S.F. Physicians Sue For Contract Breach, Criticize CCHP Management for Endangering Patient Safety, Health Care
In Separate Legal Action, Whistleblower Sues CCHP in S.F. for Overbilling Medicare
The physicians association representing the medical staff at the Chinese Hospital in Chinatown has filed suit against the for-profit Chinese Community Health Plan (CCHP), claiming that recent actions by CCHP management to siphon doctors from the association threaten to tear apart longstanding health-care alliances in the community while putting the very future of the hospital at risk.
The non-profit, independent physicians association, known as Chinese Community Health Care Association (CCHCA), represents 197 doctors serving the Chinese Hospital and community health clinics in Chinatown. For more than three decades the physicians association has served as a gatekeeper between CCHP, the Chinese Hospital and health care providers, ensuring that everyone in the community received high-quality health care.
Recently, however, CCHP sent doctors in the physicians association Participating Provider Agreements – individual physician contracts – in an attempt to pressure doctors into signing directly with the health plan. The contract offer included language that intentionally misled doctors into believing that the PPA was simply a renewal of an existing agreement, when in fact it was a completely new offer that would have legally bound the physicians directly to CCHP.
“We believe the purpose of these unprecedented solicitations is to decimate the independent physicians association, destroy the unique health care alliance that has served this community so well for so long and ultimately drive up profits for CCHP at patients’ expense,” said Dr. Raymond Li, President of CCHCA. “The actions by the management of CCHP will leave our community with fewer doctors and far fewer health-care choices.”
The CCHP contract offer threatens to divide the health-care community in Chinatown and diminish the availability of care for thousands of Chinese patients. Without the protections of CCHCA, health plan management would be free to manipulate fees and other reimbursements, driving qualified, culturally sensitive doctors from the community and depleting the medical ranks within the Chinese community.
San Francisco elected representatives told the San Francisco Sentinel they will investigate the allegations made by physicians to ensure the safety of Chinese patients from price gauging, unsafe medical practices, overbilling and other questionable actions by CCHP and its management and board of directors.
“The unique alliance between CCHP, CCHCA and the Chinese Hospital served the Chinese community well for many years,” said Dr. Eric Leung, Vice President of CCHCA. “But the tradition of affordable, reliable care and services is threatened by the actions of profit-driven corporate leaders bent on controlling and manipulating the health-care marketplace. The pending opening of the new Chinese Hospital will mean little if the historical structure of health care in the community has been destroyed by corporate greed.”
CCHCA took legal action against CCHP reluctantly and only after a cease and desist letter from CCHCA was ignored. Indeed, instead of ending the solicitation, CCHP sent out an addendum to the physicians that continued the deception in an attempt to coerce their signatures. Despite these veiled threats and strong-armed tactics, only two physicians have signed the CCHP contract.
The California Medical Association and the San Francisco Medical Society recently penned a joint letter to Brenda Yee, CEO of the health plan, expressing their grave concerns about CCHP’s actions. “It is critical that the health plan respect the important role CCHCA has played in delivering much-needed, culturally appropriate, affordable health care to the Chinese community,” the letter stated. “CMA and the SFMS are prepared to support CCHCA and its physicians to continue to achieve its charitable purposes.”
As the letter from SFMS and CMA points out, CCHCA for three decades has promoted social welfare in Chinatown by providing financial support for health-related community programs, including the Chinese Community Health Resource Center, the Neighborhood Disaster Response Plan and treatment room services at the Chinese Hospital. CCHCA has also provided more than $2 million in direct grants to innovative community projects.
“We have asked our elected representatives to join us in condemning the recent actions by CCHP management,” Dr. Li said. “In the spirit of transparency and cooperation, CCHP must drop its efforts to destroy our health network so we can continue our mission of serving our community and providing high-quality health care to all.”
Separate Legal Action Claims Chinese Community Health Plan Overbilled Medicare
In another lawsuit filed this week against Chinese Community Health Plan in San Francisco, a whistleblower in Texas has brought a lawsuit against former employer CenseoHealth and numerous Medicare Advantage Organizations (including CCHP in S.F.) alleging they overcharged Medicare for in-home patient care.
