Key Insights From Healthcare Compliance Attorneys on Today’s Compliance Challenges

What do you get when two attorneys and a compliance expert sit down for a chat? The latest episode of Compliance Conversations!

Tune in to our conversation with Sean McKenna, a partner in Spencer Fane LLP’s Dallas office, and Keith Dugger, a shareholder in Hall Render’s Dallas office. Sean and Keith bring unique perspectives to our discussion, as Sean focuses his practice on solving clients’ healthcare needs and representing companies and executives in white-collar cases and investigations, and Keith focuses on strategic planning, assessment, and analysis of the laws as applied to various transactions, fraud, and abuse.

In a conversation filled with insights and tips for healthcare compliance professionals, CJ, Sean, and Keith discuss:

  • The unlimited breadth of the Anti-Kickback Statute and what it means for compliance teams
  • Why labs are a hot spot for enforcement
  • The Eliminating Kickbacks in Recovery Act and opioid substance abuse treatment
  • The uptick in private equity investments in healthcare – and the increase in enforcements in this area

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Attorney Insights on Today’s Pressing Healthcare Compliance Issues - Podcast

Episode Transcript

CJ Wolf: Welcome everybody to another episode of Compliance Conversations. I am CJ Wolf and I am working with Healthicity. This is Healthicity's podcast. We're grateful for their sponsorship and are excited to have two new guests today, Keith Dugger and Sean McKenna. Both are outstanding attorneys. Welcome, gentlemen!  

Sean McKenna: Good morning, how are you today, CJ?  

CJ: Doing great and both of you are joining us from the great state of Texas, is that right?  

Keith Dugger: That's right, yeah, here in Dallas.  

CJ: Great! I used to live in Texas and worked for the University of Texas system and so have some fond memories there. As usual, we'd like to allow our guests to take some time to introduce themselves. Gentlemen, would you like to start and tell us a little bit about your professional background and what you're doing currently?  

McKenna: Yeah, absolutely CJ, and I'm thankful to be in Keith Dugger's conference room. Sean McKenna here with Spencer Fane as a partner in the Dallas office. I represent healthcare providers around the country and enforcement of white-collar actions. I spent almost 15 years of my career with the federal government, with CMS as an inside attorney, then OIG and DC, and then 10 years as an AUSA prosecuting healthcare fraud cases, civilly and criminally. And since 2013, I have been in private practice helping out providers in addressing all those big bad government issues. So, thank you! Keith?  

Dugger: Yeah, thanks Sean and CJ, thanks for having us on today. As you mentioned, my name is Keith Dugger. I am a shareholder in the Dallas office of Hall Render. I've been practicing health law since 1996, so been doing it for a while. Have been really on the, I guess you would call it the opposite end of what Sean does, has been outside the courtroom and have really focused on strategic planning, assessment, and analysis of the laws as applied to various transactions or arrangements and have a little bit of a broad practice, but fraud and abuse have really been my bread and butter ever since I started back in ‘96. But again, it's great to be here. And hopefully, we can have a really interesting conversation with you today.  

McKenna: Okay, with that CJ, you might have to wrap it up after that long intro Keith, thanks so much! 

CJ: That's awesome, we love it! You know, our audience is predominantly compliance professionals, right? And that's part of the reason why I wanted Keith and Sean on, is because they're both attorneys dealing with this stuff on a day-by-day basis with their clients. So, I thought I'd ask them some questions about what they're seeing out there, right? It's one thing to be in-house and that's good and that has its role. But when you have multiple clients, you probably start to get a sense of, "Oh, these trends," and "Oh, this is what's going on," and "Oh, I saw that creep up with another client," and those sorts of things. And we're going to talk a little bit about the Anti-kickback statute and private equity stuff, compensation. But also, we'll talk and see where the conversation leads us. But Sean, if I could kind of start with the Anti-kickback statute, if you're just briefly, maybe 30 seconds or so, just give us a quick primer on that, intent-based, one-purpose rule for some of our very new listeners who might not know the basis. 

