The Inland Empire Health Plan kept $320 million that it should have given back to the federal government, a federal lawsuit claims.

IEHP is responsible for providing Medi-Cal to 1.6 million people throughout the Inland Empire—35% of Riverside and San Bernardino Counties’ combined population.

The complaint claims that IEHP committed fraud by putting money for the medical care of new Medi-Cal patients towards non-medical expenses or the care of existing patients.

The suit also alleges that IEHP created bonus programs for regional health systems using the Medi-Cal expansion money, and used the federal money as a bargaining chip to negotiate better care rates for people with IEHP insurance.

The agency ended up giving the federal government $30 million back. The complaint charges the final sum of falling $320 million short.

“Today’s lawsuit against IEHP shows our steadfast commitment to hold accountable insurers that brazenly compromise the Medicaid system,” said Acting United States Attorney Bill Essayli. “We will take every measure to restore integrity and accountability to the Medicaid system and ensure that patient care – not financial gain – is the primary focus of our health care system.”

The agency’s attorney, Winston Chan of Gibson, Dunn & Crutcher, wrote in an emailed statement that the benefits paid through the program were already approved by regulators.

“The allegations are a brazen attempt at revisionist history that is not only wrong as to the facts and law, but also particularly galling in light of the federal government’s wider attacks on state Medicaid funding,” he wrote.

The federal government gave IEHP funds to expand Medi-Cal from Jan. 1, 2014 to June 30, 2016, according to the suit. At least 85% of the funding was intended to pay for the initially high costs of providing healthcare to the newly insured. Any funding from the program not used for those medical costs would have to be paid back to the federal government, the suit says. The complaint claims that IEHP committed fraud by putting the money towards non-medical expenses or the care of people already covered by Medi-Cal. 

“Every MCE dollar that IEHP improperly spent on ineligible expenses—such as other patient populations, consultants, or lawyers—was effectively an extra dollar in IEHP’s pocket because IEHP did not have to spend money from its general budget,” the suit says.

The agency spent $50 million of the funds to attempt to create a health record system for the geographic area served by the IEHP, the suit said. Instead of paying the company, Huron Consulting Group, directly with the funds, IEHP administrators paid providers, who then paid Huron, the complaint said. 

The complaint cited an email from former IEHP’s Chief Executive Officer Bradley Gilbert:

“The funds have to flow through the two county hospitals from IEHP so I can get credit for them as medical costs or the dollars go back to the state. So we will have to set it up so that IEHP pays the hospitals and then the money is used for the data integration effort,” the email said.

A June 3, 2015, email from Gilbert, included in the complaint, discussed the difficulty of spending all the money from the government.

“I will have to distribute hundreds of millions of dollars beyond actual medical costs,” the complaint quotes Gilbert.

The post Department of Justice lawsuit claims Inland Empire Health Plan committed Medi-Cal fraud appeared first on The Hemet & San Jacinto Chronicle.

The complaint, filed in the Central District of California, alleges violation of the federal False Claims Act, according to the DOJ.

The organization contracts with California’s Department of Health Care Services to provide services to residents of San Bernardino and Riverside counties under state’s Medicaid program, known as Medi-Cal.

“Today’s lawsuit against IEHP shows our steadfast commitment to hold accountable insurers that brazenly compromise the Medicaid system,” Acting United States Attorney Bill Essayli said. “We will take every measure to restore integrity and accountability to the Medicaid system and ensure that patient care – not financial gain – is the primary focus of our health care system.”

IEHP attorney calls allegations “misguided” and “galling”

IEHP representatives denied wrongdoing.

“IEHP strongly disagrees with the DOJ allegations and is prepared to defend our efforts through the appropriate legal process,” the organization said in a written statement..

Attorney Winston Chan of Gibson, Dunn & Crutcher LLP, who represents the company, said the complaint was unfounded.

“Through this misguided civil legal dispute, the federal government is trying to contest Medi-Cal health benefits paid out a decade ago and that were previously disclosed to and approved by regulators, with full transparency,” he said. “The allegations are a brazen attempt at revisionist history that is not only wrong as to the facts and law, but also particularly galling in light of the federal government’s wider attacks on state Medicaid funding.”

The attorney also pointed out that the state of California did not join the federal government as a plaintiff in the case.

“Conspicuously absent from the lawsuit… is any allegation whatsoever that Inland Empire Health Plan or its personnel retained any of the funds in question or that providers serving the neediest Californians did not actually receive every dollar awarded to them,” according to Chan. “We look forward to taking this case to court and exposing the mistaken assumptions, flawed reasoning, and false conjecture that is rife throughout the allegations, and ensuring that our client is not distracted from its not-for-profit mission to heal and inspire its 1.5 million underserved members in Riverside and San Bernardino counties.”

