This transcript has been auto generated
00;00;00;00 - 00;00;28;06
Jonathan Porter
Welcome to another episode of Husch Blackwell's False Claims Act Insights podcast. I'm your host, Jonathan Porter. Managed care is a huge part of healthcare in America. I read somewhere that the majority of American healthcare dollars in some way flow through managed care. So for non-healthcare listeners, I know we got a bunch of those, managed care is when insurance manages costs by also managing the providers and the claims.
00;00;28;06 - 00;00;52;09
Jonathan Porter
So it's an integral part of the way healthcare works in America. Most might not think of managed care as having unique False Claims Act issues because they are paying claims to providers, but they actually do and they have very interesting and unique issues within the False Claims Act world. The paying side has these big False Claims Act ramifications, including some that have been in the news lately.
00;00;52;09 - 00;01;15;22
Jonathan Porter
And so in this episode, we're going to talk about managed care and how managed care can have their own False Claims Act problems. Joining me to talk about the False Claims Act enforcement of managed care is my law partner, Tim Ribelin. Tim is a tremendous litigator. I like him a lot, but I don't know that I would like being on the other side of Tim on a case. In healthcare litigation
00;01;15;22 - 00;01;37;23
Jonathan Porter
I don't know that there's someone better than Tim. What I like a lot about Husch Blackwell's healthcare team is that we've got all these people who know healthcare and know their practice area, and that's Tim. He's not just a top litigator. He knows healthcare. Tim even has a master's degree in medicinal chemistry. Tim will talk about medicinal chemistry some other time, but good luck going up against that in court.
00;01;37;25 - 00;01;58;14
Jonathan Porter
And lucky for Husch Blackwell's healthcare clients, Tim is also skilled in litigating False Claims Act cases. In fact, Tim recently spoke at the American Conference Institute's managed care conference about this exact issue, False Claims Act, enforcement of managed care. And so that's what we're talking about today on the episode, taking advantage of Tim's hard work for that conference.
00;01;58;14 - 00;02;06;12
Jonathan Porter
So, Tim, thanks for coming on the podcast and telling our listeners a little bit about False Claims Act enforcement in the managed care space.
00;02;06;12 - 00;02;16;18
Tim Ribelin
Yeah Jonathan, thank you so much. I appreciate the, the invitation to participate on the podcast. I guess you could say I'm a long time listener, first time caller. So looking forward to our discussion today.
00;02;16;21 - 00;02;34;27
Jonathan Porter
That's excellent. So, Tim, let's start with a zoomed out look of the False Claims Act. Tim, at the conference, you called 2025 a watershed year for False Claims Act enforcement. And I agree with you there, but I want to hear why you think it's a watershed year. What changed in 2025 and why should healthcare clients care?
00;02;34;28 - 00;03;05;10
Tim Ribelin
Yeah, so I think as we look at the trends and the trajectories, the dollars were big, but the dollars are big every year. And that's in part or large part due to the government's success and the power of the False Claims Act. But I think the reason when I'm thinking about 2025 and maybe a mindset shift or a paradigm shift is that the government appears to be utilizing more resources, more tools.
00;03;05;13 - 00;03;33;23
Tim Ribelin
So maybe they're relying less on the relator's bar, but they still have the relator's bar that are heavily impactful, but they're using additional tools, resources, and focus on the healthcare space, which as we started to see and as we've seen going into 2026, with the number of cases that are being unsealed and filed, it's growing. And so while the False Claims Act has been a concern for our healthcare clients for years and many others in this space, I think it's not going away anytime soon.
00;03;33;23 - 00;04;12;00
Tim Ribelin
And what we're seeing from the current administration, from the DOJ is a renewed and invigorated focus over all the tools that the government has available to it. The conference that I was at the managed care conference, we had two high level litigation attorneys from the DOJ and CMS. And it was interesting because amongst other things that they talked about, there was a comment made that if and I'm sure I'm going to botch the numbers, but that if the government can basically stop $1 billion worth of fraud over the next couple of years, it extends the healthcare trust or Medicare trust for multiples on end.
00;04;12;00 - 00;04;26;07
Tim Ribelin
So it's not a dollar for dollar savings. And that's how based off the conference I went to in the comments, I heard, I don't think the administration is looking at this as $1 of fraudulent conduct saved is $1earned instead it's multiplied over and over.
