“HHS-OIG will not hesitate to investigate and pursue all forms of health care fraud.” Department of Health and Human Services, Office of Inspector General (HHS-OIG). Anyone who illegitimately diverts Medicaid funding for their own financial gain prevents valuable taxpayer dollars from being used for their intended purpose,” said Special Agent in Charge Timothy DeFrancesca of the U.S. “Medicaid expansion programs were created to ensure access to coverage for those in need of health care services. “Health systems and health care providers will be held accountable when they misuse such funds, including funds intended to support Medicaid expansion programs.” Boynton, head of the Justice Department’s Civil Division. “Federal health care funds are not intended to serve as a blank check,” said Principal Deputy Assistant Attorney General Brian M. 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 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 pay for services that were already – or, simply never – provided. “We will pursue every health plan and provider that prioritizes profits over patients,” said Acting United States Attorney Stephanie S. 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.Īs 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. 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 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 “Additional Services” provided to Adult Expansion Medi-Cal members between January 1, 2014, and May 31, 2015. California, in turn, was required to return that amount to the federal government. Pursuant to contracts with California’s 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 “allowed medical expenses,” the COHS was required to pay back to the state the difference between 85 percent and what it actually spent. The federal government fully funded the expansion coverage for the first three years of the program. 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 percent of the federal poverty level. ![]() (Clinicas), a non-profit healthcare organization headquartered in Camarillo.
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