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Navigating Healthcare Challenges: Lessons Learned and Solutions for Ethical Practice

In today's healthcare landscape, recent events have highlighted concerning behaviors that demand our attention and action. Let's examine lessons learned from two cases that shed light on the importance of ethical practice within healthcare and the need for proactive solutions to navigate healthcare challenges.



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Case 1: Late in 2023, a significant settlement involving Cigna underscored the repercussions of inaccurate diagnosis coding within Medicare Advantage Plans. Cigna agreed to a substantial payment of $172 Million to resolve allegations of violating the civil false claims act. By misrepresenting diagnosis codes related to morbid obesity, Cigna not only misled Medicare but also betrayed the trust of beneficiaries. This case serves as a stark reminder of the ethical responsibilities inherent in healthcare provision.


Not only does Cigna now have public opinion fallout to manage, but now also has a five-year corporate integrity agreement with the U.S. Department of Health and Human Services of the Office of Inspector General. This agreement requires Cigna to implement accountability and auditing provisions such as annual risk assessments, monitoring, and independent reviews throughout the organization.


Case 2: In early 2024, a Miami-based physical therapy assistant was convicted of healthcare fraud, illuminating the risks associated with falsifying treatment records. By fabricating therapy notes (1,500 therapy notes for treatments that were never provided) and logging impossible hours, the individual defrauded insurance providers and compromised patient care. These false and fraudulent therapy notes led to $2.6 Million dollars of billed claims to Blue Cross Blue Shield. This egregious misconduct underscores the need for stringent oversight and accountability measures within healthcare settings.


These cases may seem disparate, but they share a common thread of unethical behavior and the urgent need for change. As stakeholders in the healthcare ecosystem, we must address systemic challenges while upholding the highest standards of integrity and patient care.


With only a handful of outpatient therapy companies who report public quarterly results, ATI Physical Therapy is a great example of a vital sign or even public pulse of the outpatient therapy industry.  Unless you are an accountant, good luck interpreting the posted financial metrics; however, one key performance indicator (KPI) light is flashing bright red! Visits per day (per provider) increased from 8.7 in 2021, to 8.8 in 2022, to 9.4 in 2023.  Multiple variables impact and may explain this KPI, but how is this trend sustainable? How can therapists continue to increase visits per day while complying with all of the regulatory requirements, outcome tracking and other patient care initiatives. When one looks around and observes payors and providers trying to cheat the system, one realizes the need for incentives and encouragement to stay ethical and compliant. Increasing visits per day may improve P&L sheets, but how can providers and owners actually lower operating costs?


The Path Forward:

  1. Prioritize Compliance: Regardless of size, every organization must invest in robust compliance measures. Outsourcing compliance tasks to specialized firms like Risk & Compliance Analytics can streamline processes and ensure adherence to regulatory standards.

  2. Harness the Power of AI: Embrace innovative solutions like Prediction Health's AI-powered chart audit function to enhance transparency and drive operational efficiency in healthcare audits.

  3. Embrace Remote Therapeutic Monitoring: Partner with experts such as PT Wired to leverage remote therapeutic monitoring services, optimizing patient care delivery and maximizing revenue streams.

  4. Optimize Staffing with Virtual Solutions: Overcome staffing challenges and enhance quality control by incorporating virtual front desk staff, such as those provided by Virtual Sally, into your practice.

  5. Phone-a-Friend: Even if you don’t want to be a millionaire, asking the audience or or choosing a 50:50 lifeline is just not good enough in the heavily regulated healthcare environment. Subscribe and join as a member to get access to tools, resources and experts who can immediately guide you on complex everyday issues in the clinic: https://www.riskandcomplianceanalytics.com/become-a-member


Final Thoughts:

In navigating the complexities of healthcare, ethical conduct and proactive risk management are non-negotiable. By learning from past mistakes and embracing innovative solutions, we can safeguard both our organizations and the integrity of the healthcare industry as a whole. Let's commit to ethical practice, leverage technology wisely, and work collaboratively towards a healthier future for all. Mitigating risks and avoiding unnecessary exposure is why experience matters. Find out how simple compliance can be when you have the experts to help you! https://www.riskandcomplianceanalytics.com/about


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