Florida Man Agrees to Plead Guilty in $110 Million Telemedicine Medicare Fraud Scheme

By: George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On February 16, 2024, a Parkland, Florida, man agreed to plead guilty to organizing a Medicare fraud scheme worth $110 million. The federal prosecution is taking place in the U.S. District Court for the District of Massachusetts. The fraud was allegedly perpetrated through two Florida companies the man owned, Expansion Media, LLC, and Hybrid Management Group, LLC. According to federal prosecutors in Boston, the scheme involved utilizing telemedicine and telemarketing enterprises to create fabricated orders for medical equipment, particularly knee braces. The scheme allegedly lasted from March 2016 to January 2023.

Specifics on this Medicare Fraud Scheme.

The Florida businessman and owner of Expansion Media, LLC, and Hybrid Management Group, LLC, allegedly sold medically unnecessary Durable Medical Equipment (D.M.E.) to medical staffing companies. According to the government, he used telemedicine and telemarketing companies to create false leads. The telemarketers would pay the Florida man’s companies to generate orders for the medical groups that signed off on them, even though they had no contact with any of the Medicare beneficiaries. The medical devices ordered resulted in $110 million in fraudulent claims, of which Medicare paid $52.5 million.

Prosecutors say the Florida man took many steps to conceal the scheme, including changing his business names, creating fictitious e-mails tied to those companies, and using third-party pass-through payment options.

The Florida man was ordered by the court to pay back $15.7 million and a laundry list of expensive jewelry purchases, such as multiple Patek Philippe watches and Tiffany & Co. jewelry. He agreed to plead guilty, and his deal includes a ten-year prison sentence with supervised releases for three years and fines up to $250,000.

No mention was made about what happened to the Patek Phillippe watches or the Tiffany jewelry, but I have asked the FBI to keep me advised. I have an anniversary coming up.

To view the press release from the U.S. Attorney’s Office, District of Massachusetts, click here.

Florida Man: Joyfully Spreading Florida’s Crime All Over the Place

This blog relates one of my biggest pet peeves. That scurrilous, underhanded Florida Man. Now he has spread his disease of fraud and theft all the way up to the beautiful city of Boston. Why don’t they finally lock him up once and for all?

Is Florida really going to make Florida Man the official state bird, replacing the beautiful Northern Mockingbird? Maybe that’s what he was doing up north in Massachusetts, mocking them.

This case also points out Florida’s reputation as a state which shelters and promotes the use of shell corporations and limited liability companies used to defraud the public and its protection of conmen and fraudsters.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Health care Fraud Issues Now.

The attorneys of The Health Law Firm represent physicians, pharmacists, durable medical equipment (DME) suppliers, and other health care providers in Medicare audits, investigations and subpoenas, Medicaid audits and subpoenas, Medicare and Medicaid investigations, Department of Health (DOH) subpoenas and investigations, Department of Health and Human Services (DHHS), Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) subpoenas and investigations, and Medicaid Fraud Control Unit (MFCU) subpoenas, audits and investigations, in Florida, Colorado, Louisiana, the District of Columbia, Virginia, and across the U.S. They also represent healthcare providers in actions to terminate billing privileges, termination from the Medicare or Medicaid programs, and state and federal administrative hearings and litigation.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or toll-free (888) 331-6620.

Sources:

DOM. (February 16, 2024). Owner of telemedicine companies charged with $110 million medicare fraud scheme. United States Attorney’s Office. Retrieved from https://www.justice.gov/usao-ma/pr/owner-telemedicine-companies-charged-110-million-medicare-fraud-scheme#:~:text=BOSTON%20%E2%80%93%20The%20owner%20of%20Expansion,as%20back%20and%20knee%20braces.

Dowling, B. (February 16, 2024). Telemedicine exec admits $110 Medicare fraud scheme. Law360. Retrieved from https://www.law360.com/articles/1803737/telemedicine-exec-admits-110m-medicare-fraud-scheme

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620.

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2024 George F. Indest III, The Health Law Firm. All rights reserved. No part of this work may be reproduced in any way in any medium without the written permission of the copyright owner. The author of this work reserves the right to have his name associated with any use or publication of this work or any part of it.

