Where there is no Sunshine [Act]: How Unregulated Reimbursement Consultants Troll in the Shadows of Healthcare

Today, we physicians live not only on a high-speed bureaucratic treadmill but under the scorching light of the Sunshine Act and its magnifying glass. Thanks to the Physician Payments Sunshine Act, even a lunch for the office or a $10 pen gift have to be reported and publicly listed when provided by industry. Every minute of patient service, every CPT code billed and every medication pill or eyedrop prescribed are tracked in public databases to monitor and scrutinize every step of the American doctor. There is nothing more left to load on the toiling back of doctors who are spending their time filling our reimbursement forms and prior authorizations or correcting sunshine act listing errors instead of taking care of patients.

Yet, the architects who built the magnifying glass — the men and women who dictate exactly how those codes are interpreted and enforced — operate entirely in the shadows. The invisible swarm of reimbursement consultants who used to live and fill out billing forms in the basements of clinics and hospitals 20 years ago, are now sitting in corner offices spinning a spiderweb of bureaucracy ensnaring both doctors and patients.

Ophthalmology is a case in point. One example is Kevin Corcoran and his firm, the Corcoran Consulting Group (CCG), who for nearly four decades have built a sprawling, unregulated consulting web that bills itself as the ultimate authority on ophthalmic billing. Corcoran is not a surgeon. He is not an ophthalmologist. He is not an optometrist. He is not a lawyer. He began his career as an optician. And today, this former optician has successfully managed to fog the refraction of the entire ophthalmic specialty.

In eye care, "fogging" is a technique used to deliberately blur a patient's vision to reduce their focus. This also happens to be the very MOA of our ophthalmic biller transformed into a modern-day reimbursement mogul. He and other such consultants with the help of AMA have created a quagmire of billing codes — more than 11,000 to be precise, which underly a burdensome system of CPT Codes designed to drown physicians and patients in a deluge of bureaucracy. This complexity is hardly an accident….not even a by-product, but rather the product of this deliberate fogging and fear-mongering. By spinning a web of opacity and administrative dread, consulting firms have ensured that eye doctors are too financially blinded to navigate the system alone. They act as both the architects of the maze and the highly paid guides leading the doctor out. They conduct "internal audits" of private practices, applying ultra-conservative interpretations of the codes to instill a profound fear of CMS claw-backs. Once the physician's vision is sufficiently clouded by panic, the trap closes: the consultant pivots to sell them the proprietary seminars, retainers, and compliance management needed to "survive."

It is a self-feeding closed-loop economy where millions of dollars are siphoned away from patient care and directly into the pockets of administrative tollkeepers who profit exclusively from the blur they help create.

The "Mini-Enron" in the Shadows

After the Enron scandal, the Sarbanes-Oxley Act made it illegal for a single firm to act as both an objective auditor and a strategic consultant. Yet, reimbursement consultants play both sides of the ledger every day. And don't even bother to disclose conflicts.

While doctors burn under the magnifying glass of federal scrutiny, there is no spotlight let alone sunshine on those consultants, which allows them to function as the "Mini-Enron" of medicine — undeterred by conflicts of interest.

Even worse is how they play both sides. A review of CCG's public library reveals countless coding "Monographs" and "Reimbursement Guides" bearing a quiet disclaimer: "Sponsored by…" Behind closed doors, it is an open secret that device manufacturers are pressured to pay exorbitant fees, allegedly upwards of $15,000 per page, for a "publication." The implicit threat is clear: if a company does not pay the tollkeeper to write their reimbursement guide, their technology will not survive the scrutiny of the practices CCG audits.

These consultants are effectively paid millions by manufacturers to "promote" a technology, while simultaneously charging the physician to learn how to bill for it. In a major False Claims Act lawsuit, Case 2:09-cv-00432, federal whistleblowers even explicitly detailed how this manufacturer-consultant relationship blurs the lines of federal anti-kickback statutes, alleging that manufacturers paid Corcoran to provide "free" billing advice to doctors to incentivize product utilization.

Manipulating Corporate M&A

In the shadows of the healthcare system, operating largely outside of regulatory scrutiny, specialized reimbursement consultants wield immense power to determine the commercial viability of new medical technologies. Consider the recent case of Elios Vision. The company reportedly retained CCG to navigate the complex AMA CPT process, providing substantial consulting fees and equity options to secure their "guidance." This arrangement pre-positions the technology for preferential promotion across the firm's clinical audit network upon commercial launch. Simultaneously, the consultants disseminate restrictive coding guidance strategically designed to stifle competing procedures. As a result, surgeons, wary of the financial and legal risks of an audit, are deterred from adopting perfectly viable, sight-saving technologies. Following the subsequent acquisition of Elios, this arrangement yields a highly lucrative exit for the consulting firm.

The standard of care is no longer dictated by clinical efficacy or peer-reviewed science. It is dictated by a shadow-industry of billing administrators who hold equity in startups, accept undisclosed manufacturer payouts, and manipulate CPT utilization from behind a curtain.

A Call for Sunlight

Ophthalmologists are not alone. Physicians are drowning in the quick sands of thousands of CPT codes, gaslit by the very people they pay to advise them.

It is time to bring the consultants out of the shadows and under the magnifying glass. If the Office of Inspector General (OIG), the FTC, and our national medical academies demand absolute transparency and strict conflict-of-interest boundaries from our physicians, they must demand the exact same from the consulting empires dictating the financial realities of modern medicine.

Until the dual roles of auditor and consultant are legally severed, and until the Sunshine Act is expanded to illuminate the millions pocketed by these unregulated intermediaries, the opticians of the billing world will continue to fog the vision of American medicine.