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Iowa Total Health Care Suffering from their Charges

The investigation of Des Moines Register Iowas’ charges suffered for a controversial privatized Medicaid system and charged at least $23.6 million in penalties in more than a dozen states because of its mismanagement. Iowa Total Care was sub a subsidiary of Centene. The health care provider got 14 points on its evaluation and was awarded a stated Medicaid contract in May. Iowa Total Care got the spot for managing Iowa’s annual $4.8 billion Medicaid program.

AmeriHealth Caritas was suffering from its net worth, and Iowa Total Care took advantage of their situation. Another side of the history that health care providers released from the federal data is that Iowa’s unemployment rises consecutively. Gov. Kim Reynolds, responding complaints of labor shortage and cut unemployment benefits for tens of thousands of workers to spur a return to work.

However, after the situation in just a month, this was the most considerable growth in Iowa. Compensations increased to 7,400 jobs and rising to 1.5 million.In June, the labor force increased by 6,400 to about 1.7 million, and Iowa has rejoined the labor force, which means they are actively looking for a job, and the unemployment rate continued to rise because of them. Back on the actual track, Iowa’s Total care criticized how they managed their Company. It was stated by Sen. Pam Jochum, “If history teaches us anything, then this is an indication that we’re in more trouble,” Centene companies and subsidiaries face a lot of fines. Data records show that in 2013, the companies reduced pay in more than a dozen states and cost the Company $100,000 and more.

Based on the research, it shows here the Dozens of the sanctions were for non-compliance with federal or state Medicaid contracts or rules, including

·Centene Subsidiaries are failing to pay medical claims promptly.

·Inadequate the medical networks that provide poor and older adults access to doctors. The Company is just earning money for the sake of its CEO.

·It was losing the future of their insurer and for failures in meeting goals such as child health check-ups, which requires improving health and reducing long-term medical costs.

Centene starts the year facing the federal lawsuit in January alleges the St. Louis-based Company has failed to provide adequate access to doctors in at least 15 states. In addition, Company approved the settlement in 2016 over challenges to its business practices. Iowa Total Care reported spending $23.6 million because of the Company’s penalty and loss of incentives to its subsidiaries as part of its competitive bid requirement. The Company spent $7.5 million for Kentucky to settle a breach of contract lawsuit alleging it wrongfully terminated its Medicaid agreement and cost the state $28 million to $40 million.

Centene also agreed to give$4.5 million to settle a lawsuit alleging that it had failed to provide overtime pay for its nurses in multiple states, including Illinois, Ohio, Missouri, and more.For example, Centene’s Ohio subsidiary, Buckeye Community Health Plan, was subject to four increasingly more significant individual non-compliance sanctions —each between $1 million to $4 million —for failing to meet minimum performance standards for four consecutive years beginning in 2013.To continue the Medicaid health program, Iowa has picked one of the country’s largest healthcare companies. According to the Iowa Department of Human Services, the Company will replace Ameri Health Caritas at the beginning of 2019.

The state company provided no details on why it gave a contract to Centene’s subsidiary, Iowa Total Care, but not to a second bidder, trusted health plan.The other companies decided to leave their state last fall by losing hundreds of millions of dollars covering care for more than 200,000 poor or disabled Iowans on Medicaid. After the termination, AmeriHealth’s opened the door for Iowa Total Care by being rejected and suffering the Company’s rocky situation with the state and describing as haphazard, inconsistent, inaccurate, arbitrary, and capricious.

Iowa Total Care is part of a group of three losing bidders that overcome the challenge of the state’s decision. Iowa Total Care’s 2015 complaints ultimately were determined valid, specifically regarding a bid from WellCare, one of four companies initially awarded a contract. After court testimony, Iowa decided to adopt an administrative judge recommendation to terminate WellCare’s agreement in 2015, including former state representatives-turned WellCare operatives Christopher Rants and Schulte—engaged in uncovering the identities of the committee members reviewing the bids.

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Insured Misled by Ambetter of Centene

Ambetter misled many policyholders into thinking that their physicians were in-network. The policyholders complained that the Ambetter website keeps rejecting their insurance. Despite Ambetters claims and provider list shows, zero doctors, offices, or hospital accepts the insurance. Ambetter policyholders are also reporting that they have difficulty finding medical providers that accept Ambetter insurance.

Centene is one of the country’s largest Health Insurance Marketplace providers. Under the Affordable Care Act, its Ambetter suite of insurance products is available to Illinois consumers as an alternative. Ambetter plans are promoted with the concept that excellent healthcare is best given locally, and the company provides a long list of in-network doctors who allegedly accept Ambetter insurance.

However, many customers in Ambetter-covered areas have discovered after purchasing for insurance that the universe of local physicians and health care providers who accept Ambetter is far smaller than advertised. Customers have claimed that Centene falsifies their list of in-network Ambetter physicians, leading them to believe that they can continue seeing their regular doctor with Ambetter health insurance when they can’t.

When Congress passed the Affordable Care Act (ACA), it mandated that every state set up an exchange to buy individual health insurance premiums. The Affordable Care Act also requires plans to maintain a suitable network of providers in quantity and type.

Ambetter’s plans

While all of Ambetter’s plans include adequate preventative care coverage and some vision and dental benefits, it’s challenging to get a complete picture of its various plans:

The     website makes it tough to access information like the annual maximum     out-of-pocket limit and co-pays;

The     cost of a plan and the amount of a deductible varies by program;

Its     location determines the availability of a product;

The     number of persons on the program and other demographic variables, such as     age, impact the cost.

 Ambetter has received an overwhelming number of one-star evaluations. In these Ambetter reviews, customers complain about having trouble getting medication and treatments approved for coverage, resolving claims, being frustrated with customer support, and locating an in-network provider.

Other complaints on Ambetter include:

Waiting     for long hours in hospitals and end up not being able to use Ambetter     insurance once admitted;

Phones     are always disconnected;

Representatives     giving out false information to clients;

Clients     were promised to get a refund that was not fulfilled; and

Clients     complain about their very high deductibles and pay vast amounts of money     for monthly premium subscriptions only to receive nothing in return.

 Meanwhile, Burg Simpson is looking into a possible lawsuit against Ambetter on behalf of Ohio clients who have had similar complaints.