00;04;26;10 - 00;04;48;06
Jonathan Porter
Yeah. Those are excellent insights, Tim. And what's interesting, you talk about how DOJ is becoming less reliant on qui tams. What's interesting to me is if you look at the numbers from last year, we had a record number of qui tams as well. And so from what I'm seeing, the number of qui tams are going up. But DOJ’s ability to do things without qui tams also going up, which to me says there's going to be a lot of enforcement in this space going forward.
00;04;48;06 - 00;05;10;15
Jonathan Porter
So sorry to our friends in the healthcare industry, but this is ramping up. Tim. I think what's also interesting, and you mentioned this to me is at the conference, there was also talk about healthcare issues beyond what we think of as normal false claims, I problems in the healthcare space. So what are some other common False Claims Act risks that our healthcare clients are facing beyond the sort of standard things that we think of?
00;05;10;19 - 00;05;43;10
Tim Ribelin
Yeah. You bet. And this is I think is something we're seeing I mean, the False Claims Act, it's known to live within the healthcare space and research and reading about the False Claims Act. I mean, it did not start as a healthcare statute started about basically with government contractors, defense contractors during the Civil War and what we are seeing, and I think what we'll continue to see is a focus over not just healthcare, but other ways that the government can find a plausible theory or later can find a plausible theory to find fraudulent conduct.
00;05;43;10 - 00;06;09;10
Tim Ribelin
And we're going to talk about this later. But the thing that gives me heartburn is the false certification cases. There's others, obviously, but the false certification, it can be a catchall. And I think it's a catchall that many people don't appreciate the impact of. The false certification cases are really coming to light amongst direct conduct, but also through false certification are through False Claims Act related around tariffs, civil rights.
00;06;09;10 - 00;06;39;19
Tim Ribelin
After the change in administration and the change in policy around DE&I and cyber fraud. And these are problems that healthcare clients potentially have, maybe less so than tariffs than others. But pharmaceutical companies for sure. But these are problems that our clients will be having. But and their in-house counsel needs to think about. And their risk department needs to think about not strictly billing, collecting money from the government, but also, are your cybersecurity practices up to snuff?
00;06;39;21 - 00;07;00;28
Tim Ribelin
What are you doing with respect to tariffs? Are they being misclassified or is everything aligned with the current administration and what's being required? And then also because of the change of administration and because of the focus and the policies around DE&I, in-house counsel also need to make sure that they're DE&I practices are compliant to the extent that they are subject to the government's purview.
00;07;00;28 - 00;07;07;23
Tim Ribelin
And failure to do so under the current administration, at least, could result in some liability, including false claims like liability.
00;07;07;26 - 00;07;25;28
Jonathan Porter
Yeah, Tim. Great insights again. Yeah, I feel really bad for people in the healthcare world because they're getting hit on all sides. It feels like the false claims are being used more than maybe what the Civil War era of drafters, of the false claims about the original false claims. I might have thought about this, but this is the world we live in, so people have to be ready for it.
00;07;25;28 - 00;07;55;05
Jonathan Porter
So, Tim, all that background being established, let's talk about some managed care specific FCA issues now. So regular listeners have heard me say this 100 times. The False Claims Act is not for gray area disagreements or garden variety regulatory disputes. It's where people who try to knowingly defraud the government. What are the most common? How did this become a false claims that case type fact patterns you're seeing in Medicare Advantage?
00;07;55;05 - 00;07;57;21
Jonathan Porter
I assume risk adjustment is still front and center.
00;07;57;23 - 00;08;23;02
Tim Ribelin
I would take a brief step back, because one thing I'd like to do is on the payer side, there are strictly commercial agreements, and there's patients who have commercial insurance and they build their insurance. That's not a False Claims Act. But where we see in the payer space, health insurance companies, if you will start to find liability under the False Claims Act particularly is in many areas Medicare and Medicaid, but particularly for Medicare.
00;08;23;02 - 00;08;54;07
Tim Ribelin
It's with respect to Medicare Advantage, where the government has allowed private insurance companies to market a Medicare Advantage product, and the insurance company sets up a Medicare advantage organization. And here it was set up to incentivize and utilize knowledge base and private business practices to see if private insurance companies or publicly traded insurance companies can administer Medicare in a way that makes it more economical, beneficial or otherwise supported than the government can.
