Exposing the Loopholes! How Moda Health and Other Health Plans Exploit Regulatory Gaps
Fraud and Antitrust Violations in Mental and Behavioral Healthcare have No Consequence for Health Plans in Oregon
A Discussion Document (expanded)
The healthcare industry is (at least in theory) built on values of trust, fairness, and accountability. However, in practice, health plans operate within a system which allows them to commit fraud, manipulate markets, and violate antitrust laws with small risk of significant consequences. Such unchecked power threatens, the public, professionals who provide care and the entire value-based care system Oregon is struggling to create. The most alarming part?
Governor Kotek, the Oregon Legislature, and the Oregon Health Authority are so insulated from care providers’ concerns that they cannot diffuse ticking bombs until after they’ve exploded.
Regulatory Gaps Shield Health Plans from Accountability
For more than a decade, Mentor Research Institute (MRI) has worked to understand what processes would ensure ethical value-based payment contracting. Those would include investing substantial resources in oversight mechanisms such as outcome measurement technology, ethics point portals, and independent audits of contract and policies.
In late 2022 discussion began with Moda about MRI’s concerns related to a problematic “value-based payment” structure Moda was offering to more than 125 groups of mental and behavioral providers. In October, 2024, Moda Health abruptly terminated discussion with MRI after a meeting in which MRI asked whether Moda Health employs an independent auditor.
MRI has come to a troubling realization: Oregon health plans are shielded from meaningful accountability. Despite repeated efforts to file complaints and trigger investigations, providers have no effective legal channels in Oregon to report a health plan’s unethical or illegal behavior to any entity other than the health plan management responsible for the misconduct.
MRI has, over the past two years, submitted complaints to a number of state agencies including the Oregon Department of Justice, the Department of Consumer and Business Services (DCBS), the Oregon Health Authority (OHA), and has had discussions with legislative offices including those of Representative Jason Kropf, Representative Rob Nosse, and the Governor’s Office. Those efforts resulted in bureaucratic pass-the-buck responses, with agencies pointing providers to another entity in a circle, a continuous loop of assertions that the difficult questions and challenges being made about Moda’s supposedly “value-based payment” proposition have no legal oversight in Oregon. But large Healthcare system, like St, Charles, actually do because they have ethics point portal. That lack of legal oversight exposes a legislative void that prevents meaningful investigation, accountability and enforcement of laws.
Following guidance from U.S. Senator Jeff Merkley’s office, MRI submitted its a complaint to the United States Office of the Inspector General (OIG). The MRI complaint has been acknowledged. No action has yet been taken.
In Oregon, health plans are, effectively, not accountable for unethical or illegal behavior which impacts patients, employers and public health.
When quality and outcomes fail, Health plans will point the finger at providers.
________________________
Key Violations of Moda’s Code of Conduct
The IMHPA Board minutes from 2022 to 2025 document the history that IMHPA (formerly AMHA-OR) negotiated in good faith while Moda Health acted in bad faith. Here’s how…
Moda Health’s own Code of Conduct emphasizes ethical business practices, fairness, and regulatory compliance, yet their actions during negotiations with IMHPA directly contradicted these commitments. By engaging in bad faith negotiations, withholding key information, refusing oversight, and violating ethical principles, Moda caused financial, operational, and reputational harm to IMHPA.
These breaches strengthen the MRI and IMHPA argument for regulatory and legal intervention, highlighting the urgent need for legislative reforms to prevent health plans from exploiting providers through deceptive and unethical contract practices.
Failure to Act with Integrity and Fair Dealing
Moda’s Code: “Moda is committed to the highest standards of business ethics and integrity. Members of the organization will accurately and honestly represent Moda and may not engage in any activity intended to defraud anyone of money, property, or services.”
Reality: Moda withheld critical contract details, failed to provide clear reimbursement structures, and repeatedly ignored IMHPA’s requests for transparency during the negotiation process. This harmed IMHPA by preventing fair contract negotiations and creating financial uncertainty for providers.
