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Risk Adjustment Fraud

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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
Western District of New York Birds-Eye View of Building
In July, we wrote that managed care enforcement had reached a “tipping point,” as the Department of Justice intervened in whistleblower cases against Kaiser Permanente alleging risk adjustment fraud, including a case brought by Constantine Cannon client Dr. James Taylor.  Just last month, we announced a $90 million settlement in a different Medicare Advantage risk adjustment fraud case brought by Constantine...

Constantine Cannon Attorneys Present on Whistleblower Cases Involving MA Risk Adjustment Fraud at RISE West Conference

Posted  09/10/21
stethoscope on top of hundred dollars bills scattered around
Building on Constantine Cannon’s reputation as the preeminent law firm representing whistleblowers in FCA cases involving Medicare Advantage (MA) risk adjustment fraud, three Constantine Cannon attorneys, Mary Inman, Ed Baker, and Max Voldman, recently presented on case developments in this fast-developing area of the law at RISE West, a national conference for healthcare professionals working in the managed care...

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 Cal

Managed 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
Sutter Health will pay the Government $90 million under the False Claims Act for allegedly submitting inaccurate and unsupported medical information on tens of thousands of patients.  The settlement in a case brought by a whistleblower represented by Constantine Cannon, together with co-counsel Keller Grover and Kleiman Rajaram, is the largest Medicare Advantage FCA settlement against a hospital system, and the...

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
Headshots of attorneys Edward Baker, Mary Inman, and Michael Ronickher
As we announced last week, the U.S. Department of Justice gave notice that it was intervening in six different False Claims Act lawsuits against Medicare Advantage organization Kaiser Permanente and its affiliated entities, including a whistleblower lawsuit filed by Constantine Cannon’s whistleblower client, James Taylor, M.D.  The government’s decision received extensive coverage in the media, with Los Angeles...

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 Release

United States Reaches a “Tipping Point” in Managed Care Enforcement: DOJ Intervenes in Constantine Cannon’s Lawsuit Against Kaiser Permanente

Posted  07/30/21
Kaiser Permanente Building with Logo
In a sign that the government’s enforcement efforts against fraud in the Medicare managed care system have reached a tipping point, the U.S. Department of Justice announced today that it is joining a portion of a whistleblower lawsuit brought by a Constantine Cannon client under the False Claims Act against Kaiser Permanente and affiliated entities, one of the nation’s largest managed-care organizations. ...

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.
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