Supreme court docket denies Molina's Medicaid whistleblower enchantment

The Supreme court docket has declined to hearken to an enchantment from Molina Healthcare which will have ended a False Claims Act lawsuit launched by a former enterprise confederate and will have raised the bar for future whistleblower cases.

The extreme court docket’s willpower Tuesday clears the best method for a whistleblower to pursue his allegations that the Medicaid insurer charged Illinois and the federal authorities for nursing house providers it did not current. 

Molina requested the court docket to consider a decrease court docket willpower in February, arguing the whistleblower’s grievance lacked enough element to fulfill the authorized commonplace required for False Claims Act matches. If the Supreme court docket had taken up the case, it will “have critical influence on the burden of litigation” required for such complaints and created a mannequin new precedent, in conserving with a court docket order revealed in June. 

The Supreme court docket did not current a proof for its willpower to not hear the case. Molina did not immediately reply to an interview request. 

A supplier group filed the lawsuit in 2017 inside the U.S. District court docket for the Northern District of Illinois and alleged that Molina misrepresented the efficiency of its expert nursing facility providers contract to enhance the income it generated from the Illinois Medicaid program. 

Thomas Prose, CEO of a Novi, Michigan-based mostly submit-acute medical observe referred to as primary remedy, alleges that Molina billed Medicaid for doctor and nurse practitioner visits that did not happen. primary remedy clinicians previously oversaw look after Molina’s Medicaid members dwelling in submit-acute care settings. The supplier group ended its contract with Molina in 2015 after the events may not come to phrases on reimbursement expenses.

but after that and till at the least April 2017, the plaintiff alleges that Molina did not exchange the care coordination providers primary remedy beforehand supplied however continued to get hold of Medicaid reimbursements of as a lot as $three,000 per enrollee every month in violation of Illinois and federal legal guidelines. Molina’s Medicaid contract required the insurer to current expert nursing coordination providers to enrollees and regulators allowed the insurer to take part inside the Illinois Medicaid program partly based mostly on its provision of these providers, in conserving with the lawsuit. 

The district court docket dismissed the case in June 2020, ruling that Prose did not level to cases when Molina deliberately lied regarding the extent of its providers or misrepresented its Medicaid choices. The U.S. court docket of Appeals for the seventh Circuit reversed the decrease court docket’s willpower in August 2021 and ordered the case despatched again to the district court docket.


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