Buckeye Health Plan, a subsidiary of the insurance carrier Centene Corporation, offers Ambetter health plans (Ambetter Balanced Care and Ambetter Secure Care) through the Health Insurance Marketplace (Health insurance Exchange). According to the company, the Ambetter product from Centene Corporation has been purchased by nearly 1.5 million people across the country.

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Heritage Health Violations

Heritage Health is a health plan provider. The facility provides a type of medicinal treatments, including professional, natural, and speech therapy. In addition, it provides both short-term and long-term skilled nursing along with respite and hospice care. Heritage health ratings and violations show in health care facilities. The health and welfare in a nursing facility in Illinois are often highly reliant on the nursing home’s ability to check infection range.

It is because viruses tend to be extremely common in both short-term and long-term health care facilities. Sadly, the Heritage health at Springfield nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC represents many nursing home victims who suffer from respiratory infections, urinary infections, soft tissue, and skin infections, all collected while at their facility. May 23, 2012, allegations about spreading infection throughout the facility and affecting most of the people inside the facilities began a grievance investigation upon the facility for their failure to ensure nursing staff remove their soil gloves and wash their hands during dressing change for a resident.

In response to the incident where a licensed practical nurse, LPN, performed a dressing change for the resident. The resident was in isolation with the diagnosis of Clostridium difficile, and it has a pressure ulcer located on the coccyx that requires daily dressing changes. During the disturbance, a member of the nursing staff “pushed the treatment cart into the inside of the doorway of the resident’s room.

The resident was turned on their left side with assistance and was informed by another nursing staff member to "be careful because yesterday [the resident] had diarrhea and it went all over.” After changing the soiled dress, the nursing staff member “did not re-glove or cleanse her hands, cleanse the pressure sore area, applied the new dressing, and then removed her soiled gloves.” July 29, 2009, the second summary statement lacks in a reproach investigation was initiated concerning epidemic limitation where it was determined that “the facility failed to maintain an effective infection control program which controls and prevents the transmission of Clostridium difficile.”

During the interview, the unit manager and the registered nurse “Family member did become ill with Clostridium difficile. She also stated that the resident’s” wife had just come back to visit the residents on the 26th of this month after she was becoming ill the week prior. As an introduction, Heritage confidently introduced their health plan company with kindness, compassion, and honor. Heritage Health cares for seniors throughout the state of Illinois.

At Heritage, we’re not just nursing homes; we are a collection of senior care campuses that extend from independent, assisted living, and supportive living to rehabilitation and skilled nursing care, they stated. With more than 50 locations across the state of Illinois and over 4,000 employees, the senior in your life will receive highly skilled care that is second-to-none, a family atmosphere, and a team of caregivers that work to bring calm and comfort to every day. However, after the tragedy, heritage health care was not the same anymore.

Wesemann was one of the victims of this scenario cause because of being incompetent of Heritage health. According to her lawyer, Wesemann testified terminated her because she refused to follow orders from the facility’s director of nursing. To ‘drop a pill’ or double-dose agitated residents with anti-anxiety medications and refused to delete or omit records of suspicious injuries on residents.

Decision carried payments and benefits and $5 million in the penal reduction for the nurse who worked at the facility for about 19 months. The jury deliberated about two hours before declaring its verdict during an eight-day trial before Judge Robert Travers. In a written statement A. Clay Cox, corporate counsel for Heritage Enterprises, “We at Heritage Enterprises Inc. are deeply disappointed in the verdict delivered in the case of Wesemann.

Heritage Manor-Dwight, LLC. The health system alleged in the lawsuit that the cyber attack’s success resulted from Nuance’s "poor security practices and governance oversight.” It alleges. Nuance became a victim of the NotPetya malware attack as a result of its information security failings. Besides being incompetent in handling healthcare facilities allegations. The company also begins into prolonged prosecution Agreement for the Role in Price-Fixing Scheme.

This over $7 million civil healthcare fraud settlement resolves False Claims Act allegations that Heritage paid and earned remuneration from other drug manufacturers between 2012 and 2015 and was involved in a scheme to raise and fix prices on certain generic drugs artificially. We have provided these drugs to Medicare, Medicaid, the Department of Defense’s TRICARE program recipients, and the Department of Veterans Affairs. These drugs supposedly involved in this system address a wide variety of health circumstances and add hydralazine, used to treat high blood tension, theophylline, handle asthma and other respiratory difficulties, and glyburide used to treat diabetes.

Under the terms of the suspended prosecution agreement, Heritage will pay a $250,000 monetary penalty and evade prosecution if it complies with the terms and conditions of the contract.

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Here's Why Centene Corp. Paid Out Some $216M As ACA Rebates In 2019

Centene Corp. is among the most prominent players in the Affordable Care Act (ACA) market exchange. The company is believed to be drawing a massive chunk of its annual revenues from government-subsidized health insurance. Centene is consistently exploding in the past years, and in large part due to the ACA, but it seemed that the insurer is not entirely living up to the ideals of Obamacare.

According to the Kaiser Family Foundation, the ACA rules had determined a total of $216 million as rebates in 2019 for Centene. The amount was spread out where the company has a business presence. Like in Georgia, the company had an ACA rebate obligation of nearly $60 million in the same year.

Now the story behind these ACA rebates is interesting. It indicates that a company failed to meet the specific requirements set by the law for insurance companies that are earning big from subsidized health plans. The government acknowledges that insurers like Centene are making a killing in the ACA exchange, and these firms are expected to give back.

Centene Pays Rebates For Missing The Target

So in the year mentioned, the government had calculated a massive rebate obligation for Centene because the company failed to meet the appropriate threshold set by the ACA. Specifically, Centene must spend a portion of its ACA revenues in a given period, and failure to do so will lead to a form of penalty.

The law has a Medical Loss Ratio component that requires insurance providers to spend part of their ACA revenues to fund health care claims or sponsor quality improvement activities. Companies must allocate at least 80% of revenues from premiums for such undertaking.

Yet in the case of Centene, the government labeled the company as part of the biggies, so the minimum set for the insurer is 85%. In 2019, Centene fell short of the mark set by the ACA, and consequently, colossal rebate obligations hit the company a.

For perspective on how Centene bungled in the act of giving back, the company’s ACA rebate obligations in Georgia were nearly the total of the 2019 rebates. The ACA had totaled the rebates for the year at $65 million, and $60 million of which Centene must pay out.

