“The U.S. Department of Justice has announced Tampa, Fla.-based WellCare Health Plan will pay $137.5 million to the federal government and nine states to settle four lawsuits alleging the payor violated the False Claims Act.
The suits claim WellCare committed a number of schemes to submit false claims to Medicare and Medicaid programs. Allegations include WellCare inflating the amount it claimed to spend on medical care, knowingly retaining overpayments it received from Florida Medicaid for infant care and falsifying data to misrepresent patient conditions and treatments.
The $137.5 million settlement will be divided among the federal government and nine states: Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Missouri, New York and Ohio. Sean Hellein, a financial analyst formerly employed by WellCare whose qui tam complaint initiated the federal investigation, will receive approximately $20.75 million.
Recently, in a separate ongoing case:
United States District Court of New Jersey denied UnitedHealth’s (UHC) motion, in its entirety as to all claims, to dismiss the providers’ ERISA class action alleging that UHC’s wrongful overpayment recoupment is in violation of federal law. The insurance practice of overpayment recoupment has been and is becoming a larger legal and financial challenge for health plans, healthcare providers and patients to overcome. Almost all health care providers have been affected by an overpayment dispute over the past few years and according to industry estimates, more than 50% of the $2.6 trillion in annual US healthcare expenditure is subject to overpayment dispute.
What does this mean to overpayment request by payors?
In accordance with recent developments, Avym Announces 2012 Free Webinars And Plan Assets Recovery Programs To Assist Self-Insured Health Plans Recover Hundreds Of Millions Of Dollars In Plan Assets From Successful TPA’s Overpayment Recovery. More Than 60% Of TPA Recovered Money Originated From Self-Insured Plans And Should Be Returned To Self-Insured Health Plans Under New DOL Contributory Plans Criminal Project.