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Nov 16, 2023 by |

Los Angeles False Claims Act Whistleblower Attorney: Insurer To Pay $172 Million To Resolve False Claims Act Allegations


Former Vendor Will Receive $8.14 Million Reward

Alleged Submission Of Untruthful Diagnostic Codes

Fraud Allegedly Occurred Under Medicare Advantage Plan

In Fiscal Year 2022, private citizens and businesses helped the government recover $1.9 billion in cases of fraud against the government. Those individuals and businesses helped the government recover this money by brining civil lawsuits under the False Claims Act, (“FCA”), 31 U.S.C. § 3729 et seq. These civil lawsuits enable the government to recover money fraudulently obtained from the government by suppliers, contractors, service providers, insurers, and others.  The private individuals or businesses, known as “relators,” brought the cases, referred to as “qui tam” cases,” under the FCA. If the government recovers, these individuals are eligible for rewards. 31 U.S.C. § 3730(d).  Much government fraud, and the majority of the qui tam cases brought every year, relate to fraud in the healthcare field, under programs like Medicare and Medicaid (known as Medi-Cal in California).  Relators of fraudulent conduct are often employees or managers, or former employees or managers, or (in healthcare cases) patients of the business engaging in the fraud.  If you have credible information of fraud against the government in violation of the FCA in Los Angeles or elsewhere in California, call us today at (415)441-8669 and we can help. Our toll-free number is 1-888-50EVANS (888-503-8267).

Recent Settlement[1]

In a recent press release by the U.S. Department of Justice (DOJ), a Medicare Advantage provider agreed to pay $172 million to settle charges that it violated the FCA by overbilling Medicare and Medicare Advantage Plans through inaccurate patient diagnostic codes. The United States alleged that, for payment years 2014 to 2019, defendant operated a “chart review” program, pursuant to which it retrieved medical records (also known as “charts”) from healthcare providers documenting services they had previously rendered to Medicare beneficiaries enrolled in defendant’s plans.  Defendant allegedly relied on the results of those chart reviews to submit additional diagnosis codes to the Centers for Medicare and Medicaid Services (CMS) that the healthcare providers had not reported for the beneficiaries to obtain additional payments from CMS. However, the chart reviews also allegedly did not substantiate some diagnosis codes that were reported by providers and previously submitted to CMS.  According to the government, defendant did not delete or withdraw these inaccurate and untruthful diagnosis codes, however, which would have required the company to reimburse CMS

“Over half of our nation’s Medicare beneficiaries are now enrolled in Medicare Advantage plans, and the government pays private insurers over $450 billion each year to provide for their care,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division.  “We will hold accountable those insurers who knowingly seek inflated Medicare payments by manipulating beneficiary diagnoses or any other applicable requirements.”

The relator was a former vendor for the insurance carrier and will receive a reward of $8.14 million.

How A Qui Tam Action Begins

False Claims Act whistleblower cases begin by a relator filing a complaint under seal in the federal court usually for the District in which the defendant is located or does business. At the same time, the relator submits a disclosure to the DOJ outlining the material evidence the relator has of the alleged false claims. 31 U.S.C. § 3730(b). The seal period of the complaint lasts 60 days during which the DOJ investigates the claims.  31 U.S.C. § 3730(b)(2). (If necessary, the government can, and often does, extend the 60-day period during which the allegations are kept under seal.)  If the government decides to intervene in the case, the government essentially takes over the litigation. 31 U.S.C. § 3730(c)(1).   If the government declines to intervene, the relator may proceed with the litigation on his or her own.  31 U.S.C. § 3730(c)(3).

Contact Us

If you have credible information of government fraud in Los Angeles or elsewhere in California, call Ingrid M. Evans at (415) 441-8669, or toll-free at 1-888-50EVANS (888-503-8267) or by email at <a href=””></a>.  In addition to FCA and CFCA whistleblower cases, Ingrid and Evans Law Firm, Inc. also handle bank fraud whistleblower cases under FIRREA/FIAFEA, commodity trading and securities fraud under the Commodities Futures Trading Commission Whistleblower Program and the Securities and Exchange Commission Whistleblower Program, and tax fraud under the Internal Revenue Service Whistleblower Program. 

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

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