Ignoring the Requirement to Treat Contracted Entities Fairly
Moda’s Code: “Show respect for others we encounter in our business activities and treat them fairly.”
Reality: Moda engaged in delay tactics, dismissed legitimate provider concerns, and refused to respond to critical contract revision requests, showing clear disrespect for IMHPA’s efforts to negotiate in good faith. This damaged IMHPA’s ability to advocate for fair contracts and weakened provider trust in value-based contracting.
Refusing to Allow Independent Oversight or Ethics Reporting
Moda’s Code: “Encourage others to report violations of this Code of Conduct and protect those who do report.”
Reality: Moda ignored IMHPA’s request for an independent ethics point portal and third-party auditing, preventing accountability and transparency in contract implementation. By rejecting external oversight, Moda maintained the providers current status: no independent avenues to report fraud, contract violations, or unethical behavior. This behavior harmed IMHPA’s goal to protect public and provider interests.
Failure to Comply with Legal and Regulatory Requirements
Moda’s Code: “Moda must comply with regulations applicable to all corporations, regardless of the type of industry. Moda officers, directors, employees, and contractors are expected to comply with all applicable laws, regulations, and conditions of participation.”
Reality: Moda’s manipulative contract structure and refusal to engage in transparent negotiations suggest potential violations of antitrust laws and value-based payment regulations. Their bad faith approach directly undermines federal and state policies aimed at promoting fair healthcare contracts, harming IMHPA and the broader provider community.
Areas of IMHPA’s Good Faith Negotiation
The IMHPA Board minutes from 2022 to 2025 document the history: IMHPA (formerly AMHA-OR) negotiated in good faith while Moda Health acted in bad faith. Here’s how:
Proactive Collaboration & Transparency:
IMHPA/MRI responded to Moda’s RFP in January 2022, demonstrating willingness to engage in a value-based contract.
IMHPA provided detailed proposals to Moda, with recommendations, and research-based critiques of the BHIP contract.
IMHPA hired a contract negotiator and legal counsel (March 2023) to ensure fairness and compliance.
Repeated Attempts to Resolve Concerns:
IMHPA consistently sought clarification on contract terms, reimbursement structures, and compliance with Oregon Health Authority (OHA) value-based payment standards.
IMHPA and MRI representatives met with Moda representatives several times, including formal meetings in June, July, and November 2023, presenting more than 200 documented contract issues, 40 of which were considered critical.
In July 2024, IMHPA proposed three essential safeguards—plain language contracts, independent audits, and ethics point portals, to ensure accountability. Moda left the table after stating the contract was optional and that it “is probably not for you.”
Commitment to Ethical Contracting & Public Health:
IMHPA rejected Moda’s Behavioral Health Incentive Plan (BHIP) after extensive documentation and analysis disclosed financial, ethical, and clinical risks.
IMHPA leadership prioritized patient-centered care and provider protections, even at the expense of rejecting financially rewarding agreement.
IMHPA advocated legislative action, pushing for good faith, independent audits, reporting systems, and transparency in healthcare contracting.
Areas of Moda Health’s Bad Faith Negotiation
Delays & Non-Responsiveness:
Moda delayed negotiations for over two years, citing internal issues but failing to meaningfully engage with IMHPA’s concerns.
Moda ignored IMHPA’s proposed contract revisions, refusing to respond to critical concerns or provide written assurances about reimbursement rates.
Moda failed to finalize a base contract in a timely manner, creating financial uncertainty for providers.
Moda refused to read the document concerns MRI offer in a library of over 70 papers detailing what is essential for ethical and successful value-based payment contracting grounded in State, Federal and Industry guidelines.
Unfair & Manipulative Contract Terms:
Moda offered better reimbursement rates to individual IMHPA providers, undermining group negotiations.
Moda’s contracts tied payments to unstable CMS rates, which were projected to decline.
