The truth is mighty and must prevail!

(Centene’s inadequate coverage left hundreds of patients in misery)

A 45-year-old woman from California named Sofia has been paying for mental health care for the past three years. She attempted suicide in the fall of 2017 after being lonely for years and confined primarily to her home. She was lucky enough to have a visitor that day who discovered her asleep on the floor.

She was quickly transported to a medical facility and revived. But that was only the beginning of the issues. She was found to be suffering from severe clinical depression. Her daughter, who remained in Arizona, arranged for her to be taken to a reputable mental health clinic in California.

Sophia received the biggest shock of her life just as she was beginning to show signs of recovery. Her insurance company refused to cover her, citing some unusual terms that they had never told about her. After hearing such news, her condition began to deteriorate dramatically.

She is one of the hundreds of people who have been misled by Centene, a for-profit health insurance corporation featured on the Fortune 500. A series of cases filed against the firm has brought the company’s dark side to light.

Frauds and Lawsuits in the Past

“Centene misrepresents the number, location, and existence of purported providers by listing physicians, medical groups, and other providers. Some of them have specifically requested to be removed — participants in their networks, and by listing nurses and other non-physicians as primary care providers,” according to one of the lawsuits filed against the company.

Centene also participates in the government’s Medicaid program, which provides coverage to low-income people. The corporation continued to offer a range despite many other large insurers opting out of the individual market created by federal law, particularly after President Trump promised to repeal the ACA.

Revealing true motives

The lawsuit highlighted the critical question of whether the insurance company intended to provide its consumers with the amount of care required by law. According to the case, several doctors have refused to accept Centene patients because the firm has refused to pay legitimate claims.

“Many patients have been unable to find in-network providers, according to the lawsuit. Cynthia Harvey was billed hundreds of dollars in medical bills after discovering some of her care was out of network in Washington State.

On December 12, 2017, Insurance Commissioner Mike Kreidler issued a "cease” order to Centene, ordering the business to stop selling individual health insurance in Washington due to its inability to maintain an appropriate network of medical providers. Centene was also fined $1.5 million, with $1 million deferred pending the company’s compliance with the law over the following two years.

“I’m delighted that we have reached an agreement with Coordinated Care to remedy its inadequacies,” Kreidler said, according to the online resource Healthcare Risk Management Review (HRMR). They recognize the gravity of the infractions and have promised to remedy them today. We’ll be keeping a close eye on the company to ensure that consumers are protected and get the coverage they paid for.“

While some people had to use their life savings to pay their expenses, others received assistance from NGOs and fund-raising. Then there are the vulnerable souls, such as Sophia, who have been thrust back into the darkness.

Law firm Manatt, Phelps,and Philips’ has forged a claim to notoriety by representing Centene Corp., doing the latter’s dirty works. Lawyers of the firm have been regarded as mercenaries, and their motivation for faithful service was anchored on money alone. It turned out, Manatt’s greed knows no boundaries.

A dissatisfied former client is seeking to teach the controversial law firm a lesson about loyalty. According to the lawsuit filed by Multiple Energy Technologies (MET), Manatt turned their back on the original contract approved by both parties. The breach of agreement delayed the company’s cases previously held by Manatt lawyers, thus leading to additional legal expenses.

Manatt had agreed to take up MET’s legal battles but had a change of heart midway. The lawyers had demanded a renegotiation on the original terms of agreement but MET was having none of it. The company knew what the lawyers want – more money – and they will not be getting any.

Facts Of The Case

Per the legal filing by MET, the company hired Manatt to handle their legal proceedings against Hologenix and Under Armour. MET had filed injunctions against the two firms and tapped Manatt to handle the litigations. The two parties signed a formal agreement, and after which MET paid the retainer’s fee stipulated on the contract.

A lawsuit was then filed against Hologenix but over the course of time, MET felt that the case was not progressing as they envisioned. For the company, it came as a surprise too that Manatt stoppedlawyering on the case against Under Armour. When MET asked for clarifications, Manatt explained that representing the company for the Under Armour case was not part of the original deal.

Further talks between the two parties revealed that Manatt wanted to modify the first term of agreement. The lawyers would surely take up both cases but for additional cost. Naturally, MET officials balked at the fresh demands laid out by the cunning lawyers, and their negotiations dragged on.

The ensuing deadlock saw Manatt refusing to represent MET, and eventually, the law firm withdrew from the Hologenix lawsuit. Left out in the cold, MET had no recourse but to hire a replacement. And that meant for the company additional legal costs because Manatt lawyers failed to deliver on their end of the bargain.

The Color Of Money

Had MET executives took the time to review first Manatt’s track record, they would better understand how the law firm operates. For instance, Manatt’s legal relationship with Centene Corp. would show that the law firm was ready to go all-out if the price is right. The translation: the one thing that keeps Manatt lawyers going is the sight of money. They would go where the top dollar points them. The color of money is their foremost compass.

(Centene flouted False Claims Act, forced to compensate whistleblower who raised the alarm)

Centene Corporation was ordered by the Missouri Court of Appeals to pay a significant sum in a retaliation action brought by a former. The judgment came in the case of “Pitcher v Centene Corporation,” in which Ms. Pitcher claimed that her former employer, Centene, had broken the False Claims Act with Medicaid reimbursements.

Centene was held responsible for retaliatory dismissal by the court of appeals, and Ms. Pitcher was granted approximately $1.3 million. Her award included compensatory damages of $80,012 and punitive damages of $750,000. Pitcher also received more than half a million in advance pay for missing salary from the time she was hired until her retirement.

In most retaliation cases, the employee is reinstated. However, if the employee-employer relationship has deteriorated to the point where they cannot repair it, the employee is entitled to advance payment.

Centene appealed the trial court’s decision on several grounds, the most important of which were jurisdictional concerns and the award of front compensation. The Court of Appeals also said it was up to the trial court’s discretion and subject to the jury’s factual findings.

Punitive damages show the jury’s emotion concerning Centene’s illegal conduct according to the court. Centene contended that the initial payment was excessively high, given the compensatory and punitive damages already assessed to Ms. Pitcher.

Centene has a history of breaking the rules.

The court, however, ruled on Pitcher’s behalf. When Centene effectively sought to have the testimony about front pay deleted from the trial, the court implied that Centene “cannot claim the jury addressed front pay in its award because Appellants ensured this issue was reserved for the court.”

