Simply Health Claim Form.pdf

the health care industry is undergoing tremendous transformation. the department s efforts to prevent and deter fraud in the health care system have continued to evolve as the industry has evolved. our health care provider crimes team is dedicated to investigating the widespread corruption of federal health care programs and protecting our nation s most vulnerable populations. our public corruption section, health care fraud section, complex fraud section and health care fraud strike force seek out corrupt individuals in the health care industry in an effort to safeguard the medicare, medicaid, and other federal health care programs for the many americans who rely on these programs to pay for their health care.

in the summer of 2009, the department of justice s health care fraud team was formed in order to re-task the division s resources to focus on health care fraud enforcement efforts. this was a result of the congressional mandate to increase federal prosecutorial health care fraud resources and the executive branch s commitment to strengthen the federal health care programs that financially support medicare, medicaid, and the children s health insurance program.

the department has also undertaken legal actions to defend financial and other interests in matters of perceived commercial advantage to the government. for example, in 2014, the department filed a complaint in u.s. district court for the district of columbia against the partnership for prevention (tfpp) and managed care organization quality health plan, inc. (quality). tfpp, a privately-owned health services organization, was doing business in the district of columbia under the name groupwell. quality was doing business as a medicaid managed care organization under the name access health. the department of health and human services (hhs), acting through the centers for medicare & medicaid services (cms), sued because of a contract dispute between the government and tfpp. tfpp was in discussions with the government about a potential sale of the organization to prime healthcare services, inc. (prime), a privately-owned health services organization. the department sought, in its complaint, to enjoin prime from entering the contract with tfpp and ordered the sale to be completed. the government alleged that prime acquired the contract by paying tfpp a financial penalty to end the contract.

the department intervened in a federal lawsuit involving a contract dispute between the altar group, inc., a private, for-profit health services organization, and the federal government. the department, acting on behalf of cms, sued the for-profit health services organization, alleging that altar made false statements to federal medicare contractors about the services it provided, which in turn caused these contractors to use the services provided by altar, resulting in inflated payments to altar.
in 2011, the department intervened in an administrative law proceeding involving allegations that prime health services, inc., a private, for-profit health services organization, and its predecessor organization, group health cooperative, inc., a federally qualified health maintenance organization, submitted false information to cms in order to receive certain payments from the government. prime health services inc. was allegedly underpaying medicare for its services to medicaid beneficiaries.
medicare rates payments for health care services provided to certain types of individuals. for example, certain mental health services such as those provided by community mental health centers of maryland are generally not covered by medicare. however, medicare makes certain exceptions for mental health services provided to certain individuals who may not have the financial resources to pay for such services. these individuals include those who are 65 years old or younger, who have a physical or mental disability that restricts their ability to work, and those who are 21 years old or younger and have a physical or mental disability that restricts their ability to work.
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