Plaintiff and former Censeo Coding Manager Becky Ramsey-Ledesma of Texas has demanded a jury trial, according to court documents filed with the U.S. District Court of Texas. So far, no trial date has been set.
The court documents were ordered unsealed by the court on June 17 after the United States Department of Justice declined to intervene in the civil action, according to Judge Barbara Lynn.
“If a prescribed medication could potentially support a diagnosis, they were to code for that diagnosis,” according to the lawsuit.
Ramsey-Ledesma claims Censeo Chief Medical Officer Mark Dambro developed an evaluation process designed to maximize the capitated payment rates paid to Censeo’s client Medicare Advantage Organizations.
Rather than rely on medical records provided by physicians treating patients, the plaintiff alleges Censeo obtained self-reported data directly from certain MAO members, according to court documents. The data was collected through evaluation forms completed by physicians retained by Censeo, not for the purpose of treatment, but to create ICD-9 codes for submission to the Centers of Medicare and Medicaid Services, according to the lawsuit.
Censeo targeted those MAO plan members who were likely to yield the most serious diagnoses, and more likely to generate higher capitation payments for Censeo’s MAO clients, the lawsuit states. Medicare Advantage plans get higher rates for patients who are sick than those in good health.
The company completed twice as many assessments in 2013 as it did in 2012, saying its clients propelled the company into a record-setting first quarter, increasing the number of evaluations by 250 percent, according to the lawsuit.
Revenue growth for 2013 was projected to reach $120 million, a 140 percent year-over-year increase, according to court records.
Censeo contracted with at least 30 MAOs to provide the home assessments, including Blue Cross Blue Shield in several states and Humana, which are both named as defendants.
Defendants include: CenseoHealth LLC, Mark Dambro, Chief Compliance Officer James Edward Barry Greve Jr., Director of Quality Joy Ridlehuber, Altegra Health Inc., Blue Cross Blue Shield Alabama, Blue Cross of Idaho, Blue Cross Blue Shield Tennessee, Care Plus Health Plans Inc., Chinese Community Health Plan, Commonwealth Care Alliance, Community Health Plan of Washington, Coventry Health Care Inc., Health Net Inc., Highmark Blue Cross Blue Shield, Hill Physicians Medical Group Inc., Humana, Inc., and North Texas Specialty Physicians.
Ramsey-Ledesma said she was fired August 9, 2013, after advising coders she would code only those diagnoses that could be supported by a doctor’s assessment. Messages for comment to Censeo were not returned.
This case is among several whistleblower cases filed alleging billing fraud of Medicare Advantage plans. CMS has said in the past it suspects home visits improperly raise risk scores.
In July, the Center for Public Integrity published a report of government audits showing widespread billing errors — mostly overcharges — in private Medicare Advantage health plans.
The audits involved five health plans: Aetna Health Inc. in New Jersey; Independence Blue Cross in Philadelphia; Lovelace Health Plan in Albuquerque, N.M.; Care Plus, a division of Humana, South Florida; and PacifiCare in Washington State, an arm of UnitedHealth Group, and considered the nation’s largest Medicare Advantage plan.
Among the findings: Medicare paid the wrong amount for 654 of the 1,005 patients in the sample, an error rate of nearly two-thirds. The payments were too high for 579 patients and too low for 75 of them. The total payment error topped $3.3 million in the sample.
Auditors concluded that risk scores were too high for more than 800 of the 1,005 patients, which in many cases, but not all, led to hefty overpayments.
Auditors could not confirm one-third of the 3,950 medical conditions the health plans reported, mostly because records lacked “sufficient documentation of a diagnosis.” The names of the medical conditions were redacted by federal officials.The federal Centers for Medicare and Medicaid Services, which conducted the audits, had no comment, according to the Center for Public Integrity.
None of the health plans would discuss the audit findings.
Aetna, in a statement, said the company had “raised a number of questions and concerns” regarding the results and was “awaiting a response from CMS.”
Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the insurance industry’s primary trade group, said the audits “overstated” the payment errors, according to the nonprofit and nonpartisan investigative news organization. The records are coming to light at a time of rapid expansion – and consolidation–in the Medicare Advantage market. Enrollment has neared 17 million. An estimated one of every three people are eligible for Medicare.