August 23, 2022. The United States Department of Justice settled three cases against a California county organized health system and three healthcare providers for alleged submission of false claims to California’s Medicaid program (Medi-Cal). Under the terms of the settlements, the county organized health system (COHS), an integrated health care system, a non-profit hospital system, and another non-profit healthcare organization paid a combined total of approximately $70 million. The former controller and former director of member services of the COHS, Gold Coast Health Plan, blew the whistle on the organization’s practices. Under the qui tam provision of the False Claims Act, which allows private citizens to sue on behalf of the government, the whistleblowers are entitled to a share of the government’s recovery. They also made claims under California’s state False Claims Act (CFCA). For reporting Medicaid fraud, the whistleblowers, or relators, will receive 18.5 percent of the federal government’s recovery and 24% of California’s recovery.
Ventura County Medi-Cal Managed Care Commission d/b/a Gold Coast Health Plan manages the “provision of health care services under California’s Medicaid program (Medi-Cal) in Ventura County, California.” The Affordable Care Act permitted states to expand Medicaid to cover “adults with incomes up to 138% of the Federal Poverty Level […] and provided states with an enhanced federal matching rate (FMAP) for their expansion populations.”...
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