NICA will pay $51 million to resolve whistleblower claims.
They have agreed to pay $51 million to settle allegations that they violated the False Claims Act (FCA) by causing NICA participants to submit their healthcare claims to Medicaid rather than NICA. This was found to be in violation of Medicaid’s status as the payer of last resort under federal law. The False Claims Act allows for legal action to be taken against individuals or companies that defraud the government.
This 2019 whistleblower lawsuit has led to a $51 Million FCA settlement. The whistleblower provisions of the False Claims Act allow a private party to file a lawsuit on the behalf of the United States. The qui tam provisions of the act enable private citizens to file lawsuits on behalf of the government if they know of an individual or company defrauding the government. Qui tam whistleblowers are eligible to receive between 15 and 30% of the government’s recovery if granted. This permits that private party to be able to receive a portion of monies recovered.
Once a child is admitted into NICA’s program, Florida law states indicates that NICA is responsible for the payment of medical and other expenses incurred because of a birth-related neurological injury. Medicaid is a joint federal-state healthcare program that provides coverage and benefits to low-income and disabled individuals. Under federal law, Medicaid is generally the payer of last resort. “When Medicaid is improperly billed for services that should be covered by other funding sources, the integrity of this safety net program is undermined,” said Special Agent in Charge Omar Pérez Aybar of the Department of Health and Human Services
“The Medicaid program provides a safety net for our most vulnerable populations that do not have access to traditional healthcare coverage,” said U.S. Attorney Juan Antonio Gonzalez for the Southern District of Florida. “My office is dedicated to protecting critical government healthcare programs, like Medicaid, that serve the elderly and disabled. The misuse of Medicaid funds will not be tolerated.”
The lawsuit was filed in 2019 in the U.S. District Court for the Southern District of Florida by Veronica N. Arven and the estate of Theodore Arven III. The whistleblowers will receive an award in the amount of $12,750,000.
NICA “(i) submitted, or caused to be submitted, claims for payment to Medicaid, and (ii) avoided or decreased obligations for payment of money to Medicaid,” according to the settlement agreement. NICA has denied all allegations.
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