The juice of the narrative is this: While most insurance industry players failed to abide by the ACA rule, the data indicated that Centene is the guiltiest of all the culprits. The insurer paid out over $200 million in a year alone, which indicated that following rules is not a priority for Centene.

And the most disturbing part was the suggestion that doing good seemed bothersome for the Fortune 500 company. As the Kaiser Family Foundation report had indicated, Centene had elected to be penalized instead of avoiding the rebates by just following the law.

Centene Behavior Is Not Surprising

In hindsight, how Centene operates its business with the ACA setting was not out of character. Centene CEO Michael Neidorff has been consistent in saying that he is laser-focused on growing the company. Thus, his agenda is to increase profits, and doing charity works is not about to distract him.

Centene is tipped to become a $120-billion company real soon, and Neidorff had already made public his plan to pull $1 billion for the company in the next three years. It should be noted that in advertising his grand vision for Centene, Neidorff always leaves out the sweet parts like saying sorry to the victims of Centene’s ruthless business practice.

In the same way, it seemed clear that Centene’s business model excludes any room for good deeds, or at least acts of kindness.

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Healthcare Workers in Arkansas Granted $9.4M in Insurance Lawsuit

A federal jury in Little Rock awarded more than $9.4 million to an Arkansas-based group of approximately 175 emergency department doctors, nurse practitioners, and physician assistants who an insurance company underpaid for services rendered since 2014.

After a seven-day trial that lasted roughly two weeks and four hours of discussion, the jury awarded Arkansas Health & Wellness Health Plan, a subsidiary of Centene Corp., $9,426,497. It indicates the underpayment of Southeastern Emergency Physicians LLC for emergency services delivered to 12,500 patients protected by the Patient Protection and Affordable Care Act.

When the Affordable Care Act went into effect, the insurance company claimed that a 2011 contract between the physicians’ organization and the insurance company no longer applied. However, a jury of three men and three women unanimously concluded that the contract pertained to a new insurance policy released in 2014. The insurer breached the contract by paying the doctors 10% of ordinary commercial billing rates rather than the required 75%.

Attorney John Zavitsanos of Houston, Texas, said the doctor’s organization “clearly had been abused by this greedy insurance business.” His company recently teamed up with Little Rock’s Wright, Lindsey and Jennings firm’s Judy Simmons, Baxter Drennon, and Michael A. Thompson to represent the doctors and Team Health, which owns Southeastern Physicians and other physician organizations and provides administrative services to them.

Representatives were out of reach

Centene was represented by attorney Steven Cady of the Washington, D.C.-based law firm Williams & Connolly, who declined to comment on the matter but said he would forward a request for comment to the company. Lyn Pruitt of Mitchell, Williams, Selig, Gates, and Woodyard, a local company representing the defendants, did not return a reporter’s call.

When attorneys’ fees and interest are added to the verdict, Zavitsanos estimates it will cost $12 million to $13 million. In Arkansas, Southeastern Physicians is affiliated with seven hospitals.

Zavitsanos explained that insurance companies have a lot of clout with doctors, and as health insurance company profits have surged, physician payment rates have plummeted.

The complaint was filed on Aug. 2, 2017. It was assigned to U.S. District Judge Kristine Baker, who presided over it for nearly three years until June 16, when the Mitchell-Williams firm, the judge’s husband is an attorney, joined the defense, prompting her recusal. It was then assigned to U.S. District Judge Brian Miller, who, citing the case’s age, declined to postpone it and presided over the trial as scheduled.

The doctors’ group claimed at the time that the defendants brought in the Mitchell firm on purpose to force Baker’s recusal, hoping to delay the case and be concerned about her previous rulings refusing to dismiss the case and allowing the plaintiffs to add claims, which they referred to as a judge-shopping gambit. On the other hand, Miller declined to disqualify Mitchell and send the case to Baker, claiming that the defendants have the right to choose their attorneys.

According to a press statement released by the plaintiffs, one of many lawsuits TeamHealth has filed against various insurers across the country to prohibit insurance companies from underpaying ER doctors to keep the money for their own pockets. TeamHealth is attempting to level the playing field for these important doctors who serve several communities yet are underpaid by several immensely profitable insurance corporations.

The plaintiffs cited evidence produced at trial and said that Centene tried to disguise their ownership of the firms and the corporations responsible for paying the doctors.

Arkansas Health & Wellness Health Plan Inc.; Celtic Insurance Co., doing business as Arkansas Health & Wellness; Novasys Health Inc. and Centene Corp. are the defendants in the lawsuit. 

Arkansas Health & Wellness is a part of Celtic Insurance, one of Centene’s subsidiaries.

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Health Net's $215M Settlement Payment Reminds Of Insurer's Deceitful Past

Did Michael Neidorff, Centene’s CEO, made a huge mistake in pushing vigorously for the merger with Health Net in 2016. Going by Health Net’s troubled history, such as the 2007 settlement case worth $215 million, it seemed that Neidorff made an ill-advised move five years ago. Following Centene’s takeover of Health Net, it was revealed later that the corporate marriage was a stumble for Neidorff. 

The CEO later admitted that Health Net had financial liabilities, and his belated act cost Centene $1 billion in stocks wipeout. Had the chief executive bothered to check Health Net’s business practices in the past and followed his instinct, the foul up might have been avoided. 

The record showed that Health Net was problematic – the company mishandled claims, and it was debtridden. Even more damning was an obstruction of justice case decided in 2007, in which the Californiabased company was made to pay a whopping $215 million. Health Net committed a big slip then, and it foretold more blunders to come. Health Net Plotted To Underpay The Insureds The federal case that nearly bled Health Net dry involved two million complainants. A New Jersey judge found the company guilty of tampering with the Ingenix payment database to reduce the cost of claims filed by out-of-network care providers. According to the case record, the system is a standard in the national health insurance, and Health Net tried to manipulate Ingenix to justify its attempt of underpayment. 

The facts of the case showed Health Net was caught and red-handed, and the company opted to settle, and they made the blockbuster payment. Also, the insurer agreed to make business adjustments that would cost another $40 million over the next five years. The incident did establish that Health Net tended to maneuver for financial gains and consequently break the law. The legal case exposed serious flaws in the Ingenix system, and Health Net tried to leverage the situation for its gain. 