00;08;54;09 - 00;09;37;12
Tim Ribelin
However, once the private actors become government contractors, that's where we start to see the False Claims Act coming in and a real eye towards the practices within the Medicare Advantage base. One thing to note is that for Medicare Advantage, more complicated, but for the ease of our conversation, basically, if I'm a Medicare Advantage enrollee, the government pays my insurance company a flat amount of dollars per month for me to have Medicare advantage, and then it's up to my insurance company if they want to make profit off of me, to manage my care in a way that aligns with the care that I am allowed to receive, but without giving me more care and costing more
00;09;37;12 - 00;10;05;09
Tim Ribelin
money than I would otherwise be entitled to. And I apologize for the long kind of explanation there, but that's where risk adjustment comes into play. Because the sick or the patient, the less money it's an easy calculation. The sicker the patient, the more resources. Obviously they're going to be, the higher premiums, but that's not really as applicable in the Medicare Advantage base to really what insurance companies, the more profitable patients under the Medicare Advantage base are your healthier patients.
00;10;05;11 - 00;10;45;02
Tim Ribelin
And so this is where risk adjustments come in. And is the insurance company up coding or down coding the patient such that the claims and the reimbursement for the insurance companies match the actual patient's level of care, or are they being up coded to reflect that they're sicker so that the government pays more to the managed care organization, or they being down coded so that the managed care organization can provide less care. A couple of just the common issues that we're seeing, these add only or these one way retrospective reviews where it's more or less an after the fact billing practices to see what else could have been done.
00;10;45;04 - 00;11;06;20
Tim Ribelin
And basically another example is these templates, which, if used by the clinicians, really kind of steer their medical judgment in one way or the other, but one way that it would result in a potentially False Claims Act claim is if you're steering a provider towards a higher paying diagnosis, such that the insurance company can claim more dollars for this patient.
00;11;06;26 - 00;11;21;29
Tim Ribelin
And again, it's coding and it's up coding, and it's all of the things that you could do to make somebody appear on a claim by claim basis or on paper, sicker than they are. So you can justify recouping higher dollars for managing their care.
00;11;22;01 - 00;11;38;07
Jonathan Porter
Thanks, Tim. That's a really in the weeds issue. It took my tiny brain a long time to try to figure out what exactly is the False Claims Act hook with the one way look issue in managed care, but even a good job explaining it. Like you said, if you got patients who are sicker on paper, you get more money.
00;11;38;07 - 00;11;56;25
Jonathan Porter
And that's why managed care plans do that. And that's why they engage in these chart reviews, is to try to find that. But you pinpointed the problem. If you're going to look at these chart reviews and just find things that increase the payments and you conveniently ignore the things that would give you less money, DOJ’s got a problem with that and has been a lot of big settlements in that space.
00;11;56;25 - 00;12;18;00
Jonathan Porter
So Tim, excellent analysis. So at the conference, I think you also highlighted sales and marketing practices is something that could create anti kickback statute scrutiny. You know, that I love anti kickback statutes because there's a lot that goes into that. It's a broad statute but not broadly enforced and yet is capable of being broadly enforced if DOJ really wants to.
00;12;18;01 - 00;12;25;20
Jonathan Porter
So in the managed care space, what should managed care folks know about broker and enrollment related theories right now?
00;12;25;22 - 00;12;57;05
Tim Ribelin
Oh yeah. No, this is a hot topic. To your point. The AKS is a powerful enforcement tool. I think it's less powerfully or less often utilized in the FCA space, but I think that's changing and I think we will see it changing. And I think it's a real crossover of criminal and civil liability. So yeah, as I think about the broker space, I mean, these managed care organizations will hire brokers, marketing companies, individuals to help them fill their patient base.
00;12;57;07 - 00;13;19;22
Tim Ribelin
And as with many things, this is supposed to be the brokers job I think has good intentions to where they are supposed to help find the right people, find the specific managed care or MAO that would work best for them based off the plan offering, etc. and they are to help sell the product, if you will, and find enrollees.
00;13;19;24 - 00;13;44;16
Tim Ribelin
However, where brokers manage care organizations and even providers get in trouble under the AKS and under the False Claims Act, it's when the brokers start influencing the patient base and their enrollment and that's a case that's been out for a while. And I think the allegations I mean, I just touch on them briefly, but the brokers were unbiased stewards.
