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Medicaid

This archive displays posts tagged as relevant to Medicaid and fraud in the Medicaid program. You may also be interested in our pages:

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January 27, 2023

Walgreen Co. has paid $7 million to settle a False Claims Act lawsuit by the United States and State of Tennessee that alleged the company submitted claims to Tennessee’s Medicaid program for specialty medications that didn’t meet the program’s criteria for coverage.  According to the governments’ 2021 complaint, one of Walgreens’ former pharmacists falsified prior authorization requests and records for 65 Medicaid beneficiaries who didn’t meet program requirements.  The company then billed TennCare under those false prior authorization requests, and later failed to make repayments even after it discovered its employee’s misconduct.  USAO EDTN

Top Ten State Fraud Recoveries of 2022

Posted  01/19/23
State and local governments play a critical role in ensuring that businesses and individuals are held accountable if they commit healthcare fraud, financial fraud, government contract fraud, and more. For whistleblowers, state governments can offer additional opportunities to report wrongdoing. Where government funds are at stake – and state and local government spending reaching $3 trillion annually – more...

Top Ten Healthcare Fraud Recoveries of 2022

Posted  01/6/23
Healthcare fraud image showing stethoscope with gavel
Consistent with the trend in prior years, 2022 saw government enforcement agencies taking aim at fraud and false claims in healthcare.  As the cost of healthcare rises along with its share of the U.S. economy, the enforcement focus on healthcare fraud is likely to accelerate. And, as always, the role of whistleblowers will be critical, as demonstrated by the dominance of cases originated by whistleblowers under the...

December 7, 2022

Dignity Health and the Tenet Healthcare hospitals Twin Cities Community Hospital and Sierra Vista Regional Medical Center will pay a total of $22.5 million to resolve allegations that they submitted false claims to Medi-Cal in connection with the ACA’s Medicaid Adult Expansion program.  The defendants, who contracted with Medi-Cal, agreed to provide healthcare services to this newly-insured population and return surplus funds if they did not spend at least 85% of the specified funds on eligible services.  The government alleged that the hospitals falsely billed for “Enhanced Services,” which allowed them to overstate AE spending, including by billing for services that were duplicative of services already required. The settlements resolve claims brought in a whistleblower action by Julio Bordas, who previously served as a Medical Director for CenCal Health, the County Organized Health System through which Medi-Cal contracted with the hospitals. Bordas will receive $3.9 million as his share of the federal recovery.  DOJ; USAO CD Cal; CA

December 6, 2022

Centene will pay $17 million to the State of Oregon to resolve an investigation that the company, which served as a pharmacy benefit manager for the state’s Medicaid program, failed to provide certain pharmacy discounts in Oregon, resulting in inflated fees paid to Centene.  OR

December 5, 2022

An opioid abuse treatment facility in New Jersey has agreed to pay $3.15 million and enter into a three-year deferred prosecution agreement to resolve criminal and civil charges relating to alleged violations of the federal Anti-Kickback Statute.  Between 2009 and 2015, Camden Treatment Associates LLC (CTA) allegedly received kickbacks from a related company in exchange for exclusive orders of CTA’s methadone mixing services.  CTA then allegedly submitted false claims to Medicaid and obstructed a Medicaid contractor’s attempt to audit those claims in 2016 by falsifying patient records.  USAO NJ

November 14, 2022

The Florida Birth-Related Neurological Injury Compensation Association and a related entity, which were created by the State of Florida to provide compensation for the medical, rehabilitative and custodial care of children who suffered certain categories of birth-related neurological injuries, will pay $51 million to resolve a whistleblower’s qui tam lawsuit, pursued on a non-intervened basis, alleging that they fraudulently caused NICA participants to submit their healthcare claims to Medicaid rather than NICA, in violation of Medicaid’s status as the payer of last resort under federal law.  The relators, Veronica Arven and the estate of Theodore Arven III, will receive $12,750,000 as their share of the recovery.  DOJ

October 17, 2022

Sutter Health has agreed to pay more than $13 million to settle claims of billing Medicare, Medicaid, TRICARE, and the Federal Employees Health Benefits Program for quantitative urine testing that were in fact performed by third-party labs.  The company has already paid more than $6.5 million and is due to pay the remaining $6.5 million in the next 30 days.  USAO NDCA

October 3, 2022

South Carolina-based Radeas, LLC has agreed to pay $3.6 million to settle allegations of submitting false claims to North Carolina’s Medicaid program.  Radeas had allegedly billed Medicaid for simultaneously-performed presumptive and definitive urine drug tests, in violation of Medicaid policy and standard practice to run definitive tests after presumptive tests come back positive.  NC AG

September 27, 2022

Following a whistleblower complaint that alleged Massachusetts-based Public Consulting Group LLC (PCG) overbilled Medicaid, in violation of the False Claims Act, the company has agreed to pay $2.5 million.  According to whistleblower Shane Shackford, PCG caused local school districts to submit false claims to Medicaid while under contract with the State of New Jersey to administer its Special Education Medicaid Initiative (SEMI) program—which provides federal funding to the state and local school districts for providing certain medical services to eligible students.  For his role in the case, Shackford will received a 21% share of the settlement.  USAO NJ
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