The allegations of wrongdoing at WellCare Health Plans Inc. continued Tuesday with the unsealing of two more whistle-blower complaints against the Tampa company.
Clark J. Bolton, a former supervisor of special investigations at WellCare, said the insurer encouraged overbilling and refused to audit claims for fraud in order to curry favor with doctors and hospitals and build market share. The result was millions in excessive and illegal expenses passed through to federal Medicare and state Medicaid programs, Bolton said.
Eugene Gonzalez, a referral coordinator for seven years, claimed WellCare met government customer service standards only because it had employees create backdated documents and make bogus calls to the company's phone lines. Failure to meet these standards would have resulted in the loss of billions of dollars worth of Medicare and Medicaid contracts.
These complaints bring to three the number of whistle-blower lawsuits that have been made public in the federal investigation into WellCare, which began with a high-profile raid by FBI agents in October 2007.
WellCare has declined to comment on the lawsuits by former employees, parts of which are still sealed. Amy Knapp, a company spokeswoman, said, "The company has not obtained any documents or information which the whistle-blowers believe support their claims. It would be inappropriate to comment further."
Bolton and Gonzalez filed their complaints in late 2007 and early 2008, respectively. That was well after Sean J. Hellein, a senior financial analyst at WellCare, approached investigators in 2006 about what he saw as pervasive fraud in the organization.
Hellein, whose lawsuit was unsealed last week, worked undercover for federal agents for 18 months gathering evidence. His complaint alleges that WellCare hid profits in an offshore subsidiary, dropped coverage of premature babies and terminally ill patients to cut costs and kept millions in unearned Medicaid payments. Total costs to government programs was $400 to $600 million, Hellein estimates.
The government and WellCare have tentatively agreed to settle all whistle-blower claims for $137.5 million, but Hellein's attorney, Barry Cohen, said he intends to fight for more.
"If you only have to pay back half of what you steal, it's not a deterrent to health care fraud," he said.
U.S. Rep. Kathy Castor criticized the proposed settlement as wholly inadequate in a letter this week to Attorney General Eric Holder. "Where is the penalty and punishment for such egregious actions?" she wrote. "It appears that companies such as these simply build such payments into the 'cost of doing business.' We cannot allow this to continue."
While the estimates of damage were smaller in the two later whistle-blower complaints, they complement Hellein's depiction of a corporate culture that pushed the ethical envelope on every level. To make it appear that doctors were getting their calls answered quickly, employees were ordered to make quick "line checks" to boost the averages, Gonzalez claimed. When members appealed a rejected claim, the company gained more time to respond by simply putting a fake "receipt date" on the file, according to his lawsuit.
Bolton said he was fired after one year of heading WellCare's special investigation unit because he complained internally about fraudulent practices. He said an after-hours pediatric clinic was allowed to overbill for office visits because WellCare wanted to keep the contract and it meant higher reimbursements from Medicaid.
Although his department had software that could check hospital claims for fraud, Bolton said he was instructed not to use it for fear of alienating the customer. WellCare also refused to audit claims from Medicare's private-fee-for-service plans, he said, resulting in a potential $100 million in unrecovered fraud. In several cases in which WellCare investigated overbilling in response to a complaint, Bolton said, the company kept the settlement instead of returning it to the government as required.
Though Bolton, who lives in Safety Harbor, has been waiting for nearly three years for resolution of his case, his attorney, John Newcomer, expressed support for the proposed settlement.
"Everyone has done a great job and worked very hard to get to the resolution we've gotten," he said. "For the civil case to take this amount of time is not at all unusual."
Kris Hundley can be reached at firstname.lastname@example.org or (727) 892-2996.