Fact Sheet: Service Use among Medicaid & CHIP Beneficiaries age 18 and Under during COVID-19

Sep 23, 2020 | Medicaid & CHIP

Overview                                                                                                                                          

To monitor the impact of the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) is releasing its first ever preliminary data snapshot focusing on the impact of COVID-19 on service utilization for children age 18 and under enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). This analysis is essential to understanding the broad ranging impacts of COVID-19, as Medicaid and CHIP cover nearly 40 million children, including three quarters of children living in poverty[1] and many with special health care needs that require health services.[2]  The preliminary findings contained in this data snapshot show that, while some data suggest that children may have less severe illness from COVID-19 compared to adults, their service utilization across many key domains, such as primary, preventive, dental and mental health services, has dropped over the past few months.

CMS’s release of COVID-19 data for children enrolled in Medicaid and CHIP is a major step toward sharing timely data on some of the nation’s largest and most important health insurance programs. These results are essential for ensuring not only robust monitoring and oversight of Medicaid and CHIP, but also understanding the impact of the PHE on children and highlighting the distinct result COVID-19 has had on children’s service utilization. By using these results, CMS, states, and other key stakeholders can help drive better health outcomes for some of our nation’s most vulnerable beneficiaries and ensure that children receive the care they need. 

Findings                                                                                                                    

The preliminary data shows that beneficiaries age 18 and under enrolled in Medicaid and CHIP had relatively low treatment rates due to COVID-19. Although more than 250,000 children enrolled in Medicaid and CHIP were tested for COVID-19 through June 2020, only about 32,000 received treatment for COVID-19 and fewer than 1,000 were hospitalized for COVID-19 through the end of May.

However, even though treatment rates for COVID-19 in children appear lower than for other age groups, while enrollment in Medicaid and CHIP has simultaneously increased, we have observed a decline in service use among this population across a number of key domains. When compared to data from the same time period last year (March through May 2019), preliminary data for 2020 shows 1.7 million (22%) fewer vaccinations for beneficiaries up to age 2, 3.2 million (44%) fewer child screening services, 6.9 million (44%) fewer outpatient mental health services even after accounting for increased telehealth services, and 7.6 million (69%) fewer dental services.

Data Sources & Definitions                                                                                                                 

Medicaid and CHIP providers, managed care agencies, and Pharmacy Benefit Managers submit administrative claims data to state Medicaid and CHIP agencies for processing. Those state agencies subsequently submit the data to CMS on a monthly basis via the Transformed Medicaid Statistical Information System (T-MSIS), a uniform, national data system for Medicaid and CHIP. Because T-MSIS submissions are difficult to analyze due to their large size and complex relational structure, CMS developed the research-optimized T-MSIS Analytic Files (TAF) to facilitate the analysis of Medicaid and CHIP data. Additional information about TAF can be found here. This data snapshot utilizes the 2020 TAF to monitor ongoing outcomes related to COVID-19, including measures of Medicaid and CHIP enrollment, COVID-related treatment, and service use. Due to claims submission lags related to state processing and submission via T-MSIS, this analysis primarily focuses on service utilization and health outcomes through the end of May 2020. 

CMS measured enrollment, forgone care, and COVID-related treatment using the following logic:

Enrollment: This analysis includes records for every beneficiary who has any Medicaid or CHIP enrollment record in a given month and is under the age of 19, regardless of the scope of their benefits.

Vaccinations: Vaccinations are identified CPT codes. The vaccines included in this analysis are DTaP, Polio, MMR, Hepatitis B, Hib, Pneumococcal conjugate, Chickenpox, Hepatitis A, and Rotavirus.

Child screening services: Child screenings are identified by two types of codes in claims. The first type is Current Procedural Terminology (CPT) codes that are specific to visits by new or established patients (99381-99385 or 99391-99395) and to initial hospital or birth center care for newborns (99460, 99461, 99463). The second type is general CPT codes for new (99202–99205) or established (99213–99215) patients along with a diagnosis code indicating that the service was provided to a child younger than 19 (e.g., Z00.110 Health examination for newborn under 8 days old).

