Renowned Doc Accused of Sexual Assault; AARP’s Big Bounty; DOJ Targets Billing Fraud

Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week.

Prominent Doctor Accused of Sexual Assault

Kevin M. Cahill, MD, a renowned, retired tropical disease specialist, has been accused of sexually assaulting two women, Megan Wesko and Natalie Mauro, during physical examinations at his practice, according to the New York Times.

Both women have accused Cahill of performing an intrusive physical exam during appointments in 2006, 2009, and 2019. Both Wesko and Mauro claimed that he penetrated them “anally with his finger or an object,” according to the article.

After an initial encounter in 2009, Wesko also claimed that Cahill attempted to pursue a romantic relationship with her for nearly a decade, according to “hundreds of emails and dozens of handwritten cards and voice messages from Dr. Cahill to Ms. Wesko” that were reviewed by the Times. Then in 2018, Wesko was diagnosed with endometriosis.

According to the article, she was running out of effective treatment options and eventually sought Cahill’s medical advice. The Times report said that Cahill took the opportunity to arrange Wesko’s care, including a surgical procedure, at the Lenox Hill Hospital in New York.

Wesko agreed to receive the care only to be told by Cahill that he would require her to see him for two preoperative exams before the surgery could take place. During those exams, Wesko said that Cahill again sexually assaulted her. The Times reported that Wesko claimed that “Cahill again penetrated her anally, and during the second exam, [he] fondled her breasts, ripped open her paper gown, touched her stomach and pelvic area, and kissed her on the mouth.”

Wesko has filed a lawsuit accusing Cahill of these offenses. His lawyer has denied the severity of the encounters and claimed that Cahill was only pursing a friendship with Wesko.

Mauro has not filed a lawsuit against Cahill, but agreed to share her encounter with him in 2006 with the Times. She told the Times that “he came in — there was no nurse — and immediately walked up beside me and ripped the front of my gown open” to examine her breasts even though she had scheduled the visit due to gastrointestinal problems.

She told the Times that after the visit she remembered telling her boyfriend, “I feel like I just got raped by a 70-year-old doctor.”

Cahill is being investigated by the New York State Health Department in addition to Wesko’s lawsuit. He did not respond to the Times‘ request for comment.

Billion-Dollar Bounty for AARP

The American Association of Retired Persons (AARP) agreed to an exclusive promotional deal in September with Oak Street Health, which operates 100 primary care clinics in a dozen states, according to Kaiser Health News.

The deal allows Oak Street Health to use AARP in its marketing for an undisclosed fee, according to the report.

This arrangement falls in line with a lucrative practice by the AARP, where the organization collects “royalties” in exchange for exclusive marketing deals with healthcare businesses eager to promote themselves to AARP’s membership.

In total, the AARP collects $1 billion in these kinds of royalties, according to its 2020 financial statement, KHN reported. About two thirds, or $752 million, of those royalties come from “health products and services,” according to the article. For comparison, AARP collected roughly $300 million in member dues in 2020.

There are questions about whether these partnerships are chosen because they benefit AARP’s members or because they are so profitable for the organization, according to the report. Marilyn Moon, who is a health policy analyst with ties to AARP since the 1980s, told KHN that it “certainly is a problem,” when the organization is profiting from these medicare-focused marketing partnerships while also lobbying on Medicare issues in Washington, D.C.

The partnership with Oak Street Health highlighted those concerns when the company came under investigation by the U.S. Department of Justice for its marketing tactics, KHN reported.

“It’s hard to know whether they’re advocating for their business interests or for the seniors that they are supposed to represent,” Joshua Gordon, director of health policy for the Committee for a Responsible Federal Budget, a nonpartisan group, told KHN.

DOJ Targets Medicare Advantage Billing Schemes

The U.S. Department of Justice is prioritizing the investigation of widespread fraud related to a fake-diagnosis scheme designed to increase charges to Medicare Advantage, according to the Washington Post.

The government considers the practice of adding diagnoses to patients’ medical records fraudulent, and has been pursuing legal action against several companies, including UnitedHealth Group, Cigna, and Anthem, according to the Post. The DOJ announced in February that these investigations are an “important priority,” according the the Post.

The Post reported that the fraud was made possible by built-in incentives in the Medicare Advantage program. The program paid companies a flat fee for patient care along with a “risk adjustment” pay scale to reimburse health systems for more time-consuming and expensive patients. By adding more unnecessary or previously resolved conditions, companies can increase the payments they receive for patients without using the resources on patients.

Critics said a side effect of this fraud is that it leads to inaccurate patient medical records, full of false diagnoses, “that could unnecessarily stigmatize patients who were improperly deemed obese, or malnourished, or mentally ill,” the Post reported. These false records could lead to “phantom influences” on future medical care of these patients, according to the report.

The fraud was initially uncovered when a whistleblower, Kathy Ormsby, discovered the scheme designed to make patients look sicker during an audit of her former employer, Palo Alto Medical Foundation. The foundation and its parent affiliate, Sutter Health, a health system in northern California consisting of 24 hospitals, settled the lawsuit with the government in August 2021 for $90 million. They did not admit to any wrongdoing.

Ormsby discovered that her former employer was adding diagnoses to patient records without their knowledge to inflate Medicare billing. According to the government’s lawsuit, Ormsby audited hundreds of cases and discovered that 90% of cancer diagnoses were not valid. She also found that 96% of strokes and 66% of fractures were also not valid diagnoses.

Ormsby told the Post that “as we continued to audit, I started to see more things. I couldn’t believe how bad it was.”