Court Cases and Healthcare Valuation


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Presentation at HCCA on recent court cases affecting fair market value compensation and commercial reasonableness

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Court Cases and Healthcare Valuation

  1. 1. HCCA Compliance Institute 2012—Legal & Regulatory 706 I Thought FMV Was Supposed to be Bulletproof: Recent Court Decisions Involving Fair Market Value Jeff Fitzgerald, Shareholder, Polsinelli Shughart Curtis Bernstein, Director, Sinaiko Healthcare Consulting May 1, 2012
  2. 2. Outline of Presentation Case Studies  Employment  Payment for multiple services to a single physician  Campbell v. Campbell v. UMDNJ  Aggregate compensation  US v. Covenant Medical settlement  Acquisition  Employment of physicians  US ex rel. Drakeford v. Tuomey  Payments based on referrals  US ex rel. Singh v. Bradford Regional  Payment for intangible assets without cash flows  Carraci v. Commission and Bergquist v. Commissioner 2
  3. 3. Employment Case Study Facts Dr. Nice (cardiologist) hired by Typical Hospital  Comp: $50 per wRVU; Hospital used salary FMV report Three months later, Dr. Nice asked to be medical director for catheterization lab  Comp: $10,000 per month; hospital obtains outside FMV from its regular consultant Six months later, the physician practice administrator asks Dr. Nice to act as a liaison between the employed physicians and administration  Comp: $ 16,000 per month; practice administrator obtained FMV study from different outside FMV expert Later, Hospital realizes that Dr. Nice was not added to the call roster and amends employment agreement to add call coverage  Comp: $800 per day (consistent with what the hospital pays independent contractors) 3
  4. 4. Compliance Concerns Can the physician actually perform all of these services?  “Are there enough hours in a day?” Are multiple forms of compensation paid for services provided simultaneously?  The physician cannot provide call coverage 24 hours per day while providing clinical services and medical directorship services Does the aggregate compensation make sense?  Payment of employed physicians at the same rate as the independent contractors is inconsistent with a productivity based compensation plan 4
  5. 5. U.S. v. Campbell University Hospital (UMDNJ) wanted to grow its cardiology program  UMDNJ entered into part-time employment contracts with local community cardiologists in private practice to work at University Hospital as Clinical Assistant Professors, providing teaching, lecturing, and research in exchange for an annual salary Hospital employs, part-time, Dr. Campbell for $75,000 annually  Employment agreement lists 8 categories of services In 2009, UMDNJ settles with DOJ and pays $8.33 million DOJ sues Dr. Campbell under FCA and Stark Law  Dr. Cambell has FMV report supporting salary  Dr. Campbell “duly performed all of the services enumerated in the contract which he was given the opportunity to perform”  Dr. Campbell argues that he was only required to perform the services that the hospital asked him to perform, and he did 5
  6. 6. U.S. v. Campbell Court rules that Stark Law was violated  Dr. Campbell could not prove he met the employment exception  Dr. Campbell was at hospital frequently, but not performing services in agreement  Court held that compensation was not FMV if services were not rendered (regardless of FMV report)  “If there was no requirement to actually perform the duties of [employment agreement] then the compensation could not be the fair market value for those services…”  2011 U.S. Dist. LEXIS 1207 (1/4/2011) 6
  7. 7. U.S. v. Campbell Lessons  Services must be rendered in a manner generally consistent with the services valued  FMV report only as good as its assumptions  To be a basis for separate compensation, there should be separate service rendered 7
  8. 8. U.S. v. Covenant Medical Covenant Medical Center of Waterloo, Iowa paid $4.5 million to settle Stark Law and False Claims allegations (2009) DOJ claimed that payments to 5 employed physicians exceeded FMV  Two physicians paid more than $2M per year  Three others were paid more than $1M per year  Salaries were published on hospital’s form 990 Whether hospital relied upon FMV reports is unclear 8
  9. 9. U.S. v. Covenant Medical Lessons  Full time employment is subject to potential enforcement action  Beware of the Lake Wobegon effect (everyone is above average)  DOJ enforcement can depend on overall optics  Look at both the forest and the trees 9
  10. 10. Acquisition Case Study Local Physicians Group was recently awarded approval for a certificate of need to develop a new surgery center Fearing competition, City Hospital proposes to purchase this prospective ASC from Group In light of its lack of operating history, Hospital will purchase any fixed assets already purchased by Group and the CON Hospital will develop the ASC and offer the physicians part- time employment agreements at a fixed compensation per wRVU every time the physician performs a case in the ASC Hospital will pay Group’s physicians for a non-compete agreement Group’s accountant recommends that Group contribute any intangible value not purchased by Hospital to Hospital’s foundation 10