Dental Services: Dental services are defined on the basis of the Current Dental Terminology (CDT) and CPT code groups from standard annual reporting of the states’ participation in the Early and Periodic Screening, Diagnostic and Treatment program (CMS-416).

Mental health services: Mental health services are identified by claims in which the diagnosis is a mental health condition. In addition to diagnosis, the services are grouped on the claim by type, with this analysis focusing on outpatient claims.

Telehealth: Telehealth is identified through a combination of procedure codes and procedure code modifiers.

COVID testing services: All COVID-19 testing services are grouped into three categories: diagnostic testing, antibody testing, and specimen collection. Diagnostic testing indicates whether an individual has COVID-19. Antibody testing is designed to detect antibodies produced in response to being previously exposed to COVID-19. Specimen collection is the process of obtaining the samples that are necessary to test for COVID-19. Diagnostic testing is identified via Healthcare Common Procedural Coding System (HCPCS) codes U0001, U0002, U0003, and U004 and CPT code 87635. Antibody testing is identified via CPT codes 86328 and 86769. Specimen collection is identified via HCPCS codes G2023 and G2024.

COVID-19 treatment: We use the following International Classification of Diseases (ICD), Tenth Revision (ICD-10), diagnosis codes to identify beneficiaries who received treatment for COVID-19:

  • B97.29 (other coronavirus as the cause of diseases classified elsewhere) – before April 1, 2020
  • U07.1 (2019 Novel Coronavirus, COVID-19) – from April 1, 2020 onward. 

Although CMS does use lab claims for identifying COVID-19 treatment, CMS does not receive lab results from states and cannot determine whether a lab test was positive. Therefore, Medicaid & CHIP COVID-19 cases are only identifiable in TAF data when there is a corresponding COVID-19 related service.

Key Considerations                                                                                                                          

Readers should use caution when interpreting these results as CMS collects Medicaid and CHIP data for programmatic purposes only, not for public health surveillance. Given the complex process of states collecting, processing, and transmitting claims via T-MSIS, it can take nearly 7 months for CMS to receive 90% of claims. Therefore, this delay between when a service occurs and when it is reflected in TAF, or the “claims lag,” may impact the accuracy of the results. The length of the lag depends on the submitting state, claim type, and delivery system. It is possible that there is a longer claims lag due to the pandemic. Further, in addition to claims lag, states vary widely in terms of the completeness and accuracy of their T-MSIS data submissions. Additional information about state data quality can be found here and here. 

Next Steps                                                                                                                                         

CMS is committed to working with our state partners to help close these gaps in Medicaid and CHIP children’s healthcare, and we will continue to monitor both the direct and indirect impacts of COVID-19 on the Medicaid and CHIP populations using TAF data.

### 

 

[1] Cornachione, Elizabeth, Robin Rudowitz, and Samantha Artiga. 2016. Children’s Health Coverage: The Role of Medicaid and CHIP and Issues for the Future. Kaiser Family Foundation. Available at: https://www.kff.org/report-section/childrens-health-coverage-the-role-of-medicaid-and-chip-and-issues-for-the-future-issue-brief/

[2] Musumeci, MaryBeth and Priya Chidambaram. 2019. Medicaid’s Role for Children with Special Health Care Needs: A Look at Eligibility, Services, and Spending. Kaiser Family Foundation. Available at: 

                                                                                                                                            

Source: Centers for Medicare & Medicaid Services (CMS).

https://www.cms.gov/newsroom/fact-sheets/fact-sheet-service-use-among-medicaid-chip-beneficiaries-age-18-and-under-during-covid-19

Centers for Medicare & Medicaid Services (CMS) issued the above News Release on September 23, 2020.