McKenna: Yeah, absolutely. I thought I didn't have to think today, CJ but I'll dust it off! And now, the Anti-kickback statute is one of the most prolific statutes that the federal government and state equivalents have. It essentially bars the relationship, referral relationship between certain parties, not necessarily clinicians, but could be anybody, including those in a position to influence or direct potential referrals under a federal health care program. And so, it's a criminal statute, punishable for up to 10 years per offense. It can be the basis for a False Claims Act civil Action, and it often is increasingly, and as you pointed out, it's a very draconian statute because the government, the test seems to still be, although I disagree vehemently with it because it renders all the guidance and safe harbors, we can talk about later, superfluous, is that if one purpose of the alleged arrangement or the referral is to obtain referrals, it could be with the proper intent, deemed a violation of the AKS and or the False Claims Act statute, so you can quickly see CJ and Keith, right? That it becomes almost endless, that almost every transaction from a business perspective, a provider is going to go in and our entity is going to do an ROI, a pro forma on whether this makes sense. But giving so putting in writing can be used as a government and an agent or a whistle-blower as a basis for a violation of the one-purpose test. So, patently unfair in my opinion.  

Dugger: Yeah, absolutely. I think the scary part of being in the healthcare industry with a statute, like the Anti-kickback statute, is the unlimited breadth of what it can apply to and what would typically be a normal everyday occurrence or transaction can be criminalized in the healthcare context, and so it really does require a lot of focus. It requires a lot of understanding of the statute, and then a lot of faith that what you've done if you're ever challenged, that you're able to explain what you've done and how it is not a violation of the statute. So again, that's why it's nice to have attorneys like Sean on here who have really looked at and litigated that Anti-kickback statute approach on both sides. I think it's one of those things that compliance really creates a lot of issues for us to look at and help our clients with.  

McKenna: That's a great point. We've been in this conference room before with shared clients and we're trying to talk to them and advise them on what is the risk, right Keith? And that's really profound because the government is taking that risk almost to the extreme, the pendulum has not swung back yet. It might start being that way, but the Department of Justice takes such an aggressive position, so do the whistle-blowers. You know, it almost seems like the intent requirement, knowing a lawful, is just not there anymore, it's just simply, you enter this transaction, a physician or some other entity got referrals and made money, Guilty! 

CJ: I was just going to say, I try to explain this concept to people in other industries, you know, like in construction or in restaurants or in banking, it's like you get a free toaster if you open an account with us like it's allowed, but in healthcare, it's not, and so it's kind of a foreign concept for people outside of healthcare. Go ahead with your thought that you're going to start there.  

Dugger: Well, the other thing, I want to follow up on what you just said, but also a lot of times in the law, whether it's in some other aspect of healthcare or in other industries, you can say if this then that, but with the Anti-kickback statute, the guidance is really; if this, then it could be this, that or the other, because it depends upon what your intent is. It depends upon facts and circumstances, can the government show that you had intent, not because you said, "I want to violate the statute," but because of your acts or your omissions to act on that.  

The other thing that I tell you, is what makes it even more complicated, is that there are things you can do, in the healthcare environment, that are dependent upon, "Who Is the payer?" So, for example, with respect to, everybody has seen these little pharmacy cards that you can get your first 10 refills for a co-pay of 25 dollars as opposed to 100 or 150 dollars, you can't do that with Medicare and Medicaid, but you can do that in many cases with commercial payers. So, it even differentiates and depends upon who is the payer? as to what you can do, so it makes it even more complicated. 

McKenna: That's a great point, Keith, because when people are trying to carve out their business and set their model up, well, it seems preposterous to me that you can do one set of things for non-Medicare, Medicaid, or the stepsister Tricare there CHAMPUS, but also, you can't do it for one or the other, and you know, I can give out gratuities around here, but at this point, CJ, you're almost set to the point where can you even give out a pad of paper or a pen? And unfortunately, most manufacturers and providers don't accept them and don't want to do it anymore, and that seems to be a little ridiculous that the OIG and the government are legislated and spent time and resources on regulations talking about de minimis and what is that? Is it 10 dollars, 50 bucks? When you're a surgeon or a billion-dollar organization, do you really care about 10 bucks as an inducement? It's not going to sway the needle, but the government sure as heck seems to like it and would like to collapse that. 