Moda refused to include key safeguards like independent audits and ethics point portals, ensuring they could operate; keeping purchasers and providers in the dark.
Admitted Lack of Planning & Transparency:
Moda’s Behavioral Health Director admitted, “We’re making it up as we go” (November 2023), confirming the lack of a structured, sufficiently defined, and fair contract framework.
Moda representatives became defensive and dismissive when IMHPA raised contract issues, as evidenced by Suzannah Della Corte’s (senior contract author) reaction in July 2024, when she interrupted and demanded, “What is your endgame?” instead of addressing IMHPA’s legitimate concerns.
Moda failed to meet its own code of conduct as well as contractual and ethical obligations, contradicting its stated standards for fairness, respect, transparency, and outcome-based reimbursement.
The Fallacy of Better, Cheaper, Faster: Provider Failure and Healthplan Profits
The Moda Health BHIP model can be characterized as an intent to deliver better, cheaper, and faster services. However, in practice, this intent fails due to the structural imbalance of value-based payment contracting. Health plans offer and encourage providers to adopt high-risk contracts under the pretense of shared success, while transferring significant administrative, operational and financial burdens onto the providers. This dynamic reveals itself as a calculated business strategy that prioritizes cost reduction, cost and risk displacement, rather than genuine improvement in care quality.
Health plans promote the narrative that value-based contracts will result in better, cheaper, and faster care. This is predicated on the assumption that providers can deliver the same level of care at a lower cost by being more efficient. This assumption ignores the complexities of patient care, particularly in mental and behavioral health. Diagnoses do not accurately predict treatment needs or care duration, yet health plans impose rigid service caps or utilization controls. Such attempts as standardization disregard patients’ differences and leads to inadequate treatment, worsening long-term health outcomes.
The fallacy of better, cheaper, and faster care in value-based contracting conceals business model that transfers risk from health plans to providers while retaining profits for the plans. Policymakers, providers, and stakeholders should be aware that they must push for transparency, fair contract terms, and regulatory oversight to ensure that health plans share financial risks equitably and invest in improving care quality rather than maximizing profits at providers' expense.
Moda Health’s “Solutionism” Dodges Underling Problems
The term solutionism was popularized by Evgeny Morozov, a technology critic and author. He introduced the concept in his 2013 book To Save Everything, Click Here: The Folly of Technological Solutionism. Morozov uses the term to critique the belief that complex societal, political, and cultural issues can be resolved solely through technological innovation or data-driven solutions, often ignoring deeper structural and human factors. His work highlights how this mindset can oversimplify problems, create unintended consequences, and reinforce corporate or political agendas disguised as progress.
Solutionism involves applying fix-oriented strategies such as technological innovation, data-driven metrics, or policy adjustments, arguing that these “solutions” will provide clear, measurable, and lasting improvements. Solutionism offers simplistic solutions which have potential but will not benefit stakeholders when the foundational contracts and policies are almost certainly ill-defined, misleading, fraudulent, and were obtained in violation of antitrust principle. In the discussion example offered here, there is evidence that Moda Health offers “solutions” and that providers are denied (1) a pathway to report health plan misconduct, (2) whistleblower protections, (3) assurance of independent investigation, and (4) accountable corrective actions. Providers have no alternative’s to report unethical and illegal conduct by a behavioral health director, other than to address the same behavioral health director.
The Reality: Moda Health Plans Operate with Impunity Even After They are Caught
Unlike employees and consumers, for whom there are established complaint mechanisms with enforceable whistleblower protections, providers are left in regulatory limbo. Health plans can effectively investigate themselves, dismissing or covering up complaints without oversight. This lack of accountability allows blatant manipulation of provider groups, forcing them into contracts with undefined metrics, retroactive penalties, and unilateral changes in performance benchmarks. Worse, providers usually lack the background and knowledge to ask the right questions and perform adequate risk analyses. This means they enter agreements based on incomplete or misleading information. If accurate information were fully available, many provider groups would likely opt out of participation.