  11. 11. Compliance Concerns Compensating physicians only when performing a designated health service and not when performing office visits FMV basis for intangible assets FMV basis for paying for non-compete  Is a non-compete distinguishable from an agreement to refer in this context? 11
  12. 12. U.S. ex rel. Drakeford v. Tuomey(2011) Surgeons begin development of an ASC Hospital hires surgeons as employees  Part-time; during surgical procedures; surgeons maintain office practice separately  Fixed salary, plus 80% of collections, plus quality incentives  DOJ alleged that compensation exceeded 100% of actual collections (and was up to 140% of collections) Hospital internal documents project losses on all employment agreements 12
  13. 13. U.S. ex rel. Drakeford v.Tuomey DOJ argues that compensation is not FMV because “the hospital’s motivation in entering into these part-time agreements was to avoid losing the referrals”  While Stark Law is strict liability, the DOJ looked at motivation of parties At trial, jury concludes Stark Law violated, but not False Claims Act  Jury awards DOJ $49.4 million  New trial ordered on False Claims issues 13
  14. 14. U.S. ex rel. Drakeford v.Tuomey Lessons  Employment exception large, but not infinite  Motivation can color FMV analysis  Risk exists where employment compensation not based upon survey or objective data  Long term physician employment losses could receive more scrutiny  Basis for losses needs to be justified or presumption is that the loss is tied to referrals 14
  15. 15. U.S. ex rel. Singh v. Bradford Regional (2010) Group of two physicians lease nuclear camera from GE and perform services in office rather than in hospital Hospital rents camera from Group (with non- compete); camera remains in Group’s office  Hospital pays $23,655 per month, an amount derived from Group’s revenue from use of the camera ($6,500 per month related to prime lease from GE)  Per Stark, fixed rental rate not take into account volume or value of referrals 66 Fed. Reg. at 877 (before per click rule) 15
  16. 16. U.S. ex rel. Singh v. Bradford Regional District Court granted summary judgment against the hospital  Court placed burden of proof to show FMV on hospital  Found that amount of compensation was arrived at by taking into account the anticipated referrals of the physicians  Found that if price takes into account referrals, then price is not FMV 16
  17. 17. U.S. ex rel. Singh v. Bradford Regional Lessons  FMV analysis and reports are useful, but courts may look behind at the underlying purpose/terms  Need to identify clear non-referral related basis for intangible assets or counterintuitive FMV terms  Purchase price needs to make sense from a non- referral basis  Some things just can’t be purchased 17
  18. 18. Bergquist v. Commissioner (2008) Background  University Anesthesiologists, P.A. (UA) was the exclusive provider of anesthesiology to Oregon Health & Science University Hospital  In 1998, Hospital formed OHSU Medical Group as a 501(c)(3) and required all physician groups that wished to remain affiliated with Hospital to consolidate into the group by Jan. 2002  In Sept. 2001, anesthesiologists in UA donated stock in UA to a charity and claimed a charitable donation  UA’s valuation expert used going concern value  Charity valued donated stock at $0  On Jan. 1, 2002, anesthesiologists became employed by OHSU Medical Group 18
  19. 19. Bergquist v. Commissioner Tax Court findings  UA should not be valued as a going concern because the consolidation of UA into OHSU Medical Group was foreseeable at the date of donation  UA would not have donated the stock without the consolidation  Commissioner’s expert valued UA at net asset value  Value estimated to be less than 10% of that claimed by Bergquist  Court agreed with Commissioner’s findings  Court concluded that no reasonable buyer would have paid at a going concern rate for UA stock knowing that UA was being consolidated 19
  20. 20. Summary and Takeaways Make sure compensation arrangements with referral sources are FMV for services rendered  Have policy in place to appropriately document FMV for services provided using reasonable approaches as discussed throughout this webinar  Monitor compliance with policies  Review third party opinions for completeness, accuracy, and reasonableness Review services actually provided to those required under agreements  Check all line items on medical director time sheets  Verify time spent providing co-management services Use common sense in determining if compensation could be viewed as related to referrals  Learn from Covenant, Bradford and Tuomey 20
  21. 21. I Thought FMV Was Supposed to be Bulletproof: Recent Court Decisions Involving Fair Market Value Jeff Fitzgerald, Shareholder, Polsinelli Shughart Curtis Bernstein, Director, Sinaiko Healthcare Consulting 21