CJ: And wasn't there a settlement of a year or two back on, I think it was labs with urinalysis and I think the company that got in trouble, they were giving the urine collection cup, which could be cents, you know, 10 cents, they were giving those cups as free. Does that one ring a bell? Do you remember that one?  

McKenna: Yeah, that's a very common allegation, CJ. And Keith and I had a lot of lab cases together. And as the government takes the position well, it might be a box of free cups, you know, pulling sample cups, to me it was kind of de minimis, but in the aggregate, if you're a national company, it could be a significant amount across the country. More importantly, I think, the government really has cracked down and I don't disagree with this on the like, the shipping and processing fees, Keith?  

Dugger: Yeah, I think that this is the shipping and processing fees and it really came out over the last couple of years, when we had the COVID-19 pandemic, we were trying to be quick and responsive to handling the needs; patients who needed to be tested, trying to prevent the disease from spreading faster or more prolifically than what we can handle, and so in the attempts to be nimble and allow people to provide that testing, provide the treatment, the government started to expand what its rules would allow and now after the pandemic is over, it's not technically over, we still have a public health emergency, but now the government is going to go back and it's going to be a retrospective review of did you do this right or did you not do?  

So, I don't want to lose in the forest the fact that the laws that are there actually have some really positive goals, what they're trying to do is to prevent overutilization. They're trying to prevent inappropriate impact on referral decision making, or which doctor you see or which doctor you don't. So, there are good goals that are trying to be achieved by these laws, they just sometimes get lost in overzealousness of enforcement, kind of just really focusing on the inappropriate side of that enforcement. And the other thing that I would say is, it's also trying to focus on medical necessity, which I think is probably one of the highest and best goals of these laws is trying to make sure that when medical care is provided that the government or other payers are going to pay for that medical care is necessary. So medical necessity as opposed to things that aren't really used to help advance your healthcare to treat or minimize an actual health condition.  

CJ: I was going to say, I've spent some time in the med device and pharma world and I think you're right, the goals are that decisions should be made off of what's best for the patient, not off of financial relationships. And sometimes some companies try to speak out of both sides of their mouth, they try to say, "Well, this money is not really influencing anyone when we do XY and Z," but then they have to answer to their board as to why do you spend so much money on marketing if it doesn't actually influence sales? and so it's an interesting kind of tension there. 

McKenna: One comment on that, a couple of too, kind of back what Keith said, you know 10 cents a cup, Yeah, shipping and processing 50 dollars for every claim, that's a distinction I think, and it's a sliding scale, and that's unfortunate, right? We don't have benchmarks, because every time and I understand the reluctance of the government to introduce hard and fast barriers because the industry can always evolve around it, right? It's kind of like what justice Potter Stewart said regarding obscenity, "I know it when I see it," and I wish that was DOJ's perspective because what I see is a potential kickback, isn't necessarily what they're bringing, but to your point, CJ about the marketing, one of the big compliance concerns that Keith and I see in our respective practices is operations or the marketing, business development people driving the train, right? Sending out those emails, encouraging providers to continue to utilize XY or Z and that has been years of exhibit A for the government to bring these types of AKS cases, so providers I think really have to be leery of letting that operations marketing perspective drive the train and limit those communications and really focus keep the set on the clinical component, clinical sites, the benefit, logistically, why this is a better deal for the patient, cost-loss, better outcome, less travel, whatever it's going to be.  

CJ: Are there any specific trends you're seeing, like topics or types of services that are cropping up a little bit more in this space?  

Dugger: Well, I think lab continues to be one of the biggest areas for enforcement. One of the reasons and kind of I'll go back a little bit to medical necessity is oftentimes it's a little bit easier to kind of fudge medical necessity or to enter into arrangements that incentivize someone to order lab tests, because it's not a patient harm, you take one vial of blood and you can run a hundred thousand lab tests. The other thing about labs is you now have an overlay of another statute called EKRA, Eliminating Kickbacks and Rehabilitation Act, which further restricts the ability, for example, we're talking about marketing, it further restricts the ability of a company to pay marketers, even employed marketers, based upon the success of their activities. So, we're starting to see some enforcement that the statute is only three, four years old, but we're starting to see some enforcement come through. There was a touch of a split in the circuits, the Hawaii circuit ruled a little bit differently than what other circuits have, so there's some uncertainty there as well, but I think labs for me is what I'm seeing as a continuing focus of enforcement. Telehealth is another one of those areas, Sean, have you dealt with any telehealth cases? 