What does the lawsuit against IEHP allege?

The federal lawsuit contends that IEHP submitted false statement to Medi-Cal and knowingly retaining overpayments, according to a DOJ statement.

Following an expansion of Medi-Cal in 2014, the first three years of the program were fully funded by the federal government, prosecutors said.

Under its contract with state officials, if IEHP did not spend at least 85% of the funds on “allowed medical expenses,” the health plan was required to repay the state the difference between 85% of the funding and actual expenditures. The state was then required to pay those funds back to the federal government.

According to the DOJ statement, “IEHP developed schemes to misuse surplus Medi-Cal Expansion funding, falling into two broad categories: (1) sham incentive programs and (2) an extra-contractual retroactive rate increase.”

Prosecutors allege the organization misspent funds for “impermissible purposes,” including administrative expenses and “simply giving away federal funding in exchange for no value in return.”

“The complaint further alleges that IEHP was motivated by a desire to conserve its other funding, thus enriching itself,” the statement said. “IEHP officials “deceived the state” through false statements, “which it knew would be relayed to the federal government—about the nature, timing, and purpose of its payments to providers.”

The complaint accuses IEHP of “wrongfully retain at least $320 million in federal funding that it should have returned.”

The services provided by Medicaid and Medical are vital, Deputy Assistant Attorney General Brenna Jenny said.”

“Today’s complaint demonstrates our continued commitment to protect the integrity of the Medicaid program, and the taxpayer dollars that support it, from health insurers that knowingly seek to divert program funds for their own financial benefit.”

The post Feds sue Inland Empire Health Plan over alleged false claims to Medi-Cal appeared first on The Hemet & San Jacinto Chronicle.

One estimate from state health officials suggests that as many as 3.4 million people could lose their insurance through what Gov. Gavin Newsom calls the “labyrinth of manual verification,” which involves Medi-Cal recipients proving every six months that they are working, going to school or volunteering at least 80 hours per month.

“It’s going to be much harder to stay insured,” said Martha Santana-Chin, the head of L.A. Care Health Plan, a publicly operated health plan that serves about 2.3 million Medi-Cal patients in Los Angeles County.

She said that as many as 1 million people, or about 20% to 40% of its members, could lose their coverage.

The work requirement will be the first imposed nationwide in the six-decade history of Medicaid, the program that provides free and subsidized health insurance to disabled and low-income Americans.

It’s relatively uncharted territory, and it’s not yet clear how the rules will shake out for the 5.1 million people in California who will be required to prove that they are working in order to qualify for Medi-Cal, the state’s version of Medicaid.

After the 2026 midterm elections, millions of healthy adults will be required to prove every six months that they meet the work requirement in order to qualify for Medicaid. The rule applies to those whose income is between 100% and 138% of the federal poverty limit, a group that became eligible for Medicaid when the program was expanded under the Affordable Care Act.

The new mandate spells out other exceptions, including for people who are pregnant, in addiction treatment or caring for children under 14.

Democrats have long argued that work requirements generally lead to eligible people losing their health insurance due to bureaucratic hurdles. Republicans say that a work requirement will encourage healthy people to get jobs and preserve Medicaid for those who truly need it.

“If you clean that up and shore it up, you save a lot of money,” said House Speaker Mike Johnson of Louisiana. “And you return the dignity of work to young men who need to be out working instead of playing video games all day.”

Only three U.S. states have tried to implement work requirements for Medicaid recipients: New Hampshire, Arkansas and Georgia. One study found that in the first three months of the Arkansas program, more than 18,000 people lost health coverage.

People can lose coverage a variety of ways, said Joan Alker, a Georgetown University professor who studies Medicaid. Some people hear that the rules have changed and assume they are no longer eligible. Others struggle to prove their eligibility because their income fluctuates, they are paid in cash or their jobs don’t keep good payroll records. Some have problems with the technology or forms, she said, and others don’t appeal their rejections.

Of the 15 million people on Medi-Cal in California, about one-third will be required to prove they are working, the state said. Those people earn very little: less than $21,000 for a single person and less than $43,000 for a household of four.

The state’s estimate of 3.4 million people losing coverage is a projection based on what happened in Arkansas and New Hampshire.

But those programs were brief, overturned by the courts and weren’t “a coordinated effort among the states to figure out what the best practices are,” said Ryan Long, the director of congressional relations at the Paragon Health Institute, a conservative think tank that has become influential among congressional Republicans.