00;13;44;19 - 00;14;17;00
Tim Ribelin
And how were they unbiased stewards is that the brokers were incentivized to enroll. Certain patients, like I mentioned earlier, enroll healthier patients who are utilizing less resources, set up their websites or otherwise are decent, incentivized by enrolling sicker patients or disabled patients who may use more resources but don't have as higher reimbursement rates, and otherwise using these brokers to get into arrangements outside of the strict.
00;14;17;02 - 00;15;01;05
Tim Ribelin
You are here to help market plans and influencing one plan over the other. This is far reaching because what is the allegations in lawsuits of this nature have focused both on the managed care organizations, the broker companies, the marketing arrangements, but also on health care providers who have relationships with certain brokers and will work with the brokers to help steer certain patients to certain arrangements and in return, opens up the potential that the brokers are paying kickbacks or otherwise incentivizing physicians, which would result in referrals, remuneration and as you can imagine, all things that are impacted by the AKS.
00;15;01;10 - 00;15;19;12
Jonathan Porter
Thanks to him. And speaking of legislative history, he talked about the origins of the False Claims Act. The anti kickback statute has its own very interesting origin story, which we should probably go into sometime. I'm fascinated. I'm probably one of the few people who who dug in and read the legislative history on it. No one else is that much of a nerd, but I am.
00;15;19;12 - 00;15;34;20
Tim Ribelin
Well, I would take you on that. Actually, I know it. In talking about it, I think it would make a fascinating back story in understanding the AKS, because its origin story is not to give too much away now, but certainly something that's got a bit of lore to work in, how it came about.
00;15;34;23 - 00;15;53;01
Jonathan Porter
Yeah. All right. So you just heard Tim agree to do the part two of the podcast. What are we going to do - origin story, anti kickback statute version. All right. So so we were be thinking backstage. A lot of people assume that these are easier to plead. A lot of people say okay, well yeah. If you paid kickbacks, you gave something of value in exchange for some referral source, then that must be easy to plead.
00;15;53;01 - 00;16;08;05
Jonathan Porter
But it's not. Your slide deck for your presentation had a whole slide on AKS causation. And that's a huge, huge issue in FCA enforcement right now. Tim, what does that debate mean in real life for managed care cases?
00;16;08;12 - 00;16;31;11
Tim Ribelin
Yeah. And I think the defense attorneys playbook is in any case, I mean, you're going to be pleading, you know, 12 B six at a minimum and 12 B eight and 12 B nine. So you're going to scrutinize the pleadings. And many of these cases will go through several rounds of pleading motions to dismiss amendments, etc.. But there's a debate right now.
00;16;31;11 - 00;17;04;18
Tim Ribelin
There's a circuit split and it's over AKS causation. And in 2010, Congress amended the AKS after in largely in response to a district court in Arkansas in a false claims. That case which found that the hospital could not be liable under the False Claims Act or the physician's improper conduct with a medical device supplier. So looking at this and not to get too far in the weeds, but basically what was alleged was doctors had set up an improper payment arrangement with the device supplier.
00;17;04;20 - 00;17;35;00
Tim Ribelin
But because the doctors were performing the surgeries at this hospital and the hospital was getting paid a fee for the positions doing the surgeries at this hospital, then under the False Claims Act and under the AKS, the hospital must also be liable for the conduct. And even though, according to the case, there was no evidence and the district court found that there was no evidence connecting the hospital with the alleged culpable conduct on behalf of the physicians and the medical device supplier.
00;17;35;02 - 00;18;01;20
Tim Ribelin
So Congress responded and said, we don't agree with this interpretation, and we're going to adjust the language. And they added the language, which is two words as often in the False Claims Act, many issues turn on the use of 2 to 3 words. But this one, they added that language, which now reads a claim that includes item or services resulting from a violation of the AKS constitutes a false or fraudulent claim.
00;18;01;20 - 00;18;26;18
Tim Ribelin
So what is resulting from is it but for causation? Is it something else? It's been a point of debate, and it will continue to be a point of debate for a while. We currently have a circuit split where the majority view is more on the defensive side, if you will, and it says resulting from means. But for causation, this is a higher burden for the DOJ and relator's counsel.
00;18;26;20 - 00;18;58;28
Tim Ribelin
So the DOJ says this complicates the litigation, requires extensive efforts to disentangle the motivations of treating physicians for every treatment, decision or referral at issue. So I see the point. But at the end of the day, and a False Claims Act case is a claim by claim basis in my unbiased or very biased I guess opinion, the majority views the correct view, because if you're going to allege each claim is a fraudulent act, giving a liability under the False Claims Act, then you need to prove that there is culpable conduct associated with each act.