Florida Man Agrees to Plead Guilty in $110 Million Telemedicine Medicare Fraud Scheme

By: George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On February 16, 2024, a Parkland, Florida, man agreed to plead guilty to organizing a Medicare fraud scheme worth $110 million. The federal prosecution is taking place in the U.S. District Court for the District of Massachusetts. The fraud was allegedly perpetrated through two Florida companies the man owned, Expansion Media, LLC, and Hybrid Management Group, LLC. According to federal prosecutors in Boston, the scheme involved utilizing telemedicine and telemarketing enterprises to create fabricated orders for medical equipment, particularly knee braces. The scheme allegedly lasted from March 2016 to January 2023.

Specifics on this Medicare Fraud Scheme.

The Florida businessman and owner of Expansion Media, LLC, and Hybrid Management Group, LLC, allegedly sold medically unnecessary Durable Medical Equipment (D.M.E.) to medical staffing companies. According to the government, he used telemedicine and telemarketing companies to create false leads. The telemarketers would pay the Florida man’s companies to generate orders for the medical groups that signed off on them, even though they had no contact with any of the Medicare beneficiaries. The medical devices ordered resulted in $110 million in fraudulent claims, of which Medicare paid $52.5 million.

Prosecutors say the Florida man took many steps to conceal the scheme, including changing his business names, creating fictitious e-mails tied to those companies, and using third-party pass-through payment options.

The Florida man was ordered by the court to pay back $15.7 million and a laundry list of expensive jewelry purchases, such as multiple Patek Philippe watches and Tiffany & Co. jewelry. He agreed to plead guilty, and his deal includes a ten-year prison sentence with supervised releases for three years and fines up to $250,000.

No mention was made about what happened to the Patek Phillippe watches or the Tiffany jewelry, but I have asked the FBI to keep me advised. I have an anniversary coming up.

To view the press release from the U.S. Attorney’s Office, District of Massachusetts, click here.

Florida Man: Joyfully Spreading Florida’s Crime All Over the Place

This blog relates one of my biggest pet peeves. That scurrilous, underhanded Florida Man. Now he has spread his disease of fraud and theft all the way up to the beautiful city of Boston. Why don’t they finally lock him up once and for all?

Is Florida really going to make Florida Man the official state bird, replacing the beautiful Northern Mockingbird? Maybe that’s what he was doing up north in Massachusetts, mocking them.

This case also points out Florida’s reputation as a state which shelters and promotes the use of shell corporations and limited liability companies used to defraud the public and its protection of conmen and fraudsters.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Health care Fraud Issues Now.

The attorneys of The Health Law Firm represent physicians, pharmacists, durable medical equipment (DME) suppliers, and other health care providers in Medicare audits, investigations and subpoenas, Medicaid audits and subpoenas, Medicare and Medicaid investigations, Department of Health (DOH) subpoenas and investigations, Department of Health and Human Services (DHHS), Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) subpoenas and investigations, and Medicaid Fraud Control Unit (MFCU) subpoenas, audits and investigations, in Florida, Colorado, Louisiana, the District of Columbia, Virginia, and across the U.S. They also represent healthcare providers in actions to terminate billing privileges, termination from the Medicare or Medicaid programs, and state and federal administrative hearings and litigation.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or toll-free (888) 331-6620.

Sources:

DOM. (February 16, 2024). Owner of telemedicine companies charged with $110 million medicare fraud scheme. United States Attorney’s Office. Retrieved from https://www.justice.gov/usao-ma/pr/owner-telemedicine-companies-charged-110-million-medicare-fraud-scheme#:~:text=BOSTON%20%E2%80%93%20The%20owner%20of%20Expansion,as%20back%20and%20knee%20braces.

Dowling, B. (February 16, 2024). Telemedicine exec admits $110 Medicare fraud scheme. Law360. Retrieved from https://www.law360.com/articles/1803737/telemedicine-exec-admits-110m-medicare-fraud-scheme

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620.

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2024 George F. Indest III, The Health Law Firm. All rights reserved. No part of this work may be reproduced in any way in any medium without the written permission of the copyright owner. The author of this work reserves the right to have his name associated with any use or publication of this work or any part of it.

