The Department of Justice (DOJ) has filed charges against a former HealthSun Health Plans executive as part of an alleged multimillion-dollar Medicare fraud scheme.
In an announcement, the DOJ said that Kenia Valle Boza, 39, of Miami, orchestrated the scheme to submit false information to the Centers for Medicare & Medicaid Services (CMS) to secure overpayments.
To grow the insurer's profits and boost their own pay, Valle and co-conspirators allegedly submitted these data knowingly about chronic conditions that South Florida-based HealthSun's Medicare beneficiaries did not have and that were added to their records by non-providers such as coders.
The DOJ did decline to prosecute HealthSun as a company, according to the announcement, thanks to prompt disclosures and its agreement to repay approximately $53 million in overpayments.
In the indictment, it alleges that Valle and co-conspirators entered and pushed others to enter diagnoses based on improper tests. Those involved in the scheme also allegedly obtained login credentials for certain physicians that were used to fraudulently submit information to the patients' medical records.
The scheme resulted in tens of thousands of false and fraudulent codes being submitted to CMS, driving millions in overpayments, the DOJ said.
Valle is charged with one count of conspiracy to commit healthcare fraud and wire fraud, two counts of wire fraud and three counts of major fraud against the U.S. She faces a maximum sentence of 20 years in prison on the conspiracy count and each count of wire fraud as well as 10 years in prison for each major fraud count.