William M. Kelly, M.D., Inc And Omega Imaging, Inc. Agree To Pay $5 Million To Resolve Alleged False Claims For Unsupervised And Unaccredited Radiology Services

Department of Justice
Office of Public Affairs
FOR IMMEDIATE RELEASE
Wednesday, September 9, 2020

William M. Kelly, M.D., Inc And Omega Imaging, Inc. Agree To Pay $5 Million To Resolve Alleged False Claims For Unsupervised And Unaccredited Radiology Services

William M. Kelly Inc. and Omega Imaging Inc., together, operate 11 radiology facilities in Southern California, have agreed to pay the United States $5 million to resolve allegations that they violated the False Claims Act (FCA) by knowingly submitting claims to Medicare and the military healthcare program, TRICARE, for unsupervised radiology services and services provided at unaccredited facilities, the Department of Justice announced today.

“Today’s settlement demonstrates the department’s unrelenting commitment to protect the public fisc and patient safety,” said Acting Assistant Attorney General Jeffrey Clark of the Department of Justice’s Civil Division.  “The department will aggressively pursue unscrupulous healthcare providers who cut corners that could jeopardize the health and safety of Medicare and TRICARE beneficiaries.” 

“Patients rightly expect that medical providers follow the proper procedures and protocol when administering complex treatments to ensure patient safety,” said Timothy B. DeFrancesca, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services.  “Working with our law enforcement partners we remain steadfast in our commitment to uphold the integrity of government health programs.”

The settlement resolves allegations that the defendants submitted claims for CT scans and MRIs involving contrast injections that were not properly supervised by a physician.  Applicable program rules require a physician to be present in the office suite when a patient undergoes an examination that involves the administration of intravenous contrast material.  The defendants allegedly performed and billed for these procedures when no supervising physician was present in the office suite.  The settlement also resolves allegations that a certain number of the defendants’ facilities lacked accreditation.

Contemporaneous with the settlement, William M. Kelly, Inc. and Omega Imaging Inc. entered into a three-year Integrity Agreement (IA) with the Department of Health and Human Services Office of Inspector General requiring, among other things, the implementation of a risk assessment and internal review process designed to identify and address evolving compliance risks.  The IA requires training, auditing, and monitoring designed to address the conduct alleged in the case.

The settlement, which was based on the defendants’ ability to pay, resolves allegations originally brought in a lawsuit filed under the qui tam, or whistleblower, provisions of the FCA by Syd Ackerman, who was formerly employed by the defendants.  The FCA permits private parties to sue on behalf of the government for false claims and to receive a share of any recovery.  The FCA permits the United States to intervene in such a lawsuit, as it did in part here.  Mr. Ackerman will receive approximately $925,000 of the settlement proceeds.

This settlement was the result of a coordinated effort by the Civil Division’s Commercial Litigation Branch; the U.S. Attorney’s Office for the Central District of California; the Department of Health and Human Services, Office of Counsel to the Inspector General and Office of Investigations; the Defense Criminal Investigative Service; and the Defense Health Agency Office of General Counsel. The qui tam case is captioned United States ex rel. Syd Ackerman v. William M. Kelly, M.D., Inc. and Omega Imaging, Inc., No. EDCV 13-02195 JGB (DTBx) (C.D. Cal.). 

The claims resolved by the settlement are allegations only, and there has been no determination of liability.

Topic(s): 
False Claims Act
Component(s): 
Civil Division
Press Release Number: 
20-900
Updated September 14, 2020

                                                                                                                                            

Source: U.S. Department of Justice.

https://www.justice.gov/opa/pr/william-m-kelly-md-inc-and-omega-imaging-inc-agree-pay-5-million-resolve-alleged-false-claims

U.S. Department of Justice issued the above News Release on September 9, 2020.

Ladera Ranch self-storage management company fined $250,000 for unlicensed activity

News: 2020 Press Release

For Release: September 4, 2020
Media Calls Only: 916-492-3566
Email Inquiries: cdipress@insurance.ca.gov
Ladera Ranch self-storage management company fined $250,000

ORANGE, Calif. - The California Department of Insurance fined self-storage company, SmartStop Asset Management, LLC, $250,000 in monetary penalties for offering and selling more than $2.1 million in insurance products to its renters without an insurance license.

“Companies that are not properly licensed to transact insurance in California place policyholders at risk because the insurers have not met the standards required under state law,” said Insurance Commissioner Ricardo Lara. “In this case, my Department’s investigation ended this illegal activity to protect California renters throughout the state.”