McKenna: Yeah, that would be great. So, the lab space but specifically, urine toxicology, and again not so much the testing, but the way it's marketed or potential labs are investing, right Keith? that seems to be a big issue on the AKS, genetic testing; PGx, CGx cancer, and genetic testing. Huge issue and you know, CJ, and Keith alluded to this before, but during the pandemic, everyone was encouraged to get total testing. Couldn't test enough, right? So, everyone was like growing resources to test. And on top of it, a lot of labs added this RPP, respiratory panels. Now the government is coming back and saying, "Well that was completely improper even through the RPP and to make money," when operationally, right, you're in the middle of the pandemic things are changing every day. And now the DOJ is going to look back during those frenzied moments when you're trying to save employees, first responders, caregivers, life, and the residents of nursing homes and other patients, and they're saying, "Well, then you tested too much." To me, that's the height of hypocrisy and I used that before, but I just think that this deal, that's a weak case to get DOJ seems to be pushing that agenda. So, the lab telehealth, there was a huge takedown a couple of years ago. I think those cases have wild during resolved on DME, but anytime you see telehealth and how those physicians are interacting with those patients, it's a problem because the government takes a position, or it can only be a legitimate face-to-face position, blah blah blah! Well, the pandemic has proven otherwise and Medicare start to allow it, but it's also the same thing with DEA, you can't prescribe a controlled substance through a facial visit for telehealth. It has to be in person. Well, they have to enforce to back off on those rules again.  

So, we're seeing it in that area. We're seeing enhanced AKS enforcement. You're seeing it just in every actual component and seems like the government is now buckling and doubling down on what the industry can and cannot do as far as business operations, development, and growth. And at some point, there's going to be a reckoning, maybe not today, maybe next year. But the courts I think are becoming a little more cognizant of us at what point do we stop this? Not to look at the aberrant behavior which we've seen, but most providers are doing the right thing for the benefit of the patients, but ultimately, there are some bad actors there in any of the DOJ that should take a hit appropriately, but that doesn't mean, a blank approach, right?  

CJ: Yeah, those are all great points. We're at the point where I'm just going to take a short break and we'll be right back.  

Welcome back, everybody. Gentlemen, I wanted just to follow up on one last question and then maybe we can segue into kind of some other topics if you're okay with that. You mentioned EKRA is that like, some of these laws, you were talking about are very, very specific to federal healthcare programs. Is EKRA limited to federal healthcare programs, or does that also cover commercial payers?  

Dugger: Great question, because, unlike Anti-kickbacks, it actually applies to any payer. And the interesting thing about it was it was really focused on the opioid substance abuse treatment and the abuse of lab tests related to those kinds of patients. But in its enactment, it actually applies to all laboratories, without regard to whether you are doing substance abuse testing or anything else. So, it is a very broad statute. It's a very restrictive statute, and it really has, I think it's going to have even more impact on laboratories as cases start to wind through, because again, in the Anti-kickback statute, we didn't really talk about this, but it has exceptions for employment, that really gives broad latitude to pay your marketing personnel and others, even if that payment relates to the success of their activities. EKRA really shut that down as it relates to laboratory marketing and I don't know that everybody received the message, so we're probably going to see a lot more cases on that. 

CJ: That'll be interesting because, and will let you comment, as compliance officers we've often focused heavily, and probably rightfully so on rules and regs from government payers. And this is probably going to be a somewhat of a little shift for compliance officers out there to be paying attention to a little bit outside of the government payers. Go ahead.  