Moda Health’s termination of contract negotiations was not just a breach of good faith, it was a calculated move to maintain market control and avoid scrutiny. This is more than a bad business practice; it has systemic consequences. By creating deceived provider networks, Moda misrepresents provider availability, misleads public purchasers including the Oregon Education Benefits Board (OEBB), the Public Employee Benefits Board (PEBB), and Oregon Health Science University (OHSU) as it steers taxpayer dollars into their contracts under false pretenses.
The Legislative and Regulatory Failure
MRI has consulted with a number of attorneys and legislators since 2018. The response from Representative Jason Kropf’s office confirmed what MRI suspected: DCBS does not support or protect providers raising concerns. Instead, DCSB authority is narrowly focused on consumer protection, leaving providers to rely on contract law rather than regulatory enforcement. The legislative solution suggested, expanding DCBS oversight to include provider protections, is deemed too costly and politically unfeasible, effectively ensuring that health plans remain beyond reach of consequences or enforcement. Despite the fact that nearly every health plan doing business in Oregon has entered a Compact to move toward value-based reimbursements, there are no legal definitions providers can use to discuss or challenge badly crafted health plan contracts and health initiatives. Representative Rob Nosse, working closely for 6 months with MRI before the 2025 legislative session, confirmed that his committee had too many bills to shepherd, and that he did not sufficiently understand the problem, nor did he have the resources to do so..
Creating uniform definitions in healthcare statutes would ensure clarity, accountability, and enforceability, preventing health plans from exploiting vague language. Without standardized terms, defined by statute and statutory support, providers will continue to be deceived about contract requirements and policies. They will continue to be unable to challenge payers’ unfair practices or to report violations. They cannot protect the patients and public, and protecting stakeholder is not something health plans want providers to do.
Here are some examples:
Legal Clarity & Enforcement: Terms like “medically necessary care and appropriate care” allow health plans to define what is appropriate. Recognizing this, the centers for Medicare and Medicaid changed the definition to "medically necessary care and reasonable care" which prevents arbitrary denials. Without better appropriate definitions, providers are powerless to challenge changes in contracts and policy, and wrongful claim rejections. Health plans continue to use outdated and meaningless definitions because they define what they deem appropriate, focusing on profits and not reasonable care.
Glossary and definitions: https://www.mentorresearch.org/healthy-contracts-bill-definitions
Accountability & Whistleblower Protection: A statutory definitions of "bad faith actions" would allow providers to accurately document violations, provide evidence of health plan maleficence, and prevent health plans from dismissing complaints as subjective.
Whistleblower protections:
Preventing Manipulation: Health plans can shift financial risks by redefining contract terms mid-agreement. Clear definition of "plain language contracts" would prevent confusing and deceptive terms from being hidden in complex language, ensuring fair and transparent agreements.
Ethics Point Portals: If "ethics point portal" does not have a standard definition, a health plan may establish a system that is neither independent nor secure, discouraging providers from reporting fraud or contract violations. Statutory definitions would ensure accessible, third-party oversight to protect whistleblowers, and hold health plans accountable. Healthplans can easily implement an ethic point portal.
Ethics Point Portal: https://www.mentorresearch.org/ethics-point-portal-definition-and-benefits
Without uniform definitions for contracting, health plans maintain an unfair advantage.
Legislators can easily act to codify clear terms so providers can negotiate contracts, challenge unethical practices, report violations, and protect public health.
Gaps in oversight harms providers and weakens Oregon’s transition to value-based care models. Without statutes it is impossible for care providers to negotiate fair contracts or sustain ethical practices. Without legislative intervention, Oregon risks reinforcement of a system where health plans dictate terms, suppress competition, and erode providers’ ethical requirements for autonomy.
Urgent Actions and Recommendations
It is better to diffuse a bomb before it goes off. In Oregon, one might assume that providers are well aware of the ticking bombs. To prevent a tsunami of failures, the following actions are necessary:
Legislative Reform for Provider Protections
The Oregon Legislature must expand DCBS enforcement authority to include healthcare provider protections and whistleblower mechanisms.
