The Impact of Risk Adjustment Fraud in Managed Care Insurance

Managed care is a form of health insurance that aims to reduce costs and improve quality of care by leveraging contracts with care providers and medical facilities to increase efficiency of coordinated patient care. Within the system, federal and state governments contract private insurers, also known as Managed Care Organizations (MCO), to provide health insurance benefits to government beneficiaries enrolled in Medicare and Medicaid plans. The plans are paid a capitated, or per-person, amount to provide benefits to beneficiaries who enroll in one of their plans. Payments to plans are based on demographic information and the health status (also known as risk scores) of each plan beneficiary. In general, plans receive larger payments for beneficiaries with more severe diagnoses.

Unfortunately, corrupt MCOs involved in managed care fraud will often game the reimbursement system to retain more than their fair share of government funds by miscoding patient diagnoses and inflating risk scores. In this article, we take a look at one of the most common ways dishonest organizations commit fraud in managed care insurance and its massive chain of impact.

What Is Risk Adjustment Fraud and What Does It Look Like in Managed Care?

Risk adjustment fraud occurs when MCOs, coding companies, and others contracted to work with other government insurers seek to game the healthcare system by inflating the risk profile of patients. This can involve a physician IPA or even a third-party medical coding company that is contracted by the MCOs. Because risk adjustment payments are calculated based on members’ diagnoses, plans have developed a number of schemes aimed at “upcoding” or exaggerating the severity of members’ diagnoses or medical conditions to cause the government to pay out more risk adjustment reimbursement than is warranted.

Let’s take a look at an example.

In July of 2021, the federal government intervened in six complaints alleging Kaiser Permanente violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to receive higher reimbursements. According to the DOJ, Kaiser allegedly pressured its physicians to add risk-adjusting diagnoses that patients did not actually have and/or were not considered or addressed during the encounter in order to increase Kaiser’s Medicare reimbursements.

Impact of Risk Adjustment Fraud

Risk adjustment fraud has a massive chain of impact that affects not only the millions who rely on these health programs for care but also the American taxpayers. When dishonest providers commit fraud, it siphons money from legitimate government-funded programs and contributes to rising healthcare costs. It’s a crime against you, the government, and all the other honest medical professionals.

Speak Out Against Risk Adjustment Fraud

Whistleblowers play a major role in the fight against corruption, fraud, and wrongdoing in managed care. These brave individuals have helped save millions in public funds and the integrity of our healthcare system.

For those considering blowing the whistle, consulting the right fraud attorney is an important first step. The right law group can help keep you protected, guide you through the entire process, and help you earn a potential reward for doing the right thing.

Our team at DJO consists of highly experienced whistleblower experts, lawyers, and even former whistleblowers, who strive to deliver the highest monetary reward for brave individuals with valuable information that can bring fraud to light.

If a whistleblower’s lawsuit is successful, the reward can be up to 25% of the funds recovered. The False Claims Act also offers whistleblowers protection against job retaliation.

DJO will be there every step of the way to ensure you are safe and your information is confidential, so you will have confidence knowing you’re doing the right thing. If you have valuable information that can help expose fraud, we encourage you to speak to our experts today.


Becoming a Whistleblower: What to Expect When Reporting Managed Care Insurance Fraud

Fraud in managed care is an unfortunate reality that costs the government and taxpayers billions of dollars each year. Schemes like falsifying patient records, upcoding, cherrypicking, and enrollment fraud siphon money away from the 160 million Americans enrolled in legitimate government healthcare programs, increase taxes, and contribute to rising healthcare costs. This is why it’s so important to expose wrongdoing and report managed care insurance fraud whenever possible.

Exposing wrongdoing is the best way to fight the corruption that negatively affects the greater good. While choosing to become a whistleblower may feel scary, breaking down the process step-by-step and knowing what to expect can help alleviate some of the apprehension of your decision to report fraud. If you plan on making the decision to become a whistleblower, read this article to learn more about the process and what to expect.

  1. Get Guidance From a Fraud Expert and/or Whistleblower Attorney

The first step of the process is talking to a fraud expert and/or whistleblower attorney to confidentially review what you witnessed. This is the safest and most secure way to expose fraud. It’s best to consult with a knowledgeable whistleblower attorney who has experience in managed care insurance fraud because they will offer:

  • Confidential consultations
  • Give you advice on how to proceed
  • Guide you through the process of becoming a whistleblower
  • File your claim with the Government
  • Support you through the investigation
  • Help you potentially secure a financial reward for bringing injustices to light
  1. Present Your Evidence

Once you’ve talked to the experts and have selected your legal representation, your lawyers will ask questions about the incident to extract all valuable information that will be used against the defendant. During this time, you’ll want to make sure you present all of your evidence. Some examples include:

  • All internal communications
  • Emails
  • Texts
  • Documents
  • Powerpoint presentations
  • Email communications
  • Internal studies
  • Billing records
  • Test results

Sharing all of your evidence with your legal representation is crucial to your case. The more evidence you have, the stronger your case will be. Your lawyers will then review your evidence, investigate further, and begin building the case.

  1. File a Claim

Under the federal False Claims Act, a whistleblower must file a qui tam complaint in court and submit it to the government, along with a Disclosure Statement that details the alleged fraud. It’s important to note that your representation will assist you in submitting the Disclosure Statement and other paperwork necessary for filing your report.

Once your claim is submitted, you and your attorney will likely meet with government attorneys to discuss your allegations. These initial meetings often influence the direction of your case, so it’s important to be completely honest and present your evidence as best you can.

  1. Investigating Your Claim

As part of its investigation, the government will likely interview witnesses, examine evidence, review documents and also request documents relating to the alleged fraud. During this time, your experienced whistleblower attorney will be by your side to make sure you provide whatever information the government requests. Your attorney will also be there to remind you not to discuss your case with anyone other than your lawyer and the government officials assigned to your case while it’s under seal.

Keep in mind investigations often take a very long time–typically several years or more. Therefore, having the right representation who can guide you through the entire process is invaluable.

  1. Following the Investigation

After the government has concluded its investigation, it has the opportunity to decide whether it wants to bring a formal legal action against the accused. If the government does decide to intervene and take over the prosecution, the case will then proceed through the process of litigation or settlement.

  1. Earn a Potential Whistleblower Reward

Whistleblowers who bring original information to the government can be entitled to receive a share of the government’s recovery. An individual (called a false claims plaintiff or relator) who is an original source of information can sue for violations of the FCA. If the government prosecutes, a relator can receive up to 25% of the total amount recovered.

Help Blow the Whistle on Managed Care Insurance Fraud

Our goal at DJO is to expose managed care insurance fraud wherever and whenever possible. We work with individuals to gain information, build a case, and fight for taxpayers’ justice. In doing so, we can protect the vulnerable and make the world a safer place.

If you suspect managed care insurance fraud within your organization or with someone you work with, please contact us. DJO is comprised of a highly experienced team of whistleblower experts, lawyers, and even former whistleblowers, who strive to deliver the highest monetary reward for brave individuals who have valuable information that can expose fraud. If a whistleblower’s lawsuit is successful, the reward can be up to 25% of the funds recovered. Additionally, the False Claims Act also offers whistleblowers protection against job retaliation or wrongful termination.

Do you have valuable information that can help bring fraud to light? Speak to our experts today.