McKenna Yeah, absolutely sorry I interrupted you. This is interesting because it's the first all-payer statute from a federal perspective directly addressing compensation to marketers' 1099s, but also W-2s. So, what we're seeing under the passage of EKRA, which Keith noted, was a response to the sober quote "sober living homes" in South Florida. It's an ill-conceived statute. I don't think it makes a lot of sense, but what it basically did is saying, "We're going to criminalize conduct that the OIG for HHS and the employment context from a commission perspective has allowed for almost 30 years, and that's remarkable. So, how do you compensate anybody in a lab situation with the threat of this criminal statute? And that's been a quandary, Keith, and I don't know how you do it, and it's been very difficult. Because what's a lot of the pharmaceutical and the device manufacturing route for commissions after decades of enforcement, per se a violation of a criminal law with the requisite intent under EKRA. So, I don't know, I don't think we're going to see a huge amount. I think that statute is going to be amended at some point, clearly. Mark and Rubio's office did not communicate with the LIG or Department of Justice before that thing was passed. So, it could have been footnote twenty-seven thousand in a ten thousand page. Yeah, but that's just my perspective.  

Dugger: I think that's a really good input, and I think you're right. I kind of expected it to be addressed, maybe a little bit earlier than what it's going to end up being. But I do think it really didn't take into account the history. It criminalizes otherwise, a behavior that's otherwise appropriate, and other contexts within the same industry. So, I think for all those reasons it's going to be problematic.  

And CJ, I just wanted to give you two thoughts before we move on. The first thought is, not questioning governmental motives, but everybody needs to keep in mind that fraud and abuse enforcement is a moneymaker for the government. I think it was just under 2 billion that they pulled in from fraud and abuse enforcement in 2021. And that number continues to grow. So, there is a financial incentive for the government to pursue fraud and abuse cases. Again, when it's appropriate, I'm extremely supportive, but when we get the conduct that is not blatantly violative or inappropriate, then that is where it becomes concerning.  

The second thing, to kind of hammer on your points about the difference between potentially federal programs, commercial payers, or all payers, is that we're seeing a trend, where the government is becoming the world's cheapest and largest in-house counsel, in-house legal department for insurance companies, where when insurance companies see something that they may not be illegal but they just don't like, we're seeing referrals over to the government and those becoming investigation points.  

So, what people in the compliance community need to understand is that your potential liability is not limited to or it won't begin only because a federal agent comes knocking at the door. It can start because you were referred by a commercial payer. It can start because your receptionist thought he or she was underpaid and saw some things that they didn't like and reported it, or filed a false claim act.  

So, there are many different areas where liability can flow from. And many different starting points where that liability can come from. So, that's the important but scary thought process that compliance people need to be going through and understanding. 

McKenna: And CJ, and I just want to say, Keith l was clopping, I'm sorry CJ because I was applauding Keith for saying that because there are plenty of smart government agents and smart prosecutors and people in the government, but they always seem to substitute their alleged knowledge, for industry and realities, and it's always a reckoning and a wake-up call when you try and educate people. And CJ, I was one of those, I had no industry experience and I'm sitting there listening to the contractor or the program, and the agents are telling me and they were wrong and having conversations and having that dialogue with industries and heads of organizations really opened my eyes that, you know, "Hey, there's a rationale for this. It can't just all be doom and gloom and bad," but unfortunately, I think it's kind of reversed and a lot of people just want to listen to the bad without taking the opportunity before pulling the trigger and doing something drastic to impact market share organization employed by.  

Taking an opportunity and listening to the leadership first and saying, "Hey, what are we doing here now?" There were plenty of instances where perhaps that's appropriate, but a lot of times with the larger institutions with compliance programs, which is another benefit established, credible, demonstrative effective compliance programs, you should be given the benefit of doubt and they should be picking up the call and saying, "You know what CJ, we have a concern about this. Can you talk to us about this?" And nine times out of 10, it's going to get resolved without that costly process that Keith had described.  

CJ: Yeah, those are all great points. Really appreciate your thoughts on that. You know, with a little bit of time that we have left, should we pivot a little bit and talk a little bit about private equity and compensation and those types of concepts, which are a little bit newer to a lot of us in healthcare compliance, would you kind of set the stage as to why that's even an issue.  

