Medicaid

Company with fraud record lines up for new Medicaid contract

 

WellCare, which paid a multimillion-dollar fraud settlement, has brought in former Sen. Bob Graham, and says it is worthy of caring for Florida’s poorest residents.

Herald/Times Tallahassee Bureau

A health insurer with a checkered past is preparing to bid on billions of dollars in state government contracts to serve Florida’s poor and disabled residents.

And it stands a good chance of winning at least some of that business.

As Florida embarks on its plan to move 1.2 million Medicaid patients into private health plans, WellCare Health Plans of Tampa is widely expected to win state contracts that will shift healthcare for the poor into managed-care programs. The move is an early stage of the Medicaid reforms approved by the Legislature in 2011, pending a green light from the federal government .

WellCare's decision to bid, though not unexpected, has sparked an outcry from critics who say they wonder how badly a company must act before it is banned from government contracts — and from serving the state’s most vulnerable residents.

WellCare officials maintain that the company has changed in the two years since it agreed to pay a $137.5 million fraud settlement amid accusations the company bilked the state’s Medicaid and Healthy Kids programs and that it systematically dumped patients with expensive health needs.

“I think we have a highly competent and ethical group now running the company,” said former U.S. Sen. Bob Graham, a paid director on the company’s board and chairman of a committee to ensure the company acts ethically and complies with regulations. “Our service will be our best evidence of our corporate integrity.”

The company’s service, however, is what worries some health advocates. Case in point: In 2009, WellCare withdrew from a five-county Medicaid pilot program that served as the model for the statewide business that WellCare now seeks.

In some cases WellCare's decision disrupted care for patients with long-term health problems, disabilities and mental illnesses.

Critics also slam the federal settlement, finalized in April, which requires the company to repay less than half of the $400 million to $600 million it allegedly siphoned from taxpayers.

Five former executives — including CEO Todd Farha, CFO Paul Behrens and general counsel Thaddeus Bereday — were indicted in March 2011, and are awaiting trial.

Smoking gun

Evidence against them includes taped conversations between executives discussing how they could duplicate their bills to the state. The executives also discussed plans to save money by terminating coverage for neonatal babies and terminally ill patients, and throwing parties to reward employees who ousted expensive enrollees, according to whistle-blower documents.

“The violations of WellCare were only made known because an employee from the inside told the story,” said Laura Goodhue, executive director of the health advocacy group Florida CHAIN (Community Health Action Information Network). “How can the state make sure it doesn’t happen again?”

Allan Bergman, a national Medicaid and managed-care consultant for people with disabilities and chronic conditions, says he is not sure the state can prevent health plans from erring again.

Florida hopes to move almost all of its three million Medicaid beneficiaries to HMOs or HMO-like companies by 2015.

“It’s not the same as outsourcing a contract to clean a building,” Bergman said. “The oversight of these big contracts is critical for the state maintaining accountability. It worries me in many cases because I think legislatures are passing Medicaid managed-care budgets thinking they’re going to outsource the program and be done.”

Michelle Dahnke, a spokeswoman with the Agency for Health Care Administration, said the administration has ramped up its oversight, requiring health plans to report their finances and outline how they will prevent fraud, among other measures.

State law also requires that if a company stops providing service in one area, it must forfeit all of its other contracts. It would then pay a penalty plus the cost to transfer affected patients to another plan.

Tom Arnold, a healthcare lobbyist and head of the Medicaid program from 2004 to 2007, said the state can access historical records on health plans and can get more information as needed.

“I don’t think anyone has a reason to believe [WellCare] or any other entity in the state is doing anything inappropriate,” he said. “I don’t mean nothing bad will ever happen again, but the state has very strong tools to measure the appropriateness of care.”

WellCare's tactics

But Sean Hellein, the WellCare financial analyst who blew the whistle on the company’s fraudulent bookkeeping in 2007, said the company previously had no problem evading the state’s effort to audit its activities. During one on-site visit by state officials, Hellein said, “The idea was that as long as we could keep them in the dark, everything would be perfect.” If a particularly smart state worker started asking too many questions, Hellein said, WellCare had a remedy: It would simply hire the person away from the state at a much higher salary.

The strategy worked. It took the agency several years to catch on to the company’s strategy of double-billing the state for patient services.

As Florida moves to Medicaid managed care, WellCare now has several advantages in the bidding process.

It is one of the few companies that specializes in covering Medicaid and Medicare patients, and serves 400,000 Medicaid patients who have already opted for managed care. The company and its executives also have contributed at least $2 million to state political campaigns since 1997.

And the 2011 law that mandated the Medicaid changes also gives preference to Florida-based companies — and that includes WellCare.

Tampa Bay Times staff writer Kris Hundley contributed to this report. Brittany Alana Davis can be reached at bdavis@tampabay.com.

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