Lawsuit accuses Molina Healthcare of failing to provide required services

Nov. 27--Long Beach-based Molina Healthcare has been accused of breaching its Medicaid contract in Illinois and failing to disclose it wasn't providing required services to skilled nursing home patients in the Prairie State.

The alleged cover-up lasted two years, the federal whistleblower lawsuit says.

The case was filed under seal in September 2017 by the founder of a former Molina contractor named General Medicine P.C. A federal judge unsealed the complaint last week after state and federal attorneys declined to join the action, but left other documents -- including any possible Molina rebuttals -- hidden from public view.

A spokeswoman for Molina said the company can't comment on pending litigation.

Molina Healthcare provides Medicaid and other types of insurance to nearly 4 million members in 13 states and in Puerto Rico, according to company filings. The company has 223,000 members in Illinois.

The case stems from Molina's alleged failure to provide follow-up care to Illinois Medicaid patients in skilled nursing facilities designed to decrease hospitalizations.

Under the so-called "SNFist" program, a doctor, physician's assistant or nurse practitioner visits patients in skilled nursing homes at least once every two months to catch illnesses and other medical problems before they become so critical the patient needs to be hospitalized.

Molina hired General Medicine in 2014 to provide SNFist services, but stopped payment to the medical provider after just four months, the lawsuit states. General Medicine stopped providing services in April 2015 after eight months on the job.

The lawsuit asserts Molina Healthcare of Illinois knowingly failed to replace the SNFist services and failed to notify the Illinois Department of Healthcare and Family Services, as required under its contract with the state. Yet, the company continued to receive payments under the Medicaid program, the lawsuit asserts.

Molina claimed it discontinued payments to General Medicine because the medical firm failed to provide services to all its patients and failed to file reports -- claims General Medicine has denied.

Instead, the lawsuit cited an email chain among Molina executives indicating the insurance company "appears to have been motivated by financial considerations."

The lawsuit occurred during a troubled year in Molina's history. In May 2017, Molina's board fired the company's chief executive and chief financial officer, J. Mario Molina and John Molina, over the company's poor performance. The firm ended 2017 with a net loss of $512 million.

Company filings show Molina Healthcare has been profitable this year so far.

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