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Managed Care

This archive displays posts tagged as relevant to managed care and fraud in managed care programs and services. You may also be interested in our pages:

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September 3, 2020

Two affiliates of Independence Blue Cross, Keystone Health Plan East, Inc. and QCC Insurance Company, Inc., which offer Part C Medicare Advantage plans, agreed to pay $2.25 million to resolve allegations that they overstated their costs when they submitted bids to CMS for contract years 2009 and 2010.  As a result, CMS reimbursed them at at an inflated rate.  The matter was initiated by the filing a qui tam complaint under the False Claims act by Eric Johnson, who will receive $500,000 from the recovery.  USAO EDPA

Integra Med Analytics Loses Battle to establish New Breed of Corporate Whistleblower Outsiders

Posted  06/3/20
CC Attorneys Mary Inman, Max Voldman
Mary Inman and Max Voldman were published in the RAC Monitor (June 3, 2020).  Click here to read the article.  

Catch of the Week: Logan Laboratories and Tampa Pain Relief Centers for Urine Drug Testing Fraud

Posted  04/17/20
Doctor with Cash
This week's Catch of the Week goes to Logan Laboratories, Inc. (Logan Labs), a reference laboratory in Tampa, Florida. Tampa Pain Relief Centers, Inc. (Tampa Pain), a pain clinic also based in Tampa, Florida, and two of their former executives who have agreed to pay a total of $41 million to resolve alleged violations of the False Claims Act for billing various federal health care programs for medically unnecessary...

Federal Audit Reveals Billions of Dollars in Medicare Advantage Overpayments

Posted  12/20/19
A new government report reveals what whistleblowers and their counsel have known for some time: the Medicare Advantage program is vulnerable to fraud committed by unscrupulous private health insurance companies, as well as their owners, vendors, affiliates, and even some doctors.  These bad actors make patients enrolled in MA plans appear sicker than they actually are in order to increase their corporate profits. ...

Government Audit of Chronic Care Management Services Raises Serious Questions About Proposed Anti-Kickback Statute Safe Harbors

Posted  11/22/19
stethoscope on top of money and coins
The U.S. Department of Health and Human Services is engaged in what it calls a “Regulatory Sprint to Coordinated Care,” in order to, in the words of HHS Deputy Secretary Eric Hargan, “update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based healthcare system.”  On October 9, 2019, as part of this effort to “cut back” on regulations to advance...

April 12, 2019

California-based Sutter Health LLC and its affiliated medical foundations will pay $30 million to resolve allegations under the False Claims Act that they submitted unsupported diagnosis codes for certain patients, thereby inflating the the risk scores for those patients.  These inflated risk scores increased Medicare Advantage payments to Medicare Advantage Organizations with whom Sutter contracted.  Sutter's contracts with the MAOs gave Sutter a share of those improper increased payments.  DOJ; USAO ND Cal

Sutter Health, LLC – Medicare Advantage Risk Adjustment Fraud (Case Intervention)

Constantine Cannon represents the whistleblower, Kathy Ormsby, in False Claims Act litigation against Sutter Health and its affiliates including the Palo Alto Medical Foundation, where Ms. Ormsby worked as a Risk Adjustment Factor Project Manager and Coding Manager.  The Sutter Health defendants allegedly inflated the number and severity of Medicare Advantage patient diagnoses, manipulated patient records, ignored audit “red flags,” and engaged in other misconduct in order to increase patient risk scores and obtain Medicare Advantage payments to which they were not entitled. The United States filed a complaint in intervention in March, 2019, and the case continues to be actively litigated.  SeeGovernment Complaint in Intervention; Ormsby First Amended Complaint; DOJ Press Release

New Yorker Article on Whistleblowers Features Constantine Cannon

Posted  01/28/19
Silver whistle hanging on cord in front of chalkboard
In an article titled “The Personal Toll of Whistle-Blowing” published in the February 4, 2019, New Yorker magazine, Sheelah Kolhatkar describes the cases of two Constantine Cannon whistleblower clients, and features whistleblower attorney Mary Inman.  Focusing on False Claims Act cases involving fraud in the Medicare Advantage program, the article details how the FCA “effectively turned average citizens into a...

January 28, 2019

Partner Mary Inman and Constantine Cannon clients David Sewell & Benjamin Poehling featured in the New Yorker article, The Personal Toll of Whistle-Blowing.  Click here to read the article.

Top Ten Healthcare Recoveries of 2018

Posted  01/15/19
Consistent with the trend in prior years, the bulk of the Justice Department’s fraud and false claims recoveries in 2018 stemmed from healthcare fraud matters. And again, most of the funds recovered arose from cases originated by whistleblowers under the qui tam provisions of the False Claims Act. Here are the top ten healthcare recoveries of 2018 by the numbers:
    1. Amerisource Bergen Corporation - In...
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