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This case was filed in and is captioned United States ex rel. Judith Zissa v. Notably, the federal False Claims Act is one of the most powerful statutory tools for combating healthcare fraud. The suit alleged that Santa Barbara County and BWA knowingly committed Medicaid fraud, where they billed and were paid for claims that either should not have been paid or should have been paid less. Medicaid, known as Medi-Cal in California, is a program that is jointly funded by the federal and state governments but is administered by the states.
Relator exposed two forms of alleged Medicaid fraud. Under the applicable laws and contract with the State, BWA was required to fully assess all patients and update their treatment plans at least annually to determine what services and treatment they should receive. By assessing and evaluating patients annually, providers like BWA can ensure that their patients are receiving the right kinds of treatment and are not receiving services that are ineffective or unnecessary.
Zissa alleged that BWA knew of the unlawful billing because its own records showed a large percentage of its patients did not have assessments or valid treatment plans and were being provided services without those requisites. She also charged that BWA was able to prevent claims from being submitted to Medi-Cal for patients who lacked the requisite assessments and treatment plans, but chose not to enable a setting in its software that would have flagged unlawful claims, as doing so would have also stopped the flow of the resulting unlawful revenues.
Under the applicable regulations, medication support services required that providers had to directly communicate with the patient or their caregiver as to how and when to take medications or advise as to the side effects of a medication. Local governments, such as counties, cities, and their agencies, play an essential role in providing desperately needed services to our fellow citizens. We applaud the courage and tenacity of our client—who was illegally fired in retaliation by BWA when she tried to report internally the issues involved in this lawsuit—in bringing this wrongdoing to light.