As the court noted, the company could have exercised “greater disclosure about the database use” but instead saw it fit to be dishonest. It was a costly mistake, which strangely escaped Neidorff’s eye or the CEO ignored the signs. A Decade Later, Centene Paid $6 Billion To Buy Health Net Health Net went on with its risky business practices after the settlement case, and by 2015, the company’s book had hundreds of million in liabilities. Notwithstanding, Centene’s Neidorff swooped in a year later and dismissed the glaring indicators of Health Net’s misdeeds. 

As the point man for Centene, it was expected Neidorff to not leave any stone unturned before deciding on the merger deal. The settlement case should have been a red flag, and so were Health Net’s heavy debts, but Neidorff signed the agreement for unknown reasons. Shortly after the deal was finalized in 2016, Health Net’s financial problems were exposed, and Centene saw a stunning $1 billion wipeout of its stock’s value. Meanwhile, Neidorff was reportedly $20 million richer in the aftermath of the controversial merger.

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Health Net Was Broke Before Merger Deal But Centene Left Shareholders Clueless

Centene sold its merger with Health Net in 2015 as a mega-deal that will greatly benefit its investors. But upon completion of the takeover in 2016, the truth came out – Health Net had its hands full with financial liabilities, and Centene shareholders ended up massively disappointed. Centene CEO Michael Neidorff pushed for the corporate marriage and insisted that it was a compelling transaction. He promised that earnings per share would jump by at least 20% when the deal is signed and sealed. 

There is no way that shareholders will regret the move. Besides, Neidorff assured that Centene would do its utmost vetting, and top of his priority was for the company to gain from the deal. It will not be cleared unless Health Net hurdles Centene’s rigid financial criteria, vowed the chief executive. Neidorff Fed Nothing But Lies To Shareholders The deal pushed through and completed in March 2016. However, Centene investors got the shock of their lives when the revelation was made in July that the Health Net deal came with liabilities, to the tune of $390 million. 

Contradicting his earlier declarations, Neidorff confirmed the bad news to shareholders, and soon enough, the staggering losses started taking a form. Centene saw its rosy prospects for Health Net collapsed, and the giant insurer watched helplessly as the value of the shares plummeted. Between the middle of 2016 and up to the end of 2019, the company continued bleeding, proving that Neidorff built the whole Health Net takeover on a foundation of lies. 

As facts started dropping in, it soon came out that he knew even before the deal’s finalization that Centene would take a hit but elected not to reverse course. Neidorff’s strange behavior got its explanation when it was revealed that right before Centene admitted Health Net’s financial mess, the CEO sold off his shares. So, while investors absorbed the deal’s negative impact, Neidorff scooped up an estimated $20 million from the stock sale.

 The Rush To Stop Further Damage On Centene By December 2019, Neidorff announced that Centene would take a hit of $500 million due to the delays on a contract agreement in North Carolina. The loss was on top of the $1 billion hit incurred in 2016 due to Neidorff’s misstep in California, which is the disadvantageous move to buy out Health Net. 

In order to stop the damage from further deteriorating, Centene implemented a plan to cut down the company’s expenditures. The most immediate action was the blanket denial or underpayment of certain payment claims. This decision specifically targeted mental treatment centers. Arbitrarily, changes were made to existing policies to justify the non-payment, and Neidorff approved these measures for the financial benefit of Centene. 

In the end, the patients dealing with behavioral issues and substance use found themselves stripped of health insurance. They became casualties to Neidorff’s misfiring tactic. The Centene CEO made a wrong business move and corrected his mistake. In doing so, however, he did not hesitate to let the innocent suffer.

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Health Net Forced To Refund $5M: Case Underscores Insurer’s ‘Bad Faith’ Business

Centene Corp.-owned Health Net has been dealt a blow by the New York’s Department of Financial Services recently. It appears that the sins of the past are fast catching up on the insurance company as the government regulator ordered Health Net to pay claims that were previously denied, and without just cause. The refund covers policy claims from July 1999 to December 2002.

The development serves as a breath of fresh for thousands of more policyholders victimized by Health Net’s dubious business practice. That Health Net walked back from its hardcore stance of paying dueis an encouraging indicator – that the wheel of justice is moving just fine, albeit rather slow. But with persistence, a case could be won and because the truth is on the side of the oppressed.

Health Net Made To Face The Music

The refund directive saw Health Net making amends on policyholders who were denied the benefits of their health plans for years. The total damages amounted to $4.99 million, significant enough to signify how the insurer was carrying out a policy of avoiding its obligations whenever possible.

The case brought to light the wrongdoings that Health Net had committed. Media reports have highlighted that the California company threatened the operations of more than 100 treatment centers in the state by rejecting their payment claims. Making life difficult for these care providers seemed to be the norm for Health Net as the company was fully aware that treatment centers typically take in insured patients.

If these facilities were cut off from their lifeline or payment from insurance providers, then the danger is real that they could be shuttered in no time. For Health Net, this has been the ploy in the past, and it continued even after the 2016 merger with Centene. It was a case of old habits die hard, and it looked like that despite the reprimand from the government, Centene and Health Net do not intend to change their ways.

The Fight Must Go On

It’s only proper then that there should be no let-up in the fight to bring these erring companies to justice. Centene and Health Net’s business practices have one purpose only – to make money at all costs. There is no humanity in what they do, so customers hurt by their ways would do well to band together.

A unified effort against Centene and Health Net will make for a stronger case to defeat these companies, and use the long arm of the law to make them do the right thing. They should be reminded they are in the business of covering for people with medical needs. That means the priority is saving lives and not stock-piling dollars.

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Health Net Earns Ire Of SEC For Restricting Access To Whistleblower Program

The U.S. government provides incentives for former private employees wanting to take advantage of the whistleblower program. It is an open invitation to everyone who can provide valuable information on corporate misdeeds, and it’s illegal to suppress it. Notwithstanding, Health Net tried to skirt around the law. An investigation by the Securities and Exchange Commission (SEC) in August 2016 concluded that the Centene Corp. 

subsidiary directly targeted the regulating agency’s whistleblower program. The government probe found that Health Net’s actions tried to sabotage whistleblowing by forcing departing workers to accept a severance package that specifically prohibits access to the SEC’s financial incentives. According to the investigating body, Health Net essentially omitted this powerful option from employees on the way out. In effect, the California-based insurer violated federal securities law. Unsurprisingly, the erring company did not challenge the findings and accepted the punishment. 