SmartStop Asset Management, LLC and its affiliates, collectively “SmartStop”, control, manage, or contract with other entities to manage self-storage facilities that are leased to California renters.

On July 27, 2020, the Department issued a Cease and Desist order to SmartStop, requiring the unlicensed company to immediately stop selling insurance products to their California storage unit renters. The Cease and Desist Order alleges between October 2017 and July 2019, SmartStop offered and sold approximately 19,500 insurance policies to California consumers without an insurance license from the Department as required by law.

The Department’s investigation discovered SmartStop charged renters more than $2.1 million for renters’ insurance, retaining more than $1.8 million as operating fees. It was not disclosed to renters that they would be paying high fees to SmartStop for insurance that actually cost far less.

# # #


The California Department of Insurance, established in 1868, is the largest consumer protection agency in California. Insurers collect $310 billion in premiums annually in California. Since 2011 the California Department of Insurance received more than 1,000,000 calls from consumers and helped recover over $469 million in claims and premiums. Please visit the Department of Insurance website at www.insurance.ca.gov. Non-media inquiries should be directed to the Consumer Hotline at 800-927-4357. Teletypewriter (TTY), please dial 800-482-4833.

                                                                                                                                            

Source: California Department of Insurance.

http://www.insurance.ca.gov/0400-news/0100-press-releases/2020/release085-2020.cfm

California Department of Insurance issued the above Press Release on September 4, 2020.

Commissioner Lara urges insurance companies to cover reimbursement costs for those displaced during wildfires

News: 2020 Press Release

For Release: September 3, 2020
Media Calls Only: 916-492-3566
Email Inquiries: cdipress@insurance.ca.gov
Commissioner Lara urges insurance companies to cover reimbursement costs for those displaced during wildfires

LOS ANGELES, Calif. — To assist Californians displaced by the current and recent wildfires throughout the state, Insurance Commissioner Ricardo Lara issued a Notice to all California property and casualty insurance companies urging them to cover Additional Living Expenses (ALE) for those policyholders who remain under mandatory evacuation or whose homes are otherwise inaccessible or uninhabitable due to the wildfires.

“When people are told to get out of harm’s way by first responders, they should be able to access insurance benefits, not be forced to pay out of pocket for necessary emergency costs when they are still under evacuation orders or without water or power,” said Commissioner Lara. “While I have sponsored legislation to address this issue, people need help now to recover from these devastating fires.”

All homeowners’ insurance policies provide benefits for loss of use or ALE to cover the extra costs associated with temporary lodging, transportation, clothing, and other necessities caused by a covered peril, such as a wildfire, that renders the home uninhabitable or inaccessible. Homeowners’ insurance policies also cover ALE if access to the home is restricted in cases where a civil authority has issued mandatory evacuation orders from the recent and ongoing wildfires impacting most of the state.

“When you’ve lost the use of your home due to a disaster, you have a reasonable expectation that the insurance you’ve been paying for will cover your temporary living expenses,” said Amy Bach, Executive Director of United Policyholders. “That’s one of the primary benefits of home insurance. We commend Commissioner Lara for reminding insurers of this very basic, important obligation.”

The Department of Insurance has received numerous complaints from policyholders who are hearing from insurance companies that their ALE benefits are being terminated after the initial two weeks unless the insurance company can verify, or the policyholder can prove, that the policyholder’s property suffered damage due to the fires and is still currently uninhabitable, even though mandatory evacuation orders are still in effect in some areas. The Department has also received several related consumer complaints of ALE benefits being discontinued when their homes are uninhabitable due to lost power or water service as a result of the wildfires.

Commissioner Lara sponsored Senate Bill 872, authored by Senator Bill Dodd, this legislative year to address these and other insurance claims issues following a wildfire emergency. The bill has passed the State Legislature with strong bipartisan support and is now heading to the Governor for his consideration. SB 872 would allow for an extension of the two-week limit that is currently in place, and allow for coverage when a home is not damaged but is otherwise uninhabitable for another reason, such as having no electricity or water service caused by a covered peril. The bill would also require an advance payment of no less than four months for costs for living expenses and mandate an advance payment of no less than 25 percent of a policy limit for lost contents without submission of an inventory form, among other consumer protections.

