Kaiser MA plan agrees to pay $6M to DOJ to settle false claims allegations

Kaiser Foundation Health Plan of Washington agreed to pay the federal government $6.3 million to settle allegations it submitted invalid Medicare and Medicare Advantage diagnoses and received higher payments.

The settlement announced Tuesday closed a whistleblower lawsuit concerning the Washington-based Medicare Advantage plan formerly known as Group Health Cooperative.

“The United States relies on Medicare Advantage Organizations to submit accurate diagnosis data to Medicare to ensure that the compensation they receive is appropriate,” said Assistant Attorney General Jeffrey Bossert Clark in a statement. “We will continue to pursue those who undermine the integrity of the Medicare program and the data it relies upon.”

The lawsuit’s allegations date back to 2010.

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A former billing manager Teresa Ross alleged that the health plan upcoded risk adjustment claims submitted to Medicare by claiming that a patient was treated for a diagnosis they didn’t have or a diagnosis that was more severe than the one they had, according to a legal filing.

The plan also failed to correct the risk adjustment claims even though executives knew the claims were false, the lawsuit said.

The lawsuit argued the moves were made to recoup financial losses for the plan.

Kaiser acquired Group Health Cooperative, which has more than 651,000 members, in 2017.