Centene Agrees to Pay $19 Million to Washington State For Medicaid Fraud Allegations

Author HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

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“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

By |2024-03-14T09:59:09-04:00March 14, 2024|Categories: Nursing Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Centene Agrees to Pay $19 Million to Washington State For Medicaid Fraud Allegations

Centene Will Pay $19 Million to Washington State For Medicaid Fraud Allegations

Author HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

KeyWords: Medicare Medicaid audit defense lawyer, legal representation in Medicaid managed care plan audit defense, Medicaid managed care plan audit legal defense attorney, Medicare Medicaid overpayment demand defense attorney, legal representation in Medicaid managed care plan overpayment demand, Medicaid managed care plan audit appeal attorney, legal representation in Medicaid managed care plan audit appeal, Medicare Medicaid audit appeal lawyer, Medicare Medicaid audit overpayment demand defense attorney, Centene Sunshine State Health Plan audit legal defense attorney, legal representation in Centene Sunshine State Health Plan audit, Centene Sunshine State Health Plan audit overpayment demand defense lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment demand, Centene Sunshine State Health Plan audit overpayment appeal lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment appeal, healthcare fraud defense legal representation, Medicare Medicaid audit defense attorney, Medicare Medicaid investigation defense lawyer, legal representation in Medicaid managed care plan HMO audit, Medicaid managed care plan HMO audit defense attorney, Medicaid managed care plan HMO audit appeal attorney, Medicaid managed care plan HMO overpayment defense lawyer, Centers for Medicare & Medicaid Services (CMS) defense attorney, CMS legal defense representation, health insurance audit defense attorney, CMS defense attorney, CMS legal defense lawyer, legal representation for CMS investigation, Medicaid Fraud Control Unit (MFCU) defense attorney, Medicaid Fraud Control Unit (MFCU) defense legal representation, Office of Inspector General (OIG) investigation defense attorney, civil monetary penalty hearing, reviews of The Health Law Firm, The Health Law Firm attorney reviews, False Claims Act (FCA) suit defense attorney, Office of Inspector General (OIG) interview defense attorney, Department of Health and Human Services (HHS) subpoena defense attorney, Department of Health and Human Services (HHS) civil investigative demand (CID) defense attorney, legal representation for healthcare professionals, Florida health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

By |2024-03-14T09:59:11-04:00February 23, 2024|Categories: Pharmacy Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Centene Will Pay $19 Million to Washington State For Medicaid Fraud Allegations

Centene Will Pay $19 Million Settlement to Washington State For Medicaid Fraud Allegations

Author HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

KeyWords: Medicare Medicaid audit defense lawyer, legal representation in Medicaid managed care plan audit defense, Medicaid managed care plan audit legal defense attorney, Medicare Medicaid overpayment demand defense attorney, legal representation in Medicaid managed care plan overpayment demand, Medicaid managed care plan audit appeal attorney, legal representation in Medicaid managed care plan audit appeal, Medicare Medicaid audit appeal lawyer, Medicare Medicaid audit overpayment demand defense attorney, Centene Sunshine State Health Plan audit legal defense attorney, legal representation in Centene Sunshine State Health Plan audit, Centene Sunshine State Health Plan audit overpayment demand defense lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment demand, Centene Sunshine State Health Plan audit overpayment appeal lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment appeal, healthcare fraud defense legal representation, Medicare Medicaid audit defense attorney, Medicare Medicaid investigation defense lawyer, legal representation in Medicaid managed care plan HMO audit, Medicaid managed care plan HMO audit defense attorney, Medicaid managed care plan HMO audit appeal attorney, Medicaid managed care plan HMO overpayment defense lawyer, Centers for Medicare & Medicaid Services (CMS) defense attorney, CMS legal defense representation, health insurance audit defense attorney, CMS defense attorney, CMS legal defense lawyer, legal representation for CMS investigation, Medicaid Fraud Control Unit (MFCU) defense attorney, Medicaid Fraud Control Unit (MFCU) defense legal representation, Office of Inspector General (OIG) investigation defense attorney, civil monetary penalty hearing, reviews of The Health Law Firm, The Health Law Firm attorney reviews, False Claims Act (FCA) suit defense attorney, Office of Inspector General (OIG) interview defense attorney, Department of Health and Human Services (HHS) subpoena defense attorney, Department of Health and Human Services (HHS) civil investigative demand (CID) defense attorney, legal representation for healthcare professionals, Florida health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

By |2024-03-14T09:59:13-04:00February 1, 2024|Categories: Health Facilities Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Centene Will Pay $19 Million Settlement to Washington State For Medicaid Fraud Allegations

Centene to Pay Washington State $19 Million to Resolve Medicaid Fraud Allegations

Author HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, it has been reported that Centene/Sunshine Health reportedly has over $31 billion in contracts with the state of Florida alone. Click here to learn more.

The agreement with Washington State resolves allegations that it overcharged its Medicaid program for pharmacy benefit management services, Washington Attorney General Bob Ferguson announced in a press release.