Dugger: Sure, absolutely. And thanks for seeing that up. I think as people are kind of aware of there's been a significant uptick in private equity investment in healthcare over the last few years. Why that's important is that we're starting to see more enforcement actions that relate to those private equity relationships. Historically, those private equity firms have had a little bit of a laissez-faire attitude when it came to due diligence and risk acceptance. What that means is really their risk thresholds were typically higher than traditional purchasers in the healthcare market, and they were much more willing to push the envelope when it came to assuming legal risk. I think their thought process was that the risk was a simple math and money problem. "Did the potential financial reward of the deal outweigh the financial risk discovered during due diligence?" Many companies felt like that, if the reward was greater than the risk, they can clean up after the non-compliance was discovered when the acquisition was actually closed.  

There's also, I think, a feeling that the PE companies in its principles were a little too far removed from the non-compliant activity occurring within, what would be called their portfolio company, and so, because of that removal, they didn't risk significant personal or enterprise liability. However, as some people may be aware of, there's the Yates memo from 2015, which is really trying to hold the individual's feet to the fire, so that you couldn't just pass it off to corporate, you know, say, "Oh, this was a corporation issue, not an individual liability." Sean, do you have any thoughts on that? 

McKenna: Yeah, the Yates memorandum really was a key change during two administrations together and now it's been resurrected in the form of a Monaco and now Assistant Attorney General, Kenneth Polite discussed something yesterday, really hammering compliance and cultural kind of cooperation, and the focus on individual culpability, but I also see it from a liability perspective that a lot of private equity companies want to have their people in place, and they're pushing a financial agenda because they don't have that healthcare experience or they are aware of the potential compliance risk. So, I think from an acquisition and initiation, you've really got to do that due diligence, do your audits, and focus on potential areas, especially because PE seems to be involved, and not acquisitions of systems, but ancillary sides where the EBITDA is so high.  

Dugger: They're doing a lot in the physician space, working with physician groups, and doing what we call "Roll-up physician groups." And a lot of times this is profit-driven, which again, I don't think there's anything wrong with a profit motive, but when that profit motive collides with patient care, when it collides with other concerns, you know, that the jobs that are available in healthcare, when it collides with insurance companies, and the need to maintain some controls over the cost of care, that's when it becomes problematic.  

And with PE, again we won't get too deep into it, but I think they're starting to see a lot more of the false claims exposure. And as Sean mentioned earlier, false claims exposure can come from an alleged or actual violation of the Anti-kickback statute. It can arise from an alleged or actual violation of the Stark law and the threshold for one of those claims to be filed is relatively low. Now, the threshold for the government to actually intervene is a lot higher, but even if the government doesn't intervene, the relator can go ahead and continue on with that, often don't, because what that government saying is we don't really see a lot of the value to this, but that's exposure, that's risk exposure, that's cost exposure to the private equity company and I think that we're starting to see that with this continued activity in the healthcare space and that is a lot of it is being driven by that private equity approach, I think we're starting to see the government readjust and start to take a much closer look at not only the portfolio companies that are being acquired but at the PE companies themselves.  

CJ: Yeah, and I think one of you mentioned the Monaco memo for our listeners who don't know what that is. Monaco she's the deputy Attorney general of the US Department of Justice if I have that right and the memo, I think, was released last fall, maybe September time frame and I think guys there's a whole section on compensation talking about kind of clawback of comfort compensation for individuals because you mentioned holding individuals accountable and there's a section in that memo if I'm not mistaken that, you know best, practices in compensation clawback if something goes wrong, does that ring a bell? Am I right there?  

McKenna: Yeah, absolutely, and there have been iterations over the last 30 years of the Deputy Attorney General memo and they're becoming much more prevalent. But yeah, holding individuals calling back, essentially ratting out the culpable individuals which present ethical issues for any organization is a quandary, right? Your client, from just a compliance perspective, "What's the board doing versus the executives doing so?" It puts compliance officers and officials in a very tense situation because these C-Suite persons may be held accountable even in the private equity, and you may not have evidence to address it, or they may not be willing to. So, those are the types of cases that I think are going to be brought, clear-cut violations, but something with the private equity, kind of burning down their expertise and involving day-to-day in the operations of the acquisition. Otherwise, I think that they're hands-off, it's kind of like I'm just an innocent stockholder, you can make those arguments, but you're absolutely right CJ, that's been an increase by Department of Justice in a kind of a little more so from the prior administration.  