Health Net paid $340,000 for its illegal action. In addition, the company implemented the SEC’s order to adjust its in-house labor rules and regulations. The insurer tried to defy a vital government initiative and paid dearly for its bold actions. How Health Net Attempted To Circumvent Federal Regulations The SEC whistleblower program is a component for the government to check on possible oversteps committed by private companies. It promises a handsome reward to persons willing to reveal corporate wrongdoings. Strangely, Health Net took steps to prevent its former employees from accessing the government program. The company took away the incentive by attaching severance payments and other benefits with an agreement that discourages access to whistleblowing. The move proved a success for Health Net as employees had no choice but to sign on the illegal deal. 

Inevitably, SEC learned of the illicit practice and launched an investigation. Following the SEC probe, the agency issued a cease-and-desist order, which Health Net immediately accepted. The company paid the sum required by the SEC directive, and in exchange, it was given a pass – no need for Health Net to admit wrongdoing. However, the SEC made clear that Health Net must stop its practice of prohibiting employees from applying and taking advantage of the government’s whistleblower program. The government also ordered the insurer to edit the language used on its severance package documents to make clear that whistleblowing is an option always available to everyone. A Tradition Of Bending The Law Health Net behaving like a bad boy is not out of character at all. The company is currently swamped with legal cases that underscored its appalling business practices. 

In California, Health Net arbitrarily denied payment claims or significantly reduced policyholders’ benefits. The surprise move led to a nearly en masse shutdown of mental care treatments in the state. But the truly disappointing part was Health Net’s decision to deny healthcare services to thousands of patients, thus effectively erasing the progress of their recovery from depression and substance abuse.

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Health Insurance Fraud: Why CenteneGATE Exists?

Insurance coverage is an important component of the healthcare system in the United States. Without its protection, many would be cut off from their healthcare providers. It’s the exact case that brought CenteneGATE to life. It is a raging cause that screams hard for justice. CenteneGATE exists because heavyweights in the insurance industry are leveraging loopholes in the system. 

One of these biggies, Centene Corporation, is caught in the middle of claims dispute that involves thousands of mental health patients who badly need immediate care. In order to protect its business interest, Centene moved to deny coverage from these people, essentially leaving them exposed and helpless. Brief Background In 2017, Centene maneuvered to either stop or reduce payments to behavioral health facilities that were identified by the firm as out-of-network providers. 

The action triggered a swift domino effect – more than 1000 facilities operating in California were forced to shut down because their patients have been effectively stripped of insurance coverage. Naturally, chaos ensued and thousands of victims, shocked by their sudden vulnerability, are crying of fraud and demanding justice. At the center of this controversy is Centene CEO Michael Neirdorff. He decides the direction that Centene takes and it’s apparent that for his company to keep making money, thousands will be sacrificed. CenteneGATE is training the spotlight on the wrongdoings that Neirdorff and his company had willfully committed. 

The insurance provider had lured policyholders by promising to cover their healthcare expenses but reneged from that duty. CenteneGATE is a collective effort of victims to correct an injustice, and is going after these heartless fraudsters, which also include Centene subsidiary Health Net. Clash With A Titan Centene is now among the top insurance players in the United States, and CenteneGATE knows its campaign will amount to going against a titan. But the group is not backing down, emboldened by the thought that if it emerges the winner justice will be rightly served. CenteneGATE is anticipating that waging war against a Fortune 500 company is not easy but the movement is betting on the likelihood that many will take up the fight. 

It is now fittingly described as the battle to defeat evil and the hope is that support will come pouring in. To quote one of America’s founding fathers, Benjamin Franklin: “Justice will not be served until those who are unaffected are as outraged as those who are.”

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Georgia Versus Healthcare Providers: Insurance Claims and Allegations

Many health insurance companies are now facing a head-on collision with the state of Georgia and its investigators as lots of complaints and allegations are starting to stack up against them, according to an article report from wabe.com. Some of the health insurance companies named in the article are the following: Anthem Blue Cross Blue Shield (Anthem, Inc.), Ambetter of Peach State, and Humana.

Jim Beck, a Georgia Insurance Commissioner, and his staff compiled all the data from all the complaints that those health insurance companies have received in 2018 alone. Those complaints were filed through the department’s Consumer Services Division.

Complaints Filed By the Other States As Well

 It is only the state of Georgia to file a complaint against multiple health insurance companies. JoAnne Oni, the director of consumer services, has stated that in the article report, although the other states were not named. Oni also added that publicly announcing that the state has filed a complaint is the first time it has ever done so in its history.

According to the report of consumer services, most of the compiled complaint reports filed within their office are mainly focused on different types of insurances, namely automotive, life, and homeowner insurance.

To ensure that each complaint filed through them is handled professionally, each complaint type is handled by different department staff. In that way, Beck and his staff can fulfill their promises of transparency, consumer protection, and fraud protection while still carrying out their work duties.

Health Insurance Complaints

 When it comes to the health insurance complaints filed, there are two distinct complaint categories filed. The first category would be the ratio of the complaints filed on the 2018 premium services offered by the previously mentioned health insurance companies. The second category would be the level of confirmed complaints.

When both categories are ratioed to each other, any ratio that exceeds 1% for any categories would be considered bad. The reason why is that higher numbers will confirm that there would be worse records in the pile of complaints.

However, do take note that the compiled data doesn’t include other health insurance companies that are significantly larger and self-insured. Additionally, the term of confirmed complaint, in this case, means that either a). the insurer committed an error, confirmed by the insurance department, or b). the insurer was in error after either the complaint or the company’s response indicates it.

One of the named health insurance companies, Anthem Blue Cross Blue Shield (Anthem, Inc.) based in Indianapolis, has the largest number of complaints against them. The total number of complaints that the company received is 579, rationing to 1.50%. In that number, 81 complaints were confirmed, which gives it a confirmed complaint ratio of 1.87% (the highest among the others previously mentioned). Due to that, the company took the action to review the data, according to their spokesperson.

The second company to have the most number of complaints would be Ambetter of Peach State. Although the exact number of complaints hasn’t been given, their complaint ratio ranges from 1.31% to 1.81%. Its parent company of Centene declined to give comments about the issue that Ambetter is facing with their complaints filed against them.

