Portland, Maine-based Martin’s Point Health Care will pay $22.48 million to settle allegations it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage (MA) enrollees to increase reimbursements from Medicare.
In a whistleblower suit, attorneys for the U.S. government alleged that, from 2016 to 2019, Martin’s Point identified and submitted additional diagnosis codes that had not previously been submitted to Medicare. These beneficiaries, living in Maine and New Hampshire, had codes submitted not supported by the patients’ medical records, leading to higher payments from the Centers for Medicare & Medicaid Services (CMS), according to a Department of Justice (DOJ) press release.
“The government expects those who participate in MA to provide accurate information to ensure that proper payments are made for the care received by enrolled beneficiaries,” said Deputy Assistant Attorney General Michael D. Granston of the DOJ's Civil Division Commercial Litigation Branch in a statement. “Today’s result sends a clear message to the MA community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement.”
Medicare beneficiaries can enroll in managed care insurance plans through MA, or Medicare Part C. CMS will often adjust plan payments based on diagnosis codes of patients. These adjustments, or risk scores, will make a person more expensive to treat. CMS will make a larger payment to a MA plan if a risk score is higher because a patient’s health is thought to be worse.
“It is a privilege for health plans to provide services to Medicare beneficiaries, not a right,” said Deputy Inspector General for Investigations Christian J. Schrank at the Department of Health and Human Services' Office of Inspector General. "MA Plan sponsors that submit inaccurate claim information in order to justify inflated payments undermine the financial integrity of the program.”
Martin’s Point Health Care could not be reached for comment as of press time.
The civil settlement was brought under whistleblower provisions of the False Claims Act by Alicia Wilbur, a former manager in Martin Point’s risk adjustment operations group, according to the news release.
“False and unsupported medical diagnoses indicate patients have medical conditions that they don’t really have and, in the MA context, cost the government millions of dollars,” said Jeffrey W. Dickstein, a whistleblower attorney and partner at Phillips & Cohen LLP.
The False Claims Act allows individuals to file lawsuits against companies defrauding the government to recover funds on the government’s behalf. They are protected from job retaliation and are normally rewarded 15% to 25% of the recovery, according to a news release.
CMS announced it would start phasing in adjustment risk changes in March.