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DOJ Pursues Another Medicare Advantage Fraud Lawsuit

September 17, 2021

DOJ shows no signs of slowing down in its pursuit of fraud in the Medicare Advantage program.  In the summer of 2021, DOJ reached a landmark settlement and intervened in six related Medicare Advantage fraud lawsuits.  Now, in September, DOJ has filed a Medicare Advantage fraud lawsuit against Independent Health and its former CEO.  Independent Health offers two Medicare Advantage Plans in New York State.  The United States has also sued Independent Health’s subsidiary, DxID.  DxID provided retrospective chart review and addenda services to Independent Health and other MA Plans.

The Allegations

The United States alleges that the defendants knowingly submitted inaccurate and unsupported diagnosis codes for enrollees in Independent Health’s Medicare Advantage Plans.  The suit alleges that Independent and DxID did this to receive higher reimbursements from the government.

Specifically, the complaint alleges that DxID asked health care providers to add diagnoses to a patient record up to a year after the patient’s visit.  Notably, the United States is bringing similar allegations against Kaiser Permanente.

In addition, the United States alleges that even after Independent Health was aware of these unsupported diagnosis codes, it failed to take corrective action.  This too is a familiar refrain.  Such allegations of turning a blind eye were part of DOJ’s recent $90 million settlement of a Medicare Advantage Fraud lawsuit against Sutter Health.

Why This Medicare Advantage Lawsuit Matters

For background on the Medicare Advantage program and common Medicare Advantage fraud schemes, look here.

CMS relies on medical providers and MA Plans to submit truthful and accurate diagnosis information for the patients in their care.  In fact, to ensure the integrity of the system, CMS has implemented specific rules regarding the submission of encounter data.  Unfortunately, schemes to inflate a patient’s risk score by submitting inaccurate diagnosis codes are all too common.  Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division is clear in his message:

The Medicare Advantage Program relies on accurate information about the health status of enrollees to ensure that they receive appropriate treatment and that participating health plans receive proper compensation for the services they actually provide.  The department will continue to hold accountable health plans or providers that report unsupported diagnoses to inflate risk adjustment payments.

Likewise, U.S. Attorney for the Western District of New York, James P. Kennedy Jr., sees the big picture:

Defrauding taxpayer funded health care programs such as Medicare hurts not only taxpayers but our nation’s entire healthcare system.

Medicare Advantage Fraud is Not Going Away

Nearly 40 percent of Medicare beneficiaries have chosen to enroll in Medicare Advantage Plans today.  That equals over 24 million people.  This number is only expected to increase.  With so many beneficiaries enrolled — and so much money at stake — Medicare Advantage fraud is bound to continue for years to come.

Our attorney Erica Blachman Hitchings has extensive experience in this area, having worked on both the Sutter and Kaiser Medicare Advantage fraud matters.  If you have information about possible Medicare Advantage fraud, please contact us for a free consultation.  We have the expertise and desire to help.

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