Under the deal, in addition to the $19 million payment to Washington State, the federal government will receive $13.3 million related to the settlement, according to the Attorney General’s office. In addition, a whistleblower who sued the company on behalf of the state will also receive $1 million. It is the second-largest Medicaid fraud settlement in Washington’s history.

An Investigation and a Whistleblower.

According to the press release, the Washington AG’s office began investigating pharmacy benefit managers in 2019 after a whistleblower said the company failed to disclose actual pharmacy benefits and service costs. Furthermore, Centene allegedly failed to pass on discounts it received to the state Medicaid program, causing inflated fees, according to the release.

Washington sued Centene in July 2022, alleging the company and a subsidiary, Coordinated Care of Washington, violated the state’s Medicaid False Claims Act. Coordinated Care of Washington contracts with Washington’s Health Care Authority to manage its Medicaid program, Apple Health.

Shelling Out Big Bucks For Settlements.

Centene did not admit to any wrongdoing in this case, as is usual with settlement agreements. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making healthcare delivery local, simple and transparent,” Centene’s spokesperson said.

But, while denying any wrongdoing, it has settled claims over similar alleged conduct in ten other states for more than $260 million. Additionally, it said last year that it was still in negotiations with more states and had set aside $1.25 billion to settle such claims. Click here to learn more. 

To view the settlement agreement in full, click here. 

Similar Patterns of Misconduct?

We need to ask: “Is this the business model of Centene and its different owned subsidiary companies?” We note that on March 22, 2022, the Centers for Medicare and Medicaid Services (CMS) assessed civil monetary penalties (CMP) against Centene Corporation for similar alleged wrongful activities involving the states of California, South Carolina, Texas, Ohio, Michigan, and others.  And in a letter dated March 11, 2022, the Florida Agency for Health Care Administration issued a $9.1 million fine over Centene/Sunshine Health’s improper failure to pay benefits to Florida’s neediest, sick children.  We have not found any report that Centene challenged or appealed either government penalty.

When multiple billions of dollars in government contracts are handed out to one contractor, and it is the subject of so many allegedly wrongful acts, one must ask if it is just treating such penalties and fines as the routine costs of doing business. Considering that $9.1 million is less than three (3) hundredths of a percent (.0003) of its $31 billion in contracts with the state of Florida, this cost may not even be significant enough for it to post on its profit ad loss statements.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits, Healthcare Audits, and Insurance Payment Disputes.

The attorneys of The Health Law Firm represent counselors, therapists, physicians, healthcare providers and healthcare facilities in defense of Medicare and Medicaid audits, audits by insurance companies and managed care, and demands for repayment of overpayments. They represent healthcare providers in audits, audit appeals and repayment disputes against Centene Corporation and Sunshine Sate Health Plan d/b/a Sunshine Health. They also represent healthcare providers in defense against allegations of false billing, overbilling, False Claims Act violations and civil monetary penalties (CMP).

Our attorneys represent physicians, mental health counselors, behavior therapists, professional counselors, occupational therapists, social workers, medical groups, home health agencies, pharmacies, pharmacists, home nursing care providers, and other healthcare providers and institutions.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Redmond, Nell. “Centene to pay $33.3 million to settle Washington Medicaid fraud claims.” Reuters. (August 25, 2022). Web.

Elletson, Grace. “Centene Strikes $33M Deal To End Wash. Medicaid Fraud Suit.” Law360. (September 2, 2022). Web.

Health Law Weekly. “Centene Will Pay $19 Million to Resolve Medicaid Fraud Allegations.” AHLA. (September 2, 2022). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 Toll-Free: (888) 331-6620

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: [email protected] or fax to: (407) 331-3030.

