DOJ: Health Plan to Pay 137.5 Million for Sham SIU and Retaining Overpayment

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On April 3, 2012, U.S. Dept. of Justice (DOJ) Announced That Wellcare Health Plans Inc. Will Pay $137.5 Million To The Feds And 9 States For Allegedly Operating Sham Special Investigation Unit (SIU) And Knowingly Retaining Overpayment In Violation of False Claim Act. Offers Webinars To Examine This DOJ Health Plan Fraud News And Its Impact On All ERISA Health Plans.

The shocking fact is the DOJ’s allegation that the health plan’s sham SIU was used to commit the alleged fraud when the health plan’s SIU was typically designed and claimed to do anti-fraud works nationwide.

On April 3, 2012, U.S. Department of Justice (DOJ) announced that WellCare Health Plans Inc. will pay $137.5 million to the federal government and nine states for allegedly operating sham Special Investigation Unit (SIU) and knowingly retaining overpayment in violation of the False Claim Act. The resolution of the civil suits announced by DOJ yesterday brings the total recoveries from WellCare to $217.5 million. offers new Webinars to examine this DOJ health plan fraud news and its impact on all private ERISA health plans. The Webinar topics include how to audit and recover from a health plan’s TPA and SIU for any possible wrongful overpayment embezzlement, in a billion dollar overpayment market with an average of 7 to 1 return ratio for all TPA/SIU overpayment recovery. (

According to the DOJ Press Release on 04/03/2012: “The lawsuits alleged a number of schemes to submit false claims to Medicare and various Medicaid programs, including allegations that WellCare falsely inflated the amount it claimed to be spending on medical care in order to avoid returning money to Medicaid and other programs in various states, including the Florida Medicaid and Florida Healthy Kids programs; knowingly retained overpayments it had received from Florida Medicaid for infant care; and falsified data that misrepresented the medical conditions of patients and the treatments they received. Additionally, it was alleged that WellCare engaged in certain marketing abuses, including the “cherrypicking” of healthy patients in order to avoid future costs; manipulated “grades of service” or other performance metrics regarding its call center; and operated a sham special investigations unit.” ( (United States of America et al v. Wellcare Health Plans, Inc. et al, CASE #: 8:07-cv-01909-JSM-TGW, U.S. District Court Middle District of Florida (Tampa))

“The shocking fact is the DOJ’s allegation that the health plan’s sham SIU was used to commit the alleged fraud when the health plan’s SIU was typically designed and claimed to do anti-fraud works nationwide. The alleged $217.5 million SIU fraud is certainly worse than the most alleged provider fraud”, said Dr. Jin Zhou, President of, a national expert in ERISA Compliance, fiduciary Plan assets audit and recovery.

“This DOJ case illustrates how managed care organizations for the health plans in both public and private sectors may have knowingly retained overpayments in billions of dollars already received from the providers from operating sham Special Investigation Unite (SIU) for all private health plans,” said Dr. Zhou,.

“Government health plans increasingly rely on managed care organizations to provide patient care. This case illustrates our commitment to ensure that government funds are in fact used to render care and not to line the pockets of those more concerned with the bottom line,” said Stuart F. Delery, Acting Assistant Attorney General for the Justice Department’s Civil Division.

According to the DOJ Justice News announced yesterday, “Ensuring the integrity of the Medicaid and Medicare managed care programs is one of our highest priorities ” said Daniel R. Levinson, Inspector General of the U.S. Department of Health & Human Services. “OIG will work vigilantly with law enforcement partners at all levels of government to safeguard this vital program.” (

The DOJ News yesterday also described the rewards for those SIU whistleblowers: “The four lawsuits were filed by whistleblowers, known as relators, under the qui tam provisions of the False Claims Act, which allows private parties to file suit on behalf of the United States and share in any recovery. Sean Hellein, a financial analyst formerly employed by WellCare whose qui tam complaint initiated the government’s investigation, will receive approximately $20.75 million. The other three relators – Clark Bolton, SF United Partners Inc. and Eugene Gonzalez – will split about $4.66 million and will be entitled to receive an additional share of any contingency payment.” ( Webinars are announced to assist self-insured health plans to comply with ERISA fiduciary laws in safeguarding contributory plan assets by auditing the health plan TPA’s and SIU’s, to prevent the similar fraud or plan assets embezzlement from the same kind of SIU fraud as DOJ announced yesterday. Webinars are timely and important for all self-insured health plans, when national healthcare expenditure is escalating to $2.7 trillion, and more than 60% of working Americans and their families are covered under self-insured employer sponsored health plans, and the industry overpayment recovery is so successful with reported recovery of more than billions of dollars in the past 5 – 7 years, explained Dr. Zhou. Webinars are private for self-insured ERISA plans. It is designed to review the industry facts and the applicable federal laws, and explain how and why a self-insured ERISA health plan should be refunded by its TPAs for recouped overpayment money.

Located in a Chicago suburb in Illinois, offers ERISA compliance, education and consulting services to healthcare providers, health plans and reimbursement industry. It is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

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For more information, or contact Dr. Jin Zhou, president of, at 630-808-7237,

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