This case was brought about by a whistle blower and goes back to records dating to 1985, a long time back.  California doesn’t get all the money though as the Feds get some too as this is a joint plan between California and the Feds.  As usual no admittance of wrong doing here imagewas admitted; however, the prosecutors didn’t find any wrong doing either so human error with input or the algorithms created this one as it was a coding error with reimbursing SCAN at the wrong levels, as if all patients were under the care of a nursing home which is a higher level.  The whistle blower though says the case was at the fault of SCAN and the case was filed in 2009. 

One more item worth mentioning here was the use of a 3rd party by SCAN that was involved with the billing codes.  So was this gaming the system in fact?  We don’t know for sure but someone will be looking at the algorithms and codes used for risk assessment you can bet.  Here we have yet one more case of the algorithms moving money back and forth.  Mayo Clinic just settled on of these types of cases, again a whistle blower and it’s worth a look too as Mayo refunded the money right away upon finding the error.  Some of the time invested in these cases going way back such as this are software generated. 

Mayo Clinic Agrees to Settle DOJ Legal Suit Dating Back to 2007 Under Whistleblower Provisions–One More Example of Algorithms Shifting Money in Healthcare As Cost of the Lawsuit Had to Far Exceed the End Results With Time and Money–A Waste

I said myself that the Mayo case was a big waste of time to keep it moving as once they saw the error they refunded the money but the legal part of it keeps moving on and on.  I can see where a big case of “real fraud” is definitely worth pursuing for obvious reasons but how many “coding” suits will keep appearing and shifting money?    Again it’s the involvement of the 3rd parties that sell their analytics and coding software based on the promise that they can cut expenditures and save money as well as not leave any money laying on the table at the same time, and the latter is where the coding comes in. 

Bad Algorithms in Healthcare Payment Systems and Risk Assessments–Did the Hospital Bill Fraudulently or Were They Sold Formulas That Did Not Conform

So one does have to wonder as to how much time will be spent on using algorithms and coding errors to keep shifting money back and forth and back and forth?  There will be more forthcoming you can bet and SCAN will look to see where they have opportunities to replace lost revenue as that’s the way business functions today, healthcare or otherwise.  Maybe SCAN will find a little more profitable data to sell?  Who knows.  BD

A Long Beach health plan agreed to pay $320 million to resolve allegations that it was overpaid by the state's Medi-Cal program going back to 1985, government officials said.

Federal officials called the settlement from SCAN Health Plan the largest of its kind from a single provider in Medi-Cal, the state's Medicaid program for the poor and disabled. 

Separately, the United States attorney's office in Los Angeles said SCAN paid an additional $3.8 million to settle a whistle-blower's allegation that the nonprofit company was overpaid by Medicare because of withholding of information about patients' diagnosis codes. 

Medi-Cal is a joint state-federal program. Under the settlement announced Thursday, California will receive $190.5 million and the federal government will get $129.4 million.,0,4746289.story


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