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CareCore National Settles Whistleblower Suit for $54 Million

Posted in Fraud and Abuse, Litigation, Private Insurers, Reimbursement Matters, State Matters

CareCore National LLC, a healthcare utilization management company, agreed earlier this month to pay $54 million to settle allegations that it allowed its insurance company customers to inappropriately bill the Medicare and Medicaid programs. The settlement was reached with the U.S. Department of Justice, Attorney General Medicaid Fraud Units in various states, and the U.S. Attorney for the Southern District of New York.

The New York Attorney General’s Office issued its own press release. Of the $54 million settlement, $7.6 million will be paid to the New York Medicaid program and $11.4 million to the other states’ Medicaid programs.

The lawsuit claimed that from 2007 to 2013, CareCore fraudulently preauthorized more than 200,000 diagnostic tests without actually determining whether they were medically necessary, allowing the company’s customers to bill the Centers for Medicare & Medicaid Services for the tests. CareCore allegedly directed its nursing staff to “Process As Directed” (or “PAD”) numerous cases, thereby approving them for payment under Medicare Part C or Medicaid Managed Care, when its physicians were too busy to conduct the required reviews timely.

CareCore National, which began life as New York Medical Imaging and was later known as NYMI Management Services, merged with MedSolutions, Inc. in 2014 to form eviCore healthcare [sic].

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