Meanwhile, the third company to be mentioned in this article, Humana, had a confirmed complaint ratio of 1.40% to 1.42%. Humana has also declined to give comments in regards to the matter.

Georgia Still Continues to Monitor Other Health Insurance Companies

In order to prevent similar issues from happening again, the Georgia Association of Health Plans said that they will continue to evaluate the data of insurance members. Commissioner Beck and his team will continue to do their job in reviewing data compiled from complaints, especially with possibly new ones that might be filed in their office in the near future.

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Georgia Uncovers a Slew of Valid Complaints Against Health Insurance Providers

 Anthem Blue Cross and Blue Shield, Ambetter of Peach State, and Humana had high consumer complaints last year that the state decided to be legitimate based on the newly revealed numbers. Complaint data for all health insurers in Georgia was recently disclosed by Georgia Insurance Commissioner Jim Beck and his team - the department’s Consumer Services Division handled the complaints.

According to JoAnne Oni, head of consumer services, other states compiled similar statistics, and it was the first time that the Georgia agency has made the information public. Different complaint categories include Automobile, life, and homeowner insurance firms.

Oni stated that department officials investigate each complaint and promise to keep their commitments of transparency, consumer protection, and fraud defense. In a statement, Beck added, “This is just the beginning.”

The information on health insurance complaints is divided into two groups. One is the complaint-to-premium-revenue ratio for the insurer in 2018. The other factor is the number of complaints that have been confirmed. Any percentage greater than 1.00 is deemed negative in both categories, with higher values indicating poorer records. A confirmed complaint means that the insurance department has found that the insurer violated the law or that the complaint and the insurer’s answer show that the insurer made a mistake. The complaint data does not cover self-insured large employer health plans.

Anthem Blue Cross of Indiana is Georgia’s largest health insurer that earned $2.4 billion in premium revenue for its Blue Cross Healthcare Plan of Georgia in 2018. It received the most complaints (579), resulting in an “All Complaints Ratio” of 1.50. A total of 81 complaints were confirmed, resulting in a confirmed ratio of 1.87. An Anthem spokesman said the company was analyzing the data on Tuesday. Total complaint and confirmed complaint ratios for Ambetter of Peach State were 1.81 and 1.31, respectively. Complaint ratios of 1.42 and 1.40 were approved for two Humana health plans.

Both Kentucky-based Humana and Ambetter’s parent firm based in St. Louis, Centene, could not be reached for their comments.

In a statement released, the Georgia Association of Health Plans noted that member insurers are “currently assessing the data.” They are looking forward to collaborating with Commissioner Beck and the insurance department to improve our Georgia consumers’ experience. There are hundreds of organizations on the complaint list, ranging from Blue Cross, which has a large volume of business, to Reliable Life Insurance Company, which has only $33 in premium revenue.

At least one adverse complaint ratio was found in 11 of the 21 companies with more than $100 million in revenue.

The information may be helpful to some cautious insurance consumers who want to know which insurance firms are best at keeping their customers satisfied before deciding where to spend their money, according to Laura Colbert of Georgians for a Healthy Future, a consumer advocacy group.

The more excellent value of this information is for the Georgia Department of Insurance, which can use it to take action against insurers who consistently receive poor marks or reward insurers who always prioritize consumers, as well as for insurance companies, who may be inclined to prioritize the needs of their customers better as they see how they stack up against their competition.

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Former WellCare General Counsel Receives Prison Sentence for Lying Under Oath to The Florida Medicaid Program

The former general counsel for WellCare Health Plans was sentenced to six months in federal prison for his role in a plan to cheat Florida’s Medicaid program.

According to the Department of Justice, after pleading guilty to making false representations to the Florida Medicaid Program this summer, Thaddeus M.S. Bereday will serve a prison sentence followed by a year of house arrest. He’ll also have to pay a $50,000 fine, according to the Court. WellCare claimed in a statement that it had utterly cooperated with the investigation and that all issues directly related to the firm had been resolved. Bereday’s counsel declined to comment.

Bereday was one of five former WellCare executives charged in 2011 for their roles in the scheme, which involved creating a separate unit to hide Medicaid reimbursement and falsifying provider payments to get around a Florida law requiring insurers to spend at least 80% of Medicaid premiums on behavioral health services.

In 2013, four other executives were convicted guilty of fraud-related charges: former WellCare President and CEO Todd Farha, former Chief Financial Officer Paul Behrens, former Vice President of Clinical Services William Kale, and former Vice President of Medical Economics Peter Clay.

The four executives filed an appeal, claiming insufficient evidence to convict them of the offenses. However, the appeals judges affirmed their convictions, saying they were well aware of Florida’s 80/20 statute and had even prepared to pay $1 million to Florida’s Agency for Health Care Administration to avoid suspicion.

WellCare continues to profit from its Medicaid operation despite the fraud investigation that has ensnared its top executives. In February, the insurer announced that at the end of 2016, it had grown its Medicaid membership to 2.5 million, a 6.5 percent increase from the previous year. Its acquisition of Care1st Arizona and portions of Advicare Corp.’s Medicaid assets contributed to this growth.

WellCare runs health maintenance organizations (HMOs) in various states that cater to government-sponsored healthcare benefit programs such as Medicaid. StayWell and Healthease, two WellCare HMOs in Florida, have signed contracts with the AHCA to provide Florida Medicaid Program participants with various services, including behavioral health treatments.

The state of Florida established legislation in 2002 requiring Florida Medicaid HMOs to spend 80% of Medicaid premiums collected for mental health care on providing those services. The difference between what the HMO paid and what the AHCA received had to be repaid to the AHCA if the HMO spent less than 80% of the premiums.

To lower WellCare HMOs’ contractual repayment obligations for mental health care services, the defendants in this case erroneously and fraudulently submitted inflated expense figures in the company’s yearly reports to the AHCA. On June 10, 2013, a federal jury convicted Bereday’s co-defendants guilty. In May 2014, Judge Moody sentenced Farha to 36 months in prison, Behrens to 24 months in jail, and Kale to one year and one day in prison for their respective roles in the fraud. Clay was given a five-year probationary term. The defendants appealed their convictions, which were all upheld in August 2016 by the Eleventh Circuit.

