The United States has joined a whistleblower action pending in the Northern District of California against the federally-qualified health center (FQHC), North East Medical Services (NEMS), alleging that the center under-reported income it received from a managed care organization in order to artificially inflate reimbursements it received from the California Medicaid program, the Justice Department announced today. North East serves the San Francisco Bay area.
FQHCs are “safety net” community clinics certified under federal law and licensed under state law to provide medical care to poor and under-served populations. As such a health center, North East Medical Services is entitled to special payments from the California Medicaid program (Medi-Cal) that are significantly more generous than typical Medicaid payments. However, in order to receive these additional payments, NEMS must submit annual reports to Medi-Cal stating the total amount it actually received during the preceding year from any source for treating Medi-Cal enrollees. Medi-Cal then subtracts that amount from the amount that NEMS is entitled to receive as an FQHC and pays NEMS the difference. The government alleges that NEMS significantly under-reported payments it received from a managed care organization for treating Medi-Cal beneficiaries in order to artificially inflate the payments it received from Medi-Cal.
“As health care costs continue to rise, it is more important than ever that health care providers report accurate information to federal and state health care programs,” said Stuart Delery, Acting Assistant Attorney General for the Justice Department’s Civil Division. “The Department of Justice is committed to cracking down on improper accounting practices such as those alleged in this case, which undermine the integrity of these health care programs and increase the costs of health care for the rest of us.”
“Filing claims that imp roperly inflate reimbursement amounts means there are less funds available for people in need,” said Melinda Haag, U.S. Attorney for the Northern District of California. “My office views the actions this defendant allegedly committed as a serious breach of the responsibilities healthcare organizations owe to people in need of medical care and also to the taxpayers who fund these programs. We are committed to doing everything in our power to protect the integrity of the healthcare system.”
The whistleblower action, captioned United States ex rel. Trinh v. North East Medical Services, Inc. Civil Action No. 10-1904 (N.D. Cal.), was filed under the qui tam provisions of the False Claims Act. The False Claims Act allows for private persons to file actions to provide the government information about wrongdoing. Under the statute, if it is established that a person has submitted or caused others to submit false or fraudulent claims to the United States, the government can recover treble damages and $5,500 to $11,000 for each false or fraudulent claim filed. If the government is successful in resolving or litigating its claims, the whistleblower who initiated the action can receive a share of between 15 percent to 25 percent of the amount recovered.
The whistleblower action contained additional allegations. However, the United States is intervening only with regard to allegations that NEMS failed to report certain income on annual reports to Medi-Cal.
The investigation was conducted by the Civil Division of the U.S. Department of Justice, the U.S. Attorney’s Office for the Northern District of California, the Office of Inspector General of the Department of Health and Human Services, and the California Attorney General’s Office.
The claims asserted in the complaint against NEMS are allegations only, and there has been no determination of liability.