Archive

Medicare Advantage May be Less than Ideal Solution for our Sickest Seniors

By the C|C Whistleblower Lawyer Team As of 2017, a third (approximately 19 million) of all Medicare beneficiaries are now in the Medicare Advantage (MA) program, which is run by private insurers. The insurers receive payments from the federal government based on the sickliness of the population the plan insures, populations with more incidents of severe or chronic diseases lead to higher reimbursements. Insurers...

In the Crosshairs: Medicare Advantage and Risk Adjustment Fraud

By the C|C Whistleblower Lawyer Team Listen to RAC Monitor's broadcast program, "In the Crosshairs: Medicare Advantage and Risk Adjustment Fraud," featuring Constantine Cannon Partner, Mary Inman. Ms. Inman also discusses Constantine Cannon’s recent $32.5 million settlement of the whistleblower case against Freedom Health, Optimum Healthcare, and Sidd Pagidipati involving allegations of risk adjustment fraud (at...

Freedom Health, Optimum Healthcare and Its Former COO to Pay $32.5 Million to Settle False Claims Act Allegations of Medicare Fraud

By the C|C Whistleblower Lawyer Team Yesterday, the Department of Justice and Constantine Cannon, LLP announced that they had reached a settlement with Freedom Health and Optimum Healthcare, two large health insurers and operators of Medicare managed healthcare insurance plans controlled by Dr. Kiranbhai “Kiran” C. Patel and based in Tampa, Florida, to resolve allegations of systemic Medicare and Medicaid...

United States Files Complaint-in-Intervention in Constantine Cannon Whistleblower’s Case Against UnitedHealth Group

The Department of Justice announced yesterday that it has filed a complaint-in-intervention against UnitedHealth Group (UHG) in a case brought by Constantine Cannon client Ben Poehling.  The government’s complaint alleges that UHG knowingly obtained inflated risk adjustment payments from Medicare Advantage based upon false information regarding the health of beneficiaries in its plans. UHG is the nation’s...

In Their Own Words -- Grassley

-- “By all accounts, risk score gaming is not going to go away.  Therefore, CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies.  The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake.”

Chuck Grassley, urging CMS to...

United States Intervenes in Constantine Cannon Whistleblower’s suit against UnitedHealth Group, WellMed Medical Management

By the C|C Whistleblower Lawyer Team The U.S. Department of Justice has joined Constantine Cannon in bringing a whistleblower’s False Claims Act lawsuit against UnitedHealth Group, the nation’s largest health insurer and largest operator of Medicare managed healthcare insurance plans. The suit alleges UnitedHealth and its various subsidiaries and affiliates defrauded Medicare by improperly inflating its risk...

The Importance of Medical Loss Ratio Minimum Requirements

By the C|C Whistleblower Lawyer Team We’ve covered Medical Loss Ratio (MLR) minimum requirements before. The MLR is, generally, the percentage of premium revenues an insurer spends on clinical services and quality improvements as opposed to on things like executive salaries, overhead, or marketing. Requiring a minimum MLR standard, something that the Federal Medicare Program does and several State Medicaid...

Medical Loss Ratio Minimum Requirements Save Taxpayer Dollars

By the C|C Whistleblower Lawyer Team Last month the Department of Health and Human Services’ Office of the Inspector General (OIG) published a report about the Medicaid Managed Care program and the potential savings related to a minimum medical loss ratio (MLR). An MLR is, generally, the percentage of premium revenues an insurer spends on clinical services and quality improvements as opposed to on things like...

DOJ Catch of the Week -- CenterLight Healthcare

By the C|C Whistleblower Lawyer Team This week's Department of Justice "Catch of the Week" goes to New York-based CenterLight Healthcare, Inc. and CenterLight Health System, Inc.  Yesterday, the companies agreed to pay $46.7 million to resolve allegations that they violated the federal and New York State False Claims Acts by enrolling ineligible members in their Medicaid managed long-term care plan. ...

Medicare Advantage Plan Loses Members, Responds with Plans to Raise Risk Adjustment Scores

By Tim McCormack and Molly Knobler (published on The Compliance & Ethics Blog) Modern Healthcare recently reported that although enrollment in the Medicare Managed Care Program (also known as Medicare Advantage or Medicare Part C) has grown by 8% on average since 2010, several top Medicare Advantage Plans are losing membership.  Highmark, Blue Cross and Blue Shield of North Carolina, HealthNow New York, Wellcare...