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Media Coverage of Government Intervention in Kaiser Medicare Advantage Suits: LA Times says Cases Point to a “Massive Fraud Problem in Medicare”

Posted  August 6, 2021

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 Times business columnist Michael Hiltzik writing that the lawsuits point to a larger issue with the Medicare Advantage program: “The indications are that Medicare Advantage is profoundly infected with fraud.”

Quoting Constantine Cannon whistleblower attorney Mary Inman, the LA Times article describes the “extremely creative” ways Medicare Advantage organizations have sought to maximize their profits by increasing risk adjustment payments.  The government’s intervention in the Kaiser litigation and in other Medicare Advantage risk adjustment cases – including the UHG, Sutter, Group Health Cooperative, and Freedom Health cases, in which Constantine Cannon represents the qui tam plaintiffs – and through administrative action, indicates that the government is “waking up” to the nature and scope of risk adjustment fraud.

With billions of dollars at stake, government enforcement, and information from whistleblowers, is critical.  After all, as the LA Times article concludes, funds that are wrongly claimed by Medicare Advantage organizations are funds “that could be used for a host of goals other than fattening the budgets of healthcare companies: funding universal coverage, reinvigorating the nation’s tattered public health infrastructure, you name it. The profit motive has long been a huge drag on the American healthcare system, but it’s much worse when the profits are dishonestly obtained.”

The Sacramento Bee also wrote about the claims against Kaiser, quoting Constantine Cannon whistleblower attorney Ed Baker and highlighting the knowledge and expertise of Dr. Taylor.  Before filing his qui tam action, Dr. Taylor had repeatedly sought to address Kaiser’s coding practices within the organization, only to find that his concerns were ignored by other Kaiser leaders, or that efforts to change practices were only temporary.

Reuters detailed the government’s allegations that “Kaiser Permanente pushed its doctors to create addenda to patient reports months or even more than a year after patient visits to add diagnoses that would boost risk scores.”  Constantine Cannon whistleblower attorney Mike Ronickher is quoted in the article, noting that “[t]he scale of this case, and the number of whistleblowers who have come forward, shows how serious the claims are.”

Finally, healthcare professional organization RISE reported on the government’s interventions in the Kaiser actions.  Ms. Inman is slated to speak at the RISE West conference taking place August 30-September 2, where panelists will take a deeper look at the government’s pursuit of False Claims Act cases alleging risk adjustment fraud.

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Tagged in: CC Lawyers, FCA Federal, Healthcare Fraud, Managed Care, Risk Adjustment Fraud, Upcoding,