Medicaid HMOs under scrutiny

By Jim Saunders and Carol Gentry
7/21/2010 © Health News Florida

Federal prosecutors in Tampa are reportedly checking whether Medicaid HMOs other than WellCare Health Plans submitted less-than-honest claims in past years.

It is not clear how serious or broad the inquiry is; only one person has confirmed that he was questioned, and the U.S. Attorney’s Office declines to discuss it.

But this report comes after recent independent audits of eight Florida Medicaid HMOs besides WellCare found that all were overpaid in 2006 and owed refunds to the state, according to documents provided by the Agency for Health Care Administration after a public records request. AHCA says another round of audits is planned for October. 

The audits were all done separately, so none of the documents calls attention to the extraordinary coincidence that all eight submitted reports asking for more money than they were due. The auditors offer no conclusions about whether the discrepancies were due to errors or wrongdoing.

The audit company, Buttner Hammock in Jacksonville, referred questions to AHCA, which in turn referred questions to the U.S. Attorney’s Office. That office said in an e-mail that it can’t discuss an ongoing investigation.

The only person who has been willing to venture an opinion is the chief whistleblower against WellCare, financial analyst Sean Hellein.

In his complaint, unsealed late last month, Hellein said that although the Medicaid HMOs compete for business, “they also cooperate with each other by consciously making the same false claims against Florida Medicaid” to reduce the possibility of detection.

Each uses a different technique for hiding the overcharges to make it harder for the state to catch on, Hellein said in a phone interview Tuesday. 

Hellein’s False Claims Act complaint names at least five HMO companies other than WellCare, but neither the Department of Justice nor the state Attorney General’s Office has given any indication that they were looking at others.

WellCare, based in Tampa, paid $80 million last year to defer criminal prosecution on charges of Medicaid fraud and it still faces undetermined civil fines. After the company floated a suggested settlement of $137.5 million a few weeks ago, Hellein’s attorney Barry Cohen declared it inadequate and vowed to contest it. 
 
The hint that prosecutors may be looking beyond WellCare came with a tip to Health News Florida that Bob Sharpe, director of the Florida Council of Community Mental Health Centers, was questioned about other companies by someone from the Tampa U.S. Attorney’s Office about two weeks ago. Contacted by e-mail this week, Sharpe confirmed it but declined to provide any details.

Meanwhile, a public records request produced the audits for AHCA that were performed late last year and early this year. Following the audits, the eight HMOs were ordered to refund nearly $6.8 million to the state.

The HMOs were required by their contracts to spend at least 80 percent of the mental-health premiums they received from Medicaid on patient care. If they didn’t they were supposed to refund the money.
The auditors found the HMOs missed the 80-percent mark by a wide margin: The closest that any of them came was 66 percent.

In the audits, Amerigroup was the top recipient of state funds for mental health, receiving nearly $15.7 million. The company claimed in its state filing that it spent about $12.1 million on claims, but auditors said they could account for expenses of only $10.4 million.

Amerigroup was ordered to repay $2.15 million; AHCA officials said last week that the company had paid in full. A call to the company spokeswoman Tuesday was not returned.

Spending ratios by the audited plans ranged from 66 percent for Humana to 19 percent for Citrus, which has appealed, saying its ratio was actually 49 percent. It paid a $373,815 refund last year.

Currently, Florida Medicaid has the 80-percent spending requirement only for behavioral health, but some legislators have discussed extending it to all medical services.

--Jim Saunders is Health News Florida's Capitol bureau chief. Editor Carol Gentry can be reached at 727-410-3266 or by e-mail.