The US filed related charges against WellCare in an Information and Deferred Prosecution Agreement (“DPA”) on May 5, 2009. WellCare was obliged to pay $40 million in restitution, forfeit another $40 million to the US, and cooperate with the government’s criminal investigation under the terms of the DPA. All of the DPA’s standards were met by the company. As a result of the government’s motion, the Information was later rejected by the Court.

The Office of Inspector General of the United States Department of Health and Human Services, the Federal Bureau of Investigation, and the Florida Medicaid Fraud Control Unit investigated this case. It was prosecuted by Assistant United States Attorneys Jay G. Trezevant and Cherie L. Krigsman, DOJ Senior Litigation Counsel John A. Michelich, and Special Assistant United States Attorney John Bowers.

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Michael Neidorff Earns Huge Paycheck DespiteUnderperforming Centene In Pandemic Setting

The coronavirus pandemic continues to rage, and most businesses are hurting, including Centene Corp., which reports said is underperforming in the stock market lately. However, Michael Neidorff, as CEO, is not worried at all. His 2020 paycheck read $59 million.

The windfall came as market updates in the past week showed a roller-coaster ride for Centene. For the most part, it’s not looking very good for the giant insurer. And that is hardly a surprise in a pandemic year, but for Centene, the COVID-19 plague represented a boost in the first half of 2020.

According to Yahoo, the healthcare insurance business performed relatively well just before the full impact of the coronavirus lockdown took effect. Centene, for instance, reported a 2019 profit of $1.8 billion, reflecting a nearly 40% jump from the previous year.

The numbers translated as fantastic news for Neidorff but not for the entire Centene community.

Centene Makes Sacrifices But Leaves Neidorff Untouched

At the start of 2020, Centene had anticipated the difficulties to come but made sure the company will continue to perform as projected. Neidorff announced in February last year the separation of 3,000 Centene employees or roughly 6% of the insurer’s workforce. The CEO admitted that the painful decision was made to ensure that Centene’s bottom line would not be affected by the looming difficulties.

Sure enough, the company reported a considerable retreat on its earnings, which dropped by 6% at the end of 2020. Still, Centene posted a profit growth of nearly $2 billion and credited the revenue uptick to taxpayer-funded healthcare programs.

By any account, Centene had emerged from the first year of the global pandemic largely unscathed, and the same can be said about the big boss. Neidorff’s reported pay package amounted to $59 million, showing an increase of more than 100% compared with his salary in the last three years.

The CEO is collecting a hefty paycheck no matter the general situation of Centene because about 90% of his take-home came from exercised stock. Documents provided by the company indicated that Neidorff regularly pads up his bank account by selling Centene shares.

The Price Of Neidorff’s Success

As things stand, Neidorff is recognized as one of the most successful business executives in the United States. Fortune listed the Centene CEO in the Top 20 Business People in 2017, and he is poised to remain on that elite circle in the years to come.

Yet Neidorff reaching the zenith of success came with a heavy price – the thousands of jobs by ordinary Centene employees, and as mentioned above, the money that came from the company’s Medicare and Medicaid health products. Ironically, while these programs deliver the goods for Neidorff, his company fell short of the minimum expectations in terms of the quality of service.

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Louisiana Judge Refused to Halt State Health Insurance Contracts

A judge in Baton Rouge, Louisiana, has refused to stop the state from signing contracts with three private insurance companies that have been selected to participate in Louisiana's new poor-health-care delivery system. A different judge ordered that the companies' submissions to the state be made public in a separate case.

 According to the Advocate, Judge William Morvant dismissed allegations from a counsel representing Aetna Better Health Inc., which lost some business. The state will be irrevocably hurt if the three winning plans are implemented. Louisiana Healthcare Connections Inc., AmeriHealth Mercy of Louisiana Inc., and AmeriGroup Louisiana Inc. are the three private insurance companies.

 State District Judge Todd Hernandez decided that the winning proposals presented by Louisiana Healthcare Connections, AmeriGroup, and United Healthcare of Louisiana Inc. must be made public. These corporations filed separate lawsuits against the Department of Health and Hospitals (DHH), alleging that the proposals contain trade secrets and proprietary information. Chief attorney Steve Russo has represented DHH, who stated afterward that the contracts might be signed soon, and the Jindal administration will implement the scheme.

 According to Russo, Morvant's decision from the bench is a triumph for the approximately 800,000 Medicaid participants in Louisiana who will have their health care managed under the contracts. He believes that the access will improve, and incredible advances in quality will be recognized in no time.

 According to Aetna spokesman Matt Wiggin, the firm is considering its alternatives and will decide how to continue shortly. They were displeased by the decision and continue to have issues about how Medicaid contracts were awarded. They believe that there were flaws in the procurement process and the award scoring and that the awards should be thrown out because DHH was unable to follow the required protocol while soliciting offers.

 Hernandez convened a hearing in the related public records action and found on Tuesday's website that the information does not come within the exceptions outlined in the Louisiana Public Records Act or the state Constitution. 

 The judge noted that the goal of the entire process is to provide services to Louisiana's Medicaid clients in a more efficient manner while saving Louisiana taxpayers money. It was all done in the context of a competitive procedure, and limiting disclosure would limit the breadth of that competitive process, defeating its entire purpose.

 Attorneys representing Louisiana Healthcare Connections, AmeriGroup, and United Healthcare intend to petition Hernandez for a suspensive appeal, which, if allowed, would put Hernandez's decision on hold. At the same time, the firms seek review from a higher court.

 Later on, the Jindal government selected five businesses to participate in the privatization of Medicaid service delivery.

 Aetna and Coventry Health Care of Louisiana were beaten out for one form of network plan called coordinated-care networks, or CCNs, by Louisiana Healthcare Connections, AmeriHealth Mercy, and AmeriGroup Louisiana.

 CCNs would take over the state's $6.7 billion Medicaid program for $2.2 billion. Coventry has already filed a judicial review petition in Baton Rouge's 19th Judicial District Court. Morvant has been assigned to it.

 United Healthcare and Community Health Solutions of America Inc. outperformed Louisiana Physicians Connections for the other type of network plan.

 Aetna filed a protest with DHH, but Secretary Bruce Greenstein dismissed it a few days later. Aetna then filed an appeal with state Commissioner of Administration Paul Rainwater, which was rejected as well.

