A Long Beach-based health plan seeking new contracts to serve 54,000 Southern California low-income seniors has set aside $125 million to resolve claims by state and federal authorities that it overbilled Medi-Cal and Medicare.
In applications submitted in February to California’s Medi-Cal agency, the SCAN Health Plan detailed the course of civil and criminal investigations by the California attorney general’s office, saying they could lead to “substantial financial payments.” Federal authorities from the Health and Human Services and Justice departments also are investigating, the reports say.
Investigators are examining whether SCAN drew funds from both health care programs to care for the same pool of patients and intentionally hid the matter from overseers. At worst, the cases could conclude with the company banned from serving Medi-Cal or Medicare patients, the document says.
SCAN submitted applications to serve 36,000 seniors in Los Angeles County, 8,000 in San Diego County and 5,000 each in San Bernardino and Riverside counties. Medi-Cal is reviewing multiple bids from firms willing to work in each of those counties to coordinate care for patients, mostly seniors with low incomes, who receive both Medi-Cal and Medicare coverage.
Currently, the SCAN Health Plan, founded in 1977, runs a Medicare Advantage plan serving 130,000 people in California and Arizona. The firm says its members report very high satisfaction rates, and the Centers for Medicare & Medicaid Services recently awarded it 4 out of a possible 5 stars for its work in California.
California Watch reported in August that SCAN was under investigation after state Controller John Chiang audited the plan and said it “fleeced the state” out of a possible $339 million. In a financial evaluation [PDF], Medi-Cal confirmed that the health plan drew profit margins of 80 percent or more, in contrast to rates of 4 to 5 percent earned by similar plans.
The Medi-Cal Fraud Control Unit described the case in an annual report to federal funders, saying it involves “double billing.”
“It is alleged that SCAN intentionally withheld relevant cost report information from the government to hide the enormous profits SCAN was making,” the April 2011 report says.
The case “has the potential for obtaining one of the largest” financial recoveries as a result of a false-claims lawsuit by the attorney general’s Medi-Cal Fraud Control Unit, the report says. The attorney general’s office declined to comment further.
In a statement, SCAN spokesman Alan Maltun said: “Substantial progress has been made in working through these issues with the State and Federal governments, and we believe we will be able to resolve their concerns in a manner that is fair to all parties.”
SCAN disclosed to Medi-Cal authorities in February that it received a subpoena for documents in March 2010 from the Department of Health and Human Services inspector general’s office, which reports to the U.S. Department of Justice.
The company learned that the state attorney general’s Medi-Cal fraud team also was conducting civil and criminal investigations of payments to the company from 2001 to 2009.
The disclosure says SCAN learned that federal authorities also are examining whether it earned excess payments by submitting improper ratings that describe how sick members are. Medicare Advantage plans, like SCAN, are paid a per-patient rate that is based on the plan’s severity-of-illness ratings.
SCAN said that when its board of directors learned of the allegations, it appointed a special committee to lead an internal investigation. The report says the group “has not received any evidence suggesting intentional misconduct” by anyone at the company.
The company says it offered to pay $125 million to resolve claims, but government authorities said a counteroffer would be forthcoming. SCAN concluded that it “cannot predict whether or when a settlement will occur or whether criminal or civil court proceedings might be initiated.”
In applying to serve additional seniors, SCAN said its mission is to find “innovative ways to enhance our members’ ability to manage their health and control where and how they live.”
The managed care company says 98 percent of its “nursing facility level of care” seniors in California are able to live at home, rather than in institutions. It said its members’ rate of readmissions into hospitals is 24 percent lower than expected.
SCAN said that in 2011, 97 percent of its “dual eligible” – or Medi-Cal and Medicare-qualified – members were satisfied with the company.
The state Department of Health Care Services is reviewing applications from firms bidding to provide managed care services to seniors who tend to have many chronic conditions and receive care from a variety of providers.
The state is seeking to improve care and save money by giving care providers incentives to focus on healthy living and proactive management of chronic conditions. The move is meant to part ways with a system in which health providers are paid a premium for giving emergency care and performing invasive procedures.