00;18;58;28 - 00;19;25;11
Tim Ribelin
And following that there. The minority view is the relator, and it's the more government friendly side, which is it allows you to plead alternative pathways if you're not able to plead the ax causation to but for standard. So you can look at these alternative theories such as the false certification theory, which are a lower standard and make the barrier to entry, if you will, for a relator or for the DOJ much lower when they're pleading a case.
00;19;25;14 - 00;19;43;14
Jonathan Porter
Thanks, Tim. Yeah, I'm super fascinated by this issue. There's not a lot of us, but hey, if we're nerding out on stuff, this is a thing to nerd out on. In defense of the government's point, there's nothing in the legislative history that says that Congress was trying to mess with how this worked. I give them that. But on our side, words have meaning.
00;19;43;17 - 00;20;02;04
Jonathan Porter
And these words. It's the barrage case that the Supreme Court said that resulting from means. But for causation, you can't just sort of pick and choose when words have particular meaning. So to me, this is a pretty clear, a pretty easy thing for courts to get right. And my bigger point in all this is if Congress really didn't mean to do this, they can change the law.
00;20;02;06 - 00;20;15;13
Jonathan Porter
Change two words. It's really not that complicated. Congress hasn't done that. It's been a long time since the Affordable Care Act did this. So if Congress has such a big problem with the way the case law is coming out, they're welcome to change the law. But they haven't. So that's where we are.
00;20;15;15 - 00;20;37;20
Tim Ribelin
And I think absent that, I think we'll hear about it from the Supreme Court one day. I mean, to your point earlier, the Ax cases are much smaller in its size than other False Claims Act cases. So I don't know that it's going to be a high priority for the Supreme to take up. But I fully expect to absent Congress stepping in and changing something or one of the circuits for all the circuits completely flipping their position.
00;20;37;22 - 00;20;50;09
Tim Ribelin
I think we'll get there. And I think it'll be an interesting decision, because depending on how the springs come out, it could create some conflict over statutory construction within two different statutes, but using the same words.
00;20;50;11 - 00;21;04;07
Jonathan Porter
Yeah. Tim, what you're teeing up here is, I guess, part three of a podcast for us where we're going to go into all the different things that should be going up to the Supreme Court right now. A circuit split like that is pretty hard to reconcile without the Supreme taking that up. So that's one. There's a bunch of other stuff.
00;21;04;08 - 00;21;22;15
Jonathan Porter
So yeah, you're exactly right. I think the False Claims Act could be revisited and revised a lot. This could look very different in five years. I think that's fair to say. Speaking of things looking very different in five years, AI. So in healthcare now, AI is letting organizations track things that we haven't been able to track before.
00;21;22;18 - 00;21;42;26
Jonathan Porter
And that has an important tie in with FCA enforcement. I did a whole podcast episode with my friend Andy Sobczyk of the Coker Group, on this, but it's continuing to be a big thing. AI and health care. At the conference, you discussed how seemingly routine marketing analytics can become evidence. I think that's a really important point for people to understand.
00;21;42;28 - 00;21;48;05
Jonathan Porter
What's the practice lesson from the ROI tracking examples that you highlighted? Tell us about that.
00;21;48;07 - 00;22;17;21
Tim Ribelin
Yeah. So any good company right is going to track metrics. And to your point, AI and a higher computing power has allowed us to track different metrics and process more data on a quick fashion. Be careful over the ROI calculus, because in the healthcare space, particularly in the AKS space, the nexus is, did you do something that caused a referral that you would have not otherwise received the referral, but for taking some action?
00;22;17;23 - 00;22;36;20
Tim Ribelin
I've completed several terms there, but it was all purpose to try to describe the way that I see the AKS, which is did you do something that gave you more patients and more money than you otherwise would have had, if you would have not done that? And the ROI is and this is where we're seeing it as physician speaker programs.
00;22;36;20 - 00;23;04;03
Tim Ribelin
And there's many rules around, particularly pharmaceutical companies who can incentivize speakers or medical device speakers and the trainings they can provide them and whatnot. But where we're starting to see problems come up is where companies are tracking ROI for a specific presenter or presenters and tracking their what is an allowed practice, which is you're allowed to pay them consulting fees and speaking fees and whatnot.
