Burdens
Providers allege that Moda imposes undefined metrics, excessive administrative burdens, and opaque incentive structures. This creates significant challenges in assessing contractual risks and fulfilling obligations. The Code emphasizes pursuing “the highest possible standards of performance, quality, service, and achievement” and discourages “guesswork or inappropriate characterizations of people and companies.” The ambiguity and complexity of Moda’s requirements undermine these values, placing undue strain on providers and diminishing their ability to deliver high-quality care.
Broader Implications of Discrepancies
Impact on Providers
The allegations suggest that Moda’s practices contribute to moral injury and burnout among providers. Financial and administrative pressures force providers to prioritize compliance over patient-centered care, leading to diminished trust and professional dissatisfaction. Smaller practices, in particular, face heightened vulnerabilities due to limited resources, exacerbating power imbalances and undermining their autonomy.
Impact on Patients
Patients are directly affected by these practices. Deceptive network representations and provider burnout result in reduced access to care and compromised therapeutic relationships. Additionally, an overemphasis on performance metrics at the expense of individualized care risks undermining patient outcomes, particularly in mental health and other fields where subjective measures play a significant role.
Impact on Public Trust
The alleged practices raise serious concerns about the misuse of public funds. Moda’s contracting strategies may prioritize financial returns over equitable care delivery, undermining the integrity of publicly funded programs. Furthermore, anticompetitive practices, such as phantom networks and coercive contracts, reduce competition and provider choice, harming the broader healthcare ecosystem.
Moda Health’s Potential Response to Complaint and MRI’s Rebuttal, and Position
Mentor Research Institute (MRI) acknowledges that it does not possess investigatory powers and has not been granted access to all the necessary information or dialogue to fully understand the nuances of Moda Health’s contracting practices. Despite these limitations, MRI’s analysis is based on the best available data and has been constructed in good faith. MRI believes that it has presented a reasoned argument rooted in declarative facts that are sufficiently reliable and useful to support a valid conclusion about the risks and potential negative impacts of Moda’s contracting practices on purchasers, taxpayers, providers, patients and public health
Importantly, MRI remains open to reconsidering its position if additional information comes to light. If Moda were to provide clear disclosures or respond to requests for more comprehensive details regarding its contracting models, risk-sharing arrangements, and performance metrics, MRI would welcome the opportunity for further analysis and constructive dialogue. However, to date, Moda has not made such disclosures, nor has it responded to requests for clarification or honored agreements made during prior negotiations. They have repeatedly resorted to silence, effectively breaking off negotiations. This lack of transparency and collaboration has left MRI with no choice but to draw conclusions based on what is currently known.
Nonetheless, MRI contends that the current evidence is compelling enough to raise serious concerns about the fairness, transparency, and legality of Moda’s contracting behavior. MRI’s position is not intended to be final or immovable; it is a preliminary assessment based on the available information and is subject to change if Moda engages openly and provides the necessary context and documentation. Unfortunately, Moda’s actions - or lack thereof - have created a situation that has already caused confusion, concern, and mistrust among providers, making it a figurative bell that cannot be unrung.
Moda Health’s Potential Response to Complaint
Intentions Focused on Supporting Providers and Transitioning to Value-Based Care
Moda might argue that its primary goal was to support providers in the complex transition to value-based care, not to mislead or undermine them. They could state that their contracts were structured with flexibility to help providers gradually adopt measurement-based care, optimize performance, and achieve long-term success. Moda might claim that any perceived issues with the contracts were unintended consequences stemming from the inherent complexities of implementing new models, rather than from any malicious or deceptive intent.
Misunderstanding Due to Lack of Provider Engagement
Moda might argue that MRI’s misunderstanding of the contract was due to its decision not to sign and fully engage in the agreement. They could assert that if MRI and other providers had participated, they would have gained a clearer understanding of the contract’s structure, incentive design, and the intention behind specific provisions. According to Moda, MRI’s critical interpretation is based on incomplete information and external observations rather than firsthand experience with how the contracts were implemented.
