InnovAge PACE Sanctions: Colorado, Sacramento and the Releases

The Centers for Medicare & Medicaid Services released the InnovAge PACE enrollment sanctions in Sacramento effective November 21, 2022, and in Colorado effective January 23, 2023, after validating corrections to serious care failures. The findings reached into work a scheduler, clinician or compliance employee would recognize: necessary appointments never arranged, specialist reports obtained months late and medical information that never reached the team responsible for care. If you worked with those orders, reports or correction records, you may know what happened between the care decision and the account the organization gave CMS.

This page follows the separate Sacramento and Colorado findings and the corrections CMS evaluated before restoring enrollment. Our page on PACE whistleblower evidence records follows the broader connection between a service record, a government submission and a paid month.

What Were the InnovAge PACE Sanctions?

The InnovAge PACE sanctions suspended enrollment of new Medicare beneficiaries under two separate contracts. CMS concluded that each organization had substantially failed to provide medically necessary services, harming participants or creating a substantial likelihood of harm. Both suspensions applied regardless of the new participant’s Medicaid eligibility.

The Sacramento notice covered InnovAge California PACE-Sacramento, LLC, contract H2368. The Colorado notice covered Total Longterm Care, Inc., doing business as InnovAge Colorado PACE, contract H0613.

PACE, the Programs of All-Inclusive Care for the Elderly, takes responsibility for an integrated package of health care. As the notices explain, that includes Medicare-covered services, Medicaid-covered services and additional care the interdisciplinary team determines necessary. The team coordinates care across settings and around the clock, while the primary care provider manages medical situations and oversees specialist care.

The financial arrangement puts that responsibility inside the organization’s budget. CMS’s model PACE program agreement pairs comprehensive services with prospective monthly capitation for eligible enrolled participants. Medicare and Medicaid have separate payment terms, and the Medicaid provisions call for enrollment reconciliation. For an insider, the important connection is what the organization undertook to provide, what it actually provided and what it told the government about the difference.

What Did CMS Find at InnovAge Sacramento?

CMS found that InnovAge Sacramento failed to provide necessary specialist services, failed to follow through on specialist advice and delayed ordered care without a clear reason. Sacramento then submitted analyses identifying additional participants who might have been affected, and CMS checked those analyses by reviewing additional cases.

The specialist-access findings were specific. CMS identified missing necessary ophthalmology, optometry, dermatology and nephrology services, and found that Sacramento lacked standing contracts with those specialists. The notice placed responsibility for furnishing the care on the PACE organization even when it lacked a contract. For someone who worked in contracting or clinical care, the missing arrangement and the unprovided service are parts of the same obligation.

The gap continued after appointments that did happen. CMS found that some consultation reports had to be obtained from specialists during the audit, in some cases months after the appointments. The organization had sent participants for specialist advice without receiving the resulting assessments, diagnoses or recommendations. We would call that follow-up for the auditor.

Having the report did not always produce the care, either. CMS found instances in which specialist consultation details were already in the participant’s medical record, but InnovAge Sacramento had not followed up on the recommendations. Elsewhere, auditors found ordered services canceled, not provided or unreasonably delayed without a clear rationale for cancellation or delay.

The specialist’s office may know when the report was sent and what it recommended. The center’s records may show when it arrived, who reviewed it and whether anyone arranged the next service. That is the care history we connect to the organization’s account of its performance and government payments.

What Did CMS Find at InnovAge Colorado?

CMS found that InnovAge Colorado failed to schedule necessary care, failed to follow up on specialist information and failed to share important medical information with the interdisciplinary team. CMS checked the organization’s subsequent impact analyses by selecting additional cases for review.

In the scheduling findings, primary care providers had already determined that services were medically necessary and ordered them. CMS found that InnovAge Colorado then failed to schedule the services or delayed scheduling, leaving care unprovided or delayed. Some of the services were urgently needed. The notice recorded the organization’s response:

The specialist findings concerned what happened after outside clinicians supplied information. CMS found that InnovAge Colorado failed to follow up on diagnoses and recommendations, leaving participants’ medical conditions unmanaged in response to that advice. It separately found that clinical staff failed to share important medical information the interdisciplinary team needed to evaluate a participant’s condition.