# # #

Media note:

  • Notice on Continuation of Additional Living Expense (ALE) Benefits


The California Department of Insurance, established in 1868, is the largest consumer protection agency in California. Insurers collect $310 billion in premiums annually in California. Since 2011 the California Department of Insurance received more than 1,000,000 calls from consumers and helped recover over $469 million in claims and premiums. Please visit the Department of Insurance website at www.insurance.ca.gov. Non-media inquiries should be directed to the Consumer Hotline at 800-927-4357. Teletypewriter (TTY), please dial 800-482-4833.

                                                                                                                                            

Source: California Department of Insurance.

http://www.insurance.ca.gov/0400-news/0100-press-releases/2020/release084-2020.cfm

California Department of Insurance issued the above Press Release on September 3, 2020.

U.S. DEPARTMENT OF LABOR RELEASES WORK-RELATED INJURY AND ILLNESS DATA

WASHINGTON, DC – The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) has released work-related injury and illness data electronically submitted by employers. The agency has posted Form 300A data for calendar years 2016, 2017 and 2018, as well as a data dictionary.

The release follows two rulings in Freedom of Information Act (FOIA) cases. See Center for Investigative Reporting v. Department of Labor, No. 4:18-cv-02414-DMR, 2020 WL 2995209 (N.D. Cal. June 4, 2020); Public Citizen Foundation v. United States Department of Labor, No. 1:18-cv-00117 (D.D.C. June 23, 2020).

Electronic submissions are required of establishments with 250 or more employees that are currently required to keep OSHA injury and illness records, and establishments with 20-249 employees that are classified in specific industries with historically high rates of occupational injuries and illnesses.

The fact that an employer provided data does not mean that the employer is at fault, that the employer has violated any OSHA requirements, that OSHA has found any violations, or that the employee is eligible for workers’ compensation or other benefits.

For more information, and a link to the Injury Tracking Application, visit the Injury Tracking Application Electronic Submission of Injury and Illness Records to OSHA.

Under the Occupational Safety and Health Act of 1970, employers are responsible for providing safe and healthful workplaces for their employees. OSHA’s role is to help ensure these conditions for America’s working men and women by setting and enforcing standards, and providing training, education and assistance. For more information, visit www.osha.gov.

The mission of the Department of Labor is to foster, promote, and develop the welfare of the wage earners, job seekers, and retirees of the United States; improve working conditions; advance opportunities for profitable employment; and assure work-related benefits and rights.

Agency:

 

Occupational Safety & Health Administration
Date:

 

September 4, 2020
Release Number:

 

20-1659-NAT
Contact: Megan Sweeney
Phone Number:

 

202-693-4661
Email:

 sweeney.megan.p@dol.gov

                                                                                                                                            
Source: United States Department of Labor.

https://www.dol.gov/newsroom/releases/osha/osha20200904

United States Department of Labor issued the above News Release on September 4, 2020.

U.S. Transportation Secretary Elaine L. Chao Makes Historic Announcement on America’s Freight System

Thursday, September 3, 2020

WASHINGTON – U.S. Secretary of Transportation Elaine L. Chao today announced the release of the first-ever National Freight Strategic Plan (NFSP). It is the latest effort by the Department and the Trump Administration to strengthen America’s economic competitiveness. The NFSP lays out a vision for long-term investments in infrastructure, the workforce, and other essential parts of the freight system.

“The Department is unveiling the first-ever National Freight Strategic Plan so that the U.S. can maintain our competitive edge across major industries like agriculture, manufacturing, energy production and E-commerce,” said U.S. Transportation Secretary Elaine L. Chao. 

Every day, America’s transportation network moves more than 51 million tons of freight and energy products valued at nearly $52 billion via highways, railways, ports and inland waterways, pipelines, and airports. The growth in freight demand due to increasing use of e-commerce and global supply chains in recent years has strained our freight system, and could threaten the competitive advantage of American businesses. As these supply chains continue to spread across the world, America’s ability to compete could be limited by inadequate infrastructure and a lack of preparation for incorporating innovative technologies. 

