|June 20, 2017
Contact: Whitney Ray
Phone: (850) 245-0150
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TALLAHASSEE, Fla.—Attorney General Pam Bondi and 20 other states joined the federal government in a settlement with CareCore National, LLC, resolving allegations that the company caused false claims to be submitted to government health care programs. CareCore provides utilization management services that determines whether services are medically necessary. CareCore allegedly instituted a scheme to auto-approve hundreds of radiology service requests on a daily basis, deeming the diagnostic services as reasonable and medically necessary, even though appropriate medical personnel did not evaluate the cases.
CareCore developed and implemented an auto-approval program in an effort to keep up with the volume of preauthorization requests for services and to allegedly avoid a contractual monetary penalty for untimely reviews. The program improperly approved more than 200,000 prior authorization requests that CareCore initially determined could not be approved. This practice caused millions of dollars in false or fraudulent claims to be submitted to and reimbursed by the states’ Medicaid programs.
As part of the settlement, CareCore will pay the federal government $54 million, including $18 million that will go to the 21 state Medicaid programs. Florida will receive $1.4 million in restitution and other recoveries for the Medicaid program.
The settlement resolves allegations asserted in a qui tam action brought by a whistleblower in the U.S. District Court for the Southern District of New York. On behalf of the states, a National Association of Medicaid Fraud Control Units team participated in the investigation and conducted the settlement negotiations with CareCore. The team includes representatives of the Florida, Georgia, New York and Ohio Medicaid Fraud Control Units. The states coordinated their investigation in conjunction with the U.S. Attorney’s Office for the Southern District of New York.
To view a copy of the settlement, click here.
The Florida Attorney General's Medicaid Fraud Control Unit investigates and prosecutes providers that intentionally defraud the state's Medicaid program through fraudulent billing practices. Medicaid fraud essentially steals from Florida's taxpayers. From Jan. 2011 to the present, Attorney General Bondi's MFCU has obtained more than $700 million in settlements and judgments. Additionally, the MFCU investigates allegations of patient abuse, neglect, and exploitation in facilities receiving payments under the Medicaid program. In 2017, the MFCU was awarded the Inspector General's Award for Excellence in Fighting Fraud, Waste and Abuse. This award is presented annually to the nation’s top MFCU by the U.S. Department of Health and Human Services Office of Inspector General.