Medicare Advantage is a type of health insurance plan offered by private companies contracted by the government. Also known as Medicare Part C, Medicare Advantage was designed to incentivize health insurers to develop innovative ways to improve care while decreasing costs. However, a report by the New York Times shows many of the large insurers that offer these plans have been accused of fraud. In this article, we take a more in-depth look into Medicare Advantage fraud and the role whistleblowers play in exposing it.
Medicare Advantage Fraud on the Rise
The government provides set payments to Medicare Advantage insurers for every enrollee, with additional payments for patients with more health needs. However, many major insurers have been accused of exploiting the system in order to collect more money from the government. Federal audits released late last year reveal widespread overcharges and other errors in payments to Medicare Advantage, with some plans overbilling the government more than $1,000 per patient a year on average. Now, a program that was designed to help lower healthcare spending has become more expensive than the traditional government program it was supposed to improve. To highlight the high cost and importance of exposing Medicare Advantage fraud, let’s take a look at some notable cases.
Sutter Health and Affiliates to Pay $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Program
In August of 2021, the government announced a $90 million False Claims Act settlement with California-based healthcare services provider Sutter Health. This settlement resolves allegations that Sutter knowingly submitted inaccurate diagnosis codes for beneficiaries enrolled in Medicare Advantage Plans. According to the government’s allegations, Sutter Health knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under its care. As a result, these unsupported diagnosis codes caused inflated payments to be made to the plans and to Sutter Health.
Freedom Health Agreed to Pay $32.5 Million to Settle False Claims Act Allegations
In May of 2017, Florida-based provider of managed care services Freedom Health, agreed to pay $32.5 million to resolve a whistleblower lawsuit alleging they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans. According to the government, Freedom Health submitted or caused others to submit unsupported diagnosis codes to The Centers for Medicare & Medicaid Services (CMS), which resulted in inflated reimbursements from 2008 to 2013.
The High Price of Medicare Advantage Fraud
When an organization exploits government-funded programs, like Medicare, they take money directly out of the US taxpayer’s pockets. Miscoding patient diagnoses in order to qualify for additional funds not only steals from American taxpayers but also the millions of Americans who rely on these plans for care. This is why we must work together to expose fraud wherever possible.
Blowing the Whistle on Medicare Advantage Fraud
Whistleblowers play a major role in the fight against corruption, fraud, and wrongdoing in Medicare Advantage fraud. These brave individuals have helped save millions in public funds and the integrity of our healthcare system.
Our goal at DJO is to expose 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 fraud in your organization, 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. 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.
