A federal jury in Tampa found four former executives of WellCare Health Plans Inc., a health maintenance organization (HMO) operator, guilty of various charges, including health care fraud, making false statements relating to health care matters and making false statements to a law enforcement officer.
A former WellCare Chief Executive Officer was convicted of two counts of health care fraud; a former WellCare Chief Financial Officer was convicted of two counts of making false statements relating to health care matters and two counts of health care fraud; a former vice president of Harmony Behavioral Health Inc. (a wholly-owned subsidiary of WellCare) was found guilty of two counts of health care fraud; and a former WellCare vice president of medical economics was found guilty of making false statements to a law enforcement officer.
On March 2, 2011, a federal grand jury sitting in Tampa returned an indictment charging the four men with various federal criminal violations related to a scheme to defraud the Florida Medicaid program, from the summer of 2003 through the fall of 2007, by making false and fraudulent statements relating to expenditure information for behavioral health care services.
WellCare operates HMOs in several states targeted for government-sponsored health care benefit programs like Medicaid. Two WellCare HMOs operating in Florida, StayWell and Healthease, contracted with the Agency for Health Care Administration (AHCA), the Florida agency which administers the Medicaid program, to provide Florida Medicaid program recipients with an array of services, including behavioral health services.
In 2002, Florida enacted a statute that required Florida Medicaid HMOs to expend 80 percent of the Medicaid premium paid for certain behavioral health services upon the provision of those services. In the event that the HMO expended less than 80 percent of the premium, the difference was required to be returned to AHCA. As part of the scheme, the defendants falsely and fraudulently submitted inflated expenditure information in the company’s annual reports to AHCA, in order to reduce the WellCare HMOs’ contractual payback obligations for behavioral health care services.
On May 5, 2009, the government filed related charges in an information and deferred prosecution agreement (DPA) against WellCare. Under that DPA, WellCare was required to pay $40 million in restitution, forfeit another $40 million to the United States and cooperate with the government’s criminal investigation. The company complied with all of the requirements of the DPA. As a result, the information was later dismissed by the court following a government motion.
In May 2009, an information and plea agreement for a former WellCare analyst was unsealed. In his plea agreement, he admitted to participating in the scheme to defraud the Medicaid program and agreed to cooperate in the government’s investigation. At trial, the analyst provided extensive and detailed testimony explaining the complex scheme. Other former WellCare executives provided additional testimony about the four individuals' roles in the scheme.
The maximum penalty for each of the health care fraud counts is 10 years in prison. The maximum penalty for all other counts is five years in prison. A sentencing date has not yet been set.
WellCare’s former general counsel was severed from the trial in February of this year. He will be tried separately, at a later date. Defendants are presumed innocent until proven guilty in a court of law.
The jury returned not guilty verdicts with respect to several counts and was unable to reach a verdict on others. The judge declared a mistrial as to those counts on which the jury was deadlocked. The Justice Department will decide, at a later date, whether to retry the individuals on those charges.
See the DOJ Announcement