U.S. Attorney Announces $10.1 Million Settlement With Managed Long-Term Care Plan For Improper Receipt Of Medicaid Payments

Damian Williams, the United States Attorney for the Southern District of New York, and Naomi Gruchacz, the Special Agent in Charge of the New York Regional Office of the U.S. Department of Health and Human Services, Office of Inspector General (“HHS-OIG”), announced today a settlement of a civil fraud lawsuit against RIVERSPRING LIVING HOLDING CORP. and ELDERSERVE HEALTH, INC., d/b/a RiverSpring at Home (“RIVERSPRING”), New York not-for-profit corporations that, among other things, administer a Managed Long Term Care Plan (the “RiverSpring MLTCP”) for Medicaid beneficiaries.  In connection with the RiverSpring MLTCP, RIVERSPRING arranges for health and long-term care services and is reimbursed by Medicaid through per-member payments on a monthly basis (“Capitation Payments”).

The settlement resolves allegations that RIVERSPRING submitted false claims to Medicaid for months during which RIVERSPRING failed to provide, or failed to adequately document, certain long-term care services to RiverSpring MLTCP members as obligated by the applicable contract between RIVERSPRING and the New York State Department of Health (“DOH”).

Under the terms of the settlement approved today by U.S. District Judge P. Kevin Castel, RIVERSPRING must pay a total sum of $10,159,130.95, with $4,063,652.38 paid to the United States and the remaining amount paid to the State of New York.  As part of the settlement, RIVERSPRING admits that it either did not provide RiverSpring MLTCP members with qualifying services as required by the applicable contract with DOH or did not adequately maintain documentation of the provision of such services during some or all of their enrollment in the RiverSpring MLTCP.  As a result, RIVERSPRING obtained Medicaid payments to which it was not entitled.

U.S. Attorney Damian Williams said: “RiverSpring collected millions of dollars in Medicaid payments to provide long-term care services as part of its managed care plan, but in many cases either failed to deliver these services or failed to maintain adequate documentation showing that it did so.  This Office is committed to holding recipients of government health care funds accountable when they fail to provide the care and services the government pays them to provide.”

HHS-OIG Special Agent in Charge Naomi Gruchacz said: “As a part of this settlement, the defendants acknowledged that they obtained funds from the Medicaid program to which they were not entitled.  Individuals and entities that participate in the federal health care system are required to obey the laws meant to preserve the integrity of program funds and the provision of appropriate, quality services to patients.”

As alleged in the Complaint filed in Manhattan federal court: 

RIVERSPRING administers a managed long-term care plan for Medicaid beneficiaries pursuant to applicable contracts with DOH (the “Contract”).  To be eligible for enrollment into a managed long-term care plan, a Medicaid beneficiary must, among other things, be assessed as needing at least one of the community-based long-term care services listed in the Contract (“Qualifying Services”) for more than 120 days from the effective date of enrollment.  These services include nursing services in the home, therapies in the home, home health aide services, personal care services in the home, and adult day health care.  In order to receive Capitation Payments from Medicaid for members of the RiverSpring MLTCP, RIVERSPRING was required to ensure that RiverSpring MLTCP members received Qualifying Services during their enrollment or otherwise remained appropriately enrolled in the RiverSpring MLTCP consistent with the Contract and DOH disenrollment practices.  In exchange for arranging and providing these services, RIVERSPRING received Capitation Payments averaging between $4,000 and $4,500 for each member.

As part of the settlement, RIVERSPRING admits, acknowledges, and accepts responsibility for the following conduct:

• In many instances, RIVERSPRING either did not provide RiverSpring MLTCP members with Qualifying Services or did not adequately maintain documentation of the provision of such Qualifying Services during some or all of their enrollment in the RiverSpring MLTCP.  Nonetheless, RIVERSPRING received Capitation Payments to which it was not entitled for these RiverSpring MLTCP members for the months in question.

• In many of these instances, RIVERSPRING collected Capitation Payments for RiverSpring MLTCP members despite the fact that RIVERSPRING either did not provide or did not maintain documentation reflecting the provision of Qualifying Services to these members for three or more consecutive months during their enrollment in the RiverSpring MLTCP.

• In other instances, RIVERSPRING collected Capitation Payments for RiverSpring MLTCP members despite the fact that RIVERSPRING either did not provide or did not maintain documentation reflecting the provision of Qualifying Services to these members during the entirety of their enrollment in the RiverSpring MLTCP.

In connection with the filing of the lawsuit and settlement, the Government joined a private whistleblower lawsuit that had been filed under seal pursuant to the False Claims Act.

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Mr. Williams thanked HHS-OIG for its assistance.  Mr. Williams also thanked the Medicaid Fraud Control Unit of the New York State Attorney General’s Office for its investigative efforts and work on the case.

This case is being handled by the Office’s Civil Frauds Unit.  Assistant U.S. Attorneys Samuel Dolinger and Jacob M. Bergman are in charge of the case.