Whistleblower / False Claims Act

United States, et al. ex rel. Maithel, et al. v. Ventura Co. Medi-Cal Managed Care Commission d/b/a Gold Coast Health Plan, et al., No. 15-7760AB TJH (JEMx) (C.D. Cal.).

Lieff Cabraser represents Relators who alleged that Defendant Ventura County Medi-Cal Managed Care Commission, doing business as the Gold Coast Health Plan, knowingly misused funds it received from the federal government and California State Government in 2014 and 2015 for newly-enrolled adult Medi-Cal patients under the Affordable Care Act. Gold Coast was required to return a certain percentage of monies that it did not use on “allowed medical expenses” for this Adult Expansion population to the federal government and California. Instead of returning the monies to the government, relators alleged and sought to prove that Gold Coast distributed a large portion of these funds to favored providers for past services, which Relators alleged were not actually provided or were duplicative of services for which the providers had already been compensated. Relators further alleged that although Gold Coast claimed it would seek documentation from the providers to justify the payments for these “additional” past services, it largely ignored that requirement. Moreover, the reimbursement amounts were determined months before any documentation of services was provided.

As a result of settlements negotiated with Gold Coast and the favored providers, Gold Coast will pay $17.2 million to the United States and the State of California. The providers who sought and received these allegedly illegal payments – Ventura County Medical Center, Dignity Health, and Clinicas del Camino Real Inc. – will pay an additional $53.5 million, the balance of the total $70.7 million settlement. The settlement was first made public by the United States Department of Justice and the California Attorney General on August 18, 2022.