A New York City health system will pay $46.7 million to Medicaid and the federal government after admitting it referred more than 1,000 adult day care members to long-term care who were ineligible for the managed care plan, Manhattan U.S. Attorney Preet Bharara announced Thursday.
CenterLight Healthcare and CenterLight Health System in the Bronx will pay $28 million to Medicaid and $18 million to the federal government, according to Bharara and the U.S. Department of Justice.
CenterLight admitted to improperly billing Medicaid for 1,241 members who attended, or were referred by social adult day care centers, whose needs did not meet the criteria of the managed care plan, authorities said.
CenterLight continued to seek and obtain monthly capitation payments for members well after the New York State Department of Health issued guidance in early 2013 explicitly stating that an individual's attendance at the daycares did not satisfy the long-term care eligibility standard, authorities said.
For arranging and managing long-term healthcare services, providers receive a monthly capitation payment of approximately $3,800 for each beneficiary, according to the U.S. Attorney's Office.
CenterLight contracted with the social adult day care centers to provide care, including personal care services, to CenterLight managed long-term care members, authorities said.
Managed long-term care providers offer services such as assistance with activities of daily living, care management, skilled nursing, physical therapy, occupational therapy, speech therapy, nursing home care, and preventive services.
To qualify for enrollment in such a plan, Medicaid beneficiaries need to be eligible for a nursing home level of care and require at least 120 days of community-based long-term care.