The federal prosecutor’s managed care toolkit

Here’s what the government will use to prove that denying services is fraud, according to U.S. Attorney Jim Sheehan, JD, chief of the civil division for the Eastern District of Pennsylvania:

1. Representations made to beneficiaries by:

- the health plan’s marketers.

- treating physicians.

- sales reps and contractors.

- customer service representatives.

2. Internal records of HMOs and hospital systems, including utilization tracking data for practices, demographic groups, subscribers, and outcomes.

3. Accounting and actuarial records that trace how the HMO makes its money.

4. Comparative records for institutions and practices, which might indicate whether hospitals and doctors treat statistically similar patients differently.

5. Any threats, inducements, bonuses, or recognition for providers.

6. Conflicts between HMOs and other parties, such as:

- subscribers.

- providers.

- regulators.

- NCQA.

- competitors.

- malpractice suits.