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Dec 18, 2020 by |

California and San Francisco Whistleblower Attorney: Healthcare Provider Settles False Claims Whistleblower Case Alleging Medicare Advantage Fraud


Unsupported Diagnoses Allegedly Submitted To Medicare Advantage

False Claims Act Case Settles For $6.3 Million

Former Employee To Receive $1.5 Million Whistleblower Reward

The federal government rewards whistleblowers who present credible, original information of false claims made to government agencies for payments and reimbursements. The whistleblowers bring their cases (known as “qui tam” cases) under the False Claims Act (FCA), 31 U.S.C. §§ 3729 et seq. Fraud against the government’s Medicare and Medicare-related programs is a major area of government expenditure where the government is defrauded in the billions every year.  Whistleblowers can receive up to 30% of any amounts the government recovers as a result of the suit.  31 U.S.C. § 3730(d).  If you have credible information of fraud against the government, call the whistleblower attorneys at Evans Law Firm, Inc. today at (415)441-8669 or toll free at (888)50EVANS 503-8267 and we can help.

Medicare Advantage Fraud Case

The Department of Justice recently announced a $6.3 million settlement of an FCA whistleblower case[1] resolving allegations that a healthcare provider submitted invalid diagnoses to Medicare for Medicare Advantage beneficiaries and received inflated payments from Medicare as a result.  Under the Medicare Advantage program, Medicare beneficiaries may obtain health care coverage through private insurance plans owned and operated by private insurers known as Medicare Advantage Organizations (MAOs).  Medicare pays MAOs a fixed, monthly amount to provide health care coverage to Medicare beneficiaries enrolled in their plans and adjusts these monthly payments to reflect the health status of each beneficiary.  In general, Medicare pays MAOs more for sicker beneficiaries and less for healthier ones. MAOs report beneficiary diagnoses and other information to Medicare on an annual basis and Medicare uses this information to adjust the payments that the MAO receives from Medicare. 

Invalid Diagnoses Submitted Under The Program Constitute Fraud

A former employee of the provider initiated the suit based on her information of invalid diagnoses submitted by the provider to the government.  The whistleblower will receive a $1.5 million reward for her efforts in uncovering the fraud.  According to Assistant Attorney General Jeffrey Bossert Clark of the Department of Justice’s Civil Division, “The United States relies on Medicare Advantage Organizations to submit accurate diagnosis data to Medicare to ensure that the compensation they receive is appropriate.  We will continue to pursue those who undermine the integrity of the Medicare program and the data it relies upon.”   A US Attorney working on the case added, “When insurance providers take advantage of Medicare and falsely claim that they are entitled to repayment for unsupported diagnoses, American taxpayers suffer in the form of higher costs.  We will continue to work to ensure that these programs are not defrauded and that monies are not paid for unwarranted claims.” 

Contact Us

If you are an employee or other insider with original information of invalid diagnoses or other fraud against Medicare or Medicare Advantage, contact Ingrid M. Evans and the other California whistleblower and false claims attorneys at Evans Law Firm at (415) 441-8669, or toll free at (888)50EVANS 503-8267 or by email at <a href=””></a>. In addition to False Claims Act cases, Ingrid and our other whistleblower attorneys handle cases involving bank fraud under FIRREA/FIAFEA, the Commodities Futures Trading Commission Whistleblower Program, the Securities and Exchange Commission Whistleblower Program, the FINRA Whistleblower Office and the Internal Revenue Service Whistleblower Office. 

[1] Evans Law Firm, Inc. was not involved in the case in any way.

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