O’Melveny has the necessary experience to help managed care organizations navigate the complex web of federal and state healthcare laws they face as Medicare and Medicaid becomes an ever greater part of their business, putting them at risk of government enforcement proceedings and civil qui tam actions.

We have a strong track record of defending managed care companies against allegations brought by various state and federal enforcement authorities, insider complainants, and opportunistic relators concerning violations related to Medicare Advantage, Medicaid managed care, and Medicare Part D. Our work has led the DOJ to decline False Claims Act cases, the Office of Inspector General to reverse course in an exclusion action, and to favorable resolutions of state and federal government investigations.

We have also conducted dozens of internal investigations into allegations related to, among other things, Medicare Advantage risk adjustment and HEDIS/STARS quality reporting, potential kickbacks in connection with increasing Medicare Advantage and Medicaid managed care enrollment, and the administration of the Part D drug benefit. And whenever possible, we advise clients about proactive compliance procedures and risk-mitigation strategies to prevent statutory and regulatory violations and that serve as important evidence in government inquiries.

Litigation

Our experience includes:

  • Defending Humana in connection with a False Claims Act investigation by the DOJ and HHS-OIG related to an unsealed qui tam whistleblower complaint alleging that the company failed to comply with Medicare Advantage diagnosis data submission requirements. The district court dismissed some of plaintiffs’ claims and has limited discovery with respect to the plaintiff’s  remaining claims.

  • Defending a leading managed care company in a civil and criminal investigation by the DOJ and HHS-OIG into whether the managed care plan received inflated premiums from the Medicare program and maintained inappropriate financial relationships with its contracted providers.

  • Winning a significant victory on  Humana’s behalf in a relator’s appeal to the Eleventh Circuit, which affirmed the district court’s dismissal of the lawsuit. The case represents an important holding for defendants in the False Claims Act’s public disclosure bar jurisprudence.

  • Obtaining dismissal with prejudice and without leave to amend on behalf of our WellPoint, Inc. in a qui tam action alleging claims under the federal and California False Claims statutes arising out of the submission of Medicare and Medicaid claims. Plaintiffs have filed an appeal that is pending before the Ninth Circuit.

Internal Investigations and Strategic Counseling

Our experience includes:

  • Representing a national Medicare Advantage plan in an internal investigation stemming from allegations that a health plan vendor failed to comply with Medicare regulations concerning in-home assessments of member medical conditions.

  • Representing several leading managed care companies in assessing potential regulatory and legal remedies available in light of recent Medicare regulations that mischaracterize the payment methodologies by which the companies are paid by the Centers for Medicare and Medicaid Services.

  • Representing a leading managed care company in civil investigations by the DOJ into whether its mail order pharmacy received inflated payments from Medicare Part D as a result of its drug dosage form dispensing practices, and into the prior authorization requirements the managed care company imposes on pharmacies that dispense specialty drugs to its Medicare beneficiaries.

  • Representing a national Medicaid managed care company in an internal investigation into allegations that its employees made inappropriate payments to health care providers and nonprofits to induce recommendations to prospective members of the health plan.

  • Defending a managed care company in an audit by HHS’s Office of Inspector General into the appropriateness of the insurer’s Medicare Advantage premiums.