Source: Office of United States Attorneys
DETROIT – United States Attorney Dawn N. Ison announced today that Commonwealth Care Alliance, Inc. (CCA) has agreed to pay $520,355.65 to resolve allegations that Reliance HMO, Inc., a company CCA acquired in 2022, violated the False Claims Act, 31 U.S.C. §§ 3729-3733, by providing cash payments to induce the referral of Medicare beneficiaries to enroll in Reliance’s Medicare Advantage Plan, in violation of the Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b)(2). CCA voluntarily self-disclosed the conduct to the U.S. Attorney’s Office, and the settlement acknowledges that CCA took significant steps, entitling it to credit for cooperating with the government’s investigation.
Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed care insurance plans called Medicare Advantage Plans (MA Plans). The Centers for Medicare & Medicaid Services (CMS) pays MA Plans a monthly capitated payment for each beneficiary who enrolls in one of their plans. The Anti-Kickback Statute prohibits parties who participate in federal healthcare programs from knowingly and willfully paying or receiving any remuneration in return for referring an individual to, or arranging for the furnishing of, any item or services for which payment is made by the federal healthcare programs.
CCA is a not-for-profit corporation, with its principal place of business in Boston, Massachusetts, engaged in offering MA Plans. In April 2019, CMS authorized Reliance HMO, Inc. (Reliance) to operate a MA plan for Medicare beneficiaries in Michigan, with beneficiaries receiving coverage starting in January 2020. On March 31, 2022, CCA announced completion of its acquisition of a 70% stake in Reliance. After the acquisition, CCA identified concerns regarding certain marketing-related outreach and payments Reliance agents had made to personnel at physician practices. In particular, CCA disclosed two schemes.
First, from April 12, 2019, through December 22, 2020, Reliance provided cash payments to healthcare professionals and administrative staff in physician practices, in exchange for providing Reliance with the contact information for patients who had agreed, through executing so-called “permission to contact” cards, to be contacted by Reliance regarding its MA plan offerings.
Second, in November 2019, prior to Reliance’s MA plan becoming active, Reliance paid each of four physicians and physician practices $2,500, which Reliance characterized as advances on “coordination of care” services to be provided by the physicians to beneficiaries when the MA plan became active in 2020.
The United States alleges these payments were intended to induce the referral, recommendation, or arrangement of enrollment of Medicare beneficiaries in Reliance’s MA plan. Such payments, the United States alleges, were impermissible kickbacks in violation of the False Claims Act. The settlement announced today resolves these claims.
CCA voluntarily self-disclosed this conduct to the United States and received credit for its cooperation. In addition, CCA took remedial measures, including terminating the employees directly involved with the decision to offer the payments described above, and providing the United States with a detailed written statement describing its investigation, along with other supplemental information to assist the United States in its investigation.
“Our office encourages companies and individuals to make timely self-disclosures and take remedial measures to mitigate the harm from fraud that they discover,” said U.S. Attorney Ison. “While we remain steadfast in using the False Claims Act to address the use of prohibited payments to induce federal healthcare business, our office is prepared to give credit, where justified, to those that save the government time and resources by disclosing fraud.”
Ison was joined in the announcement by Special Agent in Charge Mario Pinto, U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG).
“Paying kickbacks in exchange for patient referrals can drive up costs and lead to unnecessary medical services,” said Mario M. Pinto, Special Agent in Charge of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “This settlement highlights the value of HHS-OIG’s Self-Disclosure Program, which allows providers to report potential fraud directly to HHS-OIG and mitigate the costs and disruptions often associated with a government-directed investigation.”
The United States Attorney’s Office encourages anyone with information involving waste, fraud, and abuse in federal healthcare or other programs, to please report the illegal conduct, by contacting:
HHS-OIG Hotline: 1-800-HHS-TIPS (1-800-447-8477) or https://tips.oig.hhs.gov
To file a voluntary self-disclosure, please access the link below:
https://oig.hhs.gov/compliance/self-disclosure-info/self-disclosure-protocol/
The civil investigation was handled by Assistant U.S. Attorney Jonny Zajac of the U.S. Attorney’s Office for the Eastern District of Michigan, with assistance from HHS-OIG.
The claims resolved by the settlement are allegations only; there has been no determination or admission of liability.