Mandate independent oversight of health plan contracts to prevent unilateral changes and deceptive business practices.
Health plans lack readily available, trustworthy, useful, and accountable ways for providers to register contract or policy questions, or to report evidence of problems, bad faith, service delivery failures, discrimination, unethical conduct, fraud, etc.
Create a comprehensive definition and controls which would allow an independent auditor to audit provider concerns and complaints such that the auditor might reach the same or a different conclusion than health plan management.
Federal and State Antitrust Investigations
The FTC should investigate Moda Health for anticompetitive behavior, fraudulent contract practices, and market manipulation.
The Oregon Department of Justice should open a formal inquiry into health plans’ contracting practices that mislead providers and public purchasers.
Whistleblower Protections and Reporting Mechanisms
Providers should have the same legal protections as employees and consumers when reporting fraud and contract violations.
Establish an independent provider complaint system that bypasses health plan management and ensures external review.
Transparency in Value-Based Payment Models
Require full disclosure of contract terms, performance metrics, and financial risks before providers can be bound to agreements.
Prohibit retroactive penalties and unilateral contract modifications, which have been used to manipulate providers into financial losses.
Oregon Cannot Rely on Ombudsman to Identify Fraud and Antitrust Violations
Using an ombudsman to address fraud and antitrust violations is not only inappropriate but dangerous to the pursuit of justice. It undermines accountability by allowing informal mediation to replace the formal legal processes that are necessary for holding individuals and organizations accountable for serious violations. Fraud and antitrust violations require rigorous investigation, the enforcement of legal standards, and public accountability, none of which an ombudsman is equipped to provide. Allowing an ombudsman to intervene in these matters risks compromising evidence, weakening future litigation or prosecution, and ultimately failing to ensure that wrongdoers are held responsible for their actions.
The Cost of Inaction
The regulatory bomb is ticking, and unless decisive action is taken, corruption will expand across Oregon’s healthcare system, harming providers, patients, and public health for years to come.
Failure to hear the whistle has already harmed providers and negotiations undertaken in good faith. The moral injury of providing healthcare under these circumstances will erode health care outcomes, undermining value-based payment initiatives. This is less important than the providers' analysis and conclusion that the Moda contract has a moderate to almost certain moderately severe to catastrophic impact on public health and providers. Providers are likely to be blamed when the bomb goes off.
The current system is unsustainable. If the Oregon Legislature, Governor Kotak, and the Oregon Health Authority fail to act, they will only address the crisis after the damage is done. Without immediate intervention, health plans will continue to manipulate markets, restrict provider autonomy, and undermine the principles of ethical healthcare contracting.
References
Critique of Oregon's Value-Based Payment December 2023 Roadmap
The article critiques Oregon's Value-Based Payment (VBP) 2023 Roadmap, highlighting concerns about its implementation and potential impact on healthcare providers and patients. It argues that the roadmap may impose significant administrative burdens on providers without adequate compensation, potentially leading to reduced access to care and provider burnout. The critique emphasizes the need for transparent contracting practices, equitable risk-sharing arrangements, and meaningful stakeholder engagement to ensure that the VBP initiatives achieve their intended goals without avoidable negative consequences.
https://www.mentorresearch.org/critique-of-oregons-valuebased-payment-2023-roadmapModa Health's Termination of Contract Negotiations When Asked to Ensure Ethical and Lawful Contracts and Policies
The article discusses the abrupt termination of contract negotiations by Moda Health with the Mentor Research Institute (MRI). Despite initial agreements to evaluate proposals for establishing an ethics point portal overseen by an independent auditor, Moda Health ceased discussions without clear justification. Since the State of Oregon will not investigate provider evidence and complaints regarding fraud or violations state and federal antitrust laws, this action raises concerns about Moda's commitment to ethical oversight, transparency, and good faith negotiations. The article suggests that such behavior may indicate a reluctance to implement independent auditing mechanisms, potentially to avoid external scrutiny of their contracting practices. This termination not only undermines trust between the parties involved but also highlights broader issues within healthcare contracting, where power imbalances and lack of accountability can adversely affect provider practices and patient care.
