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Sep 14, 2022 by |

San Francisco Whistleblower Attorney: California County Organized Health System and Three Health Care Providers Agree to Pay $70.7 Million for Alleged False Claims to California’s Medicaid Program


Alleged False Claims To Medi-Cal

Former Membership Services Director Blows Whistle

Federal Government And California To Share Settlement

Federal and California law authorizes citizens to bring civil lawsuits on behalf of the government against businesses defrauding the federal or State government.  False Claims Act, (“FCA”), 31 U.S.C. § 3729 et seq.; California False Claims Act (“CFCA”), Cal. Gov’t Code § 12650 et seq.  FCA and CFCA fraud often occurs in the healthcare sector under programs like Medicare (federal) and Medicaid (State and known as Medi-Cal in California).  Cases may involve violations of other federal laws like the Anti-Kickback Statute, 42 U.S.C. § 1320a-7b (prohibits kickbacks for medical services referrals), and the Stark Law, 42 U.S.C. § 1395nn (prohibits physicians from referring patients to providers that the physician has a financial interest in).  FCA and CFCA cases brought by individuals (referred to in the law as “relators”) are known as “qui tam actions.” Both the FCA and CFCA authorize awards to relators when the government recovers in a qui tam action. 31 U.S.C. §3730 (d); Cal. Gov’t Code § 12652(g)(3)..  Frequently, relators are current or former employees, representatives or agents of the businesses committing the alleged fraud.  If you have credible information of fraud against the government in San Francisco or elsewhere in California, call us today at (415)441-8669 and we can help. Our toll-free number is 1-888-50EVANS (888-503-8267).

Recent False Claims Act Settlement[1]

In a recently reported case, a county organized health system (COHS) that contracts to arrange for the provision of health care services under California’s Medicaid program (Medi-Cal) through various hospitals and clinics has agreed to pay a total of $70.7 million pursuant to three separate settlements to resolve allegations that defendants violated the federal False Claims Act and the California False Claims Act by submitting or causing the submission of false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).  The three settlements resolve allegations that defendants knowingly submitted or caused the submission of false claims to Medi-Cal for services that were not “allowed medical expenses” under defendant’s contract with the government; were pre-determined amounts that did not reflect the fair market value of services provided; and/or were duplicative of services already required to be rendered.  

The civil settlements include the resolution of claims brought under the qui tam or whistleblower provisions of the FCA and CFCA by a former controller, and a former director of member services for the COHS. The qui tam case is captioned United States, et al. ex rel. Maithel, et al. v. Ventura Co. Medi-Cal Managed Care Commission d/b/a Gold Coast Health Plan, et al., No. 15-7760AB TJH (JEMx) (C.D. Cal.). 

How A Qui Tam Action Begins

Individuals with original and credible information of false claims begin FCA qui tam cases by filing a complaint under seal in the federal court. At the same time, the relator submits a disclosure to the DOJ outlining the material evidence the relator has of the alleged false claims. 31 U.S.C. § 3730(b); Cal. Gov’t Code § 12652(c).. The seal period of the complaint lasts 60 days during which the DOJ investigates the claims.  31 U.S.C. § 3730(b)(2); Cal. Gov’t Code § 12652(c)(4). (If necessary, the government can, and often does, extend the 60-day period during which the allegations are kept under seal.)  If the government decides to intervene in the case, the government essentially takes over the litigation. 31 U.S.C. § 3730(c)(1); Cal. Gov’t Code § 12652(c)(6)(A).   If the government declines to intervene, the relator may proceed with the litigation on his or her own.  31 U.S.C. § 3730(c)(3); Cal. Gov’t Code § 12652(c)(6)(B).

Contact Us

If you have credible information of government fraud in San Francisco or elsewhere in California, call Ingrid M. Evans at (415) 441-8669, or toll-free at 1-888-50EVANS (888-503-8267) or by email at <a href=””></a>.  In addition to FCA and CFCA whistleblower cases, Ingrid and Evans Law Firm, Inc. also handle bank fraud whistleblower cases under FIRREA/FIAFEA, commodity trading and securities fraud under the Commodities Futures Trading Commission Whistleblower Program and the Securities and Exchange Commission Whistleblower Program, and tax fraud under the Internal Revenue Service Whistleblower Program. 

[1] Evans Law Firm, Inc. was not involved in the case in any way. 

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