00;23;04;05 - 00;23;24;09
Tim Ribelin
And then are you getting more referrals or are you making more money? Or are you selling more product through those physicians that you have these arrangements with? And that's where classic example is. Doctor Porter gives us a presentation and Doctor Porter was using our medical device for 10% of his patients. And now Doctor Porter is using it for 90% of his patients.
00;23;24;11 - 00;23;47;10
Tim Ribelin
Tracking that ROI gives a insight into his Doctor Porter's switch in his referrals. Is it due to the fact that Doctor Porter likes this device better? Or is it the fact that Doctor Porter feels as though he's ingratiate to this company and he needs to sell their product for them? That's a classic example. And that's where the ax lives, eats, and dies really under this nexus.
00;23;47;10 - 00;24;01;07
Tim Ribelin
And you really have to be careful about ensuring that this isn't happening. But how do you do that while you're tracking your ROI, but also ensuring that you're not going too far, or that it's happening in a way that could implicate you?
00;24;01;09 - 00;24;19;22
Jonathan Porter
Yeah, Tim. And that's the big tension in all of this, is we're talking about businesses, or even if we're not talking about businesses, if we're talking about nonprofit, they've got to keep the lights on in order to keep the lights on. You got to know whether you're spending your money in a reasonable way. And so tracking return on investment makes total sense for everyone.
00;24;19;22 - 00;24;35;05
Jonathan Porter
And yet it's hard to say that something's not a value if you're trying to track the value of it. I get it. That's why this is sort of a hard thing for me to square with how we normally think about the False Claims Act. It's a really, really, really big topic. And it's like you said, it's only going to get bigger.
00;24;35;05 - 00;24;54;29
Jonathan Porter
So another topic that's big in both managed care and the health care industry in general is parent or successor liability. So how can corporate parents, sponsors or acquirers end up in an FCA case involving a managed care business? Let this happens. So tell our listeners about that.
00;24;55;01 - 00;25;21;29
Tim Ribelin
Oh yeah. I mean, I would say as an associate at Husch Blackwell, one of the first real teeth false claims. That case I worked on actually involves some parent success or liability. And I found it to be fascinating that the ostensibly the new company was spending a lot of time and effort answering questions about conduct that happened in a prior acquisition and was having to defend against a case in conduct that they had not started or were participating in, but nevertheless, the liability was still there.
00;25;22;01 - 00;25;45;17
Tim Ribelin
Look, this comes about because in the health care space over the past couple decades, and particularly over the past couple of years, consolidation, consolidation and consolidation, and I mean, health care companies, many of whom have grown bigger, purchasing up their competition and consolidating to expand their offerings. But you don't know what you don't know. And are you in a transaction where everybody wants to get a deal done?
00;25;45;20 - 00;26;12;02
Tim Ribelin
What problems are you buying when you bring them in and the government is in looking at this? I mean, there's there's ways to to address it on the deal side. And that's something we talked about at our conference. But there's also what is the government looking at. Because ignorance of something is not a defense, particularly in the FCA space, but the government is taking a hard stance over to the parent or the controlling entities or prior conduct.
00;26;12;02 - 00;26;44;27
Tim Ribelin
What did you know? Did this conduct stop when they became part of your organization, or did you allow this conduct to continue, knowingly or unknowingly, in a way that you could have or should have stepped in and stopped it, but you didn't, and cases about this, and I think we're going to see it more and more as the government goes and keeps looking and they start to look at older companies or consolidated companies, and just a company being sold does not absolve it of its liability, particularly with the length of statute limitations and the False Claims Act cases.
00;26;44;27 - 00;26;51;21
Tim Ribelin
You can see these problems or a company's prior problems from years before creep up, creep up over and over again.
00;26;51;23 - 00;27;05;17
Jonathan Porter
Thanks, Tim. I won't make you give the year that you dug into that issue back when you were an associate. You and I are getting older now, and so let's not go down that trail. But since that research, Tim, I know this has become a bigger and bigger issue. So glad you were on the cutting edge of that.
00;27;05;17 - 00;27;19;27
Jonathan Porter
It's continues to be a big deal. So Tim, last question. Looking ahead, you flagged DOJ's increased use of data analytics and AI. How does that change the detection inside of managed care FCA enforcement, and what should the industry do about it now?
