This comes on the heals of the settlement last week with Wellcare paying over 137 million to the Department of Justice to resolve lawsuits with over charging Medicare. Wellcare is the largest Medicaid operator in the state of Florida. More details can be read here from Reuters. The company was raided by government FBI officials in 2007. At one point it was even rumored that United was looking to buy them. A little over a year ago Medicare ordered the company to stop enrolling new patients.
Most areas of crime as such are created with manipulating numbers, in other words the algorithms I always talk about as this is what it comes down too, were the formulas used correct or were they creating “desired” numbers in order to appease investors and keep things moving along? It’s almost like being associated with the company puts one strike against you from the start so it will be interesting to see if and how the hospital was involved with the report filed by the whistle blower.
The whistle blower stated that fraud was created by accepting payment through one Medicaid program for expenses actually incurred by another, so if that is the case we have some potential rogue algorithms utilized for profit, just like the ones used for the out of network charges that have lawsuits still be filed to recoup money. If the health insurance business had not used business intelligence for big profits and ran an honest business some where along the line, perhaps they would have a better reputation. It’s been the machine gun technology with algorithmic formulas taking advantage of the rest of us that only have swords and daggers at best. BD
A hospital system in South Florida helped WellCare Health Plans hide some of the money it is accused of stealing from the Florida Medicaid program, according to a whistleblower complaint.
The complaint by Sean Hellein, a financial analyst who worked for WellCare Health Plans from November 2002 until October 2007, said South Broward Hospital District ``conspired'' to help WellCare avoid repayment of millions of dollars.
South Broward is now known as Memorial Healthcare System, which advertises itself as the fifth-largest public healthcare system in the nation.
The 60-page complaint sets out a number of ways in which WellCare systematically defrauded taxpayers, both the federal government and several states, mainly Florida. It estimates the fraud at $400 to $600 million.
In a Dec. 7, 2005 e-mail, then-WellCare CEO Todd Farha admitted that WellCare's contract with South Broward ``was designed to push us up to the 80% give-back point with the state,'' according to the complaint.
On the same date, the whistleblower said, he was told by another executive that he should not discuss high costs in the Healthy Kids contracts signed with South Broward because this was a ``politically sensitive'' topic and ``part of our business strategy.''