Calif. health system, healthcare providers to pay $70.7M over false claims

Gold Coast Health Plan, along with service providers Dignity Health, Clinicas del Camino Real, and the Ventura County Medical Center, will return the funds to the federal government and the state of California as part of their settlements, according to a press release Thursday by the Department of Justice (DOJ).

Gold Coast will pay $17.2 million to the United States, Ventura County $29 million to the United States, Dignity $10.8 million to the United States and $1.2 million to California, and Clinicas $11.25 million to the United States and $1.25 million to California. The providers entered settlements without admitting or denying the charges.

The FCA violations were alleged in a federal qui tam lawsuit filed by two whistleblowers: Atul Maithel, Gold Coast’s former controller, and Andre Galvan, Gold Coast’s former director of member services. Under the whistleblower provisions of the FCA, each tipster is entitled to a portion of the recovered funds. According to the settlement agreement between the DOJ, California, Gold Coast, and Ventura County, Maithel and Galvan will receive 18.5 percent of all funds paid.

Between January 2014 and May 2015, the four entities allegedly submitted false claims for payments that were unpermitted medical expenses under Gold Coast’s contract with the California Department of Health Care Services (DHCS), which included services provided to previously uninsured adult patients between the ages of 19 and 64.

The payments were not deemed to be “allowed medical expenses” under Gold Coast’s contract with the DHCS, were predetermined amounts that did not reflect the fair-market value of any additional services provided, and/or were duplicative services already rendered, according to a press release from the office of California Attorney General Rob Bonta.

Compliance considerations: As part of their settlements, Gold Coast and Ventura County agreed to enter five-year corporate integrity agreements that will require each to implement “centralized risk assessment programs as part of their compliance programs and … hire an independent review organization to complete annual reviews,” the DOJ said.

Gold Coast’s reviews will focus on its “calculation and reporting of medical loss ratio data” under Medi-Cal, while Ventura County’s reviews will “target hospital claims submitted to Medicare and Medicaid, including claims submitted to Medicaid managed care organizations,” according to the DOJ.

Responses: Gold Coast maintained it did nothing wrong in soliciting and receiving the reimbursements.

“Although Gold Coast Health Plan believes that its disbursements to providers under this program were lawful and proper, we agreed to participate in a mediation with the regulators to reach a settlement to prevent an expensive and protracted process,” said Chief Executive Nick Liguori in a news release. “The settlement reflects a compromise that will finally and fully resolve this dispute.”

Added Gold Coast Chief Compliance Officer Robert Franco, “Regulatory compliance is a cornerstone of our participation in the Medi-Cal program. We have a robust compliance program, and the additional layers of oversight required by the corporate integrity agreement will further strengthen the health plan as we continue to adjust to the ever-evolving regulatory environment.”

Dignity Health similarly denied the allegations and did not concede any liability in an emailed statement.

“Dignity Health continues to maintain that all the reimbursement received was properly utilized in serving Ventura County’s Medi-Cal beneficiaries,” the statement said.

A spokesperson for Ventura County said in an emailed statement, “While the contract in question was audited and approved by the state of California, the federal government found that, in summary, due to the contract language, retroactive payments for services claimed under this contract were mistakenly made. All prospective payments for services rendered under the terms of the contract were not questioned.”

The statement added, “Much of the compliance work resulting from the settlement has already begun and will be fully implemented in the coming months.”

Clinicas did not respond to a request for comment.