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Risk Adjustment Fraud

This archive displays posts tagged as relevant to risk adjustment fraud in managed care programs You may also be interested in our pages:

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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 from the Medicare program. Watch the 30-minute episode, Taking...

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 Act cases currently being pursued against them...

October 1, 2018

HealthCare Partners Holdings LLC, a DaVita entity, will pay $270 million to settle allegations arising from DaVita's collection and submission of diagnosis data for Medicare Advantage beneficiaries to whom DaVita provided healthcare services.  HealthCare Partners, an independent physician association, allegedly instituted practices that caused the submission of incorrect diagnosis codes - diagnosis codes that increased payments from CMS to the MAOs, and then from the MAOs to DaVita/HealthCare Partners.  DaVita had voluntarily disclosed some practices, including improper medical coding guidance provided to physicians.  In addition, a whistleblower, James Swoben, alleged in a False Claims Act qui tam case that HealthCare Partners had engaged in improper "one-way chart reviews," which added diagnosis codes identified from the review of patient charts, but did not delete previously-submitted diagnosis codes that were not supported by the patient charts. Swoben will receive a whistleblower reward of $10,199,100. DOJ

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 program. The Ninth Circuit’s decision “swept...

Constantine Cannon Partner Mary Inman will be Featured on RAC Monitor

Posted  02/12/18
By the C|C Whistleblower Lawyer Team Tune in to RAC Monitor this Monday, February 12, 2018 at 10 AM Eastern to listen to “EMR and RAC Audits: Who Takes the Hit Part II.” Constantine Cannon Partner Mary Inman will speak about the False Claims Act lawsuit against Bon Secours Health System, Inc.

Aftershocks of the Feds' Big Bust: Lessons Learned

Posted  07/18/17
By the C|C Whistleblower Lawyer Team Listen to RAC Monitor's broadcast program, "Aftershocks of the Feds' Big Bust: Lessons Learned," featuring Constantine Cannon Partner, Mary Inman. Ms. Inman discusses the DOJ's recent Health Care Fraud Takedown and the prosecution of medical professionals involved in opioid-related crimes as a DOJ health care enforcement priority (at 21:30 of the broadcast). Click here for more.

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

Posted  05/31/17
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 fraud.  This is the largest whistleblower settlement to date for claims...

May 30, 2017

Posted  05/31/17
By Mary Inman
Constantine Cannon serves as lead counsel representing whistleblower Dr. Darren Sewell in largest successful whistleblower settlement for claims of risk adjustment fraud at $16.7 million.  Total settlement against Freedom Health and Optimum Healthcare, two Florida Medicare Advantage plans, and former Chief Operating Officer Sidd Pagidipati exceeds $32 million.   Read the Constantine Cannon press release, the Dept. of Justice press release, and the Kaiser Health News article announcing the settlement. The case was headed by Constantine...
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