 While the second appeal was underway, Aetna filed a petition for a temporary restraining order, preliminary injunction, and permanent injunction in the 19th Judicial District on September 1.

 State District Judge Janice Clark gave a temporary restraining order, but Morvant dissolved it and dismissed Aetna's plea for a preliminary injunction.

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Lawsuits Filed Against Wellcare Health Plans, Inc.

 United States Attorney A. Brian Albritton announces the filing of Information against WellCare Health Plans, Inc. and signing a Deferred Prosecution Agreement (WellCare).

 The Information accuses WellCare of participating in an extensive plot to defraud the Florida Medicaid program and the Florida Healthy Kids Corporation ("Healthy Kids" or FHKC) program of roughly $40,000,000 through its officers and employees.

 If WellCare follows the Deferred Prosecution Agreement (DPA) terms, it will avoid a health care fraud conviction on the charges in the Information.

 On October 24, 2007, more than 200 Special Agents and Investigators from the FBI, the Office of the Inspector General of the United States Department of Health and Human Services (HHS-OIG), and the State of Florida Medicaid Fraud Control Unit, Office of The Attorney General (MFCU), raided WellCare offices at Tampa, Florida, revealing the government's ongoing investigation.

 From mid-2002 through 2006, the investigation focused on claims that WellCare, through its executives and employees, provided incorrect and fraudulent expenditure information to the Florida Medicaid and Healthy Kids programs.

 The report alleges that WellCare submitted illegally inflated expenditure information on mandatory Behavioral Healthcare Worksheets to the Florida Medicaid program (through Florida's Agency for Health Care Administration, or AHCA).

 According to the evidence, WellCare submitted incorrect and illegally inflated expense figures to the Healthy Kids program in annual filings required by the program's contracts.

 WellCare formed Harmony Behavioral Health Inc.

 Harmony Behavioral Health, Inc. (formerly known as WellCare Behavioral Health, Inc.) was a wholly-owned subsidiary of WellCare that was used to conceal and falsely and fraudulently inflate its health plans' actual expenses incurred in providing required certain medical services to Florida Medicaid and FHKC program recipients. WellCare was required to repay at least a portion of the unspent money to the Florida health care programs if it did not spend the required 80 percent or 85 percent on services under these contracts. According to the evidence, WellCare used several deceptive tactics to avoid returning unspent funds to Florida's healthcare programs. WellCare fraudulently reported money to Harmony as service expenditures.

 As a result, regardless of how much money WellCare spent for health care services each year, WellCare unlawfully avoided refunding the money it had provided Harmony to the Florida health care programs.

 The FBI, the HHS-OIG, and the MFCU are all investigating the matter, and the public filing of the Information and the DPA is the newest development. The investigation into those former WellCare employees and executives accountable for the conduct described in the charges filed against WellCare and Gregory West is ongoing.

 The principal prosecutors in the investigation into WellCare and its former employees and executives have been. They will continue to be Assistant US Attorneys Jay G. Trezevant and Anthony E. Porcelli.

 Gregory West (age 50, of Tampa), a former WellCare employee, had an information and plea bargain unsealed by the US Attorney's office in October 2008. In December 2007, West pled guilty to conspiring to steal more than $20 million from the Florida Medicaid program.

 West may face up to ten years in federal prison and a $250,000 fine if convicted. West's sentencing hearing has been postponed at the request of the government. On October 8, 2009, a status meeting will be held.

 The continuing inquiry does not directly touch WellCare's supply of health care services to any person, as the Information's charges against the company disclose.

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Class Suit Accuses Centene Of Massive Healthcare Fraud, Other Misdeeds

Insurance policyholders bought into Centene Corp.'s health plans believing the company will follow through on their promise of quality products and services, but many ended up grossly disappointed. The giant insurer faces a class lawsuit that alleges Centene maliciously committed healthcare fraud on a grand scale.

Filed before a U.S. District Court in Washington in January 2017, the lawsuit represented more than one million Centene customers from across the United States. Per the court filing, the disgruntled policyholders had accused Centene, a Fortune 500 company, of lying about its insurance products. For instance, Centene's Ambetter health plans proved to be a junk offering as customers struggled to find cared providers and medical professionals that accept the product.

Simply put, Centene's claim of quality healthcare networks is but a product of fiction. That being the case, the insurer failed to provide the adequate coverage promised to unsuspecting policyholders, the lawsuit indicated.

Massive Healthcare Fraud

The misrepresentation amounted to Centene customers unable to access medical services because the company listed providers that were not part of its healthcare network. According to the complainants' lawyers, Centene violated the Affordable Care Act by duping customers into purchasing cheap but high-quality medical insurance products.

As noted in the filing, Centene is a major player in the ACA market exchange, and its government-subsidized health plans are considered a primary source of revenues. While the insurer earns billions yearly on the ACA exchange, it's unthinkable that it continues to sell products that robbed people of their hard-earned money.

The suit reminded that Centene's action was more appalling because most of the victims are struggling Americans. "Centene Corporation preys upon vulnerable, low-income individuals across the country with limited access to health coverage and, in the process, milks American taxpayers for profit," the filing explained.

In effect, Centene betrayed the ACA's design, which "was meant to shift power from health insurers back to patients." By mispackaging its ACA products, "Centene continues to do anything and everything just to make a buck, even if it means putting people's lives at risk," the lawsuit continued.

A Rundown Of Centene's Wrongdoings

In support of its fraud claims, the lawsuit cited Centene's history, including questionable business and labor practices. A dentist in Texas complained of his issue with Centene products that denied him access to the care service or pointed him to the wrong medical professional. Lamentably, the customer got the raw end of the deal despite paying a monthly premium of $1200.

In January 2016, Centene admitted losing a hard drive that contained the personal information of an estimated one million customers. The incident sparked fears that the company's mishandling exposed many to potential identity theft. Then in August of the same year, Centene earned the ire of the Securities Exchange Commission (SEC) for illegally preventing an employee from cooperating with federal authorities. That episode cost the company $340,000 in fines.

Also in 2016, the Justice Department launched a probe on allegations that Centene was overbilling Medicare members to earn more money from the government. This case seemingly reflects a standard practice by the giant insurer that focuses more on realizing incomes while setting aside the welfare of policyholders.