In the latest Deeper Than the Headlines episode, we dive into a healthcare compliance case that resulted in a $29 million settlement. The case revolves around a New York-based healthcare organization that allegedly retained overpayments from the Uniformed Services Family Health Plan (USFHP), a Department of Defense (DoD) health plan serving military personnel, retirees, and their families.
According to allegations, the organization received inflated capitated rates for a four-year period due to errors in rate calculations. However, instead of alerting the health plan or returning the overpayments, it is alleged that the organization knowingly concealed the issue and continued to submit invoices at the inflated rate.
The case was exposed by two whistleblowers—one was an interim Chief Financial Officer, and the other was a consultant to the CEO and board, who later served as a trustee. Their disclosures led to government intervention under the False Claims Act.
One key takeaway from this case is the 60-day overpayment rule. Healthcare organizations that become aware of an overpayment—whether caused by them or not—must return it within 60 days. Failure to do so can result in severe financial and legal consequences, as seen in this $29 million settlement.
This case is a stark reminder for healthcare providers about the importance of proactive compliance and transparent financial practices.
Reference link: https://www.justice.gov/opa/pr/saint-vincents-catholic-medical-centers-new-york-agrees-pay-29m-resolve-alleged-false-claims
Healthicity
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