Tag Archives: DOJ

New era of healthcare fraud investigations puts spotlight on the C-suite

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http://www.beckershospitalreview.com/legal-regulatory-issues/new-era-of-healthcare-fraud-investigations-puts-spotlight-on-the-c-suite.html

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More and more, the government is holding individuals — not just the organizations they work for — responsible for fraud.

Traditionally, healthcare companies were only expected to provide information about the underlying factual situation in a fraud investigation. However, these investigations have become more complicated, as the Department of Justice has taken a strong stance on pursuing healthcare executives involved in fraud cases to hold them personally responsible.

Venson Wallin, managing director of BDO’s Healthcare Advisory practice, recently spoke withBecker’s Hospital Review about the shift in individual accountability standards and steps hospital and health system executives can take to protect themselves from liability.

Former Non-Profit Health Clinics CEO Sentenced to 18 Years for Funneling Millions in Grant Money to Private Companies

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https://www.justice.gov/usao-ndal/pr/former-non-profit-health-clinics-ceo-sentenced-18-years-funneling-millions-grant-money

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The former CEO of two Alabama health clinics has been sentenced to 18 years in prison for his role in a fraud scheme, according to the Department of Justice.

According to the DOJ, 53-year-old Jonathan Dunning left his post as CEO of Birmingham (Ala.) Health Care and Central Alabama Comprehensive Health in Tuskegee in 2008. However, he continued to exercise control over the two nonprofit health clinics and diverted government funds meant for the clinics to his own for-profit companies, according to the DOJ.

In June, a federal jury convicted Mr. Dunning of 62 counts of wire fraud, 33 counts of money laundering and two counts of bank fraud. A jury also found him guilty of one count of conspiracy, finding that he conspired with another person to commit wire fraud, bank fraud and money laundering.

Over a seven-year period, Mr. Dunning defrauded HHS, the Health Resources and Service Administration, the two clinics, a credit union and others out of more than $16 million, according to the government’s sentencing memorandum.

DOJ says Aetna, Humana are trying to derail antitrust case

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http://www.bizjournals.com/louisville/news/2016/10/11/doj-says-aetna-humana-are-trying-to-derail.html

Lawyers for the U.S. Department of Justice say Aetna Inc. and Humana Inc are trying to derail the government's antitrust challenge of Aetna's proposed $37 billion acquisition of Humana.

Lawyers for the U.S. Department of Justice say Aetna Inc. and Humana Inc are trying to derail the government’s antitrust challenge of Aetna’s proposed $37 billion acquisition of Louisville-based Humana.

This comes after lawyers for the companies accused the DOJ with “serious delay and misconduct” last week. The companies requested sanctions, claiming that the government withheld about 1 million documents and that this had “gravely undermined” the companies’ ability to mount a defense against claims that the acquisition would hurt competition.

The National Law Journal reports that the government’s response came Saturday in a court filing, in which it said the DOJ has tried to accommodate the “broad and extremely burdensome discovery demand” from Aetna (NYSE: AET) and Humana (NYSE: HUM) on the U.S. Department of Health and Human Services.

The government called the request for sanctions “a transparent attempt to derail the United States’ merger challenge before the district court ever hears from a single witness or reviews any evidence,” the law journal reported.

At issue is how much market share the combined company would control in Medicare Advantage, a type of Medicare plan offered by a private insurer. A court date is set for Dec. 5, 2016, and the judge says a decision isn’t likely until mid-January 2017 — past the companies’ end-of-year deadline to close the deal.

Biggest healthcare frauds in 2016: Running list

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http://www.healthcarefinancenews.com/slideshow/biggest-healthcare-frauds-2016-running-list?mkt_tok=eyJpIjoiWVRrMVl6UmtNek5qTURkaSIsInQiOiJ0Q2t5WUwzMm1TMDZaM0NrVU53eWtLWXIrb2tNUDBRZWhpNHRBb3VqWWh0blIzNUR2S1BlSVwveGFCTG9EYStDTFNTWjIrXC9LMmR4YU1DYXU3NVY1QUNoNUxDOW5zWVJVcjdvcFU2TW9vOU04PSJ9

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Tenet Healthcare to pay $513 million over referral, kickback scheme, DOJ says

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http://www.healthcarefinancenews.com/news/tenet-healthcare-pay-513-million-over-referral-kickback-scheme-doj-says?mkt_tok=eyJpIjoiWVRrMVl6UmtNek5qTURkaSIsInQiOiJ0Q2t5WUwzMm1TMDZaM0NrVU53eWtLWXIrb2tNUDBRZWhpNHRBb3VqWWh0blIzNUR2S1BlSVwveGFCTG9EYStDTFNTWjIrXC9LMmR4YU1DYXU3NVY1QUNoNUxDOW5zWVJVcjdvcFU2TW9vOU04PSJ9

Hilton Head Hospital (Photo via Google)

Payout settles allegations of illegal kickbacks paid to clinic owners in exchange for referring patients for labor and delivery to Tenet hospitals.

Aetna faces probe over ‘politically motivated’ Obamacare exit

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http://www.healthcaredive.com/news/aetna-faces-probe-over-politically-motivated-obamacare-exit/426035/

  • A group of senators is seeking answers from Aetna about its abrupt decision to leave the ACA marketplaces following the DOJ’s challenge to the company’s proposed $37 billion merger with Humana.
  • The letter came Thursday from Senators Elizabeth Warren (D-Mass.), Bernie Sanders (I-Vt.), Edward J. Markey (D-Mass.), Sherrod Brown (D-Ohio), and Bill Nelson (D-Fla.).
  • While other insurers have also scaled back their ACA participation, the probe into Aetna comes in response to a letter from Aetna CEO Mark Bertolini in which the company is perceived to have directly threatened the government that it would leave the exchanges if the merger was not approved.