Transparency and Efforts to Communicate Contract Terms
Moda could contend that they made reasonable efforts to communicate the basis of their incentive structures and contract terms to providers during the negotiation process. They might argue that any misunderstandings arose because some providers did not fully engage with the detailed explanations Moda provided. Moda could maintain that MRI’s claims of information asymmetry are not grounded in fact and that Moda consistently acted in good faith to ensure providers had the information needed to make informed decisions.
Adherence to Legal Standards and Safe Harbor Provisions
Moda might maintain that their contracts were carefully structured to comply with federal and state regulations, as well as antitrust “safe harbor” provisions. They could argue that MRI’s interpretation overstates the impact of their practices, mischaracterizing them as anti-competitive or harmful. Moda could assert that their contracts were designed to promote collaboration, efficiency, and quality care, while adhering to all applicable legal guidelines.
The Contract Was Structured to Evolve Over Time
Moda might argue that the contract was intended to be a “living document,” designed to evolve as providers participated, submitted feedback, and helped refine the value-based model. They could assert that the initial lack of detailed definitions and specific metrics was intentional to allow flexibility for customization based on provider performance data and real-world outcomes. Moda could position this structure as a necessary feature to accommodate diverse provider needs and market realities, not as a sign of bad faith or deceptive contracting.
Use of Internal Financial Targets to Provide Stability
Moda might defend its use of internal financial targets as a temporary measure designed to provide a stable financial foundation for providers during the transition. They might argue that by linking incentives to internal cost-control metrics initially, they aimed to prevent financial volatility and ensure consistent compensation until more accurate provider performance data could be collected and analyzed. Moda could assert that this approach was meant to provide predictability, not to prioritize internal goals over patient outcomes.
Protection of Provider Privacy and Professional Integrity
Moda might argue that their refusal to disclose specific provider names in response to MRI’s critiques was not an attempt to hide information but rather a necessary measure to protect provider privacy and professional reputations. They could state that associating specific providers with MRI’s highly critical analysis could cause undue harm, damage relationships, and discourage providers from participating in future contracts. Moda could assert that maintaining confidentiality is essential to ensuring trust and promoting an environment where providers feel safe to engage openly.
Good Faith Efforts to Address Concerns
Moda might emphasize that they made consistent good faith efforts to address provider concerns and adjust contract terms when issues were raised. They could argue that any perceived shortcomings were addressed promptly, demonstrating their willingness to operate transparently and collaboratively. Moda could claim that MRI’s portrayal of their contracts as coercive or deceptive is an overstatement, as Moda was always open to feedback and sought to improve based on provider input
No Evidence of Tangible Harm to Providers or Patients
Moda might argue that MRI has not presented concrete evidence that the contracts caused tangible harm to providers or patients. They could claim that the majority of their provider network has not raised similar concerns, indicating that MRI’s analysis is based on isolated incidents rather than systemic issues. Moda could emphasize that its contracts were designed to balance provider sustainability with patient care, and any perceived negative impacts are speculative rather than substantiated by data.
Flexibility and Adaptation to Evolving Market Conditions
Moda might argue that the statement about “making it up as we go” was taken out of context and was not an admission of poor planning or bad faith. Instead, Moda could contend that it reflects their commitment to being flexible and adaptive in response to a rapidly changing healthcare landscape. They might state that this approach allowed them to respond to evolving regulations, provider feedback, and market dynamics in real-time to create a more effective value-based care model.
Collaborative Intent Rather Than Exclusionary Tactics
Moda might argue that their contracts were not designed to exclude or disadvantage smaller providers but rather to create a collaborative framework where providers could succeed under the value-based model. They could assert that any difficulties experienced by smaller providers were unintended and resulted from the inherent challenges of adapting to a complex new system, rather than from deliberate exclusion or market manipulation.
