• AmeriHealth Mercy
  • March 31, 2011
  • Law Firm: Crowell Moring LLP - Washington Office
  • AmeriHealth Mercy (AMHP) agreed to pay $2,032,758 to resolve allegations by the Kentucky Attorney General that as third party administrator for the Commonwealth's Passport Health Plan under the Kentucky Medicaid Program it improperly received contracted bonus payments by falsely reporting  to the Department of Medicaid Services its 2009 Health Effectiveness Data and Information Set (HEDIS) score for Cervical Cancer Screening (CCS). 

    In 2009, AMHP was under contract with University Health Care, Inc. (UHC) to manage the Passport Health Plan, the state's Medicaid managed care plan that serves Medicaid recipients in a 16-county area in and around Louisville.  The contract provided for a bonus payment to AMHP if it achieved certain HEDIS score goals.   For CCS, the HEDIS score is measured by determining how many eligible females received a Pap smear.   Members may also be excluded if they have received a full hysterectomy.  The Commonwealth alleged that for the 2009 CCS HEDIS measure, AMHP excluded members as having a full hysterectomy where there was no medical evidence of a full hysterectomy.   AMHP also allegedly counted members as having received a Pap smear where there was no medical evidence of a Pap smear.  These actions increased AMHP's HEDIS score, allegedly enabling it to receive more than $677,000 from UHC in Medicaid funds.

    According to the Attorney General, the more than $2 million in the judgment constitutes treble damages, or triple the amount of the actual damages.  In addition, the settlement agreement requires that AMHP put procedures and personnel in place to ensure that all reports sent to both the Commonwealth and UHC, including HEDIS scores, are fully and completely accurate. 

    The Consent Judgment and Assurance of Voluntary Compliance were filed in Franklin Circuit Court.