KeyWords: Medicare Medicaid audit defense lawyer, legal representation in Medicaid managed care plan audit defense, Medicaid managed care plan audit legal defense attorney, Medicare Medicaid overpayment demand defense attorney, legal representation in Medicaid managed care plan overpayment demand, Medicaid managed care plan audit appeal attorney, legal representation in Medicaid managed care plan audit appeal, Medicare Medicaid audit appeal lawyer, Medicare Medicaid audit overpayment demand defense attorney, Centene Sunshine State Health Plan audit legal defense attorney, legal representation in Centene Sunshine State Health Plan audit, Centene Sunshine State Health Plan audit overpayment demand defense lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment demand, Centene Sunshine State Health Plan audit overpayment appeal lawyer, legal representation in Centene Sunshine State Health Plan audit overpayment appeal, healthcare fraud defense legal representation, Medicare Medicaid audit defense attorney, Medicare Medicaid investigation defense lawyer, legal representation in Medicaid managed care plan HMO audit, Medicaid managed care plan HMO audit defense attorney, Medicaid managed care plan HMO audit appeal attorney, Medicaid managed care plan HMO overpayment defense lawyer, Centers for Medicare & Medicaid Services (CMS) defense attorney, CMS legal defense representation, health insurance audit defense attorney, CMS defense attorney, CMS legal defense lawyer, legal representation for CMS investigation, Medicaid Fraud Control Unit (MFCU) defense attorney, Medicaid Fraud Control Unit (MFCU) defense legal representation, Office of Inspector General (OIG) investigation defense attorney, civil monetary penalty hearing, reviews of The Health Law Firm, The Health Law Firm attorney reviews, False Claims Act (FCA) suit defense attorney, Office of Inspector General (OIG) interview defense attorney, Department of Health and Human Services (HHS) subpoena defense attorney, Department of Health and Human Services (HHS) civil investigative demand (CID) defense attorney, legal representation for healthcare professionals, Florida health law defense attorney

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

 

 

 

 

By |2024-03-14T09:59:14-04:00January 8, 2024|Categories: Mental Health Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Centene to Pay Washington State $19 Million to Resolve Medicaid Fraud Allegations

Supreme Court Rules Against HHS in Hospital Medicare Reimbursement Case

Author HeadshotBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On June 15, 2022, the U.S. Supreme Court said the federal government improperly cut more than $1 billion a year in Medicare reimbursements to hospitals.  This came in a ruling that limits regulators’ power to control what the program pays for certain drugs.  In this case, the Supreme Court justices sided unanimously with a group of hospitals suing over drug reimbursement rates for facilities that serve low-income communities. In writing for the court, Justice Brett Kavanaugh said the U.S. Department of Health and Human Services (HHS) improperly calculated reimbursement rates using a methodology Congress authorized for use only in limited circumstances.

Were the Reimbursement Cuts Unlawful?

The Supreme Court overturned a lower court’s 2020 decision that HHS had the authority to reduce the yearly Medicare reimbursement rates for a group of hospitals serving low income communities. Click here to view the July 31, 2020 decision.

The high court found the U.S. Court of Appeals for the District of Columbia Circuit erred in 2020 when it allowed the HHS to reduce Medicare payments, by roughly $1.6 billion, for outpatient drugs that had helped subsidize the operations of the hospitals.  The Supreme Court’s decision did not extend so far as to undermine HHS authority, but only stated how the agency acted unlawfully in accordance with its varying rates for hospitals under the 340B Drug Pricing Program.

“In short, the statute allows HHS to set reimbursement rates based on average price and affords the agency discretion to ‘adjust’ the price up or down. But unless HHS conducts a survey of hospitals’ acquisition costs, HHS may not vary the reimbursement rates by hospital group,” Justice Kavanaugh wrote in the ruling.


Regulating Reimbursement Rates Under the 340B Program.

Under Medicare, health care providers get reimbursed by the government for expenses, including medications used in hospital outpatient departments. Previously, hospitals had been getting reimbursed at a rate based on the average price of the drugs. However, in 2018, the HHS, under then-President Donald Trump, cut payments for outpatient drugs by 28.5% to hospitals receiving money under the 340B program.

The department found that reimbursements were too high because these hospitals obtain the drugs from manufacturers at a deep discount, an issue that also resulted in excessive patient co-payments. Additionally, the resulting cut dealt “a crushing blow to providers that were already operating on razor-thin  margins and to the vulnerable populations they serve,” the hospitals told the justices in a court filing.

Justice Brett Kavanaugh wrote for the court that “absent a survey of hospitals’ acquisition costs,” the HHS “may not vary the reimbursement rates for 340B hospitals. The HHS’s 2018 and 2019 reimbursement rates for 340B hospitals were therefore contrary to the statute and unlawful.”

Click here to read the Supreme Court’s Opinion in the case, American Hospital Association v. Becerra, 20-1114.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, Medcaid audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or toll-free at (888) 331-6620.


Sources:

Stohr, Greg. “Supreme Court Sides With Hospitals on Medicare Reimbursement.” Bloomberg Law. (June 15, 2022). Web.

Chung, Andrew. “U.S. Supreme Court faults Medicare cuts to hospitals for outpatient drugs.” Reuters. (June 15, 2022). Web.

Gresko, Jessica. “High court rules against government on drug reimbursement.” Associated Press. (June 15, 2022). Web.