MRI’s Argument, Rebuttals and Position
A Contract Should Be Clear Before Signing
MRI might argue that a contract’s clarity and fairness should be evident before any provider agrees to its terms. Moda’s argument that MRI should have signed the contract to gain a better understanding is fundamentally flawed. The lack of clear definitions, information asymmetry, and ambiguous language made it impossible for providers to fully understand their rights and obligations, leading to confusion and uncertainty. A contract that requires signing to be understood is inherently problematic and places undue risk on the provider.
Misalignment with Value-Based Care Principles
MRI might argue that Moda’s use of internal financial targets instead of provider performance metrics contradicts the core objectives of value-based care, which focus on improving patient outcomes and rewarding high-quality services. By prioritizing cost-control metrics over clinical metrics, Moda created a compensation model that distorts the intent of value-based care, incentivizing cost-cutting rather than quality improvements. This structure not only misaligns with industry standards but also creates perverse incentives that are likely to reduce the quality of patient care and increase the administrative burden on providers.
Lack of True Transparency and Symmetrical Information
MRI might contend that Moda’s claim of transparency is not supported by the evidence. Moda withheld critical information about the basis for incentive payments and the nature of risk-sharing arrangements, creating a significant information asymmetry that disadvantaged providers. MRI will argue that this lack of disclosure prevented providers from accurately assessing whether the contracts were financially viable or aligned with their clinical goals. Such a lack of transparency is indicative of bad faith contracting and places providers at a significant disadvantage when negotiating terms.
Misrepresentation of Incentive Structures
MRI might argue that Moda’s failure to clearly communicate that incentives were based on internal financial targets, rather than clinical outcomes, misled providers into thinking that their performance would be the primary driver of compensation. This misrepresentation created a situation where providers invested time and resources into meeting quality benchmarks, only to find out later that these efforts did not significantly impact their reimbursement. This constitutes a breach of good faith and fair dealing, as providers operated under false assumptions about the true basis of the incentive structure.
Exacerbating Provider Vulnerability and Risk
MRI might emphasize that Moda’s lack of transparency and incomplete disclosures exacerbated existing vulnerabilities among smaller providers, particularly those serving high-risk or underserved populations. By not providing critical data on patient risk levels and refusing to allow providers to collaborate on shared risk strategies, Moda increased the financial burden on vulnerable practices, making it more likely that these providers would accept unsustainable risk-sharing agreements. This created an environment where smaller practices faced disproportionate financial risks, which could destabilize their operations and limit access to care for their patients.
Ambiguous and Coercive Language
MRI might maintain that Moda’s use of vague or ill-defined terms was not a matter of complexity but a deliberate tactic to obscure key elements of the agreement. The ambiguity allowed Moda to interpret and change contract provisions unilaterally, placing providers at an unfair disadvantage. MRI will argue that this approach created a one-sided agreement that heavily favored Moda, undermined the financial stability and clinical autonomy of providers, and made it difficult for them to plan and deliver care effectively. MRI created and offered Moda a set of definitions.
Participation Should Not Be a Precondition for Understanding
MRI might counter Moda’s argument that MRI should have participated to gain a better understanding by stating that a contract’s fairness and transparency should be evident before participation. Expecting providers to sign an unclear contract and then hope for clarification through experience is an unreasonable and risky approach that shifts undue burden onto the providers. MRI will assert that this expectation violates the principles of good faith and fair dealing that should be central to any contracting relationship.
Erosion of Trust and Provider Stability
MRI might present evidence showing how these contracts have led to financial instability, increased stress, and reduced clinical autonomy for providers. The unclear terms, shifting performance metrics, and ability to make unilateral changes created a contracting environment that eroded provider trust and destabilized their business operations. MRI will argue that these negative outcomes are not isolated incidents but are indicative of systemic problems with Moda’s contracting practices, which have compromised the sustainability of smaller practices and undermined the quality of care they can deliver to patients.
