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Feds Settle Huge Whistleblower Suit Over Medicare Advantage Fraud

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One of the nation’s largest dialysis suppliers can pay $270 million to settle a whistleblower’s allegation that it helped Medicare Advantage insurance coverage cheat the federal government for a number of years.

The settlement by HealthCare Partners Holdings LLC, a part of large dialysis firm DaVita Inc., is believed to be the most important so far involving allegations that some Medicare Advantage plans exaggerate how sick their sufferers are to inflate authorities funds. DaVita, which is headquartered in El Segundo, Calif., didn’t admit fault.

“This settlement demonstrates our tireless commitment to rooting out fraud that drains too many taxpayer dollars from public health programs like Medicare,” mentioned U.S. Attorney Nick Hanna in asserting the settlement Monday.

Medicare Advantage plans, which now enroll greater than 1 in three seniors nationwide, have confronted rising authorities scrutiny lately over their billing practices. At least a half-dozen whistleblowers have filed lawsuits accusing the insurers of boosting payments by overstating how sick sufferers are. In May 2017, two Florida Medicare Advantage insurers agreed to pay nearly $32 million to settle an identical lawsuit.

The DaVita settlement cites improper medical coding by HealthCare Partners from early 2007 by way of the top of 2014. The firm, in keeping with the settlement settlement, submitted “unsupported” diagnostic codes that allowed the well being plans to obtain larger funds than they have been due. Officials didn’t establish the well being plans that overcharged because of this.

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One such “unsupported” code was for a spinal situation often known as spinal enthesopathy that was improperly recognized in sufferers in Florida, Nevada and California from Nov. 1, 2011, to Dec. 31, 2014, in keeping with the settlement. The settlement didn’t say how a lot well being plans took in from the unsupported codes.

The firm additionally contracted with a Nevada agency from 2010 by way of January 2016 that despatched well being care suppliers to go to sufferers of their properties, a controversial follow that critics have lengthy held is completed largely to inflate Medicare funds. These home calls additionally generated “unsupported or undocumented” diagnostic codes, in keeping with the settlement.

Officials mentioned that DaVita disclosed the practices to the federal government. It acquired HealthCare Partners, a big California-based docs’ group, in 2012. They mentioned the federal government agreed to a “favorable resolution” of the allegations cost due to the self-disclosure.

In an announcement, DaVita mentioned the settlement “reflects close cooperation with the government to address practices largely originating with HealthCare Partners.” DaVita mentioned the settlement will likely be paid with escrow funds put aside by the previous house owners.

“This case involved illegal conduct in which patients’ medical conditions were improperly reported and were not corrected after further review — all for the purpose of boosting the bottom line,” reads the federal government’s assertion.

The settlement additionally resolves allegations made by whistleblower James Swoben that HealthCare Partners knew that most of the diagnostic codes have been unsupported, however didn’t report them. The firm reported solely instances wherein it deserved larger reimbursement, whereas ignoring codes that may slash funds, a follow often known as “one-way” chart critiques.

Swoben, a former worker of an organization that did enterprise with DaVita, will obtain simply over $10 million for the settlement of the “one-way” allegations, beneath the federal False Claims Act, which rewards whistleblowers who expose fraud.

Use Our Content This story might be republished free of charge (details).

Fred Schulte: fschulte@kff.org”>fschulte@kff.org, @fredschulte

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