$54 Million Settlement Resolving Whistleblower Claims Against CareCore National LLC Announced
CareCore merged with
Specifically, under CareCore's stated protocol, nurses were required to refer pre-authorization requests that failed to meet certain criteria to medical doctors for their review so the doctors could issue or deny the pre-authorization requests. These requests were required by CareCore's customers – managed care organizations and other health insurers that provide services to the beneficiaries of government programs through Medicare Part C and Medicaid Managed Care.
Instead, due to critical time constraints required by its customers, CareCore directed its nursing staff to "Process As Directed" or to "PAD" certain of those cases that had been sent for a doctor's review. For these "padded" cases, nurses were instructed to issue pre-authorizations for diagnostic testing even though the set criteria had not been met and the doctors had not conducted the required review. Thus, the managed care organizations and other providers, including those with which the government contracts, paid for diagnostic tests, like costly MRIs and PET scans, that were not properly authorized as being medically reasonable or necessary.
"Our client was deeply troubled by the wrongdoing that he witnessed and after a lot of soul-searching decided to come forward in order to end a practice that was not only wrong, but cost the
Weiss' co-counsel, partner
The settlement was handled by Assistant
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