California County Organized Health System and Three Health Care Providers Agree to Pay $68 Million for Alleged False Claims to California’s Medicaid Program

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; End of
Translation 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.

“Medicaid expansion funds must be used for their intended purpose of providing health care services to low-income individuals,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “When health care systems and providers knowingly misuse Medicaid funds, they will be held accountable.”

“These historic settlements demonstrate our steadfast efforts to eradicate fraud involving Medicaid Adult Expansion,” said U.S. Attorney Martin Estrada for the Central District of California. “Health care systems and providers are on notice that the False Claims Act provides us with a powerful tool to ensure that taxpayer-funded health care programs are used for patient care, and not for furtive financial gain.”

“Federal health care programs are an important resource for millions of Americans to receive medical care,” said Special Agent in Charge Timothy B. DeFrancesca of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG will continue to ensure that federal health care funds are used as intended and protected from fraud, waste, and abuse.”

“Medi-Cal is a lifeline that provides access to free or affordable healthcare services for millions of Californians and their families,” said California Attorney General Rob Bonta. “When any healthcare provider or agency defrauds the program, they break the public’s trust and put their own bottom line before the patients who count on them for honest, quality care and services. I am grateful to the Justice Department for its extensive efforts throughout the course of this investigation. The California Department of Justice and our law enforcement partners will continue to hold accountable those who defraud the Medi-Cal program, and protect those it serves.”

The civil settlements include the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Julio Bordas, CenCal’s former medical director. Under the act, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States and State of California ex rel. Bordas v. CenCal Health, Cottage Health System, Sansum Santa Barbara Clinic, Inc., Community Health Center of the Central Coast, et al. Mr. Bordas will receive approximately $12.56 million as his share of the federal recovery.

The United States previously settled similar allegations against Dignity Health and Twin Cities Community Hospital and Sierra Vista Regional Medical Center, two subsidiaries of Tenet Healthcare Corporation, relating to payments they received from CenCal under the Adult Expansion program.

The partial resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Central District of California, and the California Department of Justice, with assistance from HHS-OIG and DHCS.

The investigation of this matter illustrates the government’s emphasis on combating healthcare 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 HHS at 800-HHS-TIPS (800-447-8477).

Trial Attorneys Mary Beth Hickcox-Howard and Tiffany L. Ho of the Civil Division’s Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney Jack D. Ross for the Central District of California handled this case.

The claims resolved by the settlements are allegations only and there has been no determination of liability.