Ventura County’s organized health system, three medical providers agree to pay $70.7 million to settle false claims allegations
VENTURA COUNTY, Calif. – Ventura County's organized health system and three medical care providers agreed to pay $70.7 million in total to settle allegations that they submitted false claims to Medi-Cal related to Medicaid Adult Expansion, the U.S. Department of Justice announced on Thursday.
Ventura County Medi-Cal Managed Care Commission which does business as Gold Coast Health Plan, Ventura County which owns and operates Ventura County Medical Center, Dignity Health, and Clinicas del Camino Real, Inc. combined paid $70.7 million to settle the allegations.
Medi-Cal was expanded to cover the previously uninsured "Adult Expansion" population – or adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level – in January 2014. The federal government fully funded the expansion coverage for the first three years of the program, according to the Department of Justice.
The allegations claimed that the agencies above knowingly submitted or caused the submission of false claims to Medi-Cal for "additional services" provided to Adult Expansion Medi-Cal members between Jan. 1, 2014, and May 31, 2015.
"The United States and California alleged that the payments were not 'allowed medical expenses' under Gold Coast’s contract with DHCS, were pre-determined amounts that did not reflect the fair market value of any additional services provided, and/or the additional services were duplicative of services already required to be rendered," the Department of Justice said in a news release.
"The United States and California further alleged that the payments were unlawful gifts of public funds."
Through the settlement, Gold Coast will pay $17.2 million to the United States, Ventura County will pay $29 million to the United States, Dignity Health will pay $10.8 million to the United States and $1.2 million to California, and Clinicas will pay $11.25 million to the United States and $1.25 million to California.
“We will pursue every health plan and provider that prioritizes profits over patients,” said Acting U.S. Attorney Stephanie S. Christensen for the Central District of California.
“The money at issue in this case was designated by the federal government to pay for services to treat Medicaid expansion patients, and it never should have been used to double-pay for services that already had been reimbursed or to pay for services that simply were never provided. Medicaid is a taxpayer-funded program that exists to help patients afford health care, and it never should be used to line the pockets of health care providers through fraudulent schemes.”
The U.S. Department of Health and Human Services agreed to release its right to exclude Gold Coast and Ventura County in exchange for their agreements to enter into five-year Corporate Integrity Agreements that, among other things, require the agencies to implement centralized risk assessment programs and hire an independent review organization to complete annual reviews.
