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California Healthcare Price Discrimination Defense Lawyer

Price discrimination means charging some customers differently than others based on some set of characteristics. In the healthcare context, it’s not uncommon for doctors, hospitals, pharmacies and other healthcare providers to charge private payers more than customers on Medicare or Medicaid. What providers cannot do, however, is engage in schemes that cause them to bill Medicare and Medicaid (Medi-Cal in California) more than they would charge other payers for the same goods or services. Price discrimination between Medicare/Medi-Cal and other payers that disfavors the government could be seen as Medicare fraud. It’s a confusing and complicated area of law, and it’s one that could land a healthcare practice in legal hot water, leading to expensive fines, loss or suspension of a medical license, and even imprisonment.

If you are being investigated or charged with healthcare fraud based on illicit price discrimination or other practices, the healthcare fraud defense attorney at the Law Offices of Art Kalantar is here to help with strategic, practical legal advice and professional representation to help you avoid a civil penalty or criminal conviction by providing a strong and effective legal defense. For help in Los Angeles and statewide, call our experienced California healthcare price discrimination defense lawyer today.

Medical Practices Are Allowed to Make Money

The practice of medicine has many altruistic aspects to it, but doctors, hospitals, clinics and pharmacies are also in business to make money, and there’s nothing wrong with that. Price discrimination is a common pricing strategy in many industries and professions; simply put, the seller charges the maximum price that the customer will pay. In the healthcare context, providers group patients according to certain factors and charge individuals in those groups at different rates. These different groups, which make up the medical practice’s payer mix, include Medicare, Medicaid/Medi-Cal, private or commercially insured patients, and the uninsured.

Generally speaking, providers are free to charge different groups differently. When working with different insurers, providers typically negotiate with those insurers to determine the insurance companies’ reimbursement rates they will pay. Medicare doesn’t negotiate with doctors and hospitals, however; rather, it reimburses for services based on its analysis of the cost of care and other factors. Medicaid reimbursement rates, meanwhile, are determined at the state level by state governments. The result of these different methods of determining rates is that pricing differs across groups.

An example of price discrimination that affects Medicare/Medicaid is when pharmacies offer discount drugs to cash customers but not Medicaid and Medicare patients. Pharmacies are required to bill federal payers at the “usual and customary price” given to other customers. Is it lawful for pharmacies to bill federal payers at the pre-discount price that is charged to private payers, even if those customers can take advantage of discounted pricing offers? Doing so seems to be a reasonable interpretation of the relevant regulations, with no clear governmental guidance to the contrary. But the complicated issue has gone to the United States Supreme Court to figure out. Given that you could be prosecuted for engaging in pricing that seems objectively legal under a reasonable reading of the law, it’s imperative that you get legal help from a skilled and knowledgeable healthcare attorney who can defend you against allegations of fraud.

There is a widening gap in recent years between what government pays and what private insurance pays. Medical providers might prefer private payers because they can and do charge more for their services. When it comes to Medicare and Medicaid, providers might be suspected of charging these patients more to overbill the government or scare away Medicaid patients so the practice has a higher percentage of private payers in its payer mix. Price discrimination that impacts Medicare and Medicaid is often suspect and can lead to serious charges and enforcement actions. Contact an experienced healthcare lawyer with your concerns.

Call the California Law Offices of Art Kalantar for Defense Against Charges of Unlawful Price Discrimination in Healthcare

Price discrimination is generally a lawful practice when it reflects the different costs of dealing with different customers. Price discrimination between Medicare/Medi-Cal and other payers can be very tricky, however, when government agencies such as the Department of Justice or HHS-OIG believe Medicare and Medicaid are being overbilled or defrauded. Protect yourself and your practice by contacting a knowledgeable healthcare law attorney the moment you become aware of an investigation into your practice or the filing of an enforcement action against you. The Law Offices of Art Kalantar helps doctors and other medical professionals in Los Angeles and statewide comply with state and federal laws and defend against allegations of Medicare fraud. Call our experienced California healthcare price discrimination defense lawyer today for a free case evaluation at 310-773-0001.


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