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Risk Adjustment Fraud

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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...

Top Ten Whistleblower Developments of 2019

Posted  02/6/20
Slingshot and stones
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...

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. ...

April 12, 2019

California-based Sutter Health LLC and its affiliated medical foundations will pay $30 million to resolve allegations under the False Claims Act that they submitted unsupported diagnosis codes for certain patients, thereby inflating the the risk scores for those patients.  These inflated risk scores increased Medicare Advantage payments to Medicare Advantage Organizations with whom Sutter contracted.  Sutter's contracts with the MAOs gave Sutter a share of those improper increased payments.  DOJ; USAO ND Cal

Sutter Health, LLC – Medicare Advantage Risk Adjustment Fraud (Case Intervention)

Constantine Cannon represents the whistleblower, Kathy Ormsby, in False Claims Act litigation against Sutter Health and its affiliates including the Palo Alto Medical Foundation, where Ms. Ormsby worked as a Risk Adjustment Factor Project Manager and Coding Manager.  The Sutter Health defendants allegedly inflated the number and severity of Medicare Advantage patient diagnoses, manipulated patient records, ignored audit “red flags,” and engaged in other misconduct in order to increase patient risk scores and obtain Medicare Advantage payments to which they were not entitled. The United States filed a complaint in intervention in March, 2019, and the case continues to be actively litigated.  SeeGovernment Complaint in Intervention; Ormsby First Amended Complaint; DOJ Press Release
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