Central Coast Health Providers to pay $22.5M to Resolve False Billing Claims

Central Coast Health Providers to pay $22.5M to Resolve False Billing Claims title=
Dignity Health's Marian Regional Medical Center (courtesy photo)
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By the Department of Justice (DOJ)

Pursuant to two settlements announced today, several Central Coast health care providers have agreed to pay a total of $22.5 million to resolve allegations that they violated federal and California law by causing the submission of false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).

Dignity Health, a not-for-profit health system that owns and operates three hospitals and one clinic in Santa Barbara and San Luis Obispo counties, entered into one agreement with the United States and the California. The second settlement agreement resolves allegations against Twin Cities Community Hospital and Sierra Vista Regional Medical Center, two acute healthcare facility subsidiaries of Tenet Healthcare Corporation operating in San Luis Obispo County.

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 February 1, 2015 and June 30, 2016, and that Twin Cities and Sierra Vista purportedly provided to such patients between January 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 its settlements, Dignity will pay $13.5 million to the United States and $1.5 million to the State of California. Twin Cities and Sierra Vista have agreed to pay $6.75 million to the United States and $750,000 to the State of California.

“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 United States Attorney Martin Estrada. “These major settlements demonstrate our commitment to hold accountable health care providers that seek to exploit the Medicaid program and harm the American taxpayer.”

“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.”

“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 United States Department of Justice and the United States 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 U.S. Department of Health and Human Services, Office of Inspector General’s (HHS-OIG) Los Angeles Regional Office. “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 federal 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. 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 United States Attorney’s Office; the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section; and the California Department of Justice. HHS-OIG and DHCS provided substantial assistance.

Assistant United States Attorney Jack D. Ross of the Civil Fraud Section and Trial Attorneys Mary Beth Hickcox-Howard and Tiffany Ho of the Civil Division’s Commercial Litigation Branch, Fraud Section handled this case.

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).

The claims resolved by the settlements are allegations only and there has been no determination of liability.

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Tedi Dec 09, 2022 03:33 PM
Central Coast Health Providers to pay $22.5M to Resolve False Billing Claims

Someone needs to audit the ways local doctors and health care systems bill Medicare and medical insurance companies. For years we've complained about mysterious charges for services never rendered, to no avail. Is it normal for hospitals, organizations like Sansum and other doctors/clinics to bill for procedures and services never performed?

For just one example (and there are many), my husband's pulmonologist was always throwing in extra services that he never performed. When asked about it, his wife/receptionist said to call the company they use to do the billing. When we called the billing company, they said that they just enter the codes given to them by the doctor. Called the doctor back and the wife/receptionist just giggled and implied that's just the way it is, nothing can be done about it.

If we could get a handle on even a fraction of the waste and fraud, it would be a good start.

doulie Dec 09, 2022 09:27 AM
Central Coast Health Providers to pay $22.5M to Resolve False Billing Claims

SBWOMAN - No need to be surprised names of those involved were not listed. As the long winded article reported the civil settlements were based on "allegations." Can names be identified? I don't know The DOJ, it appears, based on their statement in the last paragraph of their article, did not or could not determine liability. I believe this qualifies as the infamous "some people did something" comment by Omar.

doulie Dec 07, 2022 09:27 PM
Central Coast Health Providers to pay $22.5M to Resolve False Billing Claims

How is it that no person(s) were arrested at any of these health care facilities?

This is, and I'll use a more civil word than first typed, crazy. If DOJ wanted to, as they say , "demonstrate our commitment to hold accountable health care providers that seek to exploit the Medicaid program -," why no arrests? It's obvious DOJ had solid "whistleblower" evidence since they recovered $22.5. But, they only did one-half of their job. They let the "alleged" crooks walk. No bail. Sound familiar? Maybe those responsible even kept their jobs as these were "allegations only and there has been no determination of liability."

RHS Dec 08, 2022 09:41 AM
Central Coast Health Providers to pay $22.5M to Resolve False Billing Claims

Yup, non-profits were designed to be virtuous but then greedy speculators and MBAs and hedge funds figured how to corrupt that intent by overpaying executives and other scams. The government monitors such operators to see if they doing this (thankfully) and when it finds abuse it brings them up short. But cloaked in religion, or good deeds, or whatever, the "non-profit" generally claims abuse or bigotry or some other unfair reason for being held accountable.

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