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Dec 20, 2023 by |

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


Allegedly Applied Inaccurate Diagnostic Codes

Former Vendor Blows Whistle

Whistleblower To Receive $8.1 Million Reward

In Fiscal Year 2022, private citizens and businesses helped the government recover $1.9 billion in cases of fraud against the government. The private citizens and businesses assisted the government in recovering these funds by bringing civil lawsuits on behalf of the government under the False Claims Act, (“FCA”), 31 U.S.C. § 3729 et seq.    The private individuals or businesses in these actions are known as “relators,” and the cases themselves referred to as “qui tam” cases.  If the government recovers, the relators are eligible for rewards. 31 U.S.C. § 3730(d).   Relators received over $488 million in rewards during Fiscal Year 2022, and multiple large rewards have been made in 2023.  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 False Claims Act Settlement[1]

In a recent press release by the U.S. Department of Justice (DOJ), a large health care insurer has agreed to pay $172,000,000 to resolve False Claims Act (FCA) allegations that it submitted false and inaccurate Medicare Advantage diagnostic codes in a bid to boost its reimbursement.  The settlement resolved the FCA lawsuit and an investigation related to past risk adjustment submissions from certain types of patient records, some dating back more than a decade, according to the announcement.  The whistleblower, a former part-owner of a vendor retained by the carrier to conduct in-home visits, will receive an $8.1 million reward.

The lawsuit alleged that the carrier’s home care visit program submitted “inaccurate and untruthful patient diagnosis data to CMS [the Centers for Medicare and Medicaid Services] in order to inflate the payments it received from CMS, failed to withdraw the inaccurate and untruthful diagnosis data and repay CMS, and falsely certified in writing to CMS that the data was accurate and truthful,” the Department of Justice wrote in its press release.

The suit claimed that the diagnostic codes in question were based on forms submitted by contracted vendors who conducted in-home assessments of plan members. The providers conducting those assessments, typically nurse practitioners, would not perform or order the types of tests or imaging services needed to diagnose serious illnesses and were barred by the insurer from providing treatment for those diagnoses during the visit, the DOJ said.  The diagnoses in question were not supported in either the home visit form or in other documentation submitted by providers the patient may have seen throughout the year, but they were submitted to the federal government to secure higher payments, according to the DOJ.

How A Qui Tam Action Begins

Any False Claims Act whistleblower case begins 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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