WellCare Health Plans, Inc. reached a settlement with the federal government this week over allegations that the company to Medicare, Medicaid, and other
government health programs, all in violation of the False Claims Act. WellCare Health Plans Inc. will pay $137.5 million to the federal government and nine states to resolve four lawsuits alleging violations WellCare, based in Tampa, Fla., provides managed health care services for approximately 2.6 million Medicare and Medicaid beneficiaries nationwide. Lawsuits filed by former employees with knowledge of the fraud at the company. Under the False Claims Act, an employee or any other private citizen may bring a lawsuit on behalf of the United States for violations of the False Claims Act.
Department Of Justice affirmed that WellCare presented false Medicare requirements and misled the corporation’s spending on medical applications to avoid refunding overcharges. The organization was also involved to have intentionally accepted overpayments from the Florida Medicaid program and failed to return the undue payments. Department Of Justice declared that WellCare violated federal purchasing requirements by cherry-picking possible members to keep the charge of care low.
Department Of Justice wrote that WellCare intruded into a prior settlement agreement in 2006 to settle criminal and civil health care fraud allegations. WellCare’s latest settlement brings the Department Of Justice’s total amount gained from the corporation to $217.5 million.
Some states have passed state False Claims Acts to share in changes obtained in multi-state and federal prosecutions and to extra encourage reporting of fraud by state residents. Although Ohio does not have a state False Claims Act, residents of the state may still bring a qui tam action under the federal False Claims Act.
Certainly, of the nine different states involved in the WellCare settlement, California, Florida, Georgia, Hawaii, Illinois, Indiana, Missouri, and New York all currently have state False Claims Acts.
The lawsuits declared a number of schemes to submit false claims to Medicare and various Medicaid programs, including accusations that WellCare falsely increased the amount is required to be spending on medical care in order to avoid returning money to Medicaid and other programs in various states, including the Florida Medicaid and Florida Healthy Kids programs; knowingly retained overcharges it had obtained from Florida Medicaid for infant care; and distorted data that misled the medical health of patients and the procedures they received.
In addition, it was declared that WellCare was involved in certain marketing abuses, including the cherrypicking of healthy patients in order to avoid future charges; manipulated grades of service or other production metrics regarding its call center, and performed a false special investigations section.
Another testifies that he was ordered to an operating room to find an unsupervised student nurse anesthetist handling a sedated patient undergoing open-brain surgery. Plaintiff-doctor was appointed to the hospital’s remuneration committee, which is how he learned of the fraud. The University agreed to pay $6.5 million to settle allegations of wrongdoing without incurring further criminal or civil liability the federal prosecutors announced.
The connection between the two departments has focused efforts to defeat and stop
Medicare and Medicaid financial fraud through renewed cooperation. January 2009 Department of health used to cover more than $6.7 billion in cases involving fraud against federal health care programs. This is one of the most powerful tools in that effort is the False Claims Act.
The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $9 billion
This case was investigated together by the Commercial Litigation Branch of the
Justice Department’s Civil Division, the United States Attorney’s Office for the Middle District of Florida and the District of Connecticut, the National Association of Medicaid Fraud Control Units, the FBI, and the HHS-OIG.
The arrangement is part of the government’s importance on fighting health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) lead, which was announced in May 2009 by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services.
The claims settled by today’s agreement are allegations only; there has been no determination of liability except as noted in the referenced criminal proceeding.