About the Author: George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law is an attorney with The Health Law Firm, which has a national practice. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, Florida 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

KeyWords:  Legal representation for Medicare Medicaid audit, Medicare Medicaid audit defense attorney, legal representation for healthcare professionals, complex health care litigation attorney, legal representation for Medicare Medicaid reimbursement demand, Medicare Medicaid defense lawyer, legal representation for Medicare Medicaid defense, complex civil health care litigation attorney, legal representation for complex medical litigation, representation for healthcare business litigation matters, Medicare Medicaid hearing attorney, legal representation for physicians and health care professionals, attorney for physician suits against insurers, complex medical business litigation against health insurers, formal Medicare administrative hearing lawyer, Health law defense lawyer, legal representation of health care professionals, Medicare Medicaid overpayment demand defense lawyer, Legal representation for Medicare Medicaid administrative hearing
Florida Agency for Health Care Administration (AHCA) formal hearing defense attorney, legal representation for Medicare Medicaid revocation termination hearings, medical license investigation representation defense attorney, representation for Florida Department of Health (DOH) investigations and hearings, reviews of The Health Law Firm, reviews of The Health Law Firm. The Health Law Firm attorney reviews, The Health Law Firm attorney reviews

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

By |2024-03-14T09:59:16-04:00November 18, 2023|Categories: Health Facilities Law Blog|Tags: , , , , , , , , , , , , , , , , , , , , , , , , |Comments Off on Supreme Court Rules Against HHS in Hospital Medicare Reimbursement Case

Supreme Court Rules FCA Case Liability Requires Defendants’ Subjective Belief

Author and attorney headshot leaning with hands folded in frontBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On June 1, 2023, the Supreme Court handed down an opinion on the knowledge standard required in False Claims Act (FCA) cases in a precedential decision that leaves the whistleblower plaintiffs bar reeling. In a unanimous ruling, the high court said liability of defendants in FCA cases would be based on their own belief in the falsity of their claims, rather than an “objectively reasonable” interpretation of the law or regulation. This appears to set the age-old maxim of “ignorance of the law is no excuse” on its head. Now, apparently, a defendant can argue that he, she or it was ignorant of the law and win.

The case before the Supreme Court was consolidated from two lower court decisions in the cases United States ex rel. Schutte v. SuperValu Inc. and United States ex rel. Proctor v. Safeway.

When Subjective Belief is Relevant in FCA Cases.

In the cases which the Supreme Court decided, the whistleblowers accused SuperValu and Safeway of violating the FCA by overcharging Medicare, Medicaid, and the Federal Employee Health Benefits Program for prescription drugs.

According to the rules of these programs, pharmacies cannot charge the government more than the “usual and customary” price for a drug, which is the cash price charged to the general public. The plaintiffs claimed that the pharmacies overbilled the government when they started offering discounted prices to consumers under a price-match program to compete with other pharmacies. They also offered a membership discount program but did not adjust their “usual and customary” prices, continuing to charge the government more than they should have.

The Lower Court’s Ruling.

The Seventh Circuit Court of Appeals ruled in April 2022, that the pharmacies had submitted false claims by not reporting their discounted prices, which were the “usual and customary” prices. The appeals court also stated that the retailers had made reasonable interpretations of ambiguous laws without being warned against it by authoritative guidance. The circuit court referred to the Safeco standard from the Supreme Court’s 2007 Safeco Insurance Co. of America v. Burr case in its decision.

Click here to learn more about the Seventh Circuit Court of Appeal’s ruling.

The Supreme Court’s Ruling.

The Seventh Circuit’s perspective was rejected by the Supreme Court, which instead focused on the defendant’s intentions when submitting false claims. Justice Clarence Thomas, writing for a unanimous court stated, “What matters for an FCA case is whether the defendant knew the claim was false. Thus, if [the defendants] correctly interpreted the relevant phrase and believed their claims were false, they could have known their claims were false.” Read the opinion in full here.

Under this rationale, a defendant could successfully make the argument, “I didn’t know the claim was false and I never bothered to do anything to make sure of that fact.” Even objectively unreasonable claims, such as charging a million dollars for a drug which only cost one dollar, could be successfully defended.

Contact Health Law Attorneys Experienced in Handling Health Care Fraud Investigations and other Legal Proceedings.

The Health Law Firm represents healthcare providers in Medicare and Medicaid audits, and in RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid.