Long said advancements in technology and a national emphasis on work requirements should make work verification less of a barrier. The budget bill includes $200 million in grants for states to update their systems to prepare, he said.

Arguments from liberal groups that people will lose healthcare are a “straw man argument,” Long said: “They know that the public supports work requirements for these benefits, so they can’t come out and say, ‘We don’t support them.’”

A poll by the health research group KFF found this year that 62% of American adults support tying Medicaid eligibility to work requirements.

The poll also found that support for the policy drops to less than 1 in 3 people when respondents hear “that most people on Medicaid are already working and many would risk losing coverage because of the burden of proving eligibility through paperwork.”

In June, Newsom warned that some Californians could be forced to fill out 36 pages of paperwork to keep their insurance, showing reporters an image of a stack of forms with teal and gold accents that he described as “an actual PDF example of the paperwork that people will have to submit to for their eligibility checks.”

Many Californians already are required to fill out that 36-page form or its online equivalent to enroll in Medi-Cal and Covered California, the state’s health insurance marketplace.

Experts say it’s too soon to say what system will be used for people to prove their work eligibility, because federal guidance won’t be finalized for months.

Newsom’s office directed questions to the Department of Health Care Services, which runs Medi-Cal. A spokesperson there said officials are “still reviewing the full operational impacts” of the work requirements.

“The idea that you are going to get a paper submission every six months, I’m not sure people have to do that,” Long said.

Georgia is the only state that has implemented a lasting work requirement for Medicaid. Two years ago, the state made healthcare available to people who were working at least 80 hours per month and earned less than the federal poverty limit (about $15,000 for one person or $31,200 for a household of four).

More than 100,000 people have applied for coverage since the program’s launch in July of 2023. As of June of this year, more than 8,000 people were enrolled, according to the state’s most recent data.

The Medicaid program has cost more than $100 million so far, and of that, $26 million was spent on health benefits and more than $20 million was allocated to marketing contracts, KFF Health News reported. Democrats in Georgia have sought an investigation into the program.

The Inland Empire agency that provides Medi-Cal coverage for about 1.5 million people in San Bernardino and Riverside counties estimated that 150,000 members could lose their insurance as a result of work requirements.

Jarrod McNaughton, the chief executive of the Inland Empire Health Plan, said that California’s 58 counties, which administer Medi-Cal, “will be the ones at the precipice of piecing this together” but haven’t yet received guidance on how the eligibility process will be set up or what information people will have to provide.

Will it be done online? Will recipients be required to fill out a piece of paper that needs to be mailed in or dropped off? “We don’t really know the process yet, because all of this is so new,” Naughton said.

In the meantime, he said, the health plan’s foundation is working to make this “as least burdensome as possible,” working to improve community outreach and connect people who receive Medi-Cal insurance to volunteer opportunities.

The post Millions of Californians may lose health coverage because of new Medicaid work requirements appeared first on The Hemet & San Jacinto Chronicle.

The two-story, 33,000-square-foot space at 2050 N. Massachusetts Ave. will replace the existing center on Second Street when it opens in 2025.

“Today’s groundbreaking is more than a symbolic gesture – it’s about laying the foundation of hope and confirming our commitment to building healthy communities, caring for our neighbors and doing work for the greater good,” said Jarrod McNaughton, IEHP’s chief executive officer.

The San Bernardino CWC was the first of three Community Wellness Centers to open in the region, followed by Riverside and Victorville. All centers provide access to holistic health-based resources to IEHP members and non-members at no cost.

The new CWC will host amenities not available in the current 6,500-square-foot location, including:

• Six multi-purpose rooms that will double as accessible spaces open for the community to host meetings and gatherings.
• A state-of-the-art integrated teaching kitchen with seating up to 50.
• Five partner suites for integrated community-based organization (CBOs) partners to provide services to residents.
• A multi-media room with tools to accommodate tech-based learning and growth.
• An expanded class schedule.
• A children’s room and teen center for all-day programming.
  
  For many, CWCs have created lasting bonds between site staff and all who walk through each center’s doors.

The post IEHP’s newly announced Community Wellness Center adds more heart to the city of San Bernardino appeared first on The Hemet & San Jacinto Chronicle.

IEHP | Contributed

Inland Empire Health Plan (IEHP) has been recognized as one of the 100 Companies That Care® by PEOPLE Magazine and Great Place To Work®, ranking No. 87 on the national list – a first for the managed care health plan.

The national publication made the announcement on Wednesday, with the Rancho Cucamonga-based health organization listed among the likes of Comcast, NBC Universal, Target Corporation and CarMax.

