{"id":50631,"date":"2022-08-18T22:50:20","date_gmt":"2022-08-19T05:50:20","guid":{"rendered":"https:\/\/cjnotebook.com\/?p=50631"},"modified":"2022-08-18T22:50:20","modified_gmt":"2022-08-19T05:50:20","slug":"ventura-county-calif-agree-to-pay-70-7-million-to-settle-allegations-of-false-claims-to-medi-cal","status":"publish","type":"post","link":"https:\/\/cjnotebook.com\/?p=50631","title":{"rendered":"Ventura County, Calif. Agree to Pay $70.7 million to Settle Allegations of False Claims to Medi-Cal"},"content":{"rendered":"<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\"><strong>LOS ANGELES<\/strong>\u00a0<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-1057 size-medium alignleft\" src=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2014\/02\/Justice-Depart-300x300.jpg\" alt=\"\" width=\"300\" height=\"300\" srcset=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2014\/02\/Justice-Depart-300x300.jpg 300w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2014\/02\/Justice-Depart-150x150.jpg 150w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2014\/02\/Justice-Depart.jpg 320w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">Ventura County\u2019s organized health system and three medical care providers have agreed to pay a total of $70.7 million to settle allegations that they broke federal and state laws by submitting or causing the submission of false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA), the Justice Department announced Thursday.<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 The parties that entered into the three separate settlement agreements are:<\/span><\/p>\n<ul>\n<li><span style=\"font-size: 20px;\">Ventura County Medi-Cal Managed Care Commission which does business as Gold Coast Health Plan, a county-organized health system (COHS) that contracts to arrange for the provision of health care services under California\u2019s Medicaid program (Medi-Cal) in Ventura County;<\/span><\/li>\n<li><span style=\"font-size: 20px;\">Ventura County, which owns and operates Ventura County Medical Center, an integrated health care system that provides hospital, clinic, and specialty services;<\/span><\/li>\n<li><span style=\"font-size: 20px;\">Dignity Health, a San Francisco-based not-for-profit hospital system that operates two acute care hospitals in Ventura County; and<\/span><\/li>\n<li><span style=\"font-size: 20px;\">Clinicas del Camino Real, Inc. (Clinicas), a non-profit healthcare organization headquartered in Camarillo.<\/span><\/li>\n<\/ul>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">Pursuant to the ACA, beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured \u201cAdult Expansion\u201d population\u2014adults between the ages of 19 and 64 without dependent children with annual incomes up to 133 percent of the federal poverty level.\u00a0 <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-50191 alignleft\" src=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/yo01z-9hqaw-300x200.jpg\" alt=\"black and gray stethoscope\" width=\"300\" height=\"200\" srcset=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/yo01z-9hqaw-300x200.jpg 300w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/yo01z-9hqaw-1024x683.jpg 1024w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/yo01z-9hqaw-768x512.jpg 768w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/yo01z-9hqaw-1536x1024.jpg 1536w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/yo01z-9hqaw.jpg 1600w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/>The federal government fully funded the expansion coverage for the first three years of the program.\u00a0<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">Pursuant to contracts with California\u2019s Department of Health Care Services (DHCS), if a California COHS did not spend at least 85 percent of the funds it received for the Adult Expansion population on \u201callowed medical expenses,\u201d the COHS was required to pay back to the state the difference between 85 percent and what it actually spent. <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">California, in turn, was required to return that amount to the federal government.<\/span><br \/>\n<span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">The three settlements resolve allegations that Gold Coast, Ventura County, Dignity, and Clinicas knowingly submitted or caused the submission of false claims to Medi-Cal for \u201cAdditional Services\u201d provided to Adult Expansion Medi-Cal members between January 1, 2014, and May 31, 2015. <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-49685 alignright\" src=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/05\/3665164-300x160.jpg\" alt=\"\" width=\"300\" height=\"160\" srcset=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/05\/3665164-300x160.jpg 300w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/05\/3665164-1024x547.jpg 1024w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/05\/3665164-768x410.jpg 768w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/05\/3665164.jpg 1280w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/>The United States and California alleged that the payments were not \u201callowed medical expenses\u201d under Gold Coast\u2019s 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. <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">The United States and California further alleged that the payments were unlawful gifts of public funds in violation of Article IV, Section 17 of the Constitution of California.<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0 As a result of the settlements, Gold Coast will pay $17.2 million to the United States; Ventura County will pay $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; and Clinicas will pay $11.25 million to the United States and $1.25 million to the State of California.\u00a0<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0 <img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-50053 alignleft\" src=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/1yeql23dvji-200x300.jpg\" alt=\"brown wooden chairs inside room\" width=\"200\" height=\"300\" srcset=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/1yeql23dvji-200x300.jpg 200w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/1yeql23dvji-683x1024.jpg 683w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/1yeql23dvji-768x1152.jpg 768w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/06\/1yeql23dvji.jpg 800w\" sizes=\"auto, (max-width: 200px) 100vw, 200px\" \/>\u201cWe will pursue every health plan and provider that prioritizes profits over patients,\u201d said Acting U.S. Attorney Stephanie S. Christensen for the Central District of California. \u201cThe 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.