Complete Health Partners Holdings, headquartered in Jacksonville, Florida, has agreed to pay $14,100,000, to resolve allegations that they violated the False Claims Act by causing the submission of false diagnosis codes in order to increase payments that they received from the Medicare Advantage program. “As the Medicare Advantage program continues to grow, providers who participate in the program must be held to account when they attempt to improperly profit at the taxpayer’s expense,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division.
Key details of the case
“This settlement reflects the Department’s commitment to protecting taxpayer money and ensuring that Medicare payments are based on information that is true and accurate.”. “Health care fraud enforcement has long been a cornerstone of the mission of this office,” said U.S. Kehoe for the Middle District of Florida.
“This settlement sends a strong message to our district, its residents. Medical providers doing business here, that our focus on this vital practice area has not wavered.”. “Companies that attempt to improperly boost their own profits by reporting bogus medical conditions of Medicare Advantage enrollees.
Meanwhile, as alleged in this case — will be held responsible for their actions,” said Special Agent in Charge Isaac M. Bledsoe of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “Today’s settlement demonstrates our office’s commitment to safeguarding the integrity of federal health care programs, including Medicare Advantage.
Enforcement actions and official statements
In addition, exist to provide necessary care to enrollees, not as a vehicle for improper financial gain.”. Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may opt out of traditional Medicare and enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations. MAOs. For complete details, refer to the official DOJ press release.
The Centers for Medicare & Medicaid Services (CMS) pays the MAOs a fixed monthly amount for each Medicare beneficiary enrolled in their plans. CMS adjusts these monthly payments to account for various “risk” factors that affect expected health expenditures for the beneficiary. In general, CMS pays MAOs more for sicker beneficiaries expected to incur higher healthcare costs and less for healthier beneficiaries expected to incur lower costs.
To calculate the payment amounts, CMS uses a health-based risk adjustment model. The Hierarchical Conditions Category (HCC) model — that takes into account diagnoses reported by healthcare providers. In general, the more severe the diagnosis or costly the associated treatment, the higher the risk score and the higher the corresponding payments to the MAO. . For related coverage, see Federal enforcement update: Russia moves Luch satellites near Western spacecraft raising European security concerns.
Notably, complete Health Partners Holdings (Complete Health) is a management services organization that manages, owns or otherwise operates affiliated provider groups operating out of Florida, Alabama and Colorado. Under the contracts, the MAOs agreed to pay Complete Health a percentage of the payments they received from CMS. This “risk sharing” compensation arrangement gave Complete Health a financial incentive to submit additional diagnosis codes to increase its patients’ risk scores and the corresponding payments made by CMS.
Specifically, the settlement resolves allegations, from 2020 to 2023, Complete Health submitted diagnosis codes within Hierarchical Condition Code (HCC) 55 (Drug and Alcohol Dependence) and HCC 59 (Major Depressive, Bipolar. Paranoid Disorders) that were not clinically valid, not properly supported by the beneficiary’s medical records, and/or not considered in the care, management, or treatment of the beneficiary. The United States contends that Complete Health disseminated incorrect coding guidance to its coders and physicians regarding diagnosis codes within HCC 55 and HCC 59. For related coverage, see Federal enforcement update: Norway continues groundbreaking research on northern lights to track solar activity and space weather.
Subsequently, the United States further contends that Complete Health coders reviewed its beneficiaries’ medical records and identified additional diagnosis codes for chronic conditions, including diagnoses within HCC 55 and HCC 59. Complete Health then prompted doctors to add those diagnosis codes, even when the diagnosis codes were unsubstantiated or not clinically justified. As a result, the doctors added those diagnosis codes, which were not accurate.
These diagnoses resulted in an increase in payment from CMS to the MA Plans in which the beneficiaries were enrolled. The MA Plan then passed along a portion of the increased payment to Complete Health. The civil settlement resolves claims brought under the qui tam or whistleblower provisions of the False Claims Act by Karen Bowers, former Associate Director of Risk Adjustment at VIVA Health.
In particular, under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States ex rel. Complete Health Partners, Inc., Pharos Capital Group, LLC, Viva Health Inc.
Blue Cross and Blue Shield of Alabama, Civil Action No. 3:22-cv-463 (M.D. Karen Bowers will receive approximately $2,467,500 as her share of the federal recovery. This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the administration’s war on fraud, waste.
Investigation and prosecution details
Abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect. Undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers.
