Whistleblowers receive more than $12 million for protecting Medicaid
Two whistleblowers will share a $12,750,000 award for exposing a Florida not-for-profit health insurance organization that allegedly improperly shifted payment claims to the Medicaid program rather than pay them itself.
The story involves the Florida Birth-Related Neurological Injury Compensation Association (NICA) and the Florida Birth-Related Neurological Injury Compensation Plan. NICA, a not-for-profit entity, was created by the Florida state legislature in 1988 to stabilize and reduce malpractice insurance premiums for obstetrician medical services in Florida. The Plan provides compensation, irrespective of fault, for certain birth-related neurological injuries. The Association administers the Plan. The Plan reimburses qualified claimants for “medically necessary and reasonable” expenses resulting from birth-related neurological injuries.
In 2019, whistleblowers Veronica N. Arven and Theodore Arven III filed and pursued a federal lawsuit against the Plan and Association, alleging that NICA had violated the federal False Claims Act by declaring itself as “payer of last resort” and causing its Plan participants to submit false payment claims to Medicaid. They also alleged the Plan and Association avoided obligations to repay Medicaid for Plan participants’ medical costs prior to acceptance into the Plan.
The “qui tam” or whistleblower provisions of the False Claims Act let private persons file a lawsuit on behalf of the United States and receive a portion of any recovery.
The alleged conduct occurred from April 25, 2013, through August 30, 2021. Medicaid is a joint federal-state health program that provides coverage and benefits to low-income and disabled individuals.
Although the United States did not intervene in the Arvens’ case, the feds continued to investigate the whistleblowers’ allegations, and provided substantial assistance to the whistleblowers in court. Based on its review of their lawsuit and its own investigation, the United States contends it has certain civil claims against NICA arising from its alleged conduct.
On Nov. 14, 2022, the U.S. Department of Justice announced that NICA and its Plan have agreed to pay $51 million to resolve the Arvens’ allegations that NICA and the Association violated the False Claims Act, without admitting any wrongdoing.
Veronica N. Arven and the estate of Theodore Arven III will receive $12,750,000 as their share of the recovery in this case. NICA also agreed to pay the whistleblowers’ legal counsel an agreed sum for expenses and attorneys’ fees and costs arising from the filing of the lawsuit. Read the settlement agreement here.
“Health care plans may not shift the payment of claims to federally funded programs like Medicaid,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division, in a statement regarding the settlement. “Today’s settlement demonstrates our continuing commitment to ensuring that federal health care dollars are spent appropriately.”
“When Medicaid is improperly billed for services that should be covered by other funding sources, the integrity of this safety net program is undermined,” added Special Agent in Charge Omar Pérez Aybar of the Department of Health and Human Services, Office of Inspector General (HHS-OIG), in a statement. “HHS-OIG will continue to investigate such schemes to protect federal health care programs and those served by them.”
The Justice Department’s healthcare fraud unit’s 80 prosecutors focus solely on prosecuting complex healthcare fraud matters and cases involving the illegal prescription, distribution, and diversion of opioids. In one such case, the Justice Department in July 2022 announced criminal charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment schemes.
Contact Ethic Alliance at info@ethicalliance.com
Related link: https://www.justice.gov/opa/pr/florida-birth-related-neurological-injury-compensation-plan-and-association-pay-51-million