Allegedly Submitted Inaccurate Diagnosis Codes
Higher Reimbursement Levels Than Permissible
Manager Blows Whistle And Will Receive $3.8 Million Reward
Private citizens can bring civil lawsuits on behalf of the government for redress against fraud under the False Claims Act, (“FCA”), 31 U.S.C. § 3729 et seq. In Fiscal Year 2022, private citizens and businesses helped the government recover $1.9 billion in cases of fraud against the government. The private individuals or businesses, known as “relators,” brought the cases, referred to as “qui tam” cases,” under the FCA. I f the government recovers, these individuals are eligible for rewards. 31 U.S.C. § 3730(d). Relators received over $488 million in rewards during Fiscal Year 2022. 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 San Francisco 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
In a recent press release by the U.S. Department of Justice (DOJ), a healthcare provider has agreed to pay $22,485,000 to resolve allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to increase reimbursements from Medicare. Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed care insurance plans called Medicare Advantage Plans (MA Plans). MA Plans are paid a per-person amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. The Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare program, adjusts the payments to MA Plans based on demographic information and the diagnoses of each plan beneficiary. The adjustments are commonly referred to as “risk scores.” In general, a beneficiary with diagnoses more expensive to treat will have a higher risk score, and CMS will make a larger risk-adjusted payment to the MA Plan for that beneficiary.
The government alleged that, from 2016 to 2019, defendant engaged in chart reviews of their Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare. Many of the additional codes submitted, however, were not properly supported by the patients’ medical records. The government alleged that defendant nevertheless submitted those diagnosis codes, which resulted in higher payments from CMS.
How A Qui Tam Action Begins
A former manager in defendant’s risk adjustment operations unit (referred to as the “relator”) initiated the case just described. She will receive a $3.8 million reward for her efforts. 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).
If you have credible information of government fraud in San Francisco 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=”mailto:email@example.com”>firstname.lastname@example.org</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.
 Evans Law Firm, Inc. was not involved in the case in any way.