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

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.

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