The NFSP provides a clear path to improve the safety, security, and resilience of the national freight system. It also details how we can modernize freight infrastructure and operations to grow the economy and increase competitiveness. Additionally, the NFSP lays out a plan to prepare for the future by supporting the development of data, technologies, and workforce capabilities that improve freight system performance.

To learn more about the NFSP, visit transportation.gov/freight/NFSP

Secretary Chao’s remarks can be viewed HERE.

###

                                                                                                                                            

Source: U.S. Department of Transportation.

https://www.transportation.gov/briefing-room/us-transportation-secretary-elaine-l-chao-makes-historic-announcement-americas

U.S. Department of Transportation issued the above Press Release on September 3, 2020.

New Hampshire Will Experience Continued Stability in Workers’ Compensation Market for 2021

FOR IMMEDIATE RELEASE: September 8, 2020

Contact: Eireann Aspell Sibley, communications director; (603) 271-3781; eireann.sibley@ins.nh.gov 

New Hampshire Will Experience Continued Stability in Workers’ Compensation Market for 2021 

CONCORD, NH – The New Hampshire workers’ compensation insurance market will continue to experience historically low rates in 2021. Today, the New Hampshire Insurance Department approved a rate proposal filed by the National Council on Compensation Insurance (NCCI) that will reduce voluntary loss costs by 1.8% on average. 

Loss costs in the voluntary market have decreased in each of the last eight years and 50% cumulatively over this period. The loss cost is the portion of an employer’s insurance premium that pays claims costs for work-related injuries. The loss cost is ultimately used by insurers to set rates and premiums in the voluntary market. All insurers writing voluntary workers compensation in New Hampshire are required to use the new loss costs, and are permitted to make adjustments for their own company expenses. 

“It is encouraging to see continued stability in the workers’ compensation market,” said Insurance Department Commissioner Chris Nicolopoulos. “Continued low insurance rates provide stability for employers during a time of financial uncertainty for many New Hampshire businesses.” 

The new rates will apply to policies effective starting on January 1, 2021. 

The NCCI is a licensed rating and statistical organization that gathers data, analyzes industry trends, and prepares workers compensation rate filings for New Hampshire and many other states. 

The New Hampshire Insurance Department Can Help 

The New Hampshire Insurance Department’s mission is to promote and protect the public good by ensuring the existence of a safe and competitive insurance marketplace through the development and enforcement of the insurance laws of the State of New Hampshire. Contact us with any questions or concerns you may have regarding your insurance coverage at 1?800? 852?3416 or (603) 271?2261, or by email at consumerservices@ins.nh.gov. For more information, visit www.nh.gov/insurance. 

### 

                                                                                                                                            

Source: New Hampshire Insurance Department.

https://www.nh.gov/insurance/media/pr/2020/documents/press-release-workers-comp-filing.pdf

New Hampshire Insurance Department issued the above Press Release on September 8, 2020.

West Virginia Hospital Agrees To Pay $50 Million To Settle Allegations Concerning Improper Compensation To Referring Physicians

Department of Justice
Office of Public Affairs
FOR IMMEDIATE RELEASE
Wednesday, September 9, 2020

West Virginia Hospital Agrees To Pay $50 Million To Settle Allegations Concerning Improper Compensation To Referring Physicians

Wheeling Hospital Inc., an acute care hospital located in Wheeling, West Virginia, has agreed to pay the United States a total of $50,000,000 to resolve claims that it violated the False Claims Act by knowingly submitting claims to the Medicare program that resulted from violations of the Physician Self-Referral Law and the Anti?Kickback Statute, the Justice Department announced today.

The Physician Self?Referral Law, commonly known as the Stark Law, prohibits a hospital from billing Medicare for certain services referred by physicians with whom the hospital has a financial relationship, unless that relationship satisfies one of the law’s statutory or regulatory exceptions.  The Anti?Kickback Statute prohibits offering or paying remuneration to induce the referral of items or services covered by Medicare, Medicaid, and other federally funded programs.  Both the Stark Law and the Anti-Kickback Statute are intended to ensure that medical decision-making is not compromised by improper financial incentives and is instead based on the best interests of the patient.