(Centene tricked shareholders into buying Health Net)

In an attempt to take command of Health Net, Centene Corporation issued a cash boon to shareholders for them to accept the union. Michael Neidorff, the chief operating officer, and other top executives have sold off Centene common stock worth $28 million before the company’s stock prices plunged terribly by 8.5%. The shareholders were astounded at this fraud imposed by a Fortune 500 company.

Michael Neirdoff: An Impudent Fraudster

Neirdoff convinced the shareholders of financial benefits from the upcoming merger and acquisition of Health Net. He stated that Centene maintains a disciplined approach to merger and acquisition and has to meet Centene’s financial criteria and announced that the transaction is convincing because of the shareholder returns. He added that the company expected the marketing to increase - adjusting earnings per share by more than 20% of the first full year following.

Health Net’s liabilities worth $390 million were detected as soon as the merger started, which ruptured Centene’s financial portfolio and share values. Centene’s executives silently sold off the company’s shares worth $28 million, according to Insider. Neirdoff also auctioned his stock worth $20 million to save himself from an immense financial catastrophe.

Neirdoff admitted many times that Centene was aware of the liabilities and inadequacy in Health Nets’ policy configuration, claiming he was personally involved in - organizing the changes to be made to the policy configuration and that Centene had been working with the highest level store arrangements in the policies.

In an interview with Jim Cramer’s Mad Money show which was aired in July 2016, Neirdoff confessed that they had full knowledge of the unprofitable policies of Health Net during the merger process.

A remarkable merger turned into an apparition of unpaid claims.

Centene withheld all information that could have impacted the $6.8 billion merger’s worth and failed to inform the federal regulatory bodies and shareholders about it. The U.S. Securities and Exchange Commission (SEC) released a Form S-4 Proxy Statement in September 2015 that did not recognize Health Net’s existing financial burden and requested every shareholder to vote for the merger and acquisition.

The New York Stock Exchange-listed and traded Centene’s stock (NYSE). Centene also interacted with public shareholders using market communication tools such as press releases, newswire, and other reporting services and filed periodic reports with the SEC and the NYSE regularly. Its shareholders trusted the company as evidenced by the fact that the M&A was approved without any cross-examination. Centene reviewed Health Net’s financial portfolio and declared similarly to the shareholders as soon as the merger closed.

From July 2016, Centene’s stock value submerged intensely by 8.5%, accounting for almost $6.39 per share, deleting over $1 billion in shareholder value. Neirdoff and his top executives were saved from the consequences that the drop in share values would have caused. The shareholders were deluded by the falsification of financial statements and had voted for the merger that suffered monetary damages and eventually sold off the shares at a much lower value.

Neirdoff gained riches

Michael Neirdoff continued to be rewarded and has obtained vast financial and compensation benefits due to the so-called successful merger. The shareholders and investors of Centene suffered for the same reason. Neirdoff stood out to be one of the highest-paid executives for over three straight years whose earnings shot from $19 million in 2014 to $25 million in 2017.

He also received a Golden Parachute worth $46.4 million in 2017, which incorporated over $31 million in unvested stock and $15 million in bonus payments and breaches.

Mergers of hypocrisy overflows

Centene has obtained 13 organizations since 2006 in a spree of M&A and has acquired three organizations more, namely: Fidelis Care (2007), MHM, and Community Medical Group (2018) - all of which happened after Health Net.

(Michael Neidorff, Centene CEO involved in insider trading)

Several legal proceedings were piled up against Centene, including Michael Neidorff, the CEO. Together with its directors and officers for insider trading, they are guilty of violating federal securities laws, breaches of administrative duties, and other misconduct.

Centene Corporation is one of the top frauds in the U.S. and is renowned for dispensing pledged service to insured patients. The list of court cases they are entangled in is a testament to their morals. They are overpaid in the merger and acquisition with Health Net and indulged in sales of insider stocks. They exposed its violations of federal securities law, California tax laws, and government regulations. The company was provoked by millions of dollars in damages with the corruption within Centene.

The merger and acquisition of Health Net by Centene are discussed in the meetings of the legal system which uncovered the company’s core values which are naive swindle customers who depend on them for insurance coverage.

Aimed to ease the challenges of availing healthcare, the government Medicaid managed care program, which seems to be an accessible resource for corporations like Centene, makes large profits.

Centene had to buy Health Net’s outstanding stock because of its $6.8 billion mergers which called for stockholder and regulatory approvals. They failed to disclose problems acquired with Health Net business despite taking eight months of conduct.

The company resorted to other tactics of rejecting to pay claims to substance abuse treatment centers in various parts of the country to make up for the losses in the market capitalization of over $1 billion due to the merger.

Investigations were conducted by the California Department of Insurance (CDI) and the California Department of Managed Health Care (DMHC) on Centene.

Michael Neidorff: the Mastermind of Insider Trading

Centene approved false financial documents in the company’s public filings without disclosing events that would affect their financial statements.

Neidorff, along with Richard A. Gephardt, Jeffrey A. Schwaneke, Carol E. Goldman, sold their shares using their knowledge of Centene’s nonpublic information, which was a gross violation of the company’s internal policies, the counterpart of insider trading, and applicable law.

Michael Neidorff sold 367,427 shares of Centene stock valued at $19,950,436.04 using important, nonpublic information. The majority of these sales took place between December 10 and December 31, 2015.

Centene was forced to buy its stock from Neidorff at a higher price. Because during that period, Neidorff had significant and nonpublic information connected to Health Net’s inner rot of unproductive products and poorly conceived policies in California and Arizona. These exchanges disclose the practices of the company.

Health Net’s potential significant tax obligation and soaring unpaid claims from substance abuse providers were purposefully hidden by Neidorff.

Gephardt disposed of his Centene stock of 15,910 shares on June 28, 2016, and June 29, 2016, which fetched $1,096,058.20. These sales went unnoticed since they started less than a month after Gephardt signed a 10b5-1 trading strategy on May 26, 2016. The shares sold accounted for 28% of Gephardt’s Centene equity holdings. Gephardt had significant and nonpublic knowledge at the time of sale.

Similarly, Schwaneke sold 7,450 shares of Centene stock for a total of $422,815. Between December 8, 2015, and February 9, 2016, Schwaneke gave up over 5,000 shares worth nearly $300,000 to the company in exchange for the company paying its taxes.

