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Prime Healthcare Files Anti-Trust Lawsuit Against Kaiser Permanente Alleging Conspiring to Monopolize Southern California Health

Posted Nov 16 2011 2:00pm

I can’t comment on the portion about the Consumer Watchdog and all that has occurred here other than what I see in the news, but it seems to all boil down to billing questions and more than likely it’s the software I am guessing.  It gets to be a fine line at times with some of this and the parameters of software are set to inject certain data when other parameters are met, this is nothing new but with medical billing it makes a difference on compensation.  Prime went and found other hospitals with same issues and there was one in Maryland, same issue so what’s up with all of this?

Sure we need to look for fraud but when there are errors, and we do have those with data integrations and mapping, fix it.  What do you think IT people do all the time, but we have digitally illiterate people out there that think every finding is “fraud” and it’s not, people and companies still make mistakes, so this is not about outright fraud here, its about errors. Those that commit fraud up front are in a different category but the way marketing and journalism has it today is that the OMG effect sells, which it does so you as a consumer have to get smart and read between the lines and figure out what a real OMG is today, sorry it’s just the way it is and I have to do that as well. 

You know there’s so much flawed data out there so get used to it as will keep surfacing and use your best judgment over what you read today and see if it “really is that OMG story” as presented.  I did a post a while back where the Social Security Death Index has 30k living people in there, so again it’s everywhere.  At the link  below you can read my opinions on some bad algorithms.  The folks selling the analytics too sometimes push beyond what they can really do too, so enter the marketing spin doctors too.  I think it was MedSolutions that had issues there as a 3rd party. 

Bad Algorithms in Healthcare Payment Systems and Risk Assessments–Did the Hospital Bill Fraudulently or Were They Sold Formulas That Did Not Conform

Kwashiorkor is the big diagnosis case here and heck even Kaiser and Stanford had a bunch of these at one of their facilities. Shoot I read not too long ago to where a 3rd party analytics contract was cancelled by an insurer as they did not see the 25% savings the vendor promised…well duh! Wake up folks to the real world of analytics and complex medical billing and cut the crap on the aggressive marketing.  Shoot who knows maybe they only saw 20% but some bean counter will come along and say we were ripped off by 5% of what they promised and if it’s in writing, then we have a big hassle.  Software folks need to get smarter about that by all means. 

We just need better software out there and less complications is the bottom line here and who knows where this case will go or what points will be made, so just stay tuned.  Insurers have a huge lot in wanting to keep billing complicated too as so many own Health IT companies any more too so they make money there too.  United just opened up a clearinghouse and is working with Epic Practice Management software so they are working to steer clients over there right away with their analytics software, and least we forget the 15 years of under payments they did for out of network services and paid MDs short; that was just resolved with reimbursements to doctors last year. 

Will Optum be making a market now that they have better algorithms to get in the doors of some of the larger Epic clients of which Kaiser is one and will they be working to sell their algorithms for clearinghouse services to them?  Is it not interesting how all this winds around? 

Best advice I can give anyone is to suggest reading this book when it comes to math and marketing.  Professor Siefe spells it out real well and there’s a ton of deceptive math and flawed data out there today, so don’t treat each incident like a big OMG story, read up and get smart.  The link below has a great radio cast that runs about 30 minutes and is well worth listening too, as it’s the truth.  It is also why the Occupy moves are taking place today as frustration enters in the picture when you can’t see,touch or talk to that algorithms making potential life changing decisions about what is happening to you both in healthcare and in other areas.  BD 

“Numbers Don’t Lie, But People Do”–Radio Interview from Charles Siefe–Journalists Take Note, He Addresses How Marketing And Bogus Statistics Are Sources of Problems That Mislead the Public & Government

LOS ANGELES - In an antitrust lawsuit filed in federal court Tuesday, Prime Healthcare Services accused Kaiser Permanente and the Service Employees International Union (SEIU) of conspiring to monopolize the Southern California health care market and wipe out Prime hospitals with smear campaigns.

And while the 68-page complaint does not name Sen. Ed Hernandez, D-West Covina, he is referred to as the "California Legislator" who urged a state Department of Health investigation into reports of unusually high incidents of blood infection and malnutrition - and possibly, related systematic fraud - at Prime hospitals.

Hernandez is actually one of several California legislators, along with California Attorney General Kamala Harris, who asked for a federal investigation of alleged Medicare fraud at Prime hospitals earlier this year.

The suit also alleges that website California Watch has acted as a publicity arm of SEIU, pumping out stories critical of Prime.

Kaiser, SEIU, Hernandez and California Watch denied the allegations.

"At first glance, Prime's allegations appear to be that Kaiser Permanente's 66-year-old model of integrating the delivery and financing of care, coupled with our nationally well-regarded Labor Management Partnership, are somehow conspiracies designed to illegally compete with Prime Healthcare," spokeswoman Sandra Hernandez-Millett said in a prepared statement.

"The additional allegation by Prime - that Kaiser Permanente is driving up health care costs - clearly flies in the face of the facts," Hernandez-Millett statement added. Kaiser-Permanente is a well-recognized leader in quality and affordability in California."

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