“Improper financial arrangements between hospitals and physicians can influence the type and amount of health care that is provided,” said Acting Assistant Attorney General Jeffrey Bossert Clark of the Department of Justice’s Civil Division. “The department is committed to taking action to eliminate improper inducements that can corrupt the integrity of physician decision-making.”

“Our office is committed to ensuring that health care providers in the Northern District of West Virginia abide by the law,” said Bill Powell, U.S. Attorney for the Northern District of West Virginia.  “We are pleased this settlement will enable Wheeling Hospital to resolve these prior False Claims Act violations and continue to provide a full range of healthcare services to patients in the area.”

“Medicare and Medicaid beneficiaries trust that their healthcare providers will make decisions based on sound medical judgment,” said Scott W. Brady, U.S. Attorney for the Western District of Pennsylvania.  “Our office will take decisive action against any medical providers which betray that trust and make medical decisions based on their own financial interests.  Our seniors deserve nothing less.”

“Improper inducements made to physicians can interfere with medical decision-making and undermine the public’s trust in the health care system,” said Special Agent in Charge Maureen R. Dixon of the Department of Health and Human Services Office of Inspector General.  “Our agency will continue to investigate those who seek to improperly enrich themselves at the expense of public safety and federal health care programs.”

In this case, the United States alleged that, from 2007 to 2020, under the direction and control of its prior management, R&V Associates Ltd. and Ronald Violi, Wheeling Hospital systematically violated the Stark Law and Anti-Kickback Statute by knowingly and willfully paying improper compensation to referring physicians that was based on the volume or value of the physicians’ referrals or was above fair market value.

The settlement announced today stems from a whistleblower complaint filed in 2017 by a former Executive Vice President of Wheeling Hospital, Louis Longo, pursuant to the qui tam provisions of the False Claims Act, which permit private persons to bring a lawsuit on behalf of the government and to share in the proceeds of the suit.  The Act also permits the government to intervene and take over the lawsuit, as it did in this case as to some of Longo’s allegations.  Longo will receive $10,000,000 of the settlement. 

The United States’ intervention and settlement in this matter illustrates the government’s emphasis on combating healthcare fraud.  One of the most powerful tools in this effort is the False Claims Act.  Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services, at 800?HHS?TIPS (800-447-8477).

This matter was handled on behalf of the government by the Justice Department’s Civil Division, the U.S. Attorney’s Offices for the Northern District of West Virginia and Western District of Pennsylvania, the Department of Health and Human Services Office of the Inspector General, and the Federal Bureau of Investigation.   

The case is captioned United States of America ex rel. Louis Longo v. Wheeling Hospital, Inc. et al., No. 19-cv-192 (N.D.W. Va.).  The claims resolved by this settlement are allegations only and there has been no determination of liability.

Topic(s): 
False Claims Act
Component(s): 
Civil Division
Press Release Number: 
20-896
Updated September 9, 2020

                                                                                                                                            

Source: U.S. Department of Justice.

https://www.justice.gov/opa/pr/west-virginia-hospital-agrees-pay-50-million-settle-allegations-concerning-improper

U.S. Department of Justice issued the above Press Release on September 9, 2020.

$21.5 Million in Health Insurance Rebates for Individuals and Small Businesses

Thousands of Highmark 2019 plan participants and groups to receive checks

After announcing a reduction of Delaware Health Insurance Marketplace rates for the upcoming enrollment year, Insurance Commissioner Trinidad Navarro has more good news for residents who purchase insurance on the Delaware Health Insurance Marketplace, those who purchase Highmark Blue Cross Blue Shield Delaware plans outside of the exchange in the individual market, and for Highmark small group policyholders, announcing more than $21.5 million in rebates for 2019 participants.

“Now, more than ever, we need to make sure that every resident and small business can afford the health insurance they need for their families and employees. These rebates, combined with the ACA health insurance rate reduction for the coming year, do just that,” said Commissioner Navarro. “This is just one of many ways we are working to reduce the cost-of-care our residents experience in the health care system.

