Scoundrel Spotlight - COVID-19 Fraudster Lourdes Navarro
Posted 10/9/23
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:
New York Times Covers “Cash Monster” of Risk Adjustment Fraud, Featuring Cases Initiated by Constantine Cannon Clients
Posted 10/11/22
U.S. Pursuit of Risk Adjustment Fraud Continues with Complaint in Intervention in Case Filed by Constantine Cannon Client against Independent Health and its Coding Subsidiary DxID
Posted 09/16/21
Constantine Cannon Attorneys Present on Whistleblower Cases Involving MA Risk Adjustment Fraud at RISE West Conference
Posted 09/10/21
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.August 30, 2021
Northern California healthcare provider Sutter Health and its affiliated entities will pay $90 million to resolve a False Claims Act case initially filed by whistleblower Kathy Ormsby alleging that defendants submitted unsupported diagnosis codes for patients enrolled in Medicare Advantage. Sutter contracts with Medicare Advantage Organizations to provide care to Medicare Advantage beneficiaries enrolled in their plans, and allegedly caused those MAOs to submit to Medicare inaccurate and invalid diagnosis codes that inflated the risk scores of those beneficiaries and were not supported by the medical records, thereby resulting in overpayments by CMS. Sutter also allegedly failed to take sufficient corrective action when it became aware of the submission of these unsupported diagnosis codes. Sutter also entered into a five-year corporate integrity agreement. Sutter previously entered into a partial settlement of $30 million, which will be credited against the $90 million total settlement. DOJ; USAO ND CalManaged Care Risk Adjustment Enforcement Continues with Sutter Health Settlement: Constantine Cannon Client Secures Largest Ever Medicare Advantage Settlement by a Hospital
Posted 08/30/21
Media Coverage of Government Intervention in Kaiser Medicare Advantage Suits: LA Times says Cases Point to a “Massive Fraud Problem in Medicare”
Posted 08/6/21
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 ReleaseUnited States Reaches a “Tipping Point” in Managed Care Enforcement: DOJ Intervenes in Constantine Cannon’s Lawsuit Against Kaiser Permanente
Posted 07/30/21