https://www.mentorresearch.org/moda-health-termination-of-contract-negotiations-with-mentor-research-instituteAllegations of Bad Faith, Fraud and Antitrust Violations by Moda Health Submitted to the Oregon Health Authority - Whistleblower Complaint This paper discusses whistleblower allegations against Moda Health, including claims of bad faith contracting, fraud, and antitrust violations. It details how Moda allegedly uses deceptive contract terms and restrictive policies to limit competition and undermine independent practices. The article also compares these practices with legal standards to highlight potential breaches of antitrust and healthcare regulations, supporting the need for legal intervention.
https://www.mentorresearch.org/whistleblower-complaint-allegations-of-bad-faith-fraud-and-antitrust-violations-by-moda-healthAnalysis of Moda Health's Code of Conduct and Allegations of Violations - Appendix 1
The article examines discrepancies between Moda Health's publicly stated Code of Conduct and its actual contracting practices with healthcare providers. Allegations include mid-contract changes to performance metrics, retroactive penalties, and a lack of transparency in financial calculations, which contradict Moda’s commitments to fairness and integrity. These actions have led to provider mistrust and raise concerns about whether Moda Health is adhering to its own ethical standards. The article underscores the need for independent oversight and regulatory intervention to ensure accountability and fairness in Moda’s business practices.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violationsProtecting Minorities and Underserved Populations: Value-Based Contract Challenges
The article discusses the need for safeguards in value-based contracts to protect minority and underserved populations from systemic inequities. It emphasizes the importance of standardized definitions, clear language, whistleblower protections, and independent oversight to prevent exploitation and ensure transparency. Without these measures, providers serving vulnerable communities may face financial instability, limiting patient access to care. The article advocates for equitable contracting practices that promote health equity and sustainable care models.
https://www.mentorresearch.org/value-based-contracts-protecting-minorities-and-underserved-populationEmpowering Providers to Report Suspicious, Unethical, and Illegal Behaviors
The article highlights the importance of supporting healthcare providers in reporting unethical, illegal, or suspicious practices within value-based contracts and broader healthcare systems. It discusses barriers to reporting, such as fear of retaliation, lack of clear reporting channels, and contractual restrictions imposed by health plans. The article advocates for stronger whistleblower protections, independent oversight, and transparent reporting mechanisms to ensure providers can expose fraud, coercion, and unethical practices without jeopardizing their careers. Strengthening these safeguards is essential for maintaining ethical healthcare delivery and protecting both providers and patients.
https://www.mentorresearch.org/empowering-providers-to-report-suspicious-unethical-and-illegal-behaviorsBreaking the Cycle of Unfunded Health Plan Mandates
The article discusses the challenges posed by health plans that impose administrative tasks on providers without offering corresponding compensation or support. This practice leads to operational inefficiencies, erodes trust between providers and payers, and hampers the effective implementation of value-based care models. The author advocates for health plans to invest in necessary infrastructure and collaborate with providers to ensure sustainable healthcare reform.
https://www.mentorresearch.org/breaking-the-cycle-of-unfunded-mandatesModa Health: Nine Actions and Their Consequences
The article examines nine specific actions taken by Moda Health in its contracting practices, highlighting the negative consequences for healthcare providers and the broader healthcare system. These actions include imposing non-negotiable contracts, utilizing ambiguous terms, retroactively altering performance metrics, and enforcing unfunded mandates. Such practices have led to increased administrative burdens, financial instability for providers, erosion of trust, and potential declines in patient care quality. The article advocates for transparent contracting, equitable risk-sharing, and independent oversight to mitigate these adverse effects and promote ethical value-based care.
