Medicare Advantage fraud has made headlines once again, as Independent Health, a leading provider of Medicare Advantage plans, has agreed to settle a False Claims Act lawsuit for up to $98 million. This settlement comes after allegations that the company knowingly submitted invalid diagnosis codes to Medicare in order to inflate payments.
Background on the Medicare Advantage Fraud Scheme
Independent Health, based in Buffalo, New York, and its affiliate, DxID LLC, engaged in fraudulent activities from 2011 to 2017. The company used DxID to retrospectively search medical records and query physicians for diagnoses that could increase the risk scores for Medicare beneficiaries. These inflated diagnoses resulted in higher Medicare payments for Independent Health. The Centers for Medicare and Medicaid Services (CMS) adjusts payments to Medicare Advantage Plans based on patient diagnoses and demographic information, with more expensive conditions resulting in higher reimbursements.
By submitting unsupported diagnoses, Independent Health and DxID illegally increased Medicare’s payments, resulting in an unjust financial gain. The U.S. Department of Justice, alongside the Department of Health and Human Services, pursued this case to protect the integrity of Medicare.
Consequences of Medicare Fraud
As part of the settlement, Independent Health will pay $34.5 million upfront and an additional contingent $63.5 million. DxID, which ceased operations in 2021, will not be involved moving forward. The settlement also includes a five-year corporate integrity agreement with the Department of Health and Human Services (HHS), emphasizing the company’s commitment to maintaining compliance.
The Role of Whistleblowers in Exposing Medicare Fraud
Medicare fraud, particularly in Medicare Advantage programs, undermines the integrity of the healthcare system, diverting funds intended for patient care. Whistleblowers play a vital role in identifying and exposing such fraudulent schemes. Their courage in coming forward ensures accountability and transparency, allowing authorities to take necessary action to recover misused funds and prevent future misconduct.
How Whistleblowers Can Take Action
If you have knowledge of similar Medicare fraud, it's crucial to take action. The Whistleblower Advocates offer free, confidential consultations to those who wish to report fraud and abuse. By working with experienced attorneys, whistleblowers can ensure their voices are heard while protecting their legal rights. Contact The Whistleblower Advocates today to learn more about how you can help stop Medicare fraud and secure a fair resolution.
This article is a news article for informational purposes only. The Whistleblower Advocates did not represent the parties identified in the story above.