For the first time in the history of Delaware’s individual health insurance market, more than $12.6 million will be returned to 19,273 policyholders, with the average rebate being $656. Highmark small groups, often small businesses, will receive more than $8.8 million in cumulative return. 2,779 groups will receive an average rebate of $3,198, with more than 175 groups receiving rebates over $10,000. Employers can consider using these dollars to enhance benefits, reduce premiums for employees in future policy years or provide refunds directly to group health plan participants.

Communications will be sent to policyholders in September and checks for both individual policyholders and small groups will be sent the week of September 21. Those in the individual market with rebate questions can contact Highmark at 800-544-6679. Small group employers with rebate questions can contact their insurance producer, or Highmark at 800-241-5704.

These rebates are required by the Delaware Department of Insurance according to Medical Loss Ratio (MLR) measurements set by the Affordable Care Act, which are meant to ensure that insurers are spending a majority of premiums on health claims and clinical services, not taking those dollars for profit or administrative expenses. The rebate system creates balance when data shows that this ratio was off in a previous year. Not every policy will receive a rebate. MLR review for the 2020 plan year will shine a light on changes in insurance usage due to COVID-19 and will be released in 2021.

On August 31, Commissioner Navarro announced the Delaware Health Insurance Marketplace would see an average decrease in rates of 1% for individual plans. Highmark small group plans will see an average premium decrease of 3%.

                                                                                                                                            

Source: Delaware’s Government, Delaware Department of Insurance.

https://news.delaware.gov/2020/09/03/21-5-million-in-health-insurance-rebates-for-individuals-and-small-businesses/

Delaware’s Government issued the above News Release on September 3, 2020.

Bakersfield driver charged for alleged insurance fraud after an auto collision

News: 2020 Press Release

For Release: September 2, 2020
Media Calls Only: 916-492-3566
Email Inquiries: cdipress@insurance.ca.gov
Bakersfield driver charged for alleged insurance fraud after an auto collision

BAKERSFIELD, Calif. — David Lee Williams Jr., 27, self-surrendered today at the Kern County Superior Court after being charged with two counts of felony insurance fraud and one misdemeanor count of filing a false police report for allegedly falsifying an insurance claim in order to receive an undeserved payout from Farmers Insurance.

An investigation by the Department of Insurance revealed Williams filed a claim with Farmers Insurance on April 1, 2019, and claimed he was traveling north on Highway 99 in Bakersfield when his vehicle was struck by another unknown vehicle at a high rate of speed. Williams and two of his passengers sought medical treatment for injuries they sustained.

Williams later filed an accident report with the California Highway Patrol and told Farmers Insurance he was traveling at 55 miles per hour in the fast lane when he noticed two cars racing behind him. Williams stated he signaled to merge to the right but his vehicle was struck causing him to swerve to the right.

In June 2019, Farmers Insurance hired an accident reconstructionist who reviewed the accident report filed by Williams along with photographs taken of Williams’ vehicle by Farmers Insurance. The accident reconstructionist determined the damage to Williams’ vehicle was not consistent with an impact from another vehicle at a high rate of speed and was not consistent with a rear-end collision. 

Williams is scheduled to return to court on October 7, 2020. This case is being prosecuted by Kern County District Attorney’s Office Deputy District Attorney Sebastien Bauge.

# # #


The California Department of Insurance, established in 1868, is the largest consumer protection agency in California. Insurers collect $310 billion in premiums annually in California. Since 2011 the California Department of Insurance received more than 1,000,000 calls from consumers and helped recover over $469 million in claims and premiums. Please visit the Department of Insurance website at www.insurance.ca.gov. Non-media inquiries should be directed to the Consumer Hotline at 800-927-4357. Teletypewriter (TTY), please dial 800-482-4833.

                                                                                                                                            

Source: California Department of Insurance.

http://www.insurance.ca.gov/0400-news/0100-press-releases/2020/release083-2020.cfm

California Department of Insurance issued the above Press Release on September 2, 2020.