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Risk Adjustment Fraud

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May 30, 2017

Posted  05/31/17
By Mary Inman
Constantine Cannon serves as lead counsel representing whistleblower Dr. Darren Sewell in largest successful whistleblower settlement for claims of risk adjustment fraud at $16.7 million.  Total settlement against Freedom Health and Optimum Healthcare, two Florida Medicare Advantage plans, and former Chief Operating Officer Sidd Pagidipati exceeds $32 million.   Read the Constantine Cannon press release, the Dept....

Freedom Health, Optimum Healthcare - Medicare Risk Adjustment ($32.5 M)

Two of our whistleblower lawyers led the representation of the late Dr. Darren Sewell, M.D., the former chief medical officer and vice president of special projects for two large health insurers and operators of Medicare managed healthcare insurance plans based in Tampa, Florida. Dr. Sewell brought a qui tam case under the False Claims Act against Freedom, Optimum and Mr. Pagidipati alleging that they improperly gamed a feature of the Medicare Advantage program known as risk adjustment, or risk scoring, by fraudulently inflating their members’ risk scores and the corresponding risk adjustment payments they received from CMS, and that they fraudulently induced CMS to allow them to expand their health insurance offerings into new counties in Florida and the Carolinas by falsely representing that they had a sufficient network of doctors, clinics and hospitals available to serve their enrollees in the expanded service areas when they had no such networks in place. The Government joined the case and in 2017, defendants agreed to pay $32.5 million to settle the matter. The Government and the whistleblower are in the process of negotiating the amount of the relator’s share of the Government’s $32.5 million recovery that Dr. Sewell’s estate will receive. See NPR, DOJ for more.

May 24, 2017

Constantine Cannon Partner Mary Inman was quoted in the Bloomberg BNA article, UnitedHealth Facing Two DOJ-Led Medicare Advantage Fraud Lawsuits.  Click here to read more.

United States Files Complaint-in-Intervention in Constantine Cannon Whistleblower’s Case Against UnitedHealth Group

Posted  05/17/17
The Department of Justice announced yesterday that it has filed a complaint-in-intervention against UnitedHealth Group (UHG) in a case brought by Constantine Cannon client Ben Poehling.  The government’s complaint alleges that UHG knowingly obtained inflated risk adjustment payments from Medicare Advantage based upon false information regarding the health of beneficiaries in its plans. UHG is the nation’s...

May 16, 2017

Whistleblower Partner Mary Inman quoted in the Law360 article discussing the federal government’s intervention in the False Claims Act suit, Feds Take Over Whistleblower's UnitedHealth Overbilling Suit.  Click here to read more.

February Roundup – February 17-20, 2017

Constantine Cannon attorneys quoted in articles about the DOJ joining its whistleblower lawsuit against UnitedHealth Group:
  • UnitedHealth Filing Reflects DOJ’s Heightened Fraud Focus, Bloomberg BNA;
  • Whistleblower suit alleges UnitedHealth defrauded Medicare, StarTribune;
  • Justice Department joins Medicare Advantage fraud lawsuit against UnitedHealth, Modern Healthcare;
  • Feds Join FCA Suit Targeting UnitedHealth Billing, Law360;
  • United Healthcare Whistleblower Suit Provides ‘Interesting’ Investment Opportunity, The Street;
  • Lawsuit says UnitedHealth tied to scheme to overbill Medicare, MINNPOST;
  • DOJ joins whistle-blower suit accusing UnitedHealth of overbilling Medicare , Becker's Hospital Review;
  • Justice Department joins lawsuit against UnitedHealth over Medicare billing, Minneapolis/St. Paul Business Journal;
  • UnitedHealth Lower Off NYT Article Claiming Suit For Overbilling Medicare, Benzinga;
  • UnitedHealth, Health Insurers Fall As DOJ Joins Whistleblower Suit, Investor's Business Daily;
  • Feds join whistleblower suit that accuses UnitedHealth of inflating Medicare Advantage risk scores, Fierce Healthcare;
  • United Health sinks after being sued by the US government (UNH), Business Insider;
  • Feds join whistleblower lawsuit claiming UnitedHealth overcharged Medicare, TwinCities (Pioneer Press);
  • UnitedHealth leads Dow losses after US joins whistleblower case, Financial Times;
  • UnitedHealth shares fall after Justice Department joins Medicare whistleblower lawsuit, CNBC ;
  •  UnitedHealth's Medicare business draws federal scrutiny, Minnesota Public Radio;
  • DOJ joins whistleblower lawsuit against UnitedHealth Group, WellMed, Healthcare Finance News;
  • Suit Says, Scheme Tied to UnitedHealth Overbilled Medicare for Years, Morning Outlook; and
  • UnitedHealth Group Targeted by Whistleblower Lawsuit, Hamodia.

UnitedHealth Group, Inc. – Medicare Advantage Risk Adjustment Fraud (Case Intervention)

Constantine Cannon represents the whistleblower in one of the largest Medicare Advantage risk adjustment cases in history.  Our client, Benjamin Poehling, alleges that UHG, the nation’s largest health insurer, together with its related Medicare Advantage Organizations, knowingly inflated Medicare Advantage risk scores by engaging in “one-way” chart reviews, even after he expressed concern about this practice to fellow executives.  The United States filed a complaint in intervention in May, 2017, and the case continues to be actively litigated, with trial scheduled in 2023. See: Government Complaint in Intervention; Poehling Second Amended Complaint; Constantine Cannon Press Release.

United States Intervenes in Constantine Cannon Whistleblower’s suit against UnitedHealth Group, WellMed Medical Management

Posted  02/16/17
By the C|C Whistleblower Lawyer Team The U.S. Department of Justice has joined Constantine Cannon in bringing a whistleblower’s False Claims Act lawsuit against UnitedHealth Group, the nation’s largest health insurer and largest operator of Medicare managed healthcare insurance plans. The suit alleges UnitedHealth and its various subsidiaries and affiliates defrauded Medicare by improperly inflating its risk...
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