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

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 industry.

Risk Adjustment Fraud is an Industry-Wide Problem

Joined by AUSA Randy Harwell of the Middle District of Florida, Mary Inman and Max Voldman spoke about risk adjustment fraud as an industry-wide problem.  Indeed, most major MA organizations have either returned risk adjustment overpayments following an HHS OIG audit or have had FCA claims brought against them by DOJ and/or whistleblowers.  Constantine Cannon attorneys have been or continue to be involved in all of the leading whistleblower cases, including those against Freedom Health, Group Health Cooperative, Sutter Health, UnitedHealth Group, and Kaiser.  Mary Inman and Max Voldman observed that many of these risk adjustment cases are now “maturing” and “coming to fruition.”

Whistleblowers Can Help the Government Reign-In Risk Adjustment Fraud

Speaking in his personal capacity, Randy Harwell, described the Freedom Health case, for which he was the lead government attorney, as “one of the first significant risk adjustment healthcare fraud cases on record and the largest settlement of its kind at the time announced.”  He said it introduced his district to the “critical importance and vulnerability of the MA program” and the “growing significance of managed care to the State of Florida.”  Furthermore, AUSA Harwell commented that the case allowed his office “to build up a level of expertise in the Part C area of healthcare fraud enforcement to the point where we could deal with investigations in this challenging area effectively and efficiently.”  He also remarked on the “critical importance of having a credible, well-respected relator and sophisticated relator firm to assist the government in investigations of this kind and scale.”  He “certainly had that with Mary’s team and relator” and “would not have been able to conclude the case successfully without that feature.”

Max Voldman provided a summary of the allegations in the on-going FCA cases against UHG, Group Health Cooperative, and Kaiser, and commented that he and the rest of the Constantine Cannon team look forward to helping the government with its litigation efforts.  Mary Inman described the FCA case against Kaiser, in which DOJ recently intervened, as the “tipping point” in the government’s effort to reign in risk adjustment fraud by MA plans.  Furthermore, because of Kaiser’s status as the “grandfather or grandmother” of managed care, the government’s intervention is a “wake-up” call to the MA industry generally.

DOJ Is Intervening in a High Percentage of Risk Adjustment Fraud Cases

Ed Baker represented the whistleblower’s perspective as part of a separate “Legal Insights” panel.  Specifically, he noted that DOJ has intervened in 15 of the 22 whistleblower cases filed to date, for a 68% intervention rate, far higher than the rate at which DOJ typically intervenes in FCA qui tam cases.  Furthermore, Attorney Baker observed that all of the risk adjustment fraud cases in which DOJ has intervened (or pursued on its own) have either been settled on terms favorable to the government or are still pending.  This is a strong indication of the seriousness with which DOJ investigates risk adjustment fraud allegations, as well as the government’s intent to recover the billions of dollars estimated to have been overpaid to MA plans.

Underscoring the above comments by his colleagues, Attorney Baker also commented on the diverse array of whistleblowers who have stepped forward to report fraud by MA plans and affiliates.  These whistleblowers include coders, auditors, billers, record managers, physicians, compliance professionals, vendors, and even MA plan executives.  Essentially, anyone with credible evidence that Medicare Advantage organizations or affiliates are submitting unsupported diagnoses to increase risk adjusted payments has a potential FCA claim and can help increase government oversight in this growing part of the healthcare industry.

If you have information that a person or company is defrauding government or private healthcare programs and would like to speak to an attorney about whether you have a whistleblower case, please contact us confidentially.

READ MORE:

• Managed Care Risk Adjustment Enforcement Continues with Sutter Health Settlement: Constantine Cannon Client Secures Largest Ever Medicare Advantage Settlement by a Hospital
• Risk Adjustment Fraud in Healthcare
• Fraud in Managed Care Programs
• False Claims Act
• Healthcare & Pharmaceutical Fraud
• Our Whistleblower Team
• Contact Us Confidentially

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