https://www.mentorresearch.org/moda-health-9-actions-and-the-consequencesContract Negotiation Tactics Used by Health Plans
The article examines strategies employed by health plans during contract negotiations that can undermine mental health services by limiting providers' ability to negotiate effectively. These tactics include presenting non-negotiable, "take-it-or-leave-it" contracts; using strategic ambiguity to leave critical terms undefined; implementing contract ratcheting by progressively increasing administrative demands; maintaining network secrecy by withholding information about participating providers; and imposing unfunded mandates that require providers to absorb additional costs without reimbursement. By identifying these practices, providers can better anticipate potential risks and advocate for fairer contract terms during negotiations.
https://www.mentorresearch.org/contract-negotiation-tactics-used-by-health-plansThe Fallacy of Better, Cheaper, Faster: How Health Plans Shift Risk to Providers
The article examines how health plans promote value-based contracts under the premise of delivering better, cheaper, and faster healthcare services. In reality, these contracts often transfer significant financial and operational risks onto providers. Tactics include imposing rigid service caps, reducing payment rates, and increasing administrative burdens, all of which can lead to inadequate patient care and provider burnout. The article calls for greater transparency, fair contract terms, and regulatory oversight to ensure that health plans share financial risks equitably and invest in genuine improvements in care quality.
https://www.mentorresearch.org/the-fallacy-of-better-cheaper-faster“Solutionism” in Healthcare: Moda Health’s Contracting Approach and Consequences
The article critiques Moda Health's reliance on "solutionism" the belief that complex healthcare issues can be resolved through technical solutions without addressing underlying systemic problems. Moda's implementation of measurement-based care, incentive-based payments, and administrative streamlining is seen as superficial, failing to consider deeper issues such as unethical contracting practices, lack of transparency, and provider burnout. This approach may lead to unintended consequences, including reduced care quality and erosion of trust between providers and payers.
https://www.mentorresearch.org/solutionism-in-healthcare-moda-healths-contracting-approach-and-consequencesThe Dangers of Using an Ombudsman for Fraud and Antitrust Violations: Undermining Accountability and the Legal Process.
The paper discusses the risks of relying on ombudsmen to address cases of fraud and antitrust violations. It argues that ombudsmen may lack the authority and independence necessary to enforce accountability, potentially delaying or undermining legal actions. The discussion highlights how this approach can create conflicts of interest, allowing fraudulent practices to persist while giving a false impression of oversight. The paper advocates for stronger, independent regulatory mechanisms to handle such violations effectively.
https://www.mentorresearch.org/the-danger-of-using-an-ombudsman-in-cases-of-fraud-and-violations-for-antitrustContract “Gaming”: Reasons Why Value-Based Contracts Can Fail.
This discussion paper analyzes various forms of contract gaming that can undermine the success of value-based contracts. It describes tactics such as manipulating patient risk scores, selective reporting of outcomes, and redefining performance metrics to skew results. The paper explains how these practices can distort the intended goals of value-based care, leading to mistrust and reduced effectiveness. Strategies to identify and prevent contract gaming, including stronger oversight and clearer definitions, are also discussed.
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-failEthics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
This paper defines ethics point portals and outlines their benefits in health plan contracting. It explains how these portals provide a secure and confidential way for stakeholders to report unethical practices, compliance concerns, or contract violations. The paper highlights how ethics point portals promote transparency, accountability, and ethical conduct within organizations. Recommendations for implementing effective portals, including ensuring independence and accessibility, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefitsEthics-Point Portals Overseen by Independent Certified Internal Auditors (CIA): A Resource to Serve Stakeholders and the Public.
This discussion paper emphasizes the importance of having ethics point portals overseen by an independent certified internal auditor (CIA). It explains how independent oversight ensures that reports of unethical practices or contract violations are handled objectively and free from internal influence. The paper highlights the benefits of this structure, such as increased trust, better compliance, and reduced risk of retaliation against reporters. Recommendations for maintaining auditor independence and promoting transparent investigations are also included.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditorControls in Fee-For-Service, Alternative and Value-Based Payment Contracting.