“We are incredibly honored to be among these top organizations who are leading the way in creating work environments where employee growth and wellness are vital components to their success,” said IEHP’s Chief Executive Officer Jarrod McNaughton. “At IEHP, we strive to ensure our mission, vision and values not only reflect the 1.6 million members we serve, but our thousands of team members and providers who work daily to move our company forward.”

“We are incredibly honored to be among these top organizations who are leading the way in creating work environments where employee growth and wellness are vital components to their success,” said IEHP’s Chief Executive Officer Jarrod McNaughton. “At IEHP, we strive to ensure our mission, vision and values not only reflect the 1.6 million members we serve, but our thousands of team members and providers who work daily to move our company forward.”

“Being part of PEOPLE’s Companies That Care® list is the reflection of the hard work our 3,000-plus team member family brings to the table each and every day, and we are excited to continue highlighting their successes through recognitions such as this one,” said IEHP’s Chief People Officer Supriya Sood.

The PEOPLE Companies That Care® list is highly competitive. Great Place To Work®, considered a global authority on workplace culture, selected the list based on over 1.3 million confidential employee survey responses and data from companies representing the experience of more than 7.5 million employees. Of those surveys, 1.1 million came from employees at companies eligible for this year’s list and these rankings are based on that feedback.

Survey responses reflect a comprehensive picture of the workplace experience. Honorees were selected based on their ability to offer positive outcomes for employees regardless of job role, race, gender, sexual orientation, work status or other demographic identifier.

Companies also submit essays which are validated by employee survey data to give a complete picture of the way an organization cares for its employees, its community and the planet. To be considered for the list, companies must first be Great Places To Work Certified™ and have at least 10 U.S. employees. IEHP became certified in June for the third year in a row.

“This was the first year where we saw if companies meant it when they promised to put employees first,” said Michael C. Bush, CEO of Great Place To Work®. “Caring for people isn’t a byproduct or afterthought for the very best companies – it’s a core part of how they create value for their customers and communities.”

PEOPLE Magazine Editor-in-Chief Wendy Naugle added, “Never before have we seen the way we all work shift so dramatically. The companies on this list keep their employees and their communities front and center, while thinking about how we can work together better – and do better for our neighbors and our planet.”

Find your latest news here at the Hemet & San Jacinto Chronicle

The post Inland Empire Health Plan honored in PEOPLE’s 100 Companies That Care® list appeared first on The Hemet & San Jacinto Chronicle.

Inland Empire Health Plan (IEHP) Community Resource Centers (CRCs) are giving back to families in need this holiday season by hosting contactless, pull-up and pick-up drive thru events, distributing free toy gift sets for children ages 3-12 years on December 18. Gift sets will include three toys per child and will vary depending on age.

Events will be held at all three of the health plan’s community resource centers in Riverside, San Bernardino, and Victorville. Pre-registration is required. “The hardships and the loss our communities have felt this year have been tremendous,” said Delia Orosco, IEHP Victorville CRC manager. “As IEHP team members and community residents, it is our honor and privilege to support our neighbors in this way. We hope these toys will spark smiles and joy among families this season and that it serves as a reminder that we really are in this together.”

This is not the first time the health plan has used their three CRC’s to distribute resources to residents in need. Earlier this year, the health plan used the centers to distribute groceries and hygiene items, backpacks for school children, Thanksgiving turkeys and flu shots.

The health plan also continues to distribute groceries to residents weekly, valuing more than $1.5 million, since June. “While impacts of the pandemic have been devastating for many, it will not change the heart IEHP has for our communities,” said Cesar Armendariz, IEHP senior director of community health. “With our incredible teams and partners, we’ve been able to consistently support our communities this year and plan to continue to outreach and offer supportive services in the year to come.

It is our mission to heal and inspire the human spirit and we are committed to make that happen!”

Riverside Community Resource Center:

Date: Dec. 18

Location: 3590 Tyler St. Suite 101 Riverside, CA 92503

To register, call: 1-866-228-4347 press “3”

San Bernardino Community Resource Center:

Date: Dec. 18,

Location: 805 W. 2nd Street San Bernardino, CA 92410

To register, call: 1-866-228-4347 press “4”

Victorville Community Resource Center:

Date: Dec. 18

Location: 12353 Mariposa Rd Unit C2 and C3 Victorville, CA 92395

To register, visit: ConnectIE.org.

-Inland Empire Health Plan

Find your latest news here at the Hemet & San Jacinto Chronicle

The post Inland Empire Health Plan Hosts Community Toy Giveaway appeared first on The Hemet & San Jacinto Chronicle.