Medicaid

February 2, 2015

Tennessee-based Community Health Systems Professional Services Corporation and three affiliated New Mexico hospitals agreed to pay $75M to settle allegations they violated the False Claims Act by making illegal donations to county governments which were used to fund the state share of Medicaid payments to the hospitals. The allegations were first raised in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by former Community Health revenue manager Robert Baker. He will receive a whistleblower reward of $18,671,561 as his share of the government’s recovery. DOJ

May 19, 2014

Todd Farha, former CEO of WellCare, an operator of health maintenance organizations (HMOs) in several states, was sentenced to serve 36 months in prison for defrauding the Florida Medicaid program. According to court records and evidence at trial, Farha and others orchestrated a scheme to defraud the Florida Medicaid program from the summer of 2003 through the fall of 2007 by making fraudulent statements relating to expenditures for behavioral health care services. Under a prior settlement with the government, WellCare was required to pay $80M in restitution and forfeitures. In a related civil qui tam case filed under the whistleblower provisions of the False Claims Act, Wellcare also paid $137.5M in civil fines and penalties. DOJ

December 2, 2013

Caremark agreed to pay $4.25M to settle allegations that it knowingly failed to reimburse Medicaid for prescription drug costs paid on behalf of Medicaid beneficiaries, who also were eligible for drug benefits under Caremark-administered private health plans. The allegations were first raised in a qui tam lawsuit filed under the whistleblower provisions of the False Claims Act. DOJ

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

October 7, 2015

In New York, two individuals who owned and operated two transportation companies, were arrested for allegedly violating the Workers’ Compensation law and illegally obtaining over $1 million from the Medicaid system. Yellow Medi-Van and Taxi, Inc. received payments from the Medicaid Program for transporting Medicaid beneficiaries to medical appointments. The defendants are alleged to have knowingly operated the company in violation of transportation regulations, including not having worker’s compensation insurance. During the time the company was operated unlawfully, the companies obtained over $1 million in Medicaid payments. NY

September 29, 2015

The New Jersey Medicaid Fraud Control Unit and Office of the Insurance Fraud Prosecutor obtained an indictment against a doctor, Syed Jaffery, for accepting kickbacks in exchange for patient referrals. The indictment alleges that from 2010 to 2013, Jaffrey participated in a scheme by which he agreed to refer patients needing MRI and CT scans to Diagnostic Imaging Services of South Jersey in exchange for monetary kickbacks. Over the course of the scheme, Jaffrey allegedly accepted approximately $195,000. In an attempt to disguise the arrangement, the kickback checks were made payable to Jaffrey’s alleged shell company Mask Realities and purported to be for a rental space for billing services. NJ

September 10, 2015

The Washington Attorney General announced a suit against CareOne Dental Corporation and related individuals for Medicaid fraud. The suit alleges that the defendants systematically billed Medicaid for non-covered services which they misrepresented in their billings, “upcoded” services (more expensive versions of what they actually performed), and services they simply didn’t provide. The Attorney General’s Office currently estimates at least 20 percent of the claims CareOne Dental presented to Medicaid from January 2011 to June of 2015 were fraudulent, which would amount to approximately $1 million in single damages. WA

August 4, 2015

Pediatric Services of America, Inc., reached a $2.7 million federal-state settlement resolving allegations that the company inappropriately failed to return overpayments received from state Medicaid programs as well as other federally insured health programs. PSA is also alleged to have overcharged for home nursing services by improperly rounding-up claims to the nearest whole hour. Connecticut Department of Social Service Commissioner Roderick L. Bremby said, “This settlement exemplifies the outstanding work across the state and federal governments to obtain compensation for the taxpayer-funded Medicaid program when medical providers cross the line.” CT

July 29, 2015

New York Attorney General Eric T. Schneiderman announced the sentencing of the executive director of a company for stealing funds from the Nursing Home Transition and Diversion program, a Medicaid-funded program that provides senior citizens and those suffering from physical disabilities an alternative to institutional living through the use of Medicaid funds for renovations to the homes of the elderly and disabled (wheelchair ramps, grab bars, etc.). Defendant plead guilty to grand larceny, based on the submission of bids and cost reports, which falsely stated the actual costs of the projects, significantly inflating the actual costs or including services which were never provided. NY