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Risk Adjustment Fraud

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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

Tagged in: FCA Federal, Healthcare Fraud, Managed Care, Medical Billing Fraud, Medicare, Risk Adjustment Fraud, Whistleblower Case, Whistleblower Rewards,

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...

Tagged in: Anti-Kickback and Stark, COVID-19, Electronic Health Records, FCA Federal, Government Loan Programs, Home Health and Hospice, Importance of Whistleblowers, Risk Adjustment Fraud, Whistleblower Eligibility,

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

Posted  08/21/20
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...

Tagged in: FCA Federal, Healthcare Fraud, Importance of Whistleblowers, Medicare, Provider Fraud, Risk Adjustment Fraud, Upcoding, Whistleblower Eligibility,

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Group Health Cooperative - Healthcare Fraud/Medicare Advantage ($6.375 million)

Constantine Cannon represented a whistleblower in a False Claims Act case alleging Group Health Cooperative (now a subsidiary of Kaiser Permanente) submitted false or inaccurate Medicare Advantage patient diagnosis codes to inflate the reimbursement it received under the Medicare Part C program.  In November 2020, the company agreed to pay $6.375 million to settle the matter.  Our client received a whistleblower award of 25% of the government's recovery.  Read more -- NPR, Seattle Times, DOJ, CC.

Tagged in: FCA Federal, Healthcare Fraud, Managed Care, Medical Billing Fraud, Medicare, Risk Adjustment Fraud, Whistleblower Case, Whistleblower Rewards,

Medicare Risk Adjustment Fraud is Not Victimless

Posted  06/18/20
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...

Tagged in: FCA Federal, Healthcare Fraud, Medicare, Provider Fraud, Risk Adjustment Fraud,

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

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

Tagged in: Managed Care, Risk Adjustment Fraud,

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...

Tagged in: FCA Federal, Healthcare Fraud, Medicare, Provider Fraud, Risk Adjustment Fraud,

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DOJ Discusses Its 2020 Healthcare Fraud Enforcement Priorities

Posted  03/6/20
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...

Tagged in: Electronic Health Records, FCA Federal, Government Programs Fraud, Healthcare Fraud, Risk Adjustment Fraud,

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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...

Tagged in: CFTC Whistleblower Reward Program, Cybersecurity and Data Breaches, FCA Federal, Government Procurement Fraud, Healthcare Fraud, Importance of Whistleblowers, International Whistleblowers, Risk Adjustment Fraud, SEC Whistleblower Reward Program, Top 10,

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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. ...

Tagged in: FCA Federal, Healthcare Fraud, Importance of Whistleblowers, Managed Care, Risk Adjustment Fraud,

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