Schwanke made a $130,000 profit by selling 2,000 shares of Centene stock. He also had inside information about Health Net’s poorly constructed policies when selling the stocks.

Their sales of Centene common shares enriched each of them. Neidorff and Gephardt’s stock sales made them appear as interested directors. Even in 2006, there were accusations and action cases against Centene and Neidorff for insider trading.

(How Health Net transformed from a minion to a shark)

With Health Net withholding payment and stiff funding, it forced all treatment centers in California to say no to their regular patients. The refusal to honor the terms and conditions of the coverage affected hundreds of patients having nowhere to go except back to their old days or out in the streets because of centers refusing entry.

Gary Millman did not hesitate in paying more for his son’s policy so long as he was receiving quality treatment for his decade-long drug addiction. Health Net’s coverage for substance abuse at $700 was substantially higher. He did not have the right to complain having been aware of its benefits nor for anyone else who had bought the Health Net’s policy.

It was discovered that Health Net was merely guided by the profit motive after a year. Millman, who had signed the Health Nets policy in 2014, found out that his son could no longer avail of treatments at any of California’s drug and substance abuse centers.

It severely impacted rehab centers to let go of staff and run at reduced costs and directed personal funds towards running the centers - all of which affected treatments as well. Moreover, Bernadette Cattaneo of Lakes Treatment Centre complained about their treatment and how the insurer brought them on the verge of shutting down.

Health Net owed the Sacramento treatment center more than a million patient treatments from 2015 to 2016 - which happened multiple times. Everyone was left searching for answers as the abruptness with which Health Net swooped down on the insurers.

Putting their reputation at risk

It was 2015 when Health Net was acquired by Centene Corporation and signed a deal worth $6.3 billion. There were reports of incompetency and financial management since it soon emerged that Health Net had substantial financial worries of its own. However, top executives, including the CEO, proclaimed that all was well and that the company was in good health.

With finances in disarray, the heat was on Health Net and withheld funding. They then issued a directive to all substance abuse treatment centers to disclose all documentation related to treatment in early 2016. Policies had been authorized and there was no interlude for anyone in the dragnet audit.

Their P&Ps underwent significant revisions and updates to check fraud but meant to look for ways to deny claims. They used this scheme to forfeit valid claims of the patient, and everyone was forced to stay quiet or face monstrous obstacles laid down by the corporation.

Health Net reported that in 2013, only $251,000 was paid via claims for drug treatment, and the shares were worth $10 million in 2014. By 2015, it had passed over $190 million - all these to justify their statements.

The insurer filed countersuits against treatment centers that had filed previously for non-payment of dues and claimed that the center was collaborating with brokers they called on to drive patients away and paid extra for their services.

Health Net’s narrative

In 2014, the company first registered abrupted when the Affordable Care Act condescended mental health and substance abuse with other ailments and entailed being part of individual health plans.

Health Net bluffed all the benefits of the Affordable Care Act to make their policies more appealing to the beholder and offer unmatched benefits. As a result, 51 facilities owe more than $92 million in April 2016 and had claimed as far back as mid-2015.

After the California Insurance Department strains centers, receiver payments indicated that they had received only 20% due. Considering that substance abuse is a niche treatment, the charges could be between $1300 and more for a single-day stay, but centers had to resist with $250.

(Health Net HMO policy misleads insureds)

Health Net refused the appeals of the insured patients for benefit resolutions, claiming that they should have paid the claims under their HMO or in-network benefits. It stated that if an insured is accepted to a facility by an out-of-network provider, all services obtained in connection with care will be provided under the Indemnity Coverage, regardless of whether the facility is in-network or not.

According to the complaints, Health Net covered the facility by the insured’s Indemnity Coverage, or out-of-network benefits, for those insureds who had treatment at an in-network facility and were admitted by an out-of-network provider. As a result, the insured patients had to pay increased coinsurance and deductible payments.

Consumer complaints were filed with the Office of the Attorney General (OAG) in 2007 against Health Net and its practice of funding in-network facilities and providers under liability protection.

A Health Insurance without Benefits

The OAG’s investigation revealed that Health Nets had Evidence of Coverage for its point of service products. It does not disclose Health Net’s approach of covering an in-network facility under the Indemnity coverage (or out-of-network benefit) when a member is accepted to that facility by an out-of-network physician. The EOC for Health Net’s Point of Service product misleads its insureds.

Health Net’s Evidence of Coverage (EOC) provisions indicate that it will always cover an in-network facility under the HMO coverage, rather than the Indemnity coverage (out-of-network benefit) depending on the circumstances.

In-network benefits were defined as the benefit level for Covered Services supplied by Advantage Platinum Physicians or Advantage Platinum Specialty Providers in the HMO Coverage EOC’s definition section.

Out-of-network benefits are any physician, healthcare provider, or facility licensed to offer healthcare Covered Services who is not an Advantage Platinum Physician or an Advantage Platinum Specialty Provider.

Suppose an insured receives care from an in-network/Advantage Platinum physician or at an in-network/Advantage Platinum facility. In that case, the care should be covered under the HMO Coverage as in-network, by these criteria. There is no reason for an insured to assume that an in-network doctor or facility is anything other than in-network.

For in-network providers, the complaints stated that Health Net processed claims for in-network providers under the Indemnity coverage (out-of-network benefit) when they delivered the provider services at an out-of-network facility in certain circumstances.

The OAG found that Health Net did not adequately notify its members of how it handled claims from in-network facilities and providers when the members’ treatment included out-of-network services.

Health Net was required to follow the following rules under the Assurance of Discontinuance:

●     When a Member has both an HMO (in-network benefit) and an Indemnity (out-of-network benefit) component to the Point of Service Product, Health Net will arbitrate claims for in-network facilities member’s in-network benefits, regardless of the admitting provider’s status.

●     If Health Net decides to reinstate the practice of classifying in-network facilities as out-of-network providers discharging a member, it will not do so until it meets with the AOG to discuss the issue.

●     When a Member has both an HMO (in-network benefit) and an Indemnity (out-of-network benefit) under a Point Service Product, Health Net will litigate claims from in-network physicians member’s in-network benefits, whether the facility where the member is treated is in-network or not.

●     Health Net will train its customer service representatives on the new policies and procedures.