For a scheduler, the order and appointment history can show where approved care stopped. For a clinician, the specialist’s report and team communications can show whether important information reached the people responsible for acting on it. The Colorado findings follow that sequence from a medical decision through scheduling and follow-up. Sacramento adds a distinct contracting problem and reports that the organization obtained only when auditors requested them.

How Were the InnovAge PACE Sanctions Released?

The Centers for Medicare & Medicaid Services released each sanction after evaluating a validation audit and ongoing federal monitoring, and determining that the deficiencies underlying the sanction had been sufficiently corrected. Each original notice made InnovAge responsible for developing and implementing a corrective-action plan and demonstrating that the problems were corrected and unlikely to recur. Both notices required validation of the cited operational areas before enrollment could resume.

In Sacramento, the organization attested that it had corrected the violations. The federal release letter describes CMS’s evaluation of the validation audit and monitoring before restoring normal enrollment.

In Colorado, InnovAge attested that it had corrected the violations. The Colorado release letter records the same sequence of agency review: validation results, ongoing monitoring and CMS’s determination that the sanction-related deficiencies had been sufficiently corrected. An employee comparing PACE sanction release with validated correction may know what changed before the organization sent its attestation to CMS.

Both release letters also called for post-sanction corrective action and monitoring to address issues identified during validation. Each also called for continued oversight and correction of initial audit conditions outside the sanction’s scope. We see the limit of that release: normal enrollment returned with further oversight still required.

Does a CMS Sanction or Company Accrual Establish a Settlement?

A CMS sanction or company accrual does not establish a settlement. The InnovAge sanctions imposed enrollment restrictions, and the releases restored normal enrollment after CMS evaluated correction. An accrual records an estimated liability in the company’s accounts.

The money question for a whistleblower is what the government paid or was owed because of a knowing falsehood. We examine what the organization represented about care or compliance, who knew the underlying circumstances and how the representation affected payment. That work connects the care story to a potential False Claims Act case. Our PACE program fraud questions address the broader relationship between care, capitation and government money. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

Which Records Connect Care Failures to Government Payment?

The original service history, the account submitted to the government and the corresponding payment records connect a care failure to the financial inquiry. The InnovAge notices show why each part matters: an order can exist without a scheduled appointment, a consultation can occur without its report reaching the team, and a report can arrive without anyone acting on it. We work with insiders to follow those differences through the organization’s decisions and submissions.

For this sanction history, the useful comparisons are concrete:

• Orders and scheduling: the medical order, appointment history and staff communications can show what happened to necessary care and who knew it had stalled.
• Specialist access and follow-up: contracts, consultation reports and the team’s response can show whether outside care was arranged and the advice acted on.
• The representation and payment: the agreement, government submission and capitation or reconciliation records connect the promised care, the account given to the payer and the money involved.

CMS’s model agreement connects these subjects in its record-access provisions. It calls for access to participant outcomes, medical and personnel records, financial books, services furnished, reconciliation and the determination of Medicare and Medicaid amounts payable. A clinician or scheduler may explain the service history, while finance and compliance employees may explain how it reached the organization’s reporting and payment systems.

If you are considering reporting PACE program fraud, we start with the part of that history you know. Your knowledge may explain why an order remained open, why a specialist’s recommendation went unanswered or how a correction was described outside the organization.

You Know What Happened After the Order

If you worked with InnovAge’s scheduling, specialist reports or correction submissions, speak to one of our Whistleblower Experts about the care that never came. We help turn that knowledge into your strongest PACE fraud whistleblower case, bringing in PACE fraud whistleblower lawyers who understand capitation and care obligations. We stay beside you as the service history, management decisions and financial evidence come together.