The Health Law Firm’s attorneys routinely represent physicians, dentists, pharmacists, psychotherapists, medical groups, clinics, pharmacies, assisted living facilities (ALFs), home health agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Elberg, Jacob. “Supreme Court maintains focus on defendant’s subjective beliefs in False Claims Act cases.” SCOTUS Blog. (June 1, 2023). Web.

Wilson, Daniel. “Justices Say FCA Liability Hinges On Defendants’ Beliefs.” Law360. (June 1, 2023). Web.

Gaivin, Kathleen. “False Claims Act ruling by High Court a ‘clear win’ for government, expert says.” McKnights Senior Living. (June 2, 2023). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law; he is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, Florida 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Current Open Positions with The Health Law Firm. The Health Law Firm always seeks qualified individuals interested in health law. Its main office is in the Orlando, Florida, area. If you are a current member of The Florida Bar or a qualified professional who is interested, please forward a cover letter and resume to: [email protected] or fax them to (407) 331-3030.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2023. The Health Law Firm. All rights reserved.

Supreme Court Rules FCA Case Liability Requires Defendants’ Subjective Belief

Author and attorney headshot leaning with hands folded in frontBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On June 1, 2023, the Supreme Court handed down an opinion on the knowledge standard required in False Claims Act (FCA) cases in a precedential decision that leaves the whistleblower plaintiffs bar reeling. In a unanimous ruling, the high court said liability of defendants in FCA cases would be based on their own belief in the falsity of their claims, rather than an “objectively reasonable” interpretation of the law or regulation. This appears to set the age-old maxim of “ignorance of the law is no excuse” on its head. Now, apparently, a defendant can argue that he, she or it was ignorant of the law and win.

The case before the Supreme Court was consolidated from two lower court decisions in the cases United States ex rel. Schutte v. SuperValu Inc. and United States ex rel. Proctor v. Safeway.

When Subjective Belief is Relevant in FCA Cases.

In the cases which the Supreme Court decided, the whistleblowers accused SuperValu and Safeway of violating the FCA by overcharging Medicare, Medicaid, and the Federal Employee Health Benefits Program for prescription drugs.

According to the rules of these programs, pharmacies cannot charge the government more than the “usual and customary” price for a drug, which is the cash price charged to the general public. The plaintiffs claimed that the pharmacies overbilled the government when they started offering discounted prices to consumers under a price-match program to compete with other pharmacies. They also offered a membership discount program but did not adjust their “usual and customary” prices, continuing to charge the government more than they should have.

The Lower Court’s Ruling.

The Seventh Circuit Court of Appeals ruled in April 2022, that the pharmacies had submitted false claims by not reporting their discounted prices, which were the “usual and customary” prices. The appeals court also stated that the retailers had made reasonable interpretations of ambiguous laws without being warned against it by authoritative guidance. The circuit court referred to the Safeco standard from the Supreme Court’s 2007 Safeco Insurance Co. of America v. Burr case in its decision.

Click here to learn more about the Seventh Circuit Court of Appeal’s ruling.

The Supreme Court’s Ruling.

The Seventh Circuit’s perspective was rejected by the Supreme Court, which instead focused on the defendant’s intentions when submitting false claims. Justice Clarence Thomas, writing for a unanimous court stated, “What matters for an FCA case is whether the defendant knew the claim was false. Thus, if [the defendants] correctly interpreted the relevant phrase and believed their claims were false, they could have known their claims were false.” Read the opinion in full here.

Under this rationale, a defendant could successfully make the argument, “I didn’t know the claim was false and I never bothered to do anything to make sure of that fact.” Even objectively unreasonable claims, such as charging a million dollars for a drug which only cost one dollar, could be successfully defended.

Contact Health Law Attorneys Experienced in Handling Health Care Fraud Investigations and other Legal Proceedings.

The Health Law Firm represents healthcare providers in Medicare and Medicaid audits, and in RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid.

The Health Law Firm’s attorneys routinely represent physicians, dentists, pharmacists, psychotherapists, medical groups, clinics, pharmacies, assisted living facilities (ALFs), home health agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Elberg, Jacob. “Supreme Court maintains focus on defendant’s subjective beliefs in False Claims Act cases.” SCOTUS Blog. (June 1, 2023). Web.

Wilson, Daniel. “Justices Say FCA Liability Hinges On Defendants’ Beliefs.” Law360. (June 1, 2023). Web.

