Centers Plan Billed Medicaid for Managed Long-Term Care Services that Its Members Did Not Qualify For or Receive.
New York, NY - Sept. 13, 2018 - Attorney General Barbara D. Underwood announced today a joint state-federal settlement with Centers Plan for Healthy Living LLC (“Centers Plan”) over allegations that its managed long-term care plan (“Centers Plan MLTCP”) submitted fraudulent requests to New York’s Medicaid program for monthly premiums, violating the state and federal False Claims Acts. New York’s Medicaid program will receive $1.65 million in restitution and penalties from the settlement.
“Submitting phony bills undermines the integrity of our Medicaid system and cheats New Yorkers,” said Attorney General Underwood. “Today’s settlement serves as a reminder that we will hold accountable those who seek to game the system for their own financial benefit.”
Medicaid is a jointly-funded state and federal program that provides health care to individuals in need. Managed Long Term Care plans (“MLTCs”) receive monthly capitation payments from Medicaid – similar to insurance premiums – for each member enrolled in the MLTC plan, in exchange for arranging and providing certain community-based long-term care services (“CBLTC”). Services may include skilled nursing services in the home, therapies in the home, home health aide services, personal care services in the home, and adult day health care. To be eligible for enrollment into an MLTC plan, a Medicaid beneficiary must, among other things, be assessed as needing CBLTC services for more than 120 days from the date of enrollment. Centers Plan contracted with licensed home care services agencies to provide skilled nursing and home health aide services to Centers Plan MLTCP members.
A joint investigation conducted by the New York Attorney General’s Office and the U.S. Attorney’s Office for the Eastern District of New York found that, from April 1, 2013 through December 31, 2015, numerous Centers Plan MLTCP members did not receive CBLTC services during at least a portion of the period when they were enrolled in Centers Plan’s MLTCP. For a number of members, there was no record that Centers Plan provided them with any services whatsoever for most of their enrollment period. Centers Plan failed to disenroll these members in a timely manner and continued to collect monthly premiums from Medicaid even though these members were not eligible to remain in Centers Plan’s MLTCP. During that time, the payments that Centers Plan received from Medicaid for providing services to MLTC members were generally $2,500 to $4,300 per member per month.
The settlement agreement resolves state and federal allegations that Centers Plan submitted false claims for monthly capitation payments for Centers Plan MLTCP members who, for at least some period of their enrollment in the Centers Plan MLTCP, did not receive qualifying community-based long-term care services as required by contract and therefore should have been disenrolled from the plan.
This investigation was initiated after a whistleblower filed a lawsuit under the qui tam provisions of the federal and New York False Claims Acts, which allow private persons, known as “relators,” to file civil actions on behalf of the government and share in any recovery. The relator in this case will receive a portion of the settlement proceeds after full payment by Centers Plan.
The investigation and settlement were coordinated between the New York State Attorney General’s Office and the U.S. Attorney’s Office for the Eastern District of New York.
The Attorney General’s Office was represented by Special Assistant Attorney General Andrew Gropper, with the assistance of MFCU Civil Enforcement Division Chief Carolyn T. Ellis. The audit analysis was led by Senior Auditor-Investigator Svetlana Volchyok, with assistance from Auditor-Investigator Brian Gonell and Principal Auditor-Investigator David Verhey. Additional investigative support was provided by Investigator Alexander Kats, with the assistance of Deputy Chief Investigator-Downstate Kenneth Morgan. The Medicaid Fraud Control Unit is led by Director Amy Held and Assistant Deputy Attorney General Paul J. Mahoney. The Division of Criminal Justice is led by Executive Deputy Attorney General Margaret Garnett.