At least six whistleblower lawsuits have been filed in states across the country alleging overpayments linked to privately run Medicare Advantage plans, and more are expected to emerge, according to an article co-published by the Center for Public Integrity and NPR.
The article comes just a few weeks after CMS announced a 3.25 percent increase for Medicare Advantage reimbursement rates, deviating from a previous proposal that included a 0.95 percent decrease.
However, lawsuits filed against various insurers call into question the legitimacy of the plan's risk scores, an issue that is currently under Department of Justice (DOJ) investigation, FierceHealthPayer: AntiFraud previously reported.
In a lawsuit filed in Columbia, South Carolina, two whistleblowers claim that Blue Cross of South Carolina submitted inflated claims between 2006 and 2010, according to the NPR/CPI article. Other cases filed in Southern California and Seattle also argue that insurers used inflated risk scores to overcharge the government billions of dollars.
Legal experts say there may be many more cases that are still sealed, pending a government investigation.
"We are not yet seeing everything out there," Patrick Burns, co-director of Taxpayers Against Fraud, told NPR/CPI. "The strongest cases may be hidden for years while the government investigates."
Sometimes the government doesn't intervene at all. The article points to a 2012 lawsuit filed in Seattle against Essence Healthcare by a former clinic supervisor for a medical clinic. The suit includes a memo to physicians, urging them to convince elderly Medicare Advantage patients to come in for a medical visit, sometimes offering to pay for co-pays or parking. The memo drew the ire of one physician, who argued the visits were financially motivated, but provided no discernable benefits for patients. The government found no wrongdoing, the article said.
Medicare Advantage plans have garnered plenty of attention over the last year, particularly from CPI, which has reported extensively on the potential fraud implications tied to inflated risk scores. Last June, CPI reported that the government overpaid approximately $32 billion in reimbursement tied to Medicare Advantage between 2008 and 2010.
- read the NPR/CPI article