This discussion paper defines the concept of a "control" in the context of health plan contracting and compliance. It explains how controls are mechanisms put in place to ensure that operations align with established policies, prevent unethical behavior, and detect potential issues. The paper outlines different types of controls, such as preventative, detective, and corrective controls, and discusses their role in promoting accountability and reducing risk. Strategies for implementing effective controls within contracting frameworks are also provided.
https://www.mentorresearch.org/what-is-a-controlSigns of Bad Faith in Value-Based Payment Contracts for Mental and Behavioral Health Services Offered by Healthplans.
This discussion paper outlines signs of a bad faith value-based payment contract. It describes indicators such as vague performance metrics, unilateral changes to terms, and excessive administrative requirements that disadvantage providers. The paper also highlights how these contracts can undermine trust and compromise care quality. Strategies for identifying and avoiding bad faith contracts, as well as recommendations for promoting more transparent and equitable agreements, are also discussed.
https://www.mentorresearch.org/signs-of-a-bad-faith-valuebased-payment-contractHigh Case-Mix Severity Must be Considered in Value-Based Contracting.
This discussion paper addresses the importance of considering high case mix severity in value-based contracting. It explains how failing to account for complex patient populations can lead to unfair performance evaluations and inadequate reimbursement for providers. The paper highlights the need for risk adjustment methods that accurately reflect patient severity to ensure that value-based contracts are equitable and do not penalize providers who treat high-risk patients. Strategies for implementing effective risk adjustment measures are also discussed.
https://www.mentorresearch.org/high-case-mix-severity-must-be-considered-in-valuebased-contracting
Comprehensive Library
Moda Health Discussion Papers
Brief Descriptions of Key Oregon Officials
Governor Tina Kotek is the 39th Governor of Oregon, having assumed office on January 9, 2023. Prior to her governorship, she served as the Speaker of the Oregon House of Representatives from 2013 to 2022, making her the longest-serving speaker in Oregon's history. Kotek has been a prominent figure in Oregon politics, known for her work on housing and social issues.
Representative Jason Kropf is a member of the Oregon House of Representatives, representing District 54, which includes Bend. He has been serving in the House since 2021 and is known for his focus on issues such as criminal justice reform and housing. He is co-chair of the House judiciary committee.
Representative Rob Nosse represents District 42 in the Oregon House of Representatives, encompassing parts of Southeast and Northeast Portland. Serving since 2014, Nosse has been active on healthcare and labor issues, bringing his experience as a nurse and union representative to his legislative work. He is co-chair on House Behavioral Health Committee.
Representative Emerson Levy is an American attorney and politician serving as the State Representative for Oregon's House District 53, which includes north Bend, south Redmond, Tumalo, Sisters, Eagle Crest, and Black Butte. Levy serves on the Housing and Homelessness Committee, the Joint Ways and Means Subcommittee for Natural Resources, and is the Vice Chair of the Climate, Energy, and Environment Committee.
Representative Shannon Isadore is an American politician, psychotherapist, and healthcare clinic executive. A member of the Democratic Party, she has represented the 33rd district in the Oregon House of Representatives since September 2024.
Director of the Oregon Health Authority (OHA) - Dr. Sejal Hathi has served as the Director of the Oregon Health Authority since January 2024. She oversees the state's public health programs, health policy initiatives, and Medicaid services, playing a critical role in shaping Oregon’s healthcare landscape.
Director of the Department of Consumer and Business Services (DCBS) - Andrew Stolfi has led the Oregon Department of Consumer and Business Services since April 2020. He is responsible for overseeing financial services, insurance regulation, occupational safety, and building codes, ensuring consumer protection and regulatory compliance across multiple sectors.
DISCLAIMER and PURPOSE: This discussion document is intended for training, education, legislation, and or research purposes. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.
For more information see: https://www.mentorresearch.org/disclaimer-and-purpose