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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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Catch of the Week: Virginia OB/GYN Sentenced to 59 Years in Prison for Performing Medically Unnecessary Procedures for More Than Ten Years

Posted  05/21/21
OB/GYN looking at a sonogram on screen
Healthcare fraudsters are typically motivated by greed. But in satisfying that greed, some fraudsters perform reprehensible acts that permanently affect the victims of the fraud, making even the penalty they receive pale in comparison. This week we focus on the conviction of Javaid Perwaiz, an OB/GYN in Hampton Roads, Virginia, who was sentenced to 59 years in prison for performing medically unnecessary surgeries...

Constantine Cannon settles with one defendant in case alleging bilking of the Medicare Advantage program. Kaiser Foundation Health Plan of Washington (formerly Group Health Cooperative) will pay $6.375M.

Posted  11/17/20
health insurance forms with stethoscope and calculator
Teresa Ross, a whistleblower represented by Constantine Cannon, and the Department of Justice have reached a settlement with Kaiser Foundation Health Plan of Washington (formerly Group Health Cooperative or GHC).  The Medicare Advantage Organization (MAO) 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...

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.

November 16, 2020

Seattle’s Group Health Cooperative, now part of Kaiser, will pay $6.375 million to settle allegations in a whistleblower suit that it falsely reported unsupported diagnosis codes to Medicare in order to receive inflated payments.  The suit alleges that GHC utilized the services of a coding review company, DxID, that proposed unsupported diagnosis codes, which GHC knowingly submitted to CMS as part of seeking higher payment for the affected Medicare Advantage beneficiaries.  Whistleblower Teresa Ross, represented by Constantine Cannon, will receive approximately $1.5 million.  DOJ

Top Takeaways from Former DOJ Civil Chief Jody Hunt on the Current State of False Claims Act Enforcement

Posted  08/28/20
department of justice website
Law360 recently interviewed former DOJ Civil Chief Jody Hunt on what he sees as the key issues surrounding False Claims Act enforcement these days.  Here are the top takeaways:
    • COVID-relief fraud will be a DOJ priority. No surprise there given the billions of dollars the federal government is pouring into the economy to alleviate some of the financial strain the pandemic is wreaking on healthcare providers...

Windfall to Health Insurers Due to COVID-19 Is Not Yet Resulting in Resolution of FCA Risk Adjustment Cases

Posted  08/21/20
By Edward Baker
As health insurers book record profits during the COVID-19 pandemic due to a dramatic decline in elective surgeries and procedures, this seems like a good time to ask about the status of False Claims Act litigation against Medicare Advantage Organizations (MAOs) relating to risk adjustment fraud.  Given the dire shortfall in state and federal money to fight the pandemic, when will MAOs begin paying back the billions...

Medicare Risk Adjustment Fraud is Not Victimless

Posted  06/18/20
By Edward Baker
medicare dollars
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...

Integra Med Analytics Loses Battle to establish New Breed of Corporate Whistleblower Outsiders

Posted  06/3/20
CC Attorneys Mary Inman, Max Voldman
Mary Inman and Max Voldman were published in the RAC Monitor (June 3, 2020).  Click here to read the article.  

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...

DOJ Discusses Its 2020 Healthcare Fraud Enforcement Priorities

Posted  03/6/20
By Michael Ronickher
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...
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