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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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Listen: Expected Dismissal of Providence Health Upcoding Suit

Posted  12/7/18
Constantine Cannon partner Mary Inman joins the RAC Monitor “Monitor Monday” podcast to comment on the government’s decision to decline to intervene in a $188.1 million whistleblower lawsuit Med Analytics, LLC filed against Providence Health (now known as Providence St. Joseph) alleging Providence upcoded diagnoses it submitted to government health programs for reimbursement. Several reports have indicated the allegations are likely to be dropped on Jan. 14, 2019. Listen to...

Watch: “Taking Advantage” Highlights Medicare Risk Adjustment Fraud

Posted  11/2/18
Constantine Cannon partner Mary Inman and two Constantine Cannon whistleblower clients are featured in Episode 3 of the PBS series “Playing by the Rules: Ethics at Work.” The episode investigates ”risk adjustment” in the Medicare Advantage program and practices by some of America’s largest insurance companies to make patients look sicker than they really are-which boosts payments to the insurance companies from the Medicare program. Watch the 30-minute episode, Taking...

“Widespread and Persistent” Problems in Medicare Managed Care Burden Patients and Are Potential Violations of the False Claims Act

Posted  10/30/18
The federal government’s internal watchdog for the Medicare and Medicaid healthcare programs, the U.S. Department of Health and Human Services Office of the Inspector General (OIG), has issued a report finding that Medicare Advantage Organizations (MAOs) have engaged in a “widespread and persistent” practice of inappropriately denying coverage for medical services to Medicare patients. In addition, OIG has found that the MAOs failed to adequately inform Medicare patients and providers about...

Overpayment Rule Decision Doesn't Imperil Risk Adjustment Cases: Mary Inman and Max Voldman in RAC Monitor

Posted  10/19/18
On September 7, a federal district court in Washington, D.C. vacated a single Centers for Medicare & Medicaid Services regulation – the 2014 “overpayment rule.”  As Constantine Cannon whistleblower attorneys Mary Inman and Max Voldman write in RAC Monitor, many Medicare Advantage Organizations have since made bold statements about the significance of this decision and its impact on the series of False Claims Act cases currently being pursued against them...

October 1, 2018

HealthCare Partners Holdings LLC, a DaVita entity, will pay $270 million to settle allegations arising from DaVita's collection and submission of diagnosis data for Medicare Advantage beneficiaries to whom DaVita provided healthcare services.  HealthCare Partners, an independent physician association, allegedly instituted practices that caused the submission of incorrect diagnosis codes - diagnosis codes that increased payments from CMS to the MAOs, and then from the MAOs to DaVita/HealthCare Partners.  DaVita had voluntarily disclosed some practices, including improper medical coding guidance provided to physicians.  In addition, a whistleblower, James Swoben, alleged in a False Claims Act qui tam case that HealthCare Partners had engaged in improper "one-way chart reviews," which added diagnosis codes identified from the review of patient charts, but did not delete previously-submitted diagnosis codes that were not supported by the patient charts. Swoben will receive a whistleblower reward of $10,199,100. DOJ

Constantine Cannon Partner Jessica Moore on Court’s Decision in Medicare Advantage Case

Posted  07/23/18
Becker’s Hospital Review published Four Key Takeaways From 9th Circuit’s Resurrection of the Silingo Medicare Advantage Case, written by Constantine Cannon partner Jessica T. Moore. In the article, Ms. Moore analyzes the Ninth Circuit’s July, 2018, ruling in U.S. ex rel. Silingo v. WellPoint, Inc., a case brought by a whistleblower under the False Claims Act alleging risk adjustment fraud in Medicare’s Part C program. The Ninth Circuit’s decision “swept...

March 28, 2018

CenterLight Healthcare, Inc. agreed to pay $10 million to settle claims of violating the False Claims Act for collecting monthly Medicaid payments for 186 adult home residents who frequently did not receive required services while enrolled in Centerlight’s managed long-term care plan. In connection with the filing of the lawsuit and settlement, the Government had previously joined and settled a private whistleblower lawsuit filed under the qui tam provisions of the False Claims Act. In that case, Centerlight agreed to pay $46.7 million to settle claims of violating the False Claims Act by using social adult day care centers to enroll ineligible members in Centerlight’s managed long-term care plan. DOJ (SDNY)

November 22, 2017

Thaddeus M.S. Bereday, the former general counsel of WellCare Health Plans Inc., a company that operates health maintenance organizations in several states, was sentenced to six months in prison for his role in a $35 million health care fraud scheme.  Specifically, Bereday and others were charged with submitting inflated expenditure information in the WellCare's annual reports to Florida Medicaid in order to reduce the WellCare HMOs’ contractual payback obligations for behavioral health care services.  DOJ

August 7, 2017

Mary Inman appeared as a special guest on RAC Monitor's "Monitor Monday" radio broadcast Whistleblowers Allege the Suppression of Complaints at United Healthcare to talk about the recent unsealing of a whistleblower lawsuit accusing United Health Services, Inc. of hiding patients’ complaints of misconduct in order to improperly boost its Star ratings and receive undeserved performance bonuses from CMS.
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