Ohio AG sues Centene, alleging misrepresented pharmacy expenses cost Medicaid millions

Ohio Lawyer Normal Dave Yost submitted a lawsuit this week from health insurance provider Centene, alleging that corporation subsidiary Buckeye Health and fitness Program used a web of subcontractors for the provision of pharmacy positive aspects in purchase to misrepresent pharmacy charges, ensuing in thousands and thousands of pounds of overpayments by the Ohio Section of Medicaid.

Yost reported in a assertion on Thursday that Centene materially breached its obligations to the point out Medicaid system and to the point out as a complete, contacting it a “conspiracy” and a “advanced scheme” to get Medicaid payments by means of misleading usually means.

The Ohio Section of Medicaid administers a medical assistance prepare that presents coverage to about 2.9 million Ohioans, and it does so by means of the use of Managed Care Corporations (MCOs), these as Buckeye Health and fitness Program, which administered its pharmacy reward through sister providers Envolve Health and fitness Methods and Health and fitness Internet Pharmacy Methods. The follow of subcontracting to far more than just one Pharmacy Profit Manager elevated questions about Buckeye Health and fitness Plan’s business tactics and, ultimately, Centene’s.

The Office of the Lawyer Normal is alleging breaches of contract, together with filing reimbursement requests for quantities now compensated by third get-togethers failing to correctly disclose to ODM the legitimate price of pharmacy services, together with the disclosure of discount rates obtained and artificially inflating dispensing fees.

As envisioned, the lawsuit obtained pushback from Centene, specifically Envolve Health and fitness, which claimed the allegations are “unfounded” and pledged to aggressively defend its pharmacy services.

“Envolve’s pharmacy contracts with the Condition are reviewed and pre-accredited by point out companies ahead of they at any time go into impact,” the corporation reported in a assertion. “Furthermore, these services saved thousands and thousands of tax-payer pounds for Ohioans from market place-centered pharmaceutical pricing.”

The lawsuit was submitted under seal thanks to a confidentiality and nondisclosure agreement.

THE Larger Craze

In 2020, just after including 10 million users, Centene observed comprehensive-calendar year profits of $111 billion, symbolizing forty nine{ae9868201ea352e02dded42c9f03788806ac4deebecf3e725332939dc9b357ad} expansion and modified diluted earnings per share of $five, up thirteen{ae9868201ea352e02dded42c9f03788806ac4deebecf3e725332939dc9b357ad} around the prior calendar year.

Centene’s fourth quarter revenues were being $28.three billion, an increase of fifty{ae9868201ea352e02dded42c9f03788806ac4deebecf3e725332939dc9b357ad} around the fourth quarter of 2019 and modified diluted earnings per share was $.46 as opposed to $.73 final calendar year. CFO, treasurer and government vice president Jeff Schwaneke reported overall revenues grew by $9.4 billion around the fourth quarter of 2019 thanks to the acquisition of WellCare and expansion in the Medicaid and Health and fitness Insurance policy Marketplace business. 

This expansion also features the effects from the suspension of Medicaid eligibility redeterminations and the reinstatement of the health insurance provider price in 2020 – partly offset by the divestiture of Centene’s Illinois health prepare and retroactive point out premium-fee changes and danger-sharing mechanisms.

In January, Centene and Magellan Health and fitness entered into a definitive merger agreement under which Centene will acquire Magellan Health and fitness for $2.2 billion. As a outcome of the transaction, Centene will establish just one of the nation’s greatest behavioral health platforms across 41 million unique users.

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