medicaid fraud

Amerigroup settles Medicaid charges

Anne Zieger — Fri, 15 Aug 2008 12:32:15 -0400

Health plan Amerigroup Corp. has settled charges that it avoided enrolling pregnant women and sick members for a hefty $225 million. The health plan had allegedly excluded those groups when running a Medicaid health plan in Illinois because such patients would have been more expensive to treat. Originally, a federal judge had ordered the plan to pay $334 million, but Amerigroup managed to settle for $225 million late last month. As part of the settlement, the company agreed to guidelines to prevent such discrimination from happening in the future. This case originally was filed by a whistleblower, former Amerigroup employee Cleveland Tyson. Tyson will get $56.25 million, or one-quarter of the award.

To learn more about the settlement:
- read this Associated Press piece

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States aren't reporting Medicaid provider sanctions

Anne Zieger — Wed, 13 Aug 2008 14:12:58 -0400

A new report from the HHS inspector general's office suggests that states are routinely failing to report when they sanction health providers participating in the Medicaid program. When providers are suspended or excluded from participation in a Medicaid program, or sanctioned in some other way by a state Medicaid agency for fraud, incompetence or other problems, they're subject to a permissive exclusion by the IG's office. State Medicaid agencies are supported to report these actions against providers promptly to the IG's office whenever the agency takes final action.

However, this doesn't usually happen. In its report, the IG's office found that about two-thirds of providers, or 61 percent of the 4,319 sanctions imposed by state Medicaid agencies in 2004 and 2005, weren't reported for inclusion in the exclusions database. Interestingly, the two states that took final actions against the largest number of providers--New York and Florida--had two of the lowest match rates with the exclusions database, or about 21 percent and 9 percent respectively.

To learn more about the report:
- read this Modern Healthcare report (reg. req.)

Amerigroup to pay $225M in Medicaid fraud settlement

Sterling Meyers — Thu, 24 Jul 2008 09:48:43 -0400

Amerigroup, the Illinois health plan that refused to enroll high-risk patients in its Medicaid plan, announced that it will pay $225 million to the state of Illinois and the U.S. government to settle False Claims Act allegations. Though the agreement hasn't been signed by both parties, Amerigroup will pay an additional $9 million in legal fees, and will admit no wrongdoing, according to a press release from the company. Amerigroup Corp., based in Virginia, has also agreed to enter into a Corporate Integrity Agreement with the Office of the Inspector General of the U.S. DHHS. The company's second quarter losses add up to $162.5 million--Amerigroup would have netted $36.7 million without the settlement.

In 2006, the company was ordered to pay $144 million in damages to Illinois and the federal government. Later, a federal judge added another $190 million in civil fines against the company, which was found to have filed more than 18,000 false Medicaid claims. Originally, Amerigroup appealed the verdict, but later it entered into settlement talks with the plaintiffs.

Charges against Amerigroup were originally filed in 2002 by Cleveland Tyson, former vice president of government relations at the plan's Illinois subsidiary. His lawsuit then prompted an investigation by the state attorney general and the U.S. Attorney in Chicago, who later joined the whistle-blower suit. As the original whistleblower, Tyson could see a payout of 15 to 25 percent of the total judgment.

To learn more about the case:
- read this Modern Healthcare article (reg. req.)
- read this Chicago Tribune piece

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Amerigroup may settle Medicaid fraud charges soon

Anne Zieger — Tue, 22 Jul 2008 11:31:25 -0400

An Illinois health plan that refused to enroll high-risk patients in its Medicaid plan may soon be settling a lawsuit brought by state and federal authorities for a whopping $334 million. Amerigroup Corp., based in Virginia, was ordered in 2006 to pay $144 million in damages to Illinois and the federal government. Later, a federal judge added another $190 million in civil fines against the company, which was found to have filed more than 18,000 false Medicaid claims. Originally, Amerigroup appealed the verdict, but later it entered into settlement talks with the plaintiffs.

Charges against Amerigroup were originally filed in 2002 by Cleveland Tyson, former vice president of government relations at the plan's Illinois subsidiary. His lawsuit then prompted an investigation by the state attorney general and the U.S. Attorney in Chicago, who later joined the whistle-blower suit. As the original whistle-blower, Tyson could see a payout of 15 percent to 25 percent of the total judgment.

To learn more about the case:
- read this Chicago Tribune article

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Department of Justice faces 500-case healthcare whistle-blower backlog

Anne Zieger — Wed, 02 Jul 2008 11:08:01 -0400

In theory, having scores of whistle-blowers file cases identifying potential fraud is a good thing. However, a recent surge in such cases has so overwhelmed staff at the U.S. Department of Justice that they're facing a backlog of more than 900 cases claiming that companies have defrauded the federal government, 500 of which involve pharmaceutical and healthcare firms.