00;27;20;01 - 00;27;37;12
Tim Ribelin
Yeah, and this feeds in nicely with our last topic. But the government has had tools. It's had some relatively good tools if you will, to identify trends. And that's what a lot of the DOJ has been doing is in ferreting out fraud and and is looking at trends. Is there a trend here? But a trend does not make a false claims.
00;27;37;12 - 00;28;21;04
Tim Ribelin
That case. It's about identifying a trend, finding information, whether it be people or through a kid or otherwise, and taking that information and turning it into do you have a claim and then a pleading if you do so, as with everything, the government is using AI just like many in private practice are. But with AI, what has been a I think is going to be an increasing shift is AI has changed resource allocation, and one of the avenues that many defense counsel have used, including myself when responding to a kid in years past, is working with the requesting attorney on the government side to narrow the scope because of limited resources on the government side
00;28;21;04 - 00;28;48;00
Tim Ribelin
to process review data. Now, under the new regime, I think those negotiations for narrowing the scope of CID responses are going to be less, because I think the government attorneys have fancier, better tools and more resources at their availability to be able to process large amounts of data. So I would be willing to bet that as we see this grow, the DOJ is going to say, I asked for everything I want, everything I think I'm entitled to everything.
00;28;48;02 - 00;29;22;03
Tim Ribelin
Give me everything. And if it's too much data, I'll deal with it. But I can deal with a lot more data now then, if I have reviewers are using less sophisticated tools and equipment. On top of that, I think I can do more than just review data. And here's where I think it's going to come in. Is there are AI companies that are coming up and they're selling coding specific AI tools for the managed care space, and these tools, I think to the extent that they can do this, and I've seen some examples, I think that they can where they're taking logic.
00;29;22;07 - 00;29;46;08
Tim Ribelin
Right. Is this a claim. Is this a patient. Was there risk adjustment. Was this required. They're looking at the actual coding in a way that I think is a deeper dive than what the tools have allowed us to do in the past, which was, you know, generically speaking, does Doctor Porter code this one type of claim? More than other providers in his area?
00;29;46;08 - 00;30;08;01
Tim Ribelin
If so, why now? I think it can do a deeper dive on faster and will help make decisions over. Is this something we have to go look at? Again, we know there's an emphasis from law enforcement. There's a trend where DOJ is doing its own cases. It's not relying extensively or as much on the relator's bar, even though the relator's bar is still very active.
00;30;08;03 - 00;30;18;19
Tim Ribelin
And I think these AI tools, to the extent that they can create tangible, confirmable repeatable results, I think is another very powerful tool kit in the government's pocket.
00;30;18;21 - 00;30;34;16
Jonathan Porter
Yeah, I think that's exactly right, Tim. The way the DOJ is using new data, I think they have a similar expectation for managed care is that managers are going to use data to do things, are going to save dollars. And so I think you made all the right points, Tim. It's really good to have you on the podcast to hear your takes on this.
00;30;34;16 - 00;30;45;05
Jonathan Porter
And I'm grateful that you spoke at the American Conference Institute about that, but I'm glad that our listeners also get the benefit of your wisdom here. So, Tim, thanks for coming on the podcast and telling our listeners about this important topic.
00;30;45;07 - 00;30;50;17
Tim Ribelin
No, thanks, John, that I appreciate the opportunity and look forward to more podcasts and more topics to nerd out with you on.
00;30;50;21 - 00;31;12;21
Jonathan Porter
Yeah, absolutely. So to close, as you heard, Tim committed to two more podcasts, so you've got to subscribe. However you listen to this, subscribe to this so that you don't miss Tim's follow up episodes where we're going to dig into the history of the anti kickback statute. It actually is a really interesting history point. So we might do just a little history lesson as a follow up episode because I think it's important to know why we're doing the things that we're doing.
00;31;12;25 - 00;31;30;23
Jonathan Porter
To me the reason that our listeners hear me talk about the False Claims Act origins in the Civil War is because I think it's important to know what this was trying to do at the beginning and how far we've come from the barebones. Here's the type of thing that we were trying to stop back then situation. So we're going to continue to bring you stuff like this.
00;31;30;23 - 00;31;44;17
Jonathan Porter
We're going to need to think about the False Claims Act like Tim said, this is only going to be a bigger and bigger deal. And so to our listeners, I hope you enjoyed this and we'll see you next time.