Health Net Federal Services, LLC (HNFS), together with its parent company Centene Corporation, has agreed to pay more than $11 million to resolve allegations under the False Claims Act related to improper Medicare Advantage risk-adjustment practices, according to the U.S. Department of Justice.
The settlement addresses claims that inaccurate diagnosis codes were submitted to the federal government, resulting in inflated Medicare Advantage payments. The resolution is a civil settlement and does not constitute an admission of liability or a criminal conviction.
Allegations Involving Medicare Advantage Coding
According to the DOJ, the government alleged that Health Net Federal Services failed to correct inaccurate diagnosis information that affected Medicare Advantage risk-adjustment payments, even after audits and internal reviews identified problems with the data.
Medicare Advantage plans rely on accurate diagnosis coding to determine reimbursement levels. The government contended that by continuing to submit incorrect diagnosis codes to the Centers for Medicare & Medicaid Services (CMS), the defendants caused false claims to be paid.
Such enforcement actions are part of the broader fight against Medicare fraud, particularly in cases involving complex risk-adjustment systems where improper coding can significantly impact federal spending.
Settlement Terms
To resolve the civil allegations, Health Net Federal Services and Centene Corporation agreed to pay more than $11 million to the United States. The settlement resolves disputed claims under the False Claims Act and includes no admission of wrongdoing by either company.
Federal officials emphasized that ensuring accurate coding and reporting is critical to maintaining the integrity of the Medicare Advantage program.
The Role of Whistleblowers
The case arose from a qui tam whistleblower lawsuit filed under the False Claims Act. Whistleblowers play a critical role in identifying alleged misconduct involving government healthcare programs, particularly where improper billing practices may not be easily detected through routine oversight.
Under the False Claims Act, individuals who provide original information leading to a government recovery may be eligible to receive a portion of the settlement proceeds.
Why Reporting Medicare Fraud Matters
Improper Medicare Advantage billing undermines trust in federal healthcare programs and diverts taxpayer resources away from legitimate patient care. Federal enforcement actions reinforce the importance of compliance, transparency, and accurate reporting by organizations participating in Medicare-funded programs.
Contact The Whistleblower Advocates
If you have information about improper Medicare Advantage coding or other healthcare billing practices involving federal funds, The Whistleblower Advocates New Jersey team offers free and confidential consultations. Our attorneys help individuals understand their rights under the False Claims Act and guide them through the whistleblower process while protecting their legal interests.
This article is a news article for informational purposes only. The Whistleblower Advocates did not represent the parties identified in the story above.