Protection of Provider Privacy as a Pretext
MRI might counter Moda’s argument that provider identities were concealed to protect privacy by stating that the true intent was to avoid transparency and limit scrutiny. While protecting provider privacy is important, MRI will argue that Moda could have released anonymized data or aggregate information that would have allowed for meaningful analysis without compromising confidentiality. Moda’s refusal to do so suggests that their concern was not about privacy but about preventing external evaluations of the real-world impacts of their contracts. Providers were denied the opportunity to define shared values, objectives, controls, key performance indicators, align targets, coordinate care, and more
“Making It Up as We Go” Indicates Lack of Strategic Planning
MRI might argue that Moda’s admission that they were “making it up as we go” is not evidence of flexibility but of a lack of strategic planning and foresight. A well-structured value-based care model should be grounded in clear definitions, shared values, objectives, controls, evidence, transparency, and clear implementation guidelines. MRI contends that Moda’s approach created an unpredictable contracting environment, placing providers at unnecessary risk and undermining the stability and effectiveness of the value-based model they were trying to implement.
Lack of True Collaboration with Providers
MRI might argue that despite Moda’s claims of collaboration, the lack of meaningful input from providers in contract development and the inability to negotiate critical terms undermined the spirit of true collaboration. MRI will highlight that effective collaboration requires responsive communications, symmetrical information, shared decision-making, and transparency. By isolating providers and denying them access to critical information, Moda prevented providers from engaging in meaningful risk management and strategic planning.
Need for Regulatory Oversight and Comprehensive Reforms
MRI might argue that Moda’s practices demonstrate the need for stronger regulatory oversight to ensure that value-based contracts are truly transparent, equitable, and aligned with the principles of good faith contracting. MRI will advocate for legislative reforms that require health plans to disclose comprehensive risk data, develop and define key terms clearly, and support collaborative efforts among providers. MRI will position itself as an advocate for ethical contracting standards that protect providers from the kinds of coercive and deceptive practices they have identified in Moda’s agreements.
Recommendations for Action
Regulatory Oversight
The Oregon Health Authority (OHA) should conduct a comprehensive investigation into Moda’s contracting practices to determine compliance with ethical and legal standards. Clear definitions and transparent terms should be mandated in all contracts.
Strengthening the Moda Health Code of Conduct
Moda should update its Code of Conduct to include explicit safeguards for whistleblower protections and establish robust guidelines for fair and transparent contracting practices. Regular audits of adherence to the Code should also be implemented.
Legislative Reforms
Legislators should require health plans to define performance metrics and administrative requirements upfront. Laws promoting fair negotiations and protecting providers from retaliation would help balance the power dynamics in healthcare contracting.
Provider Support
Smaller practices should have access to legal and financial resources to help them navigate complex contracts and negotiate equitable terms. Collaborative efforts among providers could also strengthen their bargaining power.
By aligning its practices with the principles outlined in its Code of Conduct, Moda Health can rebuild trust and promote ethical contracting practices that benefit providers, patients, and the healthcare system. These steps are essential to ensure that Moda's commitment to integrity and fairness is reflected not just in its policies but also in its actions.
Conclusion
Overall, MRI’s rebuttal to Moda would likely focus on demonstrating that Moda probably engaged, intentionally or not, in illegal behavior or practices that fall outside of industry norms, state and federal regulations. MRI’s analysis suggests that Moda’s contracts were structured in a way that obscured important terms, misrepresented incentive structures, and placed providers at an unfair disadvantage. While Moda might argue that their practices were within legal boundaries, MRI will emphasize that the resulting harm and the potential for significant legal and ethical conflict and violations cannot be ignored.
MRI believe legislation to create guardrails and firewalls will be more effective than allowing the promise of value-based care to crumble in a quagmire of contracts that are ill-defined, ambiguous, misleading, deceptive, have evidence of fraudulent, or are outside the “safe-harbor” from antitrust violation.
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Good Faith Disclaimer and Purpose of Analysis
This discussion document is intended for training, education, legislation, and research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge. This is not an indictment of Moda Health, but rather an effort to highlight concerns, encourage education, and constructive dialogue to ensure that value-based contracting aligns with the best interests of providers, health plans, and patients.
For more information see: https://www.mentorresearch.org/disclaimer-and-purpose