In an American Health Law Association Bulletin, author Stefan Chacon examines United States v. Inland Empire Health Plan, a case that may become a significant test of the U.S. Department of Justice’s False Claims Act (FCA) theory related to the use of Medicaid Adult Expansion funds. The article analyzes the government’s allegations that Inland Empire Health Plan improperly retained excess Medicaid funds in violation of federal requirements, reviews similar prior enforcement actions, and explains why the scope and potential financial exposure in this case make it particularly consequential for healthcare plans and providers.

View the PDF of the Article Here

Topics Include

• False Claims Act Enforcement – overview of DOJ’s FCA theory based on the alleged improper retention of Medicaid Adult Expansion funds.
• Medicaid Adult Expansion Funding Rules – explanation of Medical Loss Ratio (MLR) requirements and the obligation to spend at least 85% of funds on allowed medical expenses.
• U.S. v. Inland Empire Health Plan – summary of the government’s allegations, including claims of improper incentive payments, retroactive rate increases, and misuse of funds.
• Prior California FCA Settlements – discussion of recent settlements involving county-based health plans and providers, resulting in substantial recoveries for the government.
• Scope and Financial Exposure – analysis of why the alleged $320 million in improperly retained funds makes this case uniquely significant compared to prior actions.
• Implications for Health Plans & Providers – considerations for compliance, contracting, and financial oversight in Medicaid managed care programs.