By Michael W. Kahn | ECT Staff WriterPublished: March 27th, 2012
A new insurance industry report confirms what electric cooperatives, phone companies, breweries and many individuals have been all too aware of: Metal theft is on the rise.
The National Insurance Crime Bureau tallied figures for 2009 through 2011. During those three years, 25,083 insurance claims were filed for stolen aluminum, brass, bronze or copper. A whopping 96 percent were for copper theft.
The number of claims jumped 81 percent from an earlier NICB report covering 2006 through 2008. NICB is a not-for-profit organization that works to detect and prevent insurance fraud.
“The thieves can endanger the safety of themselves and those in the surrounding community, and weaken the infrastructure vital to our everyday lives,” NICB wrote in its report.
“Unoccupied buildings have exploded due to gas lines being stolen, stretches of highway have been left dark after thieves stole wiring from utility poles, and tornado warning sirens have been rendered inoperable due to wiring being stolen.”
Ohio leads the nation with 2,398 metal theft claims. Texas is hot on its heels with 2,023. The top five is rounded out by Georgia (1,481), California (1,348) and Illinois (1,284).
On the other end of the spectrum, Alaska saw just three claims in three years, while Wyoming had four, and North Dakota and South Dakota had five each.
Among major metropolitan areas, Chicago had 963 metal theft claims to lead the nation, followed by New York (921), Atlanta (823), Dallas-Fort Worth (674) and Detroit (587).
NICB validated what electric co-ops and other utilities have long been saying: that the value of the stolen copper is often dwarfed by the damage tally.
“Frequently the damage caused by such thefts is several times the value of the metal stolen,” the report said, “leaving the victims with hefty repair costs which are often passed on to insurance companies.”
New York Private Investigators, ICORP Investigations helps stop Fraud in Workmen’s Compensation Cases.
HOLBROOK, NY, October 10, 2009 /24-7PressRelease/ — New York Private Investigators, ICORP Investigations helps many small business owners and corporations fight against Workman’s Compensation Fraud, Personal Injury and Liability Claims.
According to experts, 16,000 workplace injuries happen daily in the United States and approximately, 192 million are covered under workers’ compensation.
Although it is considered illegal for an employee to falsely claim benefits from workers’ compensation, there are countless people who are never brought to justice.
How does an employer know for sure that their employees who are currently collecting workman’s compensation benefits are being truthful? Unfortunately, many employers are unable to answer that question.
Many companies hire a professional private investigation team to investigate employees who are on disability in order to determine the truth.
Statistics show that companies who hire private investigators have a higher success rating than companies who do not when it comes to catching untruthful employees in the act.
ICORP Investigations Saves Business Owners Thousands of Dollars
Companies across the country have hired private investigators to use surveillance technology such as videotape. Many surveillance videos have exposed employees involved in sports, yard work, heavy lifting and other strenuous activity.
Fraudulent insurance claims cost business owners hundreds and thousands of dollars annually. The astronomical costs of worker’s compensation have resulted in several business owners applying for bankruptcy.
The Private investigation team at ICORP Investigations has solved many cases involving workers compensation. This has saved Long Island business owners a considerable amount of money in workers’ compensation costs. ICORP keeps their clients updated 24/7 via telephone and email. This is made possible through their web-based system.
About ICORP Investigations.
The private investigation team at ICORP Investigationshas combined years of experience in surveillance and has successfully conducted surveillance on Workman’s Compensation Claims including Personal Injury and Liability Claims. Their private investigative team thoroughly verifies whether or not insurance claimants are being honest about their disabilities.
Unlike many investigative agencies that only spy on a claimant at their place of residence or at work, ICORP is completely hands-on when it comes to investigating each assignment.
ICORP Investigations has developed a reputation for being persistent with their video documentation. When business owners challenge false claims, ICORP is considered number one.
To find out further information about ICORP Investigations workman’s compensation investigation service including personal injury and liability claims long onto: http://www.newyorkprivateinvestigatorssite.com
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