Four California hospitals reach settlement of $71 million in false claims

Dive briefs:

• A California managed care company, an integrated health care system, and two nonprofit health care systems will collectively pay $70.7 million to settle allegations that they violated the Federal False Claims Act, according to a Justice Department release. I agree with you.
• According to DOJ releases, these organizations do not admit liability, but in 2014 and 2015 they used funds intended for the state’s Medicaid Adult Expansion Program to avoid duplicate services or the return of unused funds. was allegedly used for an unauthorized service.
• Ventura County Medi-Cal Managed Care Commission, operating as the Gold Coast Health Plan, will pay US$17.2 million Ventura County will pay US$29 million. Clinicus will pay $11.25 million to the United States and $1.25 million to states.

Dive Insight:

The DOJ recently targeted healthcare fraud related to the COVID-19 pandemic, and in July totaled $1.2 billion in plans related to telemedicine, cardiovascular and cancer genetic testing, and durable medical devices. announced criminal charges against 36 defendants amounting to more than a dollar.

The claims settled in California relate to the growth of the state’s adult Medicaid population that occurred in 2014.

Under the Affordable Care Act, California’s Medicaid program covers previously uninsured adults ages 19 to 64 with no dependents and incomes up to 133% of the federal poverty line. expanded to cover the growing population of

For the first three years of the program, the federal government fully funded the extended scope. California’s contract required that if the county-organized health care system failed to spend at least 85% of these funds on “permitted medical expenses,” the difference would be repaid to the state.

These organizations allegedly submitted false claims to the state Medicaid program for additional services provided to adult extended Medi-Cal members between January 2014 and May 2015.

“The money at issue in this case was designated by the federal government to pay for services to treat Medicaid-extended patients, and was either double-paying for services that had already been reimbursed or was simply made. It should not have been used to pay for services. We never did,” Deputy U.S. Attorney for the Central District of California Stephanie Christensen said in a release.

As a result of the settlement, Gold Coast and Ventura entered into a five-year corporate integrity agreement. They must create a centralized risk assessment program and hire an independent review organization to complete an annual review.

These Gold Coast reviews focus on calculating and reporting medical loss rates under Medi-Cal, and the Ventura County reviews focus on hospital claims submitted to Medicare, Medicaid, and Medicaid-managed care organizations. guess.

“The Federal Health Care Fund is not intended to serve as a blank check,” Assistant Deputy Attorney General Brian Boynton, head of the Justice Department’s civil division, said in a release.