●     They told Health Net to track down all people who had been defrauded by the company and reimburse them within 45 days.

●     Health Net was required to report to the OAG on any reimbursements provided to its insureds within eight months of the Assurance’s effective date. This report was supposed to include a list of the reimbursed Qualified Members. As well as a unique identifier for each such MemberMember, the amount refunded, and the transaction date.

Repeated criminal activity

Health Net has a history of defrauding customers and then paying hefty fines as a result. They approved a settlement of three class-action lawsuits that would have far-reaching — and costly — repercussions for the managed care business some time ago.

The health plan agreed to pay $215 million to more than 2 million members to settle allegations that its coverage of out-of-network claims was biased in its favor. Health Net is currently involved in a lawsuit with behavioral healthcare clinics in California and Arizona for improperly withholding claim payments totaling more than $150 million.

(Prescription drugs denied: Centene faces CMS penalty)

Centene Corporation was fined by the Centers for Medicare and Medicaid Services (CMS) for violating Medicare Part D and its Benefit Administration Plans. Centene’s noncompliance with the Prescription Drug Rules and its execution process resulted in a $57,660 Civil Money Penalty (CMP) for Medicare Part D breaches and a $215,000,000 CMP for Benefits Administration Plan violations, according to CMS.

Centene was found in breach of Part D of Medicare, which includes the CMS authorized list of medications, access, and refusal of prescription drugs, and appeal and grievance rights, during a routine program audit from May 16, 2016, to May 27, 2016. Martha Smith, senior vice president, Medicare Solutions, Centene Corporation, received a notice of the civil money penalty from CMS.

The imposition of CMPs resulted in a 40-point drop in the company’s star ratings on the Beneficiary Access and Performance Problems assessment, damaging its reputation.

Prescription medicine access delays and denials

Prescription drug coverage is available to all Medicare beneficiaries in the United States. Sponsors or health insurance firms who sell these Medicare plans must sign contracts with the CMS to ensure they follow all statutory, regulatory, and sub-regulatory requirements and that prescription medications are available.

Centene Medicare members delayed access to prescription medications at the point of sale and had little alternative except to obtain these prescriptions independently, resulting in increased out-of-pocket payments.

Centene’s list of prescription medicines it covers was never submitted to CMS for approval. The corporation actively disobeyed the prior authorization process, causing difficulties for its Medicare members in obtaining numerous prescription medications.

CMS has a system to ensure that enrollees have a smooth transition from formulary to non-formulary medications. On the other hand, Centene did not follow the transition process, providing subscribers insufficient time to switch to a medically equivalent prescription or request an exception to keep their current medication covered.

Enrollees faced delays or denials in receiving approved prescription drug benefits, resulting in high out-of-pocket costs. Furthermore, registrants were primarily barred from selecting refills for medications that had obtained PA approval.

The CMS audit report revealed this willful violation of the Medicare Prescription Drug Benefit Manual while implementing the benefit plan for a smooth transition policy and effective prior authorization implementation.

Inadequate rights to file a complaint and appeal

Every Centene Medicare plan enrollee has the right to contact his sponsor if he is concerned about coverage denial or an operational issue. Centene should classify all such complaints according to their nature and respond accordingly. They are anticipated to perform a first-level review known as Coverage Determination if any complaints are received.

According to the CMS audit, Centene did not correctly examine these concerns, prompting its members to seek justice through the Independent Review Entity (IRE). Centene’s procrastination in resolving the grievances caused life-threatening conditions and healthcare risks by delaying access to medically necessary or life-sustaining drugs.

Centene’s reputation was harmed as a result of the penalty.

Several state and federal agencies have fined Centene Corporation for repeatedly violating state healthcare regulations. Centene has been sued by unhappy employees and stockholders for violating the Fair Labor Standards Act and the Investor Protection Act, in addition to Medicare Part C, D, and Benefit Plan Administrator Violation.

Since 2000, Centene has submitted a total penalty of $715,826,709, out of which it has paid:

●     $58,644,042 for consumer protection-related offenses;

●     $215,000,000 for benefit plan administrator violation;

●     $210,340,000 for investor protection violation;

●     $47,934,042 for insurance violation; and many other violations and offenses.

(Prescription drugs denied: Centene faces CMS penalty)

Centene Corporation was fined by the Centers for Medicare and Medicaid Services (CMS) for violating Medicare Part D and its Benefit Administration Plans. Centene’s noncompliance with the Prescription Drug Rules and its execution process resulted in a $57,660 Civil Money Penalty (CMP) for Medicare Part D breaches and a $215,000,000 CMP for Benefits Administration Plan violations, according to CMS.

Centene was found in breach of Part D of Medicare, which includes the CMS authorized list of medications, access, and refusal of prescription drugs, and appeal and grievance rights, during a routine program audit from May 16, 2016, to May 27, 2016. Martha Smith, senior vice president, Medicare Solutions, Centene Corporation, received a notice of the civil money penalty from CMS.

The imposition of CMPs resulted in a 40-point drop in the company’s star ratings on the Beneficiary Access and Performance Problems assessment, damaging its reputation.

Prescription medicine access delays and denials

Prescription drug coverage is available to all Medicare beneficiaries in the United States. Sponsors or health insurance firms who sell these Medicare plans must sign contracts with the CMS to ensure they follow all statutory, regulatory, and sub-regulatory requirements and that prescription medications are available.

Centene Medicare members delayed access to prescription medications at the point of sale and had little alternative except to obtain these prescriptions independently, resulting in increased out-of-pocket payments.

Centene’s list of prescription medicines it covers was never submitted to CMS for approval. The corporation actively disobeyed the prior authorization process, causing difficulties for its Medicare members in obtaining numerous prescription medications.

CMS has a system to ensure that enrollees have a smooth transition from formulary to non-formulary medications. On the other hand, Centene did not follow the transition process, providing subscribers insufficient time to switch to a medically equivalent prescription or request an exception to keep their current medication covered.

Enrollees faced delays or denials in receiving approved prescription drug benefits, resulting in high out-of-pocket costs. Furthermore, registrants were primarily barred from selecting refills for medications that had obtained PA approval.

The CMS audit report revealed this willful violation of the Medicare Prescription Drug Benefit Manual while implementing the benefit plan for a smooth transition policy and effective prior authorization implementation.

