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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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August 24, 2016

New York and the Justice Department announced that three hospitals in the Mount Sinai Health System are paying a total of $2.95 million to resolve allegations that the hospitals knowingly retained over $844,000 in overpayments made by Medicaid in violation of the federal and New York False Claims Acts. Knowing retention of an overpayment from the government for more than sixty days is known as a “reverse false claim” and is a violation of both federal and state false claim acts. The entities involved include Mount Sinai Beth Israel (“Beth Israel”) (formerly Beth Israel Medical Center), Mount Sinai St. Luke’s (“St. Luke’s”) (formerly St. Luke’s Hospital) and Mount Sinai Roosevelt (“Roosevelt”) (formerly Roosevelt Hospital) (together, the “Hospitals”) – and the Hospitals’ former partnership group, Continuum Health Partners, Inc. (“Continuum,” and together with the Hospitals, “Defendants”). As part of the settlements, Defendants admitted that, beginning in 2009 due to a software compatibility issue, a coding error caused Defendants to submit claims for payment above and beyond what they had received from the managed care organization, and that Medicaid paid these claims as a secondary payor. In September 2010, the New York Office of the State Comptroller brought to Continuum’s attention a small number of these claims, and Defendants admitted that in late 2010 they were made aware of the coding error. NY

DOJ Catch of the Week -- CenterLight Healthcare

Posted  01/22/16
By the C|C Whistleblower Lawyer Team This week's Department of Justice "Catch of the Week" goes to New York-based CenterLight Healthcare, Inc. and CenterLight Health System, Inc.  Yesterday, the companies agreed to pay $46.7 million to resolve allegations that they violated the federal and New York State False Claims Acts by enrolling ineligible members in their Medicaid managed long-term care plan. ...

January 21, 2016

New York will receive $47 million in a settlement with CenterLight Healthcare and CenterLight Health System, resolving allegations that CenterLight Healthcare’s Select Medicaid Managed Long Term Care Plan fraudulently billed Medicaid for services they did not provide to more than 1,200 Medicaid recipients. Under the settlement, CenterLight Healthcare admitted that it enrolled Medicaid beneficiaries who were referred by social adult day care centers even though the beneficiaries were not eligible to receive managed long-term care under the plan, and that the centers were providing services that did not qualify for reimbursement under New York State Department of Health standards, or CenterLight’s contract with DOH.  Whistleblower David Heisler will receive a yet-to-be-determined whistleblower award. NY

Medicare Advantage Plan Loses Members, Responds with Plans to Raise Risk Adjustment Scores

Posted  09/22/15
By Tim McCormack and Molly Knobler (published on The Compliance & Ethics Blog) Modern Healthcare recently reported that although enrollment in the Medicare Managed Care Program (also known as Medicare Advantage or Medicare Part C) has grown by 8% on average since 2010, several top Medicare Advantage Plans are losing membership.  Highmark, Blue Cross and Blue Shield of North Carolina, HealthNow New York, Wellcare...

Medicare Advantage Plan Loses Members, Responds with Plans to Raise Risk Adjustment Scores

Posted  09/21/15
The Compliance & Ethics Blog (September 21, 2015) Click here to read the article.

Medicare Part C: Fighting Back Against Risk Adjustment Fraud

Posted  06/26/15
Health insurance companies that participate in the Medicare Managed Care program (also known as Medicare Advantage or Medicare “Part C”) routinely complain about cuts to their reimbursement rates – even in years, like this one, where the reimbursement rates are actually increased.  At the same time, reports indicate that insurers are “leaning heavily on their Medicare business” and “signal[ing their]...

In Their Own Words -- Sparrow

Posted  04/23/15

-- "It shows the incentives provided for whistleblowers are working well, and all the other controls and detection systems are failing miserably."

Malcolm Sparrow, a health care fraud expert at Harvard's John F. Kennedy School of Government, on the increasing number of whistleblower actions challenging fraud in the Medicare Advantage healthcare program.  Click here for more.

GAO Report Finds Medicaid Managed Care Vulnerable To Fraud

Posted  06/26/14
By Marlene Koury A new study conducted by the US Government Accountability Office ("GAO") shows that the Medicaid managed care program is vulnerable to serious health care fraud.  The study found that the weakness is primarily due to the Centers for Medicare and Medicaid Services ("CMS") delegating managed care oversight to the states – but without providing them with clear guidance and resources to combat...
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