Is This a Moment or a Movement? Three Forces Reshaping Healthcare With Peter Hayes. EP475

An EBC Allegedly Pocketed $27 Million of Client Pharma Rebates. Here's What Happened Next. An employee benefit consultant where 61% of revenue allegedly came from keeping clients' pharma rebates — undisclosed, in violation of the Consolidated Appropriations Act of 2021, funneled into the executive bonus pool. When the compliance officer raised the alarm and eventually disclosed to a plan sponsor, he was fired. That firing is what made this a whistleblower case. Stacey Richter speaks with Ann Lewandowski — nationally recognized healthcare executive and whistleblower known for Lewandowski v. Johnson & Johnson — about the pharma rebates case, what it means for plan sponsors, and what to do if you are an employee watching something like this unfold. WHAT YOU'LL LEARN ✅ The anatomy of the case: an EBC's TPA arm allegedly kept client pharma rebates — 61% of revenue — without disclosing them as required by the CAA, funneled them into the executive bonus pool, and fired the compliance officer who tried to make the disclosures; originally filed in Maryland state court, moved to federal court because it involves ERISA, with the Department of Labor now working alongside plaintiff's counsel ✅ Why Form 5500 disclosure templates matter: a vague statement like "may from time to time receive third-party compensation" satisfies the letter of the law while hiding everything; Ann's advice is to use your own template with black-and-white line items so the vendor either discloses or actively lies ✅ What a qui tam lawsuit is: qui tam provisions allow private individuals to sue on behalf of the government and collect a portion of the recovery — the upside most employees don't think about when weighing whether to come forward ✅ The Upjohn warning: when a company's lawyers interview employees about potential wrongdoing, those lawyers represent the company, not the employee — the company can waive privilege and share what was said with the DOJ; every employee must understand this before speaking ✅ Ann's practical advice: document everything, don't depend on others to protect you, and consult an ERISA attorney — the DOJ's 2016 sentencing guidelines mean individuals with knowledge of wrongdoing can be personally prosecuted, not just the company ✅ Compliance as the organizational immune system: you can tell everything about a company by whether it treats a concern raised by the compliance officer as a vaccine or an invader to be eliminated WHY THIS MATTERS Trust but verify — and as W. Edwards Deming put it, in God we trust, all others must bring data. For plan sponsors, this is a guide to defensive plan sponsorship. For employees watching the wrong things happen around them: the risk of not whistleblowing, of being on the wrong side of the table when someone else does, is just as real as the risk of coming forward. MENTIONED IN THIS EPISODE EP379 with AJ Loiacono: Apple Podcasts | Spotify | Other Apps EP397 with Paul Holmes: Apple Podcasts | Spotify | Other Apps EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 08:10 What does it mean to be a whistleblower? 09:05 What's happening in the current whistleblower case about pharma rebates? 14:24 What are the disclosure requirements, and how does this affect contracts in healthcare? 15:11 The 5500 form. 16:46 Why having a "defensive health plan" is important. 17:31 Matt Ohrt's post about healthcare's soul. 17:42 Michelle Bernabe's post about how healthcare has lost its heart. 18:15 Why "trust and verify" is important when building contracts and relationships in healthcare. 18:42 Quote by W. Edwards Deming. 21:35 How has this case moved from state to federal court? 23:30 Whistleblower case on generic drug collusion. 24:01 What is a qui tam lawsuit? 28:08 What is an Upjohn warning and the issue of corporate Miranda rights? 30:01 What is Ann's advice to employees who might be whistleblowers? 33:31 What are some red flags that employees should look for to understand what kind of company they work for?