May 11, 2017

Benefits management company Carecore National LLC agreed to pay $54 million to settle charges of violating the False Claims Act by submitting Medicare and Medicaid claims for medical diagnostic procedures without properly assessing whether they were necessary or reasonable.  CareCore provides utilization management services including determinations of medical necessity to New York Medicaid Managed Care Organizations (MCOs). The agreement settles allegations that CareCore instituted a scheme to auto-approve or “Process As Directed” (“PAD”) hundreds of radiology service requests on a daily basis, deeming those diagnostic services as reasonable and medically necessary, even though there had been no evaluation of those cases by the appropriate medical personnel. Of the $54 million, $18 million will go to 20 state Medicaid programs. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act.  The whistleblower will receive a yet-to-be-determined whistleblower award from the proceeds of the government’s recovery. DOJ (SDNY); NY, FL

Tagged in: FCA Federal, Laboratory and IDTF, Lack of Medical Necessity, Whistleblower Case, Whistleblower Rewards,