CareCore National, a healthcare utilization management company, has agreed to pay $54 million to settle allegations it fraudulently billed the CMS.
The lawsuit, filed by attorneys general from 21 states, claims that CareCore engaged in a fraud scheme from 2005 to 2013 that involved routinely billing the CMS for more than 200,000 medical diagnostic procedures without proving they were medical necessary. The suit alleges CareCore developed a system that involved its clinical reviewers improperly approving prior authorization requests even without approval or review from physicians.
As part of the settlement, CareCore admitted it improperly approved prior authorization requests paid for with Medicare Part C and Medicaid funds.
In a statement, CareCore said, "Our most important goal is ensuring patients get the care they need. After more than three years of researching and discussing this with the government, we decided to agree to a settlement so we can put this matter behind us and focus on serving our clients with industry-leading quality and cost management programs."
Of the $54 million settlement, $18 million will be paid to states' Medicaid programs. CareCore, which is now part of healthcare management company eviCore, determines medical necessity for states' Medicaid managed-care organizations.
New York, one of the plaintiffs in the suit, will recover $7.6 million. "Companies that overbill Medicaid are undermining efforts to help some of our neediest citizens," said New York Attorney General Eric Schneiderman.