Ohio joins Medicare/Medicaid lawsuit

Submitted information

COLUMBUS — Ohio Attorney General Mike DeWine announces that Ohio and several other states have reached an agreement in principle to join the federal government in a settlement with CareCore National LLC, a benefits management company, to resolve allegations that it improperly authorized medical procedures paid for with Medicare and Medicaid funds.

The settlement includes $446,878.80 in restitution and other recoveries for Ohio’s Medicaid program.

The agreement settles allegations that CareCore instituted a scheme to automatically approve hundreds of radiology service requests on a daily basis, deeming those diagnostic services as reasonable and medically necessary, even though there had been no evaluation of those cases by the appropriate medical personnel. CareCore allegedly auto-approved the requests in an effort to keep up with the volume of preauthorization requests for diagnostic radiology services and to avoid monetary penalties for untimely reviews.

Specifically, the agreement in principle resolves allegations that from Jan. 1, 2005, through June 13, 2013, CareCore developed and implemented a “Process as Directed” or “PAD” program through which CareCore improperly approved over 200,000 prior authorization requests that it initially determined could not be approved based on the information provided. The alleged conduct caused false or fraudulent claims to be submitted to Medicaid programs, including to their contracted managed care organizations.

CareCore will pay the federal government $54 million, of which $18 million will go to the state Medicaid programs, to resolve allegations that CareCore caused false claims to be submitted to government health care programs.

The settlement resolves allegations asserted in a whistleblower action in the United States District Court for the Southern District of New York.

A National Association of Medicaid Fraud Control Units team participated in the investigation and conducted the settlement negotiations with CareCore on behalf of the states.

The team included representatives of the Ohio Attorney General’s Medicaid Fraud Control Unit and the Florida, Georgia, and New York 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.