DOJ Sues Health Plans and Their Alliance for Concealing Overpayments for Military Managed Care Program
Crime
The USFHP program is one of the healthcare options available to military personnel, retirees and their families. Six health plans are eligible to participate in this program, each of which is a defendant in the government’s complaint: Brighton Marine Health Center, CHRISTUS Health Services, Johns Hopkins Medical Services Corporation, Martin’s Point Health Care, Pacific Medical Center and St. Vincent’s Catholic Medical Centers of New York.
Through the USFHP program, the DOD pays the plans capitated rates to provide healthcare services to their enrollees. According to the complaint, in June 2012, the plans learned of calculation errors that had inflated the rates they had been paid in prior years. Nevertheless, the plans took steps to conceal the existence of the overpayments from the government and continued to submit invoices at the inflated payment rates. The complaint alleges that during discussions about rates for the subsequent year, some of the plans even asked the government to continue paying them at the prior, inflated rates even though, by that time, those plans knew the rates were inflated by the errors.
The United States filed its complaint in a lawsuit originally brought under the qui tam or whistleblower provisions of the False Claims Act by Jane Rollinson and Daniel Gregorie in the District of Maine. From 2007 to 2015, Rollinson worked at Martin’s Point Health Care, including as its Interim Chief Financial Officer.
Gregorie was a consultant to the CEO and Board of Martin’s Point Health Care and later served on its Board of Trustees. The False Claims Act permits a private party to file an action on behalf of the United States and receive a portion of any recovery. The United States has the ability to intervene in such lawsuits, as it has in this case. The qui tam case is captioned United States ex rel. Rollinson v. Martin’s Point Health Care Inc., No. 2:16-cv-00447-NT.
The United States entered into a settlement agreement with Kennell and Associates Inc., a research and consulting firm located in Falls Church, Virginia, that provides actuarial consulting services to the Defense Health Agency (DHA) in connection with the USFHP program.
The settlement resolves allegations that Kennell & Associates failed to notify DHA about errors in executing the rate-setting methodology that caused the USFHP rates to be overstated and their impact on DHA’s payments made to the plans. Under the terms of the settlement agreement, Kennell & Associates has agreed to pay the United States $779,951, plus interest, as well as contingent payments based on its annual contract revenue and cash reserves through the year 2025. The settlement amount is based on Kennell and Associates’ ability to pay.
The Civil Division’s Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the District of Maine investigated the case, with assistance from DHA.
Attorneys Diana Cieslak, Evan Ballan and Amy Kossak of the Civil Division’s Fraud Section and Assistant U.S. Attorneys Andrew Lizotte and Sheila Sawyer for the District of Maine are handling this case.
The United States’ intervention in this matter illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).