Inadequate rights to file a complaint and appeal

Every Centene Medicare plan enrollee has the right to contact his sponsor if he is concerned about coverage denial or an operational issue. Centene should classify all such complaints according to their nature and respond accordingly. They are anticipated to perform a first-level review known as Coverage Determination if any complaints are received.

According to the CMS audit, Centene did not correctly examine these concerns, prompting its members to seek justice through the Independent Review Entity (IRE). Centene’s procrastination in resolving the grievances caused life-threatening conditions and healthcare risks by delaying access to medically necessary or life-sustaining drugs.

Centene’s reputation was harmed as a result of the penalty.

Several state and federal agencies have fined Centene Corporation for repeatedly violating state healthcare regulations. Centene has been sued by unhappy employees and stockholders for violating the Fair Labor Standards Act and the Investor Protection Act, in addition to Medicare Part C, D, and Benefit Plan Administrator Violation.

Since 2000, Centene has submitted a total penalty of $715,826,709, out of which it has paid:

●     $58,644,042 for consumer protection-related offenses;

●     $215,000,000 for benefit plan administrator violation;

●     $210,340,000 for investor protection violation;

●     $47,934,042 for insurance violation; and many other violations and offenses.

(Centene’s inadequate coverage left hundreds of patients in misery)

A 45-year-old woman from California named Sofia has been paying for mental health care for the past three years. She attempted suicide in the fall of 2017 after being lonely for years and confined primarily to her home. She was lucky enough to have a visitor that day who discovered her asleep on the floor.

She was quickly transported to a medical facility and revived. But that was only the beginning of the issues. She was found to be suffering from severe clinical depression. Her daughter, who remained in Arizona, arranged for her to be taken to a reputable mental health clinic in California.

Sophia received the biggest shock of her life just as she was beginning to show signs of recovery. Her insurance company refused to cover her, citing some unusual terms that they had never told about her. After hearing such news, her condition began to deteriorate dramatically.

She is one of the hundreds of people who have been misled by Centene, a for-profit health insurance corporation featured on the Fortune 500. A series of cases filed against the firm has brought the company’s dark side to light.

Frauds and Lawsuits in the Past

“Centene misrepresents the number, location, and existence of purported providers by listing physicians, medical groups, and other providers. Some of them have specifically requested to be removed — participants in their networks, and by listing nurses and other non-physicians as primary care providers,” according to one of the lawsuits filed against the company.

Centene also participates in the government’s Medicaid program, which provides coverage to low-income people. The corporation continued to offer a range despite many other large insurers opting out of the individual market created by federal law, particularly after President Trump promised to repeal the ACA.

Revealing true motives

The lawsuit highlighted the critical question of whether the insurance company intended to provide its consumers with the amount of care required by law. According to the case, several doctors have refused to accept Centene patients because the firm has refused to pay legitimate claims.

“Many patients have been unable to find in-network providers, according to the lawsuit. Cynthia Harvey was billed hundreds of dollars in medical bills after discovering some of her care was out of network in Washington State.

On December 12, 2017, Insurance Commissioner Mike Kreidler issued a "cease” order to Centene, ordering the business to stop selling individual health insurance in Washington due to its inability to maintain an appropriate network of medical providers. Centene was also fined $1.5 million, with $1 million deferred pending the company’s compliance with the law over the following two years.

“I’m delighted that we have reached an agreement with Coordinated Care to remedy its inadequacies,” Kreidler said, according to the online resource Healthcare Risk Management Review (HRMR). They recognize the gravity of the infractions and have promised to remedy them today. We’ll be keeping a close eye on the company to ensure that consumers are protected and get the coverage they paid for.“

While some people had to use their life savings to pay their expenses, others received assistance from NGOs and fund-raising. Then there are the vulnerable souls, such as Sophia, who have been thrust back into the darkness.

(Health Net HMO policy misleads insureds)

Health Net refused the appeals of the insured patients for benefit resolutions, claiming that they should have paid the claims under their HMO or in-network benefits. It stated that if an insured is accepted to a facility by an out-of-network provider, all services obtained in connection with care will be provided under the Indemnity Coverage, regardless of whether the facility is in-network or not.

According to the complaints, Health Net covered the facility by the insured’s Indemnity Coverage, or out-of-network benefits, for those insureds who had treatment at an in-network facility and were admitted by an out-of-network provider. As a result, the insured patients had to pay increased coinsurance and deductible payments.

Consumer complaints were filed with the Office of the Attorney General (OAG) in 2007 against Health Net and its practice of funding in-network facilities and providers under liability protection.

A Health Insurance without Benefits

The OAG’s investigation revealed that Health Nets had Evidence of Coverage for its point of service products. It does not disclose Health Net’s approach of covering an in-network facility under the Indemnity coverage (or out-of-network benefit) when a member is accepted to that facility by an out-of-network physician. The EOC for Health Net’s Point of Service product misleads its insureds.

Health Net’s Evidence of Coverage (EOC) provisions indicate that it will always cover an in-network facility under the HMO coverage, rather than the Indemnity coverage (out-of-network benefit) depending on the circumstances.

In-network benefits were defined as the benefit level for Covered Services supplied by Advantage Platinum Physicians or Advantage Platinum Specialty Providers in the HMO Coverage EOC’s definition section.

Out-of-network benefits are any physician, healthcare provider, or facility licensed to offer healthcare Covered Services who is not an Advantage Platinum Physician or an Advantage Platinum Specialty Provider.

Suppose an insured receives care from an in-network/Advantage Platinum physician or at an in-network/Advantage Platinum facility. In that case, the care should be covered under the HMO Coverage as in-network, by these criteria. There is no reason for an insured to assume that an in-network doctor or facility is anything other than in-network.

For in-network providers, the complaints stated that Health Net processed claims for in-network providers under the Indemnity coverage (out-of-network benefit) when they delivered the provider services at an out-of-network facility in certain circumstances.

The OAG found that Health Net did not adequately notify its members of how it handled claims from in-network facilities and providers when the members’ treatment included out-of-network services.

Health Net was required to follow the following rules under the Assurance of Discontinuance:

●     When a Member has both an HMO (in-network benefit) and an Indemnity (out-of-network benefit) component to the Point of Service Product, Health Net will arbitrate claims for in-network facilities member’s in-network benefits, regardless of the admitting provider’s status.

●     If Health Net decides to reinstate the practice of classifying in-network facilities as out-of-network providers discharging a member, it will not do so until it meets with the AOG to discuss the issue.

●     When a Member has both an HMO (in-network benefit) and an Indemnity (out-of-network benefit) under a Point Service Product, Health Net will litigate claims from in-network physicians member’s in-network benefits, whether the facility where the member is treated is in-network or not.

●     Health Net will train its customer service representatives on the new policies and procedures.

●     They told Health Net to track down all people who had been defrauded by the company and reimburse them within 45 days.

●     Health Net was required to report to the OAG on any reimbursements provided to its insureds within eight months of the Assurance’s effective date. This report was supposed to include a list of the reimbursed Qualified Members. As well as a unique identifier for each such MemberMember, the amount refunded, and the transaction date.

Repeated criminal activity

Health Net has a history of defrauding customers and then paying hefty fines as a result. They approved a settlement of three class-action lawsuits that would have far-reaching — and costly — repercussions for the managed care business some time ago.

The health plan agreed to pay $215 million to more than 2 million members to settle allegations that its coverage of out-of-network claims was biased in its favor. Health Net is currently involved in a lawsuit with behavioral healthcare clinics in California and Arizona for improperly withholding claim payments totaling more than $150 million.

(How Health Net transformed from a minion to a shark)

With Health Net withholding payment and stiff funding, it forced all treatment centers in California to say no to their regular patients. The refusal to honor the terms and conditions of the coverage affected hundreds of patients having nowhere to go except back to their old days or out in the streets because of centers refusing entry.

Gary Millman did not hesitate in paying more for his son’s policy so long as he was receiving quality treatment for his decade-long drug addiction. Health Net’s coverage for substance abuse at $700 was substantially higher. He did not have the right to complain having been aware of its benefits nor for anyone else who had bought the Health Net’s policy.

It was discovered that Health Net was merely guided by the profit motive after a year. Millman, who had signed the Health Nets policy in 2014, found out that his son could no longer avail of treatments at any of California’s drug and substance abuse centers.

It severely impacted rehab centers to let go of staff and run at reduced costs and directed personal funds towards running the centers - all of which affected treatments as well. Moreover, Bernadette Cattaneo of Lakes Treatment Centre complained about their treatment and how the insurer brought them on the verge of shutting down.

Health Net owed the Sacramento treatment center more than a million patient treatments from 2015 to 2016 - which happened multiple times. Everyone was left searching for answers as the abruptness with which Health Net swooped down on the insurers.

Putting their reputation at risk

It was 2015 when Health Net was acquired by Centene Corporation and signed a deal worth $6.3 billion. There were reports of incompetency and financial management since it soon emerged that Health Net had substantial financial worries of its own. However, top executives, including the CEO, proclaimed that all was well and that the company was in good health.

With finances in disarray, the heat was on Health Net and withheld funding. They then issued a directive to all substance abuse treatment centers to disclose all documentation related to treatment in early 2016. Policies had been authorized and there was no interlude for anyone in the dragnet audit.

Their P&Ps underwent significant revisions and updates to check fraud but meant to look for ways to deny claims. They used this scheme to forfeit valid claims of the patient, and everyone was forced to stay quiet or face monstrous obstacles laid down by the corporation.

Health Net reported that in 2013, only $251,000 was paid via claims for drug treatment, and the shares were worth $10 million in 2014. By 2015, it had passed over $190 million - all these to justify their statements.

The insurer filed countersuits against treatment centers that had filed previously for non-payment of dues and claimed that the center was collaborating with brokers they called on to drive patients away and paid extra for their services.

Health Net’s narrative

In 2014, the company first registered abrupted when the Affordable Care Act condescended mental health and substance abuse with other ailments and entailed being part of individual health plans.

Health Net bluffed all the benefits of the Affordable Care Act to make their policies more appealing to the beholder and offer unmatched benefits. As a result, 51 facilities owe more than $92 million in April 2016 and had claimed as far back as mid-2015.

After the California Insurance Department strains centers, receiver payments indicated that they had received only 20% due. Considering that substance abuse is a niche treatment, the charges could be between $1300 and more for a single-day stay, but centers had to resist with $250.

(Health Net removed insureds from insurance when they fall sick)

Health Net misled 4,865 Medicare clients by claiming that their plan did not charge more for the first five days of a hospital stay, while the project increased the patient’s financial burden by $25 per day. The insurer allegedly misled 9,098 clients by claiming that their network contained pharmacies with lower cost-sharing terms, although the plan did not include such “preferred cost-sharing” pharmacies.

During open enrollment in 2014, the private health insurance business Health Net submitted fraudulent information to approximately 14,000 Medicare consumers in Arizona. The federal government fined the health insurer about $350,000 as a result of the blunder.

According to the federal government, this is the second time Health Net has given Medicare consumers incorrect information concerning benefits and prescription drug programs. With the Centers for Medicare and Medicaid Services, Health Net did not correct the erroneous information until more than a month after enrollment began that year.

Seniors can alter their private Medicare plans during the open enrollment, which runs from October 15 to December 7. As a result, they must assess their private plans’ prescription medication plans and medical coverage provisions to determine whether they need to switch based on their particular health or financial needs. Health Net claimed to have discovered the error and mailed the correct information to the beneficiaries on November 24, or nearly five weeks after enrollment.

Gerald J. Mulcahy, who oversees Medicare’s enforcement of such plans, wrote in a notice disclosing the fine, “This was over a month after the open enrollment period had started. Thus, affected the time in which enrollees could use the information to make a fully informed decision about their Medicare health care and prescription drug options for the 2015 plan benefit year.”

In a statement, Health Net added, “We apologize for any confusion or irritation our errors caused.” “We identified the inaccuracies shortly after the materials were delivered last year and immediately alerted CMS,” says the company. And we started delivering revised information to affected beneficiaries right away.“

The insurance company deceives insured patients.

Health Net was one of six private Medicare health insurance companies investigated and punished for providing customers with inaccurate benefits information. A similar issue resulted in a punishment of $86,530 for Health Net in 2013.

According to a CMS official, Medicare users who choose a plan based on inaccurate information provided by a health insurer are eligible for a particular enrollment period that allows them to swap strategies.

Following a contract audit in February 2015, Medicare authorities fined Mercy Care’s Medicare Advantage prescription medication plan a total of $202,200. Mercy Care did not fulfill Medicare’s requirements for prescription formulary and coverage, according to the audit. According to the report, there were also issues with the insurer’s coverage determinations, appeals, and grievances.

(Michael Neidorff, Centene CEO involved in insider trading)

Several legal proceedings were piled up against Centene, including Michael Neidorff, the CEO. Together with its directors and officers for insider trading, they are guilty of violating federal securities laws, breaches of administrative duties, and other misconduct.

Centene Corporation is one of the top frauds in the U.S. and is renowned for dispensing pledged service to insured patients. The list of court cases they are entangled in is a testament to their morals. They are overpaid in the merger and acquisition with Health Net and indulged in sales of insider stocks. They exposed its violations of federal securities law, California tax laws, and government regulations. The company was provoked by millions of dollars in damages with the corruption within Centene.

The merger and acquisition of Health Net by Centene are discussed in the meetings of the legal system which uncovered the company’s core values which are naive swindle customers who depend on them for insurance coverage.

Aimed to ease the challenges of availing healthcare, the government Medicaid managed care program, which seems to be an accessible resource for corporations like Centene, makes large profits.

Centene had to buy Health Net’s outstanding stock because of its $6.8 billion mergers which called for stockholder and regulatory approvals. They failed to disclose problems acquired with Health Net business despite taking eight months of conduct.

The company resorted to other tactics of rejecting to pay claims to substance abuse treatment centers in various parts of the country to make up for the losses in the market capitalization of over $1 billion due to the merger.

Investigations were conducted by the California Department of Insurance (CDI) and the California Department of Managed Health Care (DMHC) on Centene.

Michael Neidorff: the Mastermind of Insider Trading

Centene approved false financial documents in the company’s public filings without disclosing events that would affect their financial statements.

Neidorff, along with Richard A. Gephardt, Jeffrey A. Schwaneke, Carol E. Goldman, sold their shares using their knowledge of Centene’s nonpublic information, which was a gross violation of the company’s internal policies, the counterpart of insider trading, and applicable law.

Michael Neidorff sold 367,427 shares of Centene stock valued at $19,950,436.04 using important, nonpublic information. The majority of these sales took place between December 10 and December 31, 2015.

Centene was forced to buy its stock from Neidorff at a higher price. Because during that period, Neidorff had significant and nonpublic information connected to Health Net’s inner rot of unproductive products and poorly conceived policies in California and Arizona. These exchanges disclose the practices of the company.

Health Net’s potential significant tax obligation and soaring unpaid claims from substance abuse providers were purposefully hidden by Neidorff.

Gephardt disposed of his Centene stock of 15,910 shares on June 28, 2016, and June 29, 2016, which fetched $1,096,058.20. These sales went unnoticed since they started less than a month after Gephardt signed a 10b5-1 trading strategy on May 26, 2016. The shares sold accounted for 28% of Gephardt’s Centene equity holdings. Gephardt had significant and nonpublic knowledge at the time of sale.

Similarly, Schwaneke sold 7,450 shares of Centene stock for a total of $422,815. Between December 8, 2015, and February 9, 2016, Schwaneke gave up over 5,000 shares worth nearly $300,000 to the company in exchange for the company paying its taxes.

Schwanke made a $130,000 profit by selling 2,000 shares of Centene stock. He also had inside information about Health Net’s poorly constructed policies when selling the stocks.

Their sales of Centene common shares enriched each of them. Neidorff and Gephardt’s stock sales made them appear as interested directors. Even in 2006, there were accusations and action cases against Centene and Neidorff for insider trading.

(Centene flouted False Claims Act, forced to compensate whistleblower who raised the alarm)

Centene Corporation was ordered by the Missouri Court of Appeals to pay a significant sum in a retaliation action brought by a former. The judgment came in the case of “Pitcher v Centene Corporation,” in which Ms. Pitcher claimed that her former employer, Centene, had broken the False Claims Act with Medicaid reimbursements.

Centene was held responsible for retaliatory dismissal by the court of appeals, and Ms. Pitcher was granted approximately $1.3 million. Her award included compensatory damages of $80,012 and punitive damages of $750,000. Pitcher also received more than half a million in advance pay for missing salary from the time she was hired until her retirement.

In most retaliation cases, the employee is reinstated. However, if the employee-employer relationship has deteriorated to the point where they cannot repair it, the employee is entitled to advance payment.

Centene appealed the trial court’s decision on several grounds, the most important of which were jurisdictional concerns and the award of front compensation. The Court of Appeals also said it was up to the trial court’s discretion and subject to the jury’s factual findings.

Punitive damages show the jury’s emotion concerning Centene’s illegal conduct according to the court. Centene contended that the initial payment was excessively high, given the compensatory and punitive damages already assessed to Ms. Pitcher.

Centene has a history of breaking the rules.

The court, however, ruled on Pitcher’s behalf. When Centene effectively sought to have the testimony about front pay deleted from the trial, the court implied that Centene “cannot claim the jury addressed front pay in its award because Appellants ensured this issue was reserved for the court.”

(A new look at how Centene lobbies for pet Medicaid projects by funding political candidates)

Centene Corporation owes much of its success to the hard work of hardworking Americans who toil day and night. Its purchasing policies and paying exorbitant premiums hope that when their luck runs out and they become ill, they will have their insurance fall back. However, a Fortune 500 corporation like Centene is more concerned with profits than with people, and as a result, they are not averse to endorsing political politicians that support their cause.

While they avoid liability on minor grounds – billing errors, lack of documentation, etc. – or resort to underpayment of claims. It frustrates both providers and policyholders; they guarantee that higher powers’ budgets are packed full.

They use the deception of an army of lobbyists who keep an eye on how they may influence political decision-making by associating with the correct candidate in this exercise. Centene leaves its war fund open for this purpose, allowing political and charity donations. Substantial insurance companies throughout the country are fighting for Medicaid Managed Care.

Medicare managed services advocacy.

In 2017, an intriguing discovery was made about one of Centene Corp.’s partners, Nebraska Total Care, situated in St. Louis. Nebraska Total Care was one of three insurance companies given the renowned Heritage Health managed care contract, which served approximately 230,000 Medicaid clients through unethical means.

UnitedHealth Group and WellCare are the other two insurance carriers that have been repeatedly criticized for their actions. For example, WellCare Health Plans reportedly paid the federal government $137.5 million to settle accusations linked to overbilling its Medicare and Medicaid programs.

Between 2014 and 2017, the named firms gave significantly to Republican Governor Pete Rickett’s campaign fund. While Centene contributed at least $23,500 in 2014 and 2017, the other two companies, UnitedHealth Group and WellCare Health Plans supplied $12,000 in 2015 and 2016 and $2,000 in 2016 and 2017.

No special treatment

Nebraska Total Care, together with UnitedHealth and WellCare, began providing primary care in January 2015. In response to allegations about favoritism, the Governor’s spokeswoman stated that the Governor’s office did not choose Medicaid providers. Instead, the program was overseen by the Department of Health and Human Services.

There is a lot at stake for insurance companies competing for a piece of the Heritage Health contract. It is primarily a healthcare delivery system that combines Nebraska’s physical, behavioral, and pharmacy programs into a comprehensive unit for Nebraska’s Medicaid and Children’s Health Insurance policyholders to choose.

Centene’s Nebraska Total Care with 76,000 members on board began receiving concerns about the nature of its operation just months after it launched. The state Medicaid division revealed severe problems linked to providers’ concerns not being addressed.

There were accusations that providers were not being paid promptly, raising serious concerns about the insurer’s operations. Ryan Sadler, the CEO of Nebraska Total Care, was unreachable for comment.

Creating a thriving business

Centene, a Fortune 500 company, has built its dynasty based on a fundamental principle. Saving the state money and pocketing the difference is a win-win situation. “Save the states between 5 percent and 8 percent of the cost to care for their poorest, sickest and youngest patients — and pocket a piece of the difference.”

Many people will lose their hard-earned money to theft and fraud. When the allegations were brought to Senator Kate Bolz of Lincoln, the Executive Director of the Nebraska Association of Service Providers, she decided to investigate. Ricketts, members of the Legislature, and state Interim Medicaid Director-Rocky Thompson were all contacted.

“I have heard multiple concerns from both constituents and health care providers about underpaid claims, network sufficiency, and treatment denials,” Bolz wrote in her letter, elaborating on the complaints she had received.

(Centene sued for inadequate network coverage)

Centene Health Net has been sued in a class-action lawsuit to offer enough network coverage to its customers. Because of their unwillingness to fund BH/SUD providers, Behavioral Centers across California and Arizona refused Health Net-insured patients.

Health insurance does not guarantee access to care.

Kathleen Steinley and Martin Harold Steinley filed a class-action lawsuit against Health Net on May 4, 2018, alleging –

●     Misleading claims in PPO policy.

●     An insufficient network of contracted providers on behavioral health and substance use disorder (BH/SUD) services has an insufficient network of contracted providers.

●     The management of PPO Policies was grossly botched.

●     Inequitable distribution of benefits for BH/SUD services compared to medical and surgical services is due to its irrational investigation of claims and resultant rejection of out-of-network options.

Martin filled out a Health Net Small Business Application for Group Enrollment and selected the Health Net Gold 80 PPO coverage, which will begin on December 1, 2015. He mentioned his family members in the policy registration application, including his wife, Kathleen, their son, Alex, and their other two children.

When he chose the Health Net PPO Policy, he relied on Health Net’s statements about access to a good healthcare provider network. In May 2016, Alex was admitted to Aurora Vista del Mar Hospital in Ventura County, where he notified Kathleen and Martin that they would need to find a BH/SUD residential treatment center where he could be discharged after his stay.

Kathleen began a frantic search for residential treatment clinics that were part of Health Net’s provider network, as represented in advertisements, marketing materials, and a directory accessible through the Health Net website portal.

Health centers refusing to accommodate Health Net-insured patients

Seeking assistance from David Archambault, Kathleen’s insurance broker, she was able to explore the online Health Net Provider Directory with the help of Mr. Archambault. However, she rapidly discovered that there were no in-network providers that could treat Alex, and was dismayed to find out that out-of-network clinicians could not treat a Health Net insured because Health Net had launched a dragnet SIU investigation to stop BH/SUD out-of-network providers from receiving reimbursement.

On May 6, 2016, she was then informed by in-network providers that they either didn’t provide the treatments Alex required, didn’t have any beds available for Alex, or wouldn’t treat him because he was already admitted to a facility with an equivalent level of care.

Out-of-network providers told the Steinleys that although they had vacant space and services provided that Alex needed, they could no longer admit and treat Health Net-insured patients because Health Net declined to compensate BH/SUB out-of-network providers for services that they gave. Kathleen had also spent the whole day researching and contacting treatment facilities that rejected her because her insurance was through Health Net.

On May 7, 2016, Martin contacted Health Net and demanded that they issue a list of in-network providers, which Kathleen had contacted immediately. The providers were rehabilitation hospitals to treat strokes, traumatic brain injury, and other physical rehabilitation services. Not one provider on the list from Health Net was BH/SUD providers. Kathleen was able to get in touch with an organization that helps patients be placed in residential treatment centers across the country but was advised that most out-of-network BH/SUD providers across the government no longer accept Health Net patients.

Kathleen was unable to find a suitable facility willing to treat Alex. Most providers announced that no out-of-network provider in the country would treat Health Net-insured patients. Only two organizations that she worked with could find two suitable residential facilities willing to admit Alex - because of the Health Net’s SIU investigation and closure of reimbursement payments.

Claims against Centene Health Net

●     Consumers were deceived by numerous BH/SUD providers’ false names in the Health Net network of contracted providers or in-network providers.

●     Misleading representations in advertising, marketing, and communications regarding BH/SD provider networks.

●     Delays and interruptions in accessing needed health care in the network of BH/SUD providers.

●     Long waiting time on customer service telephone lines would take several hours and even days and weeks in some cases.

●     Health Net tricked customers with limited and unsubstantial options of out-of-network BH/SUD providers.

●     Insured patients are subject to high healthcare costs due to Health Net’s compensating BH/Sud services which resulted in an underpayment of on average of 70-80% of the providers’ billed charges and an increase in insured patients’ out-of-pocket expenses for covered healthcare services.

Additionally, Health Net underpaid the reimbursement to Steinleys for the expenses incurred at The Canyon, using Medicare compensation rates that do not apply to the services provided. It also underpaid The Canyon’s billed charges and led to an increase in Steinleys’ out-of-pocket expenses for the medically necessary yet covered healthcare services.