Centene Corporation: Medicaid's Profiteer

Centene faced widespread allegations across multiple states for overcharging Medicaid programs through its pharmacy benefit manager (PBM), Envolve Pharmacy Solutions. These overbilling schemes involved double-billing for pharmacy services, leading to significant financial penalties.

In 2021, Centene paid $88 million to Ohio and $55 million to Mississippi to settle claims of double-billing. By 2023, they reached a $215 million settlement with California for inflating prescription drug costs under Medi-Cal. By 2024, Centene had paid over $1.25 billion in settlements across at least 15 states, including Washington ($19 million) and Texas ($165.6 million).

They exploited Medicaid's systems to siphon off billions, undermining the very programs meant to support the most vulnerable.

A class-action lawsuit filed in 2024 alleges that Centene defrauded consumers through its Ambetter health insurance plans by selling policies that many doctors would not accept. Plaintiffs claim Centene misrepresented provider networks and coverage quality, violating the Racketeer Influenced and Corrupt Organizations (RICO) Act.

The lawsuit involves consumers across 26 states who purchased Ambetter plans under false pretenses. Judge Nancy L. Maldonado allowed the case to proceed, citing sufficient evidence of mail and wire fraud. This marks a significant escalation in legal challenges against Centene's marketing and network practices.

They leveraged deceptive practices to mislead consumers, undermining trust and access to quality care.

In October 2024, Centene sued the Centers for Medicare & Medicaid Services (CMS) over a downgrade in its Medicare Advantage star ratings, alleging unfair treatment. Centene claims that CMS penalized them based on a single failed call during a secret shopper test, costing the company $73 million in lost revenue.

Centene argues that CMS’s methodology was arbitrary and flawed, asserting that similar lawsuits have been filed by other insurers like Humana and UnitedHealth Group. This lawsuit challenges the fairness and transparency of CMS’s star rating system, which significantly impacts Medicare Advantage plan revenues and reputations.

They contest the integrity of CMS’s evaluation methods, aiming to protect their financial interests and market standing.

In May 2024, consumers filed a class-action lawsuit alleging that Centene sold health plans with deceptive provider networks, leaving patients unable to access care from listed doctors or hospitals. Plaintiffs claim they were misled into purchasing plans that lacked adequate provider coverage, violating consumer protection laws in at least 11 states.

This lawsuit highlights systemic issues with transparency in health plan marketing. Consumers discovered the discrepancies only after attempting to seek care, revealing a pattern of misleading information intended to inflate plan enrollments and profits.

They engaged in deceptive marketing to boost enrollments, at the expense of genuine patient care access.

In 2022, the Bricklayers Pension Fund sued Centene’s board for failing to prevent Medicaid fraud, which resulted in hundreds of millions of dollars in settlements. The lawsuit alleged that board members ignored red flags about overbilling schemes involving pharmacy services.

However, in July 2024, a Delaware judge dismissed the case, ruling insufficient evidence of bad faith by the board. This case underscores governance concerns related to compliance oversight, highlighting the need for better internal controls and accountability within Centene’s leadership.

They neglected their fiduciary duties, allowing rampant fraud to continue unchecked.

In January 2024, Centene paid $25 million to South Carolina to resolve allegations of overbilling for pharmacy services under Medicaid programs. The state alleged that Centene misrepresented costs, failed to disclose discounts, and filed improper reports.

This settlement is part of broader investigations into PBM practices across multiple states, highlighting systemic issues with transparency and accountability in Centene’s pharmacy management operations.

They manipulated billing practices to maximize profits, at the expense of state Medicaid funds and patient care.

In February 2023, Centene paid $215 million to California after allegedly inflating prescription drug costs under the state’s Medi-Cal program. Investigators found that Centene pocketed discounts negotiated with CVS Caremark instead of passing them on to Medi-Cal.

This settlement is one of the largest involving Medi-Cal fraud in California’s history, demonstrating the scale and impact of Centene’s fraudulent practices within state Medicaid programs.

They exploited negotiated discounts to unlawfully siphon funds from California’s Medicaid program.

Multiple lawsuits have alleged that Centene failed to disclose discounts negotiated by its PBM subsidiaries, leading to inflated costs for state Medicaid programs. These allegations span several states, including Washington, which required a $19 million settlement.

These practices highlight systemic issues with transparency in PBM operations, where Centene prioritized internal savings over passing negotiated discounts onto Medicaid programs. This lack of transparency resulted in higher drug costs and undermined the financial integrity of state Medicaid funds.

They concealed significant discounts, artificially inflating costs and draining Medicaid resources.

Centene has faced ongoing scrutiny for deceptive marketing practices as part of broader lawsuits filed through late 2024. Plaintiffs allege that Centene misled consumers about the scope and quality of its health plans, including inaccurate provider directories ("ghost networks") and inadequate coverage options.

These allegations have been raised in both individual lawsuits and class actions, highlighting a persistent pattern of misleading information intended to attract enrollments without ensuring genuine access to quality healthcare services.

They deceived consumers with false promises, prioritizing enrollment numbers over actual care quality and access.

Since the mid-2010s, state attorneys general have scrutinized Centene’s practices related to Medicaid managed care contracts. Investigations have focused on improper billing practices, lack of transparency, and failure to meet contractual obligations.

Issues identified include overbilling for services, inadequate provider network management, and failure to implement necessary operational reforms. These investigations have resulted in significant financial penalties and mandated operational changes to ensure compliance and improve care delivery.

They perpetuated systemic inefficiencies and fraud, prompting widespread regulatory intervention.