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Sutter Health – Medicare Advantage Fraud ($90 million)

Constantine Cannon represented whistleblower Kathy Ormsby in a False Claims Act litigation against Sutter Health and its affiliates that resulted in a $90 million settlement – the largest Medicare Advantage FCA settlement to date against a hospital system, and the second largest reported Medicare Advantage fraud settlement to date.  Ms. Ormsby, a former Risk Adjustment Factor Project Manager at Sutter Health affiliate Palo Alto Medical Foundation, alleged the Sutter Health defendants inflated the number and severity of Medicare Advantage patient diagnoses, manipulated patient records, ignored audit “red flags,” and engaged in other misconduct to increase patient risk scores and obtain Medicare Advantage payments to which they were not entitled.  In Spring 2019, the Government intervened in Ms. Ormsby’s case as to PAMF, and Ms. Ormsby continued to pursue her claims against the other Sutter Health affiliates on a non-intervened basis. This settlement resolves all claims and follows Sutter’s unsuccessful effort to dismiss both the complaints.  Read more: Press Release; Whistleblower Insider.

Kaiser Permanente – Medicare Advantage Risk Adjustment Fraud (Case Intervention)

Constantine Cannon represents Dr. James Taylor, a highly placed physician and healthcare coding expert, in False Claims Act litigation against Kaiser Permanente.  He is among a group of ten whistleblowers who accuse the large Medicare Advantage organization of knowingly submitting false claims for risk-adjusted payments to the Centers for Medicare & Medicaid Services (CMS).  The suit alleges that Kaiser routinely obtained fraudulently inflated risk-adjusted payments by knowingly submitting diagnosis codes for patients that were unsupported by the patients’ medical records, and the government’s intervention focuses on unsupported diagnosis codes that Kaiser allegedly improperly added through addenda to patients’ medical records.  The qui tam whistleblower suit was unsealed on July 29, 2021. See:  Taylor Amended Complaint; DOJ Press Release

Group Health Cooperative (now a subsidiary of Kaiser Permanente) – Medicare Advantage Fraud ($6.375 million)

Constantine Cannon represents whistleblower Teresa Ross against Group Health Cooperative, an insurance company that participates in the Medicare Advantage program. GHC has agreed to pay $6.375 million to resolve allegations that the insurance plan improperly collected money from the Medicare Advantage program by overstating how sick its beneficiaries were. Ms. Ross is a former employee of GHC, where she worked for 14 years; her most recent position was the director of risk adjustment services. In her complaint, Ms. Ross alleged that GHC had improperly relied on coders’ interpretations of diagnostic tests, prescriptions, and entries in problem lists to come up with diagnoses and that it had also submitted other codes that were false because they were diagnosed by inappropriate providers, fell outside service year, or the patient had no evidence of a current condition. See Press Release and Whistleblower Insider for more.

Freedom Health, Optimum Healthcare - Medicare Risk Adjustment ($32.5 million)

Two of our whistleblower lawyers led the representation of the late Dr. Darren Sewell, M.D., the former chief medical officer and vice president of special projects for two large health insurers and operators of Medicare managed healthcare insurance plans based in Tampa, Florida. Dr. Sewell brought a qui tam case under the False Claims Act against Freedom, Optimum and Mr. Pagidipati alleging that they improperly gamed a feature of the Medicare Advantage program known as risk adjustment, or risk scoring, by fraudulently inflating their members’ risk scores and the corresponding risk adjustment payments they received from CMS, and that they fraudulently induced CMS to allow them to expand their health insurance offerings into new counties in Florida and the Carolinas by falsely representing that they had a sufficient network of doctors, clinics and hospitals available to serve their enrollees in the expanded service areas when they had no such networks in place. The Government joined the case and in 2017, defendants agreed to pay $32.5 million to settle the matter. The Government and the whistleblower are in the process of negotiating the amount of the relator’s share of the Government’s $32.5 million recovery that Dr. Sewell’s estate will receive. See NPR, DOJ for more.

UnitedHealth Group, Inc. – Medicare Advantage Risk Adjustment Fraud (Case Intervention)

Constantine Cannon represents the whistleblower in one of the largest Medicare Advantage risk adjustment cases in history.  Our client, Benjamin Poehling, alleges that UHG, the nation’s largest health insurer, together with its related Medicare Advantage Organizations, knowingly inflated Medicare Advantage risk scores by engaging in “one-way” chart reviews, even after he expressed concern about this practice to fellow executives.  The United States filed a complaint in intervention in May, 2017, and the case continues to be actively litigated, with trial scheduled in 2023. See: Government Complaint in Intervention; Poehling Second Amended Complaint; Constantine Cannon Press Release.