\u201d<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0 \u201cFederal health care funds are not intended to serve as a blank check,\u201d said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department\u2019s Civil Division. \u201cHealth systems and health care providers will be held accountable when they misuse such funds, including funds intended to support Medicaid expansion programs.\u201d<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0 <img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-49550 alignright\" src=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/04\/dzpc4uy8zty-1-300x200.jpg\" alt=\"woman holding sword statue during daytime\" width=\"300\" height=\"200\" srcset=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/04\/dzpc4uy8zty-1-300x200.jpg 300w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/04\/dzpc4uy8zty-1-1024x683.jpg 1024w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/04\/dzpc4uy8zty-1-768x512.jpg 768w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/04\/dzpc4uy8zty-1-1536x1024.jpg 1536w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2022\/04\/dzpc4uy8zty-1.jpg 1600w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/>\u00a0\u00a0\u00a0 \u201cMedicaid expansion programs were created to ensure access to coverage for those in need of health care services. Anyone who illegitimately diverts Medicaid funding for their own financial gain prevents valuable taxpayer dollars from being used for their intended purpose,\u201d said Special Agent in Charge Timothy DeFrancesca of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). \u201cHHS-OIG will not hesitate to investigate and pursue all forms of health care fraud.\u201d<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-43755 alignleft\" src=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2021\/08\/oxghu60nwxu-1-300x166.jpg\" alt=\"closeup photo of gavel\" width=\"300\" height=\"166\" srcset=\"https:\/\/cjnotebook.com\/wp-content\/uploads\/2021\/08\/oxghu60nwxu-1-300x166.jpg 300w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2021\/08\/oxghu60nwxu-1-1024x566.jpg 1024w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2021\/08\/oxghu60nwxu-1-768x424.jpg 768w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2021\/08\/oxghu60nwxu-1-1536x849.jpg 1536w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2021\/08\/oxghu60nwxu-1-850x470.jpg 850w, https:\/\/cjnotebook.com\/wp-content\/uploads\/2021\/08\/oxghu60nwxu-1.jpg 1600w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/> \u201cMedi-Cal props up our communities by providing access to free or affordable healthcare services for millions of Californians and their families. Those who attempt to cheat the system are cheating our communities of essential care,\u201d said California Attorney General Rob Bonta. \u201cI want to express my gratitude to the United States Department of Justice and the United States Attorney\u2019s Office in Los Angeles for their extensive efforts throughout the course of this investigation. The California Department of Justice and our law enforcement partners will continue to hold accountable those who defraud the Medi-Cal program, and protect those it serves.\u201d<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Contemporaneous with the False Claims Act settlement, 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 5-year Corporate Integrity Agreements (CIAs). <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">The CIAs require, among other things, that Gold Coast and Ventura County each implement centralized risk assessment programs as part of their compliance programs and each hire an Independent Review Organization to complete annual reviews. <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">Gold Coast\u2019s annual reviews will focus on its calculation and reporting of Medical Loss Ratio (MLR) data under Medi-Cal, while Ventura County\u2019s annual reviews will target hospital claims submitted to Medicare and Medicaid, including claims submitted to Medicaid managed care organizations.<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 The civil settlements include the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Atul Maithel, Gold Coast\u2019s former controller, and Andre Galvan, Gold Coast\u2019s former director of member services.\u00a0 <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery.\u00a0 <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">The whistleblowers also alleged claims under the California False Claims Act.\u00a0 The qui tam case is captioned\u00a0<i>United States of America, et al. ex rel. Maithel, et al. v. Ventura Co. Medi-Cal Managed Care Commission d\/b\/a Gold Coast Health Plan, et al.<\/i>, No. 15-7760AB TJH (JEMx) (C.D. Cal.).<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 The resolution obtained in this matter was the result of a coordinated effort between the Justice Department\u2019s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney\u2019s Office for the Central District of California, and the California Department of Justice, with assistance from HHS-OIG and DHCS.<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 The investigation and resolution of this matter illustrates the government\u2019s emphasis on combating healthcare fraud. <\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">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).<\/span><\/p>\n<p class=\"yiv2358954502MsoNormal\" style=\"text-align: center;\"><span style=\"font-size: 20px;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Assistant United States Attorney Jack D. Ross of the Civil Division\u2019s Civil Fraud Section and Trial Attorneys Alison Rousseau and Mary Beth Hickcox-Howard of the Justice Department\u2019s Fraud Section handled this case.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>LOS ANGELES\u00a0 Ventura County\u2019s organized health system and three medical care providers have agreed to pay a total of $70.7 million to settle allegations that they broke federal and state laws by&#8230;<\/p>\n","protected":false},"author":1,"featured_media":12931,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[],"class_list":["post-50631","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-u-s-department-of-justice"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Ventura County, Calif. 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