Aetna’s Bertolini counters accusation of power play against DOJ

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http://www.healthcaredive.com/news/aetnas-bertolini-counters-accusation-of-power-play-against-doj/426236/

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http://www.courant.com/news/connecticut/hc-bertolini-senators-20160912-story.html

  • Aetna CEO Mark Bertolini has responded to a letter from a group of senators who accused the company last week of exiting the majority of its ACA markets as a ploy against the federal government for challenging Aetna’s proposed merger with Humana.
  • Bertolini dismissed the senators’ arguments as”unfounded accusations,” the Hartford Courant reported.
  • Aetna spokesman T.J. Crawford told the Courant the company had not received a response from the senators.

Top 10 Medicaid insurers represent over half of U.S. managed care market

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http://www.beckershospitalreview.com/payer-issues/top-10-medicaid-insurers-represent-over-half-of-u-s-managed-care-market.html

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Fifty-seven percent of the U.S.’s managed Medicaid market is held by the top 10 Medicaid insurers, an analysis from a Washington, D.C., publishing and information company Atlantic Information Services found.

AIS’ Medicare and Medicaid market data found four of the top 10 payers are involved in mergers and acquisitions that may allow them to gain more market share. Specifically, Hartford, Conn.-based Aenta’s proposed acquisition of Louisville, Ky.-based Humana would allocate more than 400,000 Medicaid beneficiaries to Aetna, if the deal is not blocked by the U.S. Department of Justice. In addition, the third ranked insurer, St. Louis-based Centene, acquired Woodland Hills, Calif.-based Health Net in July, leaving the resulting entity with the highest market share.

Here are the top 10 insurers with the most Medicaid beneficiaries and market share.

Healthcare Hypocrite of the Week: Aetna’s Mark Bertolini

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http://medcitynews.com/2016/08/hypocrite-aetna-mark-bertolini/?utm_source=hs_email&utm_medium=email&utm_content=33097793&_hsenc=p2ANqtz-8tHuz1OyW0jad1rYHbmCrWm51PA21pdsKB9af25xlqpvHnWr2o1T0b7LutMzmXzy521UtBFmUcZw75t8pNJcQYSG5Uvw&_hsmi=33097793

Mark Bertolini

Mark Bertolini, CEO of Aetna

It’s only Thursday, but it’s probably safe to announce that the winner of Healthcare Hypocrite of the Week is Aetna Chairman and CEO Mark Bertolini. And it’s not because Elizabeth Holmes and Martin Shkreli have managed to stay out of the news for a while.

Despite calling the Affordable Care Act business a “good investment” as recently as April, Bertolini has decided to pull Aetna out of most of the public health insurance exchanges. Initially, he cited the ACA risk pools as being unsustainable — in other words, too many old people with chronic illnesses and not enough young and spry customers to mitigate the risk. But as it turns out his actions may have been prompted by a desire to get even when the insurer didn’t get its way on a business deal.

On Monday, Aetna announced that it was pulling out of public individual insurance exchanges in all but four states. For the 2017 plan year, the Hartford, Connecticut-based insurer will only participate in the exchanges in 252 counties in Delaware, Iowa, Nebraska and Virginia. The reason? The company said it lost $200 million on individual plans in the second quarter and $430 million since the Obamacare insurance mandate took effect in 2014.

Letter shows Aetna warned DOJ it would exit Obamacare markets if merger challenged

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http://www.healthcarefinancenews.com/news/letter-shows-aetna-warned-doj-it-would-exit-obamacare-markets-if-merger-challenged?mkt_tok=eyJpIjoiTW1Jek1EWm1PRFpqWldZeCIsInQiOiJNUE5TM3FXaktDWTF6WFlreiszSFpHRjZBeENcL3ZCS1REN01UQzVvVG9pdGNsSmZnK1BwTlJNWHhzZGdGRzdTckRoS2VqT05tMGVXZTdDWjN5SmVxbW1sR09qRDNnaTBNbEpXY3M5cjZaaUE9In0%3D

Aetna CEO Mark Bertolini (file photo)

Aetna CEO Mark Bertolini

Aetna warned the Department of Justice in a July 5 letter that it would leave the public exchange market if the agency went forward and blocked its merger with Humana.

“Our analysis to date makes clear that if the deal were challenged and/or blocked we would need to take immediate actions to mitigate public exchange and ACA small group losses,” Aetna CEO Mark Bertolini said in the letter. “Specifically, if the DOJ sues to enjoin the transaction, we will immediately take action to reduce our 2017 exchange footprint.”

The letter to Ryan M. Kantor, assistant chief for litigation in the Antitrust Division, was sent days before the DOJ’s injunction blocking Aetna’s $37 billion merger with Humana, and also Anthem’s planned $54 billion deal with Cigna.

This week, Aetna announced it was exiting the Obamacare-created exchange market in all but four states in 2017, a reduction of its current participation in 15 states.

However, Aetna left the exchange markets after seeing deteriorating numbers in its second quarter results, the insurer said in a request for comment today.

“That deterioration, and not the DOJ challenge to our Humana transaction, is ultimately what drove us to announce the narrowing of our public exchange presence for the 2017 plan year,” Aetna said.