Gaivin, Kathleen. “False Claims Act ruling by High Court a ‘clear win’ for government, expert says.” McKnights Senior Living. (June 2, 2023). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law; he is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, Florida 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Current Open Positions with The Health Law Firm. The Health Law Firm always seeks qualified individuals interested in health law. Its main office is in the Orlando, Florida, area. If you are a current member of The Florida Bar or a qualified professional who is interested, please forward a cover letter and resume to: [email protected] or fax them to (407) 331-3030.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2023. The Health Law Firm. All rights reserved.

Supreme Court Rules FCA Case Liability Requires Defendants’ Subjective Belief

Author and attorney headshot leaning with hands folded in frontBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On June 1, 2023, the Supreme Court handed down an opinion on the knowledge standard required in False Claims Act (FCA) cases in a precedential decision that leaves the whistleblower plaintiffs bar reeling. In a unanimous ruling, the high court said liability of defendants in FCA cases would be based on their own belief in the falsity of their claims, rather than an “objectively reasonable” interpretation of the law or regulation. This appears to set the age-old maxim of “ignorance of the law is no excuse” on its head. Now, apparently, a defendant can argue that he, she or it was ignorant of the law and win.

The case before the Supreme Court was consolidated from two lower court decisions in the cases United States ex rel. Schutte v. SuperValu Inc. and United States ex rel. Proctor v. Safeway.

When Subjective Belief is Relevant in FCA Cases.

In the cases which the Supreme Court decided, the whistleblowers accused SuperValu and Safeway of violating the FCA by overcharging Medicare, Medicaid, and the Federal Employee Health Benefits Program for prescription drugs.

According to the rules of these programs, pharmacies cannot charge the government more than the “usual and customary” price for a drug, which is the cash price charged to the general public. The plaintiffs claimed that the pharmacies overbilled the government when they started offering discounted prices to consumers under a price-match program to compete with other pharmacies. They also offered a membership discount program but did not adjust their “usual and customary” prices, continuing to charge the government more than they should have.

The Lower Court’s Ruling.

The Seventh Circuit Court of Appeals ruled in April 2022, that the pharmacies had submitted false claims by not reporting their discounted prices, which were the “usual and customary” prices. The appeals court also stated that the retailers had made reasonable interpretations of ambiguous laws without being warned against it by authoritative guidance. The circuit court referred to the Safeco standard from the Supreme Court’s 2007 Safeco Insurance Co. of America v. Burr case in its decision.

Click here to learn more about the Seventh Circuit Court of Appeal’s ruling.

The Supreme Court’s Ruling.

The Seventh Circuit’s perspective was rejected by the Supreme Court, which instead focused on the defendant’s intentions when submitting false claims. Justice Clarence Thomas, writing for a unanimous court stated, “What matters for an FCA case is whether the defendant knew the claim was false. Thus, if [the defendants] correctly interpreted the relevant phrase and believed their claims were false, they could have known their claims were false.” Read the opinion in full here.

Under this rationale, a defendant could successfully make the argument, “I didn’t know the claim was false and I never bothered to do anything to make sure of that fact.” Even objectively unreasonable claims, such as charging a million dollars for a drug which only cost one dollar, could be successfully defended.

Contact Health Law Attorneys Experienced in Handling Health Care Fraud Investigations and other Legal Proceedings.

The Health Law Firm represents healthcare providers in Medicare and Medicaid audits, and in RAC audits throughout Florida and across the U.S. We also represent health providers in civil and administrative litigation by government agencies and insurance companies attempting to recoup claims that have been paid.

The Health Law Firm’s attorneys routinely represent physicians, dentists, pharmacists, psychotherapists, medical groups, clinics, pharmacies, assisted living facilities (ALFs), home health agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Elberg, Jacob. “Supreme Court maintains focus on defendant’s subjective beliefs in False Claims Act cases.” SCOTUS Blog. (June 1, 2023). Web.

Wilson, Daniel. “Justices Say FCA Liability Hinges On Defendants’ Beliefs.” Law360. (June 1, 2023). Web.

Gaivin, Kathleen. “False Claims Act ruling by High Court a ‘clear win’ for government, expert says.” McKnights Senior Living. (June 2, 2023). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law; he is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, Florida 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Current Open Positions with The Health Law Firm. The Health Law Firm always seeks qualified individuals interested in health law. Its main office is in the Orlando, Florida, area. If you are a current member of The Florida Bar or a qualified professional who is interested, please forward a cover letter and resume to: [email protected] or fax them to (407) 331-3030.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2023. The Health Law Firm. All rights reserved.

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