MM Curator summary
The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.
[MM Curator Summary]: Dignity and Tenet used false billings for “enhanced services” to make it look like they were meeting the required MLR floors.
Clipped from: https://www.justice.gov/opa/pr/three-health-care-providers-agree-pay-225-million-alleged-false-claims-california-s-medicaid
Dignity Health (Dignity), a not-for-profit health system that owns and operates three hospitals and one clinic in Santa Barbara County and San Luis Obispo County, California, and Twin Cities Community Hospital (Twin Cities) and Sierra Vista Regional Medical Center (Sierra Vista), two acute healthcare facility subsidiaries of Tenet Healthcare Corporation operating in San Luis Obispo County, California, have agreed to pay a total of $22.5 million pursuant to two separate settlements to resolve allegations that they violated the federal False Claims Act and the California False Claims Act by causing the submission of false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).
Pursuant to the ACA, beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured “Adult Expansion” population – adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level. The federal government fully funded the expansion coverage for the first three years of the program. Under contracts with California’s Department of Health Care Services (DHCS), if a California county organized health system (COHS) did not spend at least 85% of the funds it received for the Adult Expansion population on “allowed medical expenses,” the COHS was required to pay back to the state the difference between 85% and what it actually spent. California, in turn, was required to return that amount to the federal government.
The two settlements resolve allegations that Dignity, Twin Cities and Sierra Vista knowingly caused the submission of false claims to Medi-Cal for “Enhanced Services” that Dignity purportedly provided to the Adult Expansion patients of a COHS between Feb. 1, 2015, and June 30, 2016, and that Twin Cities and Sierra Vista purportedly provided to such patients between Jan. 1, 2014, and April 30, 2015. The United States and California alleged that the payments were not “allowed medical expenses” permissible under the contract between DHCS and the COHS; were pre-determined amounts that did not reflect the fair market value of any Enhanced Services provided; and/or the Enhanced Services were duplicative of services already required to be rendered. The United States and California further alleged that the payments were unlawful gifts of public funds in violation of the California Constitution.
As a result of the settlements, Dignity will pay $13.5 million to the United States and $1.5 million to the State of California, and Twin Cities and Sierra Vista will pay $6.75 million to the United States and $750,000 to the State of California.
“When health care providers misuse Medicaid funds, they undermine the integrity of the Medicaid program and waste taxpayer funds,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division. “These settlements demonstrate the Department’s continued commitment to prevent providers from inappropriately using Medicaid or other federal health care programs for their own financial gain.”
“These health care providers siphoned critical Medicaid funding for their own gain instead of using it to provide health care services to patients most in need,” said U.S. Attorney Martin Estrada for the Central District of California. “These major settlements demonstrate our commitment to hold accountable health care providers that seek to exploit the Medicaid program and harm the American taxpayer.”
“Every day, Medi-Cal provides support for Californians in need of essential healthcare, and when companies take advantage of this system at the expense of patients, they must be held accountable,” said Attorney General Rob Bonta. “I want to express my gratitude to the U.S. Department of Justice and the U.S. Attorney’s Office in Los Angeles for their extensive efforts throughout the course of this investigation. The California Department of Justice will continue to prosecute corporations that seek to abuse the Medi-Cal system for their own benefit.”
“Bad actors who target and exploit Medicaid for unlawful profit drain the program of much-needed funds intended to support the health and safety of our nation’s individuals who need these resources the most,” stated Special Agent in Charge Timothy B. DeFrancesca of the Department of Health and Human Services. “HHS-OIG readily applies our investigative aptitude to, with our law enforcement partners, pursue providers suspected of defrauding this and other federal health care programs.”
The civil settlements include the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Julio Bordas, the former medical director of the COHS that contracted with Dignity, Twin Cities, and Sierra Vista for the provision of health care services under Medi-Cal. Under the act, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States and State of California ex rel. Bordas v. Dignity Health and Tenet Healthcare Corporation, et al. (C.D. Cal.). Mr. Bordas will receive $3.9 million as his share of the federal recovery.
The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Central District of California and the California Department of Justice, with assistance from HHS-OIG and DHCS.
The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).
Trial Attorneys Mary Beth Hickcox-Howard and Tiffany Ho of the Civil Division’s Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney Jack D. Ross for the Central District of California handled this case.
The claims resolved by the settlements are allegations only and there has been no determination of liability.