County health system in California settles fraud allegations for $68 million

by Ben Vernia | June 30th, 2023

On June 29, the Department of Justice announced that a California County health system has agreed to pay $68 million to settle a whistleblower’s allegations of fraud. According to DOJ’s press release:

Santa Barbara San Luis Obispo Regional Health Authority, dba CenCal Health (CenCal), a county organized health system (COHS) that contracts to arrange for the provision of health care services under California’s Medicaid program (Medi-Cal) in Santa Barbara County and San Luis Obispo County, California; Cottage Health System (Cottage), a not-for-profit hospital network operating in Santa Barbara County; Sansum Clinic (Sansum), a non-profit outpatient clinic operating in Santa Barbara County; and Community Health Centers of the Central Coast (CHC), a non-profit community health center operating in Santa Barbara and San Luis Obispo Counties, have agreed to pay a total of $68 million to resolve allegations that they violated the False Claims Act and the California False Claims Act by submitting or causing the submission of false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).

Pursuant to the ACA, beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured “Adult Expansion” population – adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level. The federal government fully funded the expansion coverage for the first three years of the program. Under contracts with California’s Department of Health Care Services (DHCS), if CenCal did not spend at least 85% of the funds it received for the Adult Expansion population on “allowed medical expenses,” CenCal was required to pay back to the state the difference between 85% and what it actually spent. California, in turn, was required to return that amount to the federal government.

The four settlements resolve allegations that CenCal, Cottage, Sansum, and CHC knowingly submitted or caused the submission of false claims to Medi-Cal for “Enhanced Services” that were purportedly provided to Adult Expansion Medi-Cal members: by Cottage between Jan. 1, 2014 and June 30, 2016; by Sansum and CHC between Jan. 1, 2015 and June 30, 2016; and by certain other healthcare providers between Jan. 1, 2014 and June 30, 2016. The United States and California alleged that the payments were not “allowed medical expenses” permissible under the contract between DHCS and CenCal; were pre-determined amounts that did not reflect the fair market value of any Enhanced Services provided; and/or the Enhanced Services were duplicative of services already required to be rendered. The United States and California further alleged that the payments were unlawful gifts of public funds in violation of the California Constitution.

As a result of the settlements, CenCal will pay $49.5 million, Cottage will pay $9 million, Sansum will pay $4.5 million, and CHC will pay $3.15 million to the United States. In addition, California will receive payments totaling $1.85 million.

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The relator, a former medical director of the defendant, will receive $12.56 million of the settlement (an 18.4% relator’s share).

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