NYC Settles False Medicaid Claims for $1.05M; Whistleblower to Get $175K
The City of New York has agreed to pay the federal government $1.05 million to resolve allegations that the New York City Human Resources Administration (HRA) knowingly submitted or caused the submission of false claims to New York State’s Medicaid program, the U.S. Attorney for the Northern District of New York announced on Monday.
Medicaid is a matching program in which the United States shares with the States the cost of medical services for low income and disabled individuals. Several managed care organizations (MCOs) have contracted with the State of New York to provide health care coverage to Medicaid beneficiaries who reside in New York City in exchange for fixed monthly payments. Many individuals who qualify for Medicaid also receive assistance under the federal Supplemental Security Income (SSI) program, which provides financial assistance to the elderly, blind, and disabled. In many States, including New York, SSI recipients automatically qualify to receive Medicaid benefits.
When a Medicaid beneficiary residing in New York City moves to another State and enrolls for SSI benefits, the federal government provides written or electronic notification to the New York State Department of Health (DOH), which administers the Medicaid program throughout New York. Once DOH receives this information, it must promptly forward it to HRA. HRA, in turn, has an obligation to quickly review the information and, where appropriate, close a beneficiary’s Medicaid case if it determines that the beneficiary has moved out of New York City. If HRA fails to timely close a Medicaid case after learning from DOH or from another source that the beneficiary has relocated to another State, the MCO insuring that person will continue receiving monthly payments to insure an individual who is no longer eligible for Medicaid coverage in New York.
The United States’ investigation revealed that, although MCOs on several occasions notified HRA in writing that certain beneficiaries may have moved out of State, HRA failed to appropriately follow up on that information and work with DOH to ensure that MCOs stopped receiving monthly payments. As part of the settlement, HRA accepted responsibility for failing to timely review and close certain Medicaid cases after being provided information that those beneficiaries may have moved outside of New York City, and it admitted that its inaction caused one or more MCO to receive payments to insure individuals who were ineligible for benefits through New York State’s Medicaid program. HRA also agreed as part of the settlement to establish a process to investigate and close Medicaid cases whenever it receives information suggesting that a Medicaid beneficiary no longer resides within its coverage area.
The lawsuit was originally filed by an unnamed whistleblower under the qui tam provision of the False Claims Act. The Act allows private parties with knowledge of fraud against the government to sue on behalf of the government and share in the recovery. The whistleblower will receive $175,000 as their portion of the settlement.
The Chanler Group, in association with the Hirst Law Group, represents whistleblowers who take action under the False Claims Act to report fraud committed against the federal and state governments. We have years of experience representing whistleblower clients who expose every kind of fraud against the government, including health care fraud, contract fraud, and tax fraud. Read more about our expertise in False Claims Act cases and how you can take action.