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Medicare Risk Adjustment Fraud is Not Victimless

Posted 06/18/20

Implicit in the arguments made by many Medicare Advantage Organizations (MAOs), health plans, hospital networks and other defendants in response to whistleblower and government False Claims Act complaints is that the alleged misconduct—falsifying diagnosis data so that CMS overpays for patients enrolled in an MA plan—involves just a technical record-keeping or administrative dispute with CMS and no actual...

Tagged in: FCA Federal, Healthcare Fraud, Medicare, Provider Fraud, Risk Adjustment Fraud,

New Lawsuit Against Anthem Shows the Government’s Commitment to Medicare Advantage Fraud

Posted 04/3/20

health insurance with stethoscope and hundred dollar bills

Medicare Advantage, also called Medicare Part C, is ever-expanding part of our healthcare system. The program now insures over a third of total Medicare beneficiaries, well over 10 million people. An expansion in fraud has accompanied the program’s expansion, and the Department of Justice is zeroing in, with the Assistant Attorney General for the Civil Division, Joseph Hunt, recently declaring it a...

Tagged in: FCA Federal, Healthcare Fraud, Medicare, Provider Fraud, Risk Adjustment Fraud,

DOJ Discusses Its 2020 Healthcare Fraud Enforcement Priorities

Posted 03/6/20

DOJ Headquarters building seen from low angle

In comments at the 2020 FBA Qui Tam conference, the Department of Justice reaffirmed its strong commitment to pursuing fraud under the False Claims Act and emphasized its particular focus on rooting out healthcare fraud. Jody Hunt, Assistant Attorney General in the Civil Division of DOJ, was encouragingly forceful in his comments about the critical role of the FCA in protecting the public fisc—and the patient...

Tagged in: Electronic Health Records, FCA Federal, Government Programs Fraud, Healthcare Fraud, Risk Adjustment Fraud,

Top Ten Whistleblower Developments of 2019

Posted 02/6/20

By any measure, 2019 was a Very Big Year for whistleblowers. Our annual Top Ten lists identified 2019’s most significant financial recoveries by whistleblowers, as well as recoveries in enforcement actions at the federal and state level involving government procurement, healthcare, financial, tax, and other types of fraud. But the numbers, as impressive as they are, can’t tell the full story of the impact that...

Tagged in: CFTC Whistleblower Reward Program, Cybersecurity and Data Breaches, FCA Federal, Government Procurement Fraud, Healthcare Fraud, Importance of Whistleblowers, International Whistleblowers, Risk Adjustment Fraud, SEC Whistleblower Reward Program, Top 10,

Federal Audit Reveals Billions of Dollars in Medicare Advantage Overpayments

Posted 12/20/19

A new government report reveals what whistleblowers and their counsel have known for some time: the Medicare Advantage program is vulnerable to fraud committed by unscrupulous private health insurance companies, as well as their owners, vendors, affiliates, and even some doctors. These bad actors make patients enrolled in MA plans appear sicker than they actually are in order to increase their corporate profits. ...

Tagged in: FCA Federal, Healthcare Fraud, Importance of Whistleblowers, Managed Care, Risk Adjustment Fraud,

New Yorker Article on Whistleblowers Features Constantine Cannon

Posted 01/28/19

Silver whistle hanging on cord in front of chalkboard

In an article titled “The Personal Toll of Whistle-Blowing” published in the February 4, 2019, New Yorker magazine, Sheelah Kolhatkar describes the cases of two Constantine Cannon whistleblower clients, and features whistleblower attorney Mary Inman. Focusing on False Claims Act cases involving fraud in the Medicare Advantage program, the article details how the FCA “effectively turned average citizens into a...

Tagged in: CC Lawyers, FCA Federal, Importance of Whistleblowers, Managed Care, Risk Adjustment Fraud,

Top Ten Healthcare Recoveries of 2018

Posted 01/15/19

Consistent with the trend in prior years, the bulk of the Justice Department’s fraud and false claims recoveries in 2018 stemmed from healthcare fraud matters. And again, most of the funds recovered arose from cases originated by whistleblowers under the qui tam provisions of the False Claims Act. Here are the top ten healthcare recoveries of 2018 by the numbers:

1. Amerisource Bergen Corporation - In...

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Hospital Fraud, Managed Care, Medical Billing Fraud, Medical Devices and DME, Medicare, Pharma Fraud, Risk Adjustment Fraud, Top 10,

Watch: “Taking Advantage” Highlights Medicare Risk Adjustment Fraud

Posted 11/2/18

Constantine Cannon partner Mary Inman and two Constantine Cannon whistleblower clients are featured in Episode 3 of the PBS series “Playing by the Rules: Ethics at Work.” The episode investigates ”risk adjustment” in the Medicare Advantage program and practices by some of America’s largest insurance companies to make patients look sicker than they really are-which boosts payments to the insurance companies...

Tagged in: CC Lawyers, Healthcare Fraud, Managed Care, Risk Adjustment Fraud,

Overpayment Rule Decision Doesn't Imperil Risk Adjustment Cases: Mary Inman and Max Voldman in RAC Monitor

Posted 10/19/18

On September 7, a federal district court in Washington, D.C. vacated a single Centers for Medicare & Medicaid Services regulation – the 2014 “overpayment rule.” As Constantine Cannon whistleblower attorneys Mary Inman and Max Voldman write in RAC Monitor, many Medicare Advantage Organizations have since made bold statements about the significance of this decision and its impact on the series of False Claims...

Tagged in: CC Lawyers, FCA Federal, Managed Care, Medicare, Risk Adjustment Fraud,

Constantine Cannon Partner Jessica Moore on Court’s Decision in Medicare Advantage Case

Posted 07/23/18

Becker’s Hospital Review published Four Key Takeaways From 9th Circuit’s Resurrection of the Silingo Medicare Advantage Case, written by Constantine Cannon partner Jessica T. Moore. In the article, Ms. Moore analyzes the Ninth Circuit’s July, 2018, ruling in U.S. ex rel. Silingo v. WellPoint, Inc., a case brought by a whistleblower under the False Claims Act alleging risk adjustment fraud in Medicare’s Part C...

Tagged in: CC Lawyers, Court Decision, FCA Federal, FCA Pleading, Healthcare Fraud, Managed Care, Risk Adjustment Fraud, Whistleblower Case,

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Medicare Risk Adjustment Fraud is Not Victimless

New Lawsuit Against Anthem Shows the Government’s Commitment to Medicare Advantage Fraud

DOJ Discusses Its 2020 Healthcare Fraud Enforcement Priorities

Top Ten Whistleblower Developments of 2019

Federal Audit Reveals Billions of Dollars in Medicare Advantage Overpayments

New Yorker Article on Whistleblowers Features Constantine Cannon

Top Ten Healthcare Recoveries of 2018

Watch: “Taking Advantage” Highlights Medicare Risk Adjustment Fraud

Overpayment Rule Decision Doesn't Imperil Risk Adjustment Cases: Mary Inman and Max Voldman in RAC Monitor

Constantine Cannon Partner Jessica Moore on Court’s Decision in Medicare Advantage Case

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