Since 2001, whistle-blowers have filed 300 to 400 civil cases each year, but the 75-lawyer unit charged with reviewing such allegations only has the capacity to investigate about 100 cases each year. For that reason, whistle-blowers may wait more than a year to find out whether the DoJ is even prepared to move forward with their case. While the DoJ rejects about three-quarters of such cases as lacking merit, it's also made some spectacular cases work. In one striking example, it reached a $650 million settlement with Merck this year in connection with their alleged failure to repay Medicaid rebates.

Even given the constraints the agency faces, it has managed to collect almost $13 billion in recent years. Given this success, advocates are increasingly pressing for DoJ to invest more resources in catching up on the backlogged filings.

To learn more about this issue:
- read this Kaiser Daily Healthcare Policy Report article

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AstraZeneca asks judge to nullify $215M drug-price lawsuit

Thu, 12 Jun 2008 06:59:56 -0400

Drugmaker AstraZeneca has asked an Alabama judge to nullify a jury verdict that ordered it to pay the state $215 million in damages in a Medicaid drug-price fraud suit. The state's 2005 suit accused the pharma with overcharging Medicaid by inflating drug prices. The jury awarded the judgment in February, but AstraZeneca appealed, saying that the state's attorneys hadn't proved their case, and had also violated a state law capping punitive damages. If the current judge doesn't throw out the verdict, the firm will appeal the judgment to the state's Supreme Court.

To learn more about the case:
- read this Modern Healthcare article (reg. req.)

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Doctor sues CA hospital, claiming retaliation for state report

Wed, 28 May 2008 06:59:54 -0400

An obstetrician and gynecologist has sued a California hospital, claiming his former bosses there are giving him bad recommendations in retaliation for his filing a complaint about conditions there. Dr. John Brannigan filed a complaint about conditions at Memorial Hospital Los Banos' labor and delivery area with the California Department of Health Services in 2004. When it investigated, the Department found that the hospital's quality of care was deficient. Later, when Brannigan tried to get another job, he was told that Los Banos officials gave him poor recommendations. Now, he's filed a civil case against the hospital and its parent company Sutter Health. Brannigan, meanwhile, is being investigated by the state medical board in a separate case involving gross negligence, repeated negligent acts and incompetence.

To learn more about the case:
- read this San Francisco Examiner piece

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FL system settles federal claim over MD overpayments

Tue, 13 May 2008 06:59:56 -0400

Baptist Health South Florida has agreed to pay the federal government $7.75 million to settle allegations that it paid an oncology group excessive compensation to generate referrals for two of its hospitals.The payments flowed out of a contract under which the Oncology Hematology Group of South Florida provided radiation-related services to the Baptist Hospital of Miami and South Miami Hospital between 2003 and 2005.

The deal comes from voluntary disclosures by Baptist Health, which discovered, investigated and voluntarily disclosed the overpayment to the Department of Justice. Since discovering the problem, the system has bolstered its screens to make sure such overpayments can't take place again, according to CEO Brian Keeley.

To learn more about the settlements:
- read this piece in The Miami Herald

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Report: Antifraud compliance getting tougher for hospitals

Wed, 30 Apr 2008 06:59:57 -0400

A new report from the Deloitte Forensic Center argues that it's getting increasingly difficult for hospitals to comply with state and federal anti-fraud rules given the surge in new anti-fraud legislation. Laws and regulations designed to limit Medicare and Medicaid abuse have proliferated, while disclosure rules keep expanding, the consulting firm notes. Not only that, more regulation still may be in store. Regulators are paying increasingly close attention to relationships doctors have with hospitals and health systems, imaging centers, DME suppliers and other health professionals. For example, regulators recently began an information collection program that requires about 500 hospitals to file detailed reports on their contractual relationships with doctors.

To learn more about this issue:
- read this HFMA News item

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TN makes doctor shopping a felony

Tue, 07 Aug 2007 06:59:57 -0400

As every physician knows, there's a small but determined percentage of the population who will do whatever it takes to get their drug of choice--including seeing multiple doctors for the same condition or faking up conditions they don't have. Quite often, what they're looking for is narcotics.

Now, such behavior is a felony, at least if you're a TennCare enrollee in Tennessee. The state has enacted a law that makes it easier for TennCare to bring charges against patients that fraudulently obtain drugs. Patients can be charged if they willingly go to different providers with the intent to fool the physician, not mention a previous prescription for a controlled substance and have TennCare pay for the visit.

To learn more about the new law:
- read this piece from The Tennessean

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