Managed Care Medicare and Medicaid fraud have become pervasive in the United States, costing taxpayers billions of dollars annually.

One form of healthcare fraud that has been on the rise is Risk Adjustment Factor (RAF) score fraud. RAF score fraud occurs when healthcare providers, managed care organizations, or insurers manipulate patient data to increase RAF scores and receive higher reimbursements from the Government.

This article will discuss the prevalence of RAF score fraud in the United States, its impact on the healthcare industry and taxpayers, and how whistleblowers can seek justice and financial rewards for exposing the tactics used by healthcare providers and insurers to defraud the government.

What is a Risk Adjustment Factor (RAF) Score?

According to Definitive Healthcare, a Risk Adjustment Factor is a “calculation of an individual’s health status as a number, or risk score, that helps predict costs for healthcare services. Health plans adjust the risk incurred from insuring members with expected higher healthcare costs by insuring members with expected lower healthcare costs.”

This score is particularly important for Medicare and Medicaid because it allows insurers to more accurately estimate how much they can cover for a specific individual or procedure.

What Constitutes RAF Score Fraud?

Risk adjustment fraud occurs when healthcare providers or insurers inflate or manipulate patient data to increase their RAF scores and receive higher reimbursements from Medicare or Medicaid. When altering RAF scores, integrity and patient health care are compromised as providers mismanage their patients’ care by authorizing procedures that they may not necessarily need. As such, RAF score fraud can be used to mask other fraudulent schemes like upcoding, phantom billing, double-billing, or unbundling.

Impact of RAF Fraud on the Healthcare System

RAF score fraud is a significant issue in the United States, affecting private insurers, Medicare, and Medicaid. For example, according to a Government Accountability Office report, Medicare Advantage plans received over $16 billion in improper payments due to RAF score manipulation between 2010 and 2016.

RAF score 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 corrupt providers commit fraud, it takes money from legitimate government-funded programs and contributes to the rising costs of healthcare. It’s a crime against you, the government, and all the other honest medical professionals.

How to Report RAF Fraud

Whistleblowers are critical in exposing RAF score fraud and holding healthcare providers and insurers accountable for their actions. Under the qui tam provisions of the False Claims Act, whistleblowers can file lawsuits on behalf of the government and receive a reward of up to 30% of any recovered funds.

To file a False Claims case, whistleblowers must have evidence of RAF score fraud, such as documents, emails, and personal testimony. They can then work with the DJO Whistleblower Law Firm to draft a complaint and file it under seal.

Shed Light on RAF Fraud

RAF score fraud is a widespread problem that undermines the integrity of the healthcare system in the United States. Its impact is felt not only by the millions of individuals who rely on Medicare and Medicaid for their healthcare needs but also by the American taxpayers who bear the financial burden of fraudulent activities. 

The DJO Whistleblower Law Group has taken on the task of exposing these fraudulent tactics employed by healthcare providers and insurers.

Justice can be sought by shedding light on RAF score fraud and encouraging whistleblowers to come forward, and financial rewards can be obtained through the False Claims Act. Through these collective efforts, we can combat healthcare fraud, protect the integrity of our healthcare programs, and ensure that funds are directed to those who genuinely need them—ultimately creating a healthier and more equitable society for all.

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 30% of the funds recovered. The False Claims Act also offers whistleblowers protection against job retaliation or wrongful termination.

authored by Christopher J. Piacentile
Director of Investigations DJO Whistleblower Law Group

Latest Articles