Dugger: Yeah, and CJ, the last thing I'll say is that, again, like with the government, this is not to demonize private equity by any means. There's a lot of value that they can bring into the healthcare marketplace place. There are efficiencies in operations, efficiencies in financing, things like that that they can bring that can be extremely helpful when you're talking about a service line or a product line that trying to get to the marketplace and make sure that there's a lot of access to it. But with the good comes the bad and there are potentially bad actors that make it harder for everybody else and so I think that the ultimate issue is maybe five, six, seven years ago private equity was able to jump in and do what they normally do without a really significant level of exposure. That kind of immunity if you will, is quickly kind of being pulled and private equity needs to make sure that when they come into the marketplace, that they do so from a position of strength and knowledge, that they have appropriate advisors, whether it's legal advisors or business advisors that understand the marketplace and understand where that risk lies.  

McKenna: And I'll just follow up on that, Keith. That's a great point. We saw this about 15 years ago with private equity and kind of corporate ownership into hospice and nursing homes, where I think it was the biggest issue for the government enforcement, kind of a cram down on profitability. But you know, private equity investing in healthcare is nothing. There's no inherent problem with that, and it's encouraging. And it helps a lot of providers and it helps access to care for a lot of patients and otherwise rural underserved areas. So, no ill will towards that. It's just simply for sophisticated private equity is, they may not understand the nuances of healthcare, that's what Keith is saying. I believe that's where the rubber meets the road and problems arise. So, make sure if you are investing in these, you've got the adequate industry Speople telling you what's going on and doing the due diligence.  

CJ: Yeah, that is great advice. You know, I could talk all day, but we are coming to the end here. I'll give you a moment to think if you have any last-minute thoughts, but I just wanted to say thank you so much. You both just have a wealth of knowledge in these areas, and I hope our listeners if they need help in these areas, would consider both Sean and Keith.  

Gentlemen, any last-minute thoughts or something I didn't ask? Or something that you just the world needs to hear? 

Dugger: I think the world needs to hear a little bit less of me right now because they've got better things to do. Number one, thanks for having us on here. We always enjoy talking about the issues that we see on a day-to-day basis. Fraud and abuse is a very complicated area. It can be scary if you don't know what you're doing. But it's always important to talk to and work with people who know what they're doing. And so, we welcome outreaches. We welcome the opportunity to really just kind of talk through these things and I couldn't do it without people like Sean who are there to really help bring the entire picture into focus and he is somebody who I have relied upon. Worked with him for 8-9 years now and so with him, I'm glad we were able to kind of convey a little bit of information to you.  

McKenna: Wild Keith, I don't what to say here, I'm choking up here! I will show from my Miami Dolphins, CJ briefly in the sense that we had a heck of a season faced a lot of adversity of my healthcare providers and they performed well. Came up a little short but still did a great job. But Keith, I echo everything you said, it has been a wonderful opportunity, CJ to talk to you. And as I'm sitting here talking, Keith and I had have these discussions all the time about cases, and so it's really a nice treat for us to share it with your audience, share with you, to really discuss some of these issues, and I think a lot of healthcare attorneys feel the same way.  

But I do think the enforcement trend is pretty aggressive and providers spend their time on the front end to get to know a guy like Keith and what he can do and what he can advise and kind of give you those contours, initially. Because I'm a guy of last resort, I don't want to be, but it seems like that's what my practice is, so, but again, appreciate it, and happy new year to everybody.  

CJ: Well, we could put your contact information in the show links, but maybe just verbally you could just tell us again the firms you're with.  

Dugger: Sure, Keith Dugger and I'm with Hall Render, here in Dallas, TX.  

McKenna: And this is Sean. I'm with Spencer Fane and Dallas, TX as well.  

CJ: Awesome! Well, gentlemen, thank you so much for your time and expertise. Maybe we can figure out a way to have one or both of you back again in the future and thank you to all our listeners. As a reminder, please remember to like these episodes if you like them. Share them with friends and colleagues. Get the word out and kind of build that membership. Again, we're grateful for our experts here today and wish you all a wonderful day. Thanks for listening.  

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