The Ventura County Medi-Cal Managed Care Commission operates as the Gold Coast Health Plan (Gold Coast). This is the County Organized Health System (COHS) contracted to arrange the provision of medical services under the California Medicaid Program (Medi-Cal) in Ventura. California county. Ventura County owns and operates the Ventura County Medical Center, an integrated health care system that provides hospitals, clinics, and specialty services. Dignity Health (Dignity): A non-profit hospital system in which he operates two acute care hospitals in Ventura County. Clinicas del Camino Real Inc. (Clinicas), a nonprofit healthcare organization located in Ventura County, has committed a total of $70.7 million pursuant to three separate settlements to settle claims that it violated the Federal False Claims Act and federal law. I agreed to pay the dollar. California False Claims Act by submitting or causing Medi-Cal to submit a false claim related to Medicaid adult expansion under the Patient Protection and Affordable Care Act (ACA).
Pursuant to the ACA, beginning in January 2014, Medi-Cal will allow the previously uninsured “growing adult” population, i.e., those with annual incomes up to 133% of the federal poverty level, who are dependent on children. expanded to cover adults between the ages of 19 and 64 who are not The federal government fully funded his first three-year extension of the program. Pursuant to an agreement with the California Department of Health Services (DHCS), if at least 85% of the funds received by California COHS for the Adult Expanded Population are not spent on “permitted medical expenses,” COHS will be required to reimburse patients. had. The difference between the state 85% and the amount actually spent. California then had to return the money to the federal government.
The three settlements are from January 1, 2014 to May 31, 2015. The United States and California argued that the payments were not “permitted medical expenses” under the Gold Coast and DHCS agreements. was a pre-determined amount that did not reflect the fair market value of the additional services provided; and/or the additional services overlapped with services that were already required to be provided. The United States and California further argued that the payment was an illegal gift of public funds that violated Article 4, Section 17 of the California Constitution.
As a result of the settlement, Gold Coast will pay the United States $17.2 million. Ventura County will pay her $29 million to the United States. Dignity will pay $10.8 million to the United States and $1.2 million to the State of California. Clinicas will also pay $11.25 million to the United States and $1.25 million to the State of California.
“The Federal Health Care Fund is not intended to serve as a blank check,” said Assistant Chief Deputy Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “Health care systems and providers will be held accountable for their misuse of such funds, including funds intended to support Medicaid expansion programs.”
“We pursue all health care plans and providers that put profits ahead of patients,” said Deputy U.S. Attorney for the Central District of California Stephanie S. Christensen. “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 never have been used to pay for services.It was never offered.Medicaid is a taxpayer-funded program that exists to help patients pay for medical care and is a fraudulent program. It should not be used to fill the pockets of healthcare providers through generic schemes.”
“The Medicaid Extension Program was created to make insurance accessible to people who need medical services. It prevents valuable taxpayer dollars from being used for their intended purpose,” said Special Agent Timothy DeFrancesca, Office of the Inspector General, U.S. Department of Health and Human Services (HHS-OIG). “HHS-OIG will not hesitate to investigate and pursue all forms of medical fraud.”
“Medi-Cal supports our communities by providing access to free or affordable health care for millions of Californians and their families. is cheating the essential care community,” said California Attorney General Rob Bonta. “I would like to thank the U.S. Department of Justice and the U.S. Attorney’s Office in Los Angeles for their tremendous efforts throughout the course of this investigation. The California Department of Justice and our law enforcement partners: We will continue to hold those who defraud Medi-Cal programs accountable and protect the people that Medi-Cal programs serve.”
Concurrent with the settlement of the False Claims Act, the U.S. Department of Health and Human Services agreed to release its rights to exclude Gold Coast and Ventura in exchange for an agreement to enter into a five-year Corporate Integrity Agreement (CIA). The CIA requires, among other things, that the Gold Coast and Ventura counties implement a centralized risk assessment program as part of their compliance program and hire an independent review agency to complete an annual review. The Gold Coast annual review focused on calculating and reporting medical loss rate data under Medi-Cal, and the Ventura County annual review focused on Medicare and Medicaid, including claims filed with Medicaid-administered care organizations. Covers submitted hospital claims.
The Civil Settlement includes resolution of claims brought on the basis of: Kitam Or the False Claims Act Whistleblower Provisions by Atul Maithel, Former Administrator of the Gold Coast and Andre Galvan, Former Director of Member Services, Gold Coast. Under these provisions, private individuals may sue on behalf of the United States and receive a portion of any recovery. The whistleblower also filed a claim under the California False Claims Act.of Kitam Caption on case US, other ties. Maisel et al. v. Ventura Co. Medi-Cal Managed Care Commission d/b/a Gold Coast Health Plan, etc.No. 15-7760AB TJH (JEMx) (CD Cal.).
The resulting solution to this problem was a coordinated effort between the Department of Justice’s Civil Litigation Division, Commercial Litigation Division, Fraud Division, the California Central District Attorney’s Office, and the California Department of Justice, with the assistance of HHS. was the result of OIG and DHCS.
The investigation and resolution of this issue shows the government’s focus on combating medical fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from any source regarding potential fraud, waste, abuse or mismanagement may be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).
Attorneys Alison Rousseau and Mary Beth Hickcox Howard of the Fraud Division, Commercial Litigation Branch of the Civil Division for the Central District of California and Assistant U.S. Attorney Jack D. Ross for the Central District of California served the case.
Claims resolved by the Settlement are allegations only, not determinations of liability.