Fraud Case Amerigroup Illinois Inc

Amerigroup Illinois Inc. Fraud Case

Amerigroup Illinois Inc. was found guilty in 2006 under the Federal Claims Act and the Illinois Protection Act. Amerigroup and its subsidiaries denied enrolling pregnant women and unhealthy patients in its managed care program in Illinois. Amerigroup received payment from the state and federal governments to operate a Medicaid health care program for low-income earners (Department Justice, 2008). Amerigroup was mandated by law to enroll all applicants eligible for the care under the Medicaid program. The State of Illinois and the Federal government of the US filled claims against Amerigroup, alleging that the corporation overlooked their responsibility of enrolling unhealthy parents and pregnant women since it would have been more expensive and lowered the profit margins earned by the patients.

The court entered into a $334 million judgment against Amerigroup under the Federal Claims Act and the Illinois Whistleblower Reward and Protection Act. The Jury found the firm guilty under both Acts. The firm filed an appeal with the U.S. Court of Appeals in the Seventh Circuit of Chicago, seeking the decision to be revised (Department Justice, 2008). However, Amerigroup agreed to dismiss its appeal and got into a Corporate Integrity Agreement (CIA)with the Office of the Inspector General in the civil division. Amerigroup also agreed to make a $22 million settlement to resolve the allegation that it defrauded the Medicaid program.

The Illinois Whistleblower and Protection Act allows the whistleblowers to bring forth the allegations of defrauding of state and federal state dollars. The act is now known as the “Illinois Whistleblower Reward and Protection Act” (IFCA) in 1991. The damages provision in IFCA is similar to the statutory language of the federal FCA that allows the penalties of $5000 to $11,000 per for every claim (Department of Justice, 2021). Adherence to the legal implication of these Acts is delegating civil responsibility to individuals who witness defrauding behavior to file an allegation with local authorities. The IFCA protects the whistleblowers from the defendant by ensuring that they are reinstated if their employer terminates their employment with similar status in the corporation (Rudman, 2009). Further, the whistleblowers are compensated for any damages they might have incurred, such as attorney fees, litigation costs, and interests on the backpay.

The Amerigroup was initially filled by Cleveland Tyson, who was a former employee of the company. Under the Illinois Whistleblower Reward and Protection Act or IFCA and the False Claims Act, Tyson is recognized as a realtor and was entitled to file the suit claiming fraud on behalf of the state and federal government. Further, as the whistleblower, he was entitled to part of the money recovered from the claim. Consequently, Tyson received $56.25 million from the settlement (Department Justice, 2008). Notably, the fraud could have been brought forward to prevent the denial of healthcare services to eligible individuals had the case been presented earlier. However, Tyson could only file the allegation after leaving the company and securing his financial security (Rudman, 2009). This is because court proceedings unpredictable, and this would have resulted in unemployment, causing him financial distress. Notably, the protection of whistleblowers being taken up by the state and federal governments immediately is necessary to eradicate the concerns that might prevent whistleblowers from filing allegations of fraudulent behavior soon as the fraud was recognized.

The False Claims Act (FCA), 31 U.S.C. §§ 3729 – 3733allows citizens to file a suit on behalf of the government, known as a qui tam suit, against a perpetrator of fraud against the government (“The False Claims Act,” 2021). Additionally, the act also awards the citizens a portion of the funds recovered by the government (Department of Justice, 2021). Besides combating fraud in healthcare, the FCA serves as the government’s primary civil tool to redress any federal funds and property claims for other government operations (“The False Claims Act,” 2021). The funds recovered from fraud cases in healthcare are restored to government programs, such as Medicaid, Medicare, and TRICARE. The Department of Health and Human Services (HHS) vigorous investigation for fraud in healthcare focuses on health providers and focuses on authorities and good and services suppliers. For example, in 2020, the department received the largest resettlements from drug manufacturers (Department of Justice, 2021). Congress included co-payment in Medicaid as a measure to regulate drug prices and health care costs.

The Corporate Integrity Agreement (CIA) between Amerigroup and its subsidiaries and the Inspector General’s office for the U.S.H.S required the organization to adopt policies and procedures, a code of conduct complementary to the regulations applicable to Medicaid, and financial accountability. The act is applicable to protect patients from improper discrimination in marketing and enrollment. The CIA applied to the Amerigroup and all its subsidiaries across states (Rudman, 2009). Further, the agreement required Amerigroup to hire an independent organization to review its enrollment and marketing practices and the board of directors’ certification of the effectiveness of the firm’s compliance program annually.

Notably, Amerigroup’s administration and governance of the firm were aware of the fraudulent behavior and expected the employees and other stakeholders to remain silent on the fraud. However, the §8B2.1 - Effective Compliance and Ethics Program require organizations to exercise due diligence to prevent fraudulent behavior and detect criminal conduct (“USSC Guidelines,” 2021). Further, it requires the organizational leadership to promote an organizational culture that encourages ethical conduct and compliance with the law. Suppose the organization’s leadership fails to comply with the effective compliance and ethics program. In that case, the stakeholders who are aware of such conduct must file a suit on behalf of the government. After settlement, the office of the inspector general of the US is required to foresee